Benefits & Risks of Adjustable Gastric Bands
Risks of the Laparoscopic Adjustable Gastric Bands:
1 . Risk of slippage of the band around the stomach to an abnormal position which blocks the stomach and results in persistent vomiting, or can even interfere with the blood supply of the stomach and cause a perforation or portion of the stomach to die. This may require deflation of the band or reoperation to revise, remove, or replace the Gastric Band in a new position.
2 . Erosion of the Adjustable Gastric Band into the stomach which becomes infected and requires removal of the band and repair of the gastric perforation. The risk of erosion is increased if patients take certain medications like aspirin, NSAIDS, or steroids, so they should avoid these after surgery if possible.
3 . Port or tubing problems which may require a reoperation to correct.
4 . Esophageal dilatation which will cause problems swallowing and require removal of the Adjustable Gastric Band
5 . Mechanical malfunction of the band.
6 . Acid Reflux, chronic vomiting or band intolerance. Many patients report an improvement in acid reflux or Gastroesophageal Reflux Disease (GERD), but it can worsen in others. Some patient’s esophagus will simply not accept a restrictive band near its outlet and will require removal due to chronic vomiting, difficulty swallowing or chronic pain.
7 . Does not limit intake of high calorie liquids or sweets and is easy to defeat. The LAGB success is totally dependent on patients following all the rules and guidelines and exercising regularly.
8 . The LAGB is not a permanent device.
9 . The band requires fluid adjustments performed in a physician’s office or hospital and can be time consuming.
Design and Technique of the LAP Adjustable Gastric Band
The designs of the Laparoscopic Adjustable Band and the techniques for implantation has undergone several changes over the past 11 years. We were involved with the FDA Clinical “B” trial of the original LAP Band © and began inserting Bands in 1999. The original LAGB in the United States was much narrower and shorter and only held 4 cc of saline, was completely tightened immediately in the operating room, and was placed directly along side the wall of the stomach (called the “peri-gastric” technique). The combination of placing the band directly against the stomach resulted in more slippages and erosions and the immediate tightening of the band also resulted in frequent vomiting which increased the risk further for slips. The narrow bands increased pressure on the stomach wall and made adjustments more difficult. This early band and technique resulted in a band
slippage rate of 10% and band erosions in 3% reported in many studies.
Several developments were made to the design of bands and the technique for insertion which has now decreased the risk of slippages to around 5% and erosions to approximately 1% after LAGB surgery. First, the band was inserted further away from the wall of the stomach, called the “Pars Flaccida” technique which also incorporated some of the fat and fibrous tissue surrounding the upper stomach to reduce the risk of slips and erosions. The Bands were left empty in the operating room to reduce vomiting and allow scar tissue to form and hold the band in place better. The Bands were then filled with slow small fills over the course of several months so patients could adjust gradually to the restriction. Finally, the bands were widened, pre-shaped in a semi circle, and made longer which improved contact with the stomach wall to reduce slips while also reducing pressure on the stomach to reduce erosion risk.
Overall multiple studies have demonstrated that approximately 25% of patients who undergo a LAGB will have it removed for complications such as recurrent slippage, erosion or band intolerance, or due to weight loss failure. The band is not permanent and will wear out in probably 15-20 as a best guess estimate. At that point patients will have several options. They can leave the band and have it not function. They can remove the band, or replace it with a new band, or be converted to another type weight loss surgery.
Benefits of the Laparoscopic Adjustable Gastric Band:
1). It requires no stapling or cutting of the stomach so this greatly reduces the risks of leaks or infections and is therefore the safest weight loss surgery currently available. The risk of dying from a LAGB is less than 1/1000 (0.1%) where the risk of a VBG, Gastric Bypass or Sleeve Gastrectomy was approximately 1/200 (0.5%).
2). The LAGB is adjustable so it can be loosened or tightened in the office to improve weight loss or reduce vomiting. Adjