Laparoscopic Banding — Alternative to Gastric Bypass Shows Early Promise
By Maryann Tomovich Jacobsen, MS, RD
Today’s Dietitian
Vol. 8 No. 4 P. 34

The procedure is emerging as a safer and less invasive alternative to traditional weight-loss surgery, but researchers question its efficacy and long-term results.

As a nutrition professional, when weight-loss surgery comes to mind, you probably think of gastric bypass. There’s good reason for that. In the United States, gastric bypass is the most commonly performed weight-loss surgery and is considered the gold standard.1 Weight-loss surgeries are categorized depending on how they work—perpetuating weight loss via restriction, malabsorption, or a combination of the two. The most common gastric bypass procedure is Roux-en-y gastric bypass (RYGB), which reduces the size of the stomach using surgical staples to cause restriction. Then, the stomach is reattached to the jejunum, bypassing the duodenum and causing malabsorption.

Outside the United States, gastric bypass is not the preferred weight-loss surgery. In fact, the most commonly performed weight-loss surgery worldwide in places such as Europe, Australia, and Latin America is laparoscopic adjustable gastric banding (LAGB)—a restrictive, minimally invasive surgery where an inflatable silicone band is placed around the upper stomach (see Figure 1).2 This creates a smaller pouch, controlling the amount of food that is able to move into—and through—the stomach. The decreased gastric emptying helps increase feelings of satiety, helping people feel full sooner, resulting in decreased food intake.

The key difference between LAGB and other procedures is that the band around the stomach can be adjusted. A port is placed under the skin during surgery that connects directly to the band. By injecting saline solution into the port, the band can be inflated or deflated, causing alterations in the restriction patients feel. The surgeon performs adjustments during outpatient visits in approximately 15 minutes. In addition to the adjustments, LAGB is reversible, which means it can be removed at any time.

History of LAP-Band
In 1986, Lubomyr Kuzmak, MD, developed an inflatable and adjustable silicone band.3 The explosion of laparoscopic surgeries in the early 1990s led to alterations in Kuzmak’s band for such surgeries, resulting in the LAP-Band (INAMED Health, Santa Barbara, Calif.). The first human LAP-Band was placed in 1993, and in 1994, the LAP-Band System became available to surgeons worldwide. Since then, it has become popular in places such as Europe and Australia.3,4

In June 1995, the FDA initiated clinical trials to test the safety and efficacy of LAGB. Unfortunately, these clinical trials produced poor results, including modest weight loss and various complications, including band slippage, gastric prolapse, and gastroesophageal reflux.2 Changes in band placement and frequent postoperative band adjustments led to fewer complications and improved weight loss results. Based on more positive outcomes, the FDA approved LAP-Band in June 2001.4

Weight Loss Results
The bariatric community uses percent excess weight loss (EWL) to describe weight outcomes in patients who have undergone bariatric surgery. Because LAGB is a restrictive procedure, it allows for slow, gradual weight loss, unlike RYGB. At two years post-op, LAGB demonstrates a range of 47% to 52% EWL based on U.S. studies.5,6 RYGB allows for quicker and more substantial weight loss early on. With RYGB, mean EWL one year post-op ranges from 57% to 65%, with some reports as high as 83% using laparoscopic procedures.1

With RYGB, most weight loss occurs in the first six months and stabilizes in 18 to 24 months. Long-term data on gastric bypass show a 15% weight regain over 14 years.7 In contrast, patients who had LAGB continue to lose gradually up to three and even four years following their procedure, showing an average of 50% to 60% EWL at the end of four years.8 Unfortunately, LAGB long-term weight loss data are not available.

As you would expect, significant reductions in comorbidities are seen with both weight-loss surgeries.1

For LAGB, some weight loss considerations include the lack of long-term data, even though proper follow-up is critical to weight-loss success. According to a study published in the 2004 issue of Obesity Surgery, consistent follow-up was essential for successful weight loss in patients who had LAGB but not for patients who had RYGB.9 In LAGB, the importance of follow-up is due to the adjustment component. When patients lose weight, they also lose the adipose tissue around their stomach, causing the band to feel open, allowing for increased dietary intake.

“I like LAP-Band because, surgically, it’s the safest and healthiest way to lose weight,” says Carson Liu, MD, a surgeon at The Surgical Weight Control Center in Los Angeles. He admits that it takes more work and constant follow-up, but he points out that it’s a good first choice for weight loss. “The research is showing that at three to five years, the weight loss is virtually the same as gastric bypass.”

Mortality and Morbidity
Over the short term, LAGB is considered the safest weight-loss surgery offered today.1,2,4,8,10 This is not surprising considering the nature of the procedure. LAGB complications typically result from placement of the band. Gastric bypass can involve breakdowns in staple-line formation and metabolic complications due to altering the gastrointestinal tract. The Australian Safety and Efficacy Register of New Interventional Procedures-Surgical found that patients who had LAGB experienced one death per 2,000 operations, roughly one tenth the mortality rate of RYGB. Additionally, patients who had LAGB had a median, overall morbidity rate of 11.3% compared with 23.6% in patients who had RYGB.8

According to a 2006 study published in the American College of Surgeons with 715 patients undergoing weight-loss surgery, 9% of the LAGB patients experienced complications compared with 23% of patients who had RYGB.10 The authors concluded that patients who had LAGB were 3.5 times less likely to develop complications compared with RYGB. Even though changes in band placement have led to fewer problems in LAGB patients, common complications still include pouch dilation, band slippage, port-related complications, and band erosion.1

“There are positives and negatives to both procedures,” says David Oliak, MD, a surgeon in a southern California-based private practice. Oliak educates potential patients on the risks and benefits of both procedures and allows them to decide. With RYGB, he insists that “the weight loss is dramatic and the effects on medical problems, especially diabetes, are more pronounced than LAP-Band.” He likes that LAGB is low risk and reversible, and for some people that’s the deciding factor.

Nutrition Post-Op
The nutrition recommendations for LAGB are similar to RYGB. Before the procedure, a weight loss of 5% is encouraged to decrease liver size and allow for easier surgical placement of the band. Following LAGB, patients follow a protein-rich liquid diet (60 to 80 grams protein per day) for approximately two weeks to maximize postoperative healing. At post-op weeks three and four, patients advance to a soft-puree diet for two weeks, including foods such as cottage cheese, yogurt, low-fat tuna salad, scrambled egg whites, oatmeal, and unsweetened applesauce. At the two-week mark, patients also begin taking a chewable multivitamin and calcium (1,000 milligrams per day). At week five, patients begin to introduce regular foods, one at a time, to determine individual tolerance.11

Patients are encouraged to consume three meals each day without grazing. The overall diet is protein rich and low in fat and sugar. One- to 1.5-cup portion sizes are recommended. All food is to be chewed thoroughly to a mushy consistency with meal duration of approximately 20 to 30 minutes. In fact, eating too fast can result in vomiting and eating longer than 30 minutes can indicate a large portion size. Regular physical activity including aerobic and resistance exercises are encouraged and reinforced during follow-up.

Weekly weight loss is set at a goal of 1 to 2 pounds per week. Band adjustments are performed when weight loss plateaus or when a patient reports the ability to eat larger portions of food.

Nutritional Factors That Can Hinder Success
Patients who had LAGB do not experience dumping syndrome like RYGB. In fact, high-calorie, high-sugar soft foods such as cheesecake or ice cream can easily get past the band, resulting in increased calorie intake. It has been suggested that sweet eaters may be less successful with LAGB, but more research is needed.1 Sometimes, a too-tight band can result in the inability to get solid food down, increasing the likelihood of eating soft, high-calorie foods.5

“It’s a lot easier to cheat,” says Oliak. He estimates that approximately 10% to 15% of his patients simply don’t lose weight with LAGB. “It’s a lot more work,” he insists, and all-day snacking can be a big problem for anyone having undergone weight-loss surgery. So matching the right person for the procedure becomes important.

