Adjustable Gastric Banding

The Lap-Band system was approved by the FDA in 2001 and was touted as a safe alternative to gastric bypass.  The Lap-Band was bought and sold by several companies and ultimately came under ownership by Allergan, the multi-billion dollar company behind Botox.  When I started performing Bariatric Surgery in 2006, the Lap-Band was everywhere.  There were commercials on TV, giant, two story booths at the Bariatric Surgery meetings and dozens of well respected experts on Allergan’s payroll publishing research and giving talks.  The Lap-Band was presented as the perfect weight loss operation – it reportedly offered patients equivalent weight loss to the gastric bypass, was easily reversible and had an exceedingly low complication rate.  

In 2008 and 2009, laparoscopic placement of adjustable gastric bands was the most popular weight loss surgery performed in the United States.   Patients not surprisingly flocked to the operation on the promises of weight loss without risk and surgeons paid big bucks to become “certified” to place the bands surgically.  

Initially, we all recognized that our Gastric Band patients were losing much less weight than our gastric bypass patients, but the research showed that the weight loss was slow and took as long as four to five years until patients lost all their weight.  At the height of the Gastric Band craze, we started hearing whispers from many surgeons that the weight loss was not as promised and the long term complication rate was alarmingly high.  Bariatric Surgeons as a group tend to be more extroverted and collaborative than other surgeons.  At conferences and meetings, we often share stories of what’s working for our patients and what troubles we’re having.  Over and over, surgeons were sharing their difficulties with adjustable gastric bands.  Patients were not losing weight and were having a terrible time with vomiting, difficulty swallowing and heartburn.  Despite surgeons following the recommendations from the experts and the device manufacturers, their patients weren’t doing as well as they expected.

Adjustable Gastric Bands have two parts.  The main part is an inflatable bladder that wraps around the upper part of the stomach.  This part is connected by a tube to the “port,” a small, round plastic piece with a rubber center that sits just beneath the patient’s skin.  Surgeons can inflate the bladder around the stomach by injecting saline via the port that sits underneath the skin.  Band adjustment procedures take just a few seconds and can be done in the office. The goal is to slowly inflate the band over a period of a few months until it is just the right tightness.  Patients should be able to eat small portions of food and feel satisfied, yet not suffer from frequent vomiting, heartburn or difficulty swallowing.

The primary problem with adjustable gastric bands it that they offer very little hormonal influence and do not significantly change your metabolic thermostat’s set point.  The primary emphasis of the band is to induce restriction – patients can only eat small amounts of food until they feel full.  As we learned in the first part of the book, simple calorie restriction alone is bound to fail in the long run and this is exactly what we were finding in our practice as patients failed to lose weight after their gastric band surgery.

In my practice, I’ve found that most gastric band patients fall into one of three groups.  The first group is the smallest and represents only 5% of all the patients.  These “super-responders” lose weight easily and quickly after surgery, requiring very few band adjustments and naturally decreasing their appetite and improving the quality of their diet without much effort.  These patients have a very powerful hormonal response to the mere placement of the band, it is rarely necessary to tighten it significantly.  For this small group, adjustable gastric bands represent the ideal weight loss surgery.  Their results are excellent, the surgical risk is negligible and the required follow up care is minimal.  Unfortunately, this group represents only a small minority of all the patients who have adjustable gastric bands placed.

The second category of patients are “partial responders” and consist of over half the group.  These patients are able to lose between 50-60 pounds easily after surgery.  However, after they lose this weight, they plateau and are unable to drop another pound.  Again, for reasons we don’t fully understand, these patients are able to lower their set point by only 50-60 pounds. Increasing their restriction by injecting more saline into the band does not lower their metabolic thermostat’s set point, it just worsens heartburn, difficulty swallowing and vomiting.

The final group of patients lose only a few pounds after surgery, largely because they are placed on a restrictive postoperative diet.  As soon as they resume their normal diet, the weight comes back and they receive no weight loss benefit from the band.  

Patients and surgeons alike who try to increase the restriction of the band by inflating it tightly to drive weight loss find themselves trapped on a miserable merry go round.  In an effort to achieve additional weight loss, the band is inflated until it is very tight.  This enforces calorie restriction, resulting in the usual weight loss we see from calorie restriction alone – 10% of your total body weight.  In an effort to achieve even more weight loss, the band is tightened further, usually to the point where the patient has difficulty tolerating solid foods.  Because the patient is now living well onto the starvation side of their metabolic thermostat, the hunger they experience increases and the patients find themselves seeking out soft, calorie dense foods.  These soft foods are able to slide through the super tight band, where healthier foods like fruits and vegetables get stuck.

Living with an extremely tight band is not sustainable and results in a life of frequent vomiting (several times a day), painful swallowing and severe heartburn, particularly at night.  Ultimately, these patients return to their surgeon who removes some of the fluid and provides immediate relief.  The patient is able to return to their normal diet, which, of course, results in significant weight regain and the patient moves out of the starvation side of their thermostat and back toward their set point.  Frustrated by their weight regain, the patients return back to their surgeon to have the fluid put back in, starting the whole cycle over again.

As surgeons across the country recognized that their own clinical experiences were quite different from the marketing research that was presented in the journals and at the conferences, the number of gastric band surgeries decreased.  The problems of heartburn, difficulty swallowing and frequent vomiting worsen with time, rather than improves.  In 2016, very few surgeons continue to offer adjustable gastric bands to their patients and there are more bands removed every year than are placed.

Although very few lap bands are being placed these days, there remain hundreds of thousands of people who still have a band in place.  I continue to see these patients frequently in my office and work with them to help them understand what the band can and cannot do for them.  Depending on how much weight the patient has lost and what type of symptoms they are having, we can often get patients to a more comfortable place without surgery.  In order to follow the Pound of Cure program, the band needs to be relatively loose to allow them to eat the large volumes of vegetables, fruits, nuts, seeds and beans that are required for success.  Sometimes we’re able to help these patients lose weight, other times, the patient decides to have the band removed and then convert to either a gastric bypass or sleeve gastrectomy.  This is a complicated decision, and should be made after careful consideration with a bariatric surgeon who performs revision surgery frequently.

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