As with any weight-loss surgery, patients who display emotional problems such as binge eating may have modest success. A 2004 study published in Obesity Surgery showed that even though binge eaters still showed improvements in their eating habits after LAGB, they were less successful in terms of weight and mental health than non-binge eaters.12 The following year, another study in Obesity Surgery found that poor compliers were more likely to graze and eat in response to negative events.13

Nutrition Deficiencies
Because LAGB does not staple off part of the stomach and alter the gastrointestinal tract, nutrition deficiencies are less likely than with RYGB. With LAGB, one year post-op, 31 women were found to have no major nutrition deficiencies.14 Research shows that one year after RYGB, when most of the weight is lost, B12 and iron deficiencies are common. Due to food bypassing the lower stomach, approximately 30% of patients fail to maintain normal B12 levels at one year and menstruating women often experience declining stores of iron up to seven years after surgery.15 Of course, proper follow-up and supplementation provide viable solutions to these problems.

Long-term data regarding nutrition deficiencies in LAGB are unknown but unlikely to be the same as RYGB. Recent studies suggest that decreased bone mineralization may be a long-term complication after RYGB. Long-term follow-up is essential for any individual who undergoes weight-loss surgery, but especially those who have had gastric bypass.

Populations That Can Benefit from LAGB
People especially concerned about safety are likely to feel more at ease with LAGB. Women of childbearing age can benefit from the band’s adjustability. When these women become pregnant, they can have the band opened to allow for adequate nutrition. Adolescents may also benefit from the procedure. If it’s decided that an adolescent needs surgery, a minimally invasive, reversible procedure may be the way to go.

“The LAP-Band works especially well with men,” says Liu, adding that men don’t eat for emotional reasons as much as women do. Additionally, men have more lean tissue, which helps the weight come off even faster. Liu also likes to use the band on those who are extremely obese and patients over the age of 65 who are at increased risk during surgery.

The Future of Weight-Loss Surgery
LAGB has many advantages: It’s minimally invasive, adjustable, and if things go awry, it can easily be removed. But it’s similar to people trying to lose weight on their own because it takes work—the weight doesn’t just slide off. Patients can always eat past their LAP-Band by eating high-calorie, soft foods all day.

But the LAP-Band is safe and may give patients—and insurance companies—a cost savings. “It’s going to become even more cost effective,” Liu insists. “Right now, a LAP-Band surgery is about two thirds the cost of bypass.”

More than anything, minimally invasive surgeries such as LAP-Band give patients more choices. And the exciting news is that RDs play an important role in the process—from screening to nutrition education to counseling. There is still much to be learned about nutrition and LAP-Band. Dietitians can also play a role, along with psychologists, in addressing the eating issues that can hinder success. The frequent follow-up required lends itself to a team approach where the RD can play a leading role.

Clearly, LAGB lacks long-term data for efficacy. Right now, the research looks promising, but it’s difficult to predict success. But if the outcomes continue to be positive, we may be seeing even more weight-loss surgeries, and patients will benefit from an RD who can enhance their chances of success.

— Maryann Tomovich Jacobsen, MS, RD, works as a freelance writer and an outpatient and a clinical dietitian at Olympia Medical Center in Los Angeles.

References
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2. DeMaria EJ, Jamal MK. Laparoscopic adjustable gastric banding: Evolving clinical experience. Surg Clin North Am. 2005;85(4):773-787.

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5. Kim TH, Daud A, Ude AO, et al. Early US outcomes of laparoscopic gastric bypass versus laparoscopic adjustable silicone gastric banding for morbid obesity. Surg Endosc. 2006;20(2):202-209.

6. Ponce J, Paytner S, Fromm R. Laparoscopic adjustable gastric banding: 1,014 consecutive cases. J Am Coll Surg. 2005;201(4):529-535.

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11. Ferraro DR. Laparoscopic adjustable gastric banding for morbid obesity. AORN J. 2003;77(5):929-940.

12. Larsen JK, van Ramshorst B, Geened R, et al. Binge eating and its relationship to outcome after laparoscopic adjustable gastric banding. Obes Surg. 2004;14(8):1111-1117.

13. Poole NA, Al Atar A, Kuhanendran D, et al. Compliance with surgical after-care following bariatric surgery for morbid obesity: A retrospective study. Obes Surg. 2005;15(2):261-265.

14. Giusti V, Suter M, Heraief E, et al. Effects of laparoscopic adjustable gastric banding on body composition, metabolic profile and nutritional status of obese women: 12-months follow-up. Obes Surg. 2004;14(2):239-245.

15. Fujioka K. Follow-up of nutritional and metabolic problems after bariatric surgery. Diabetes Care. 2005;28(2):481-484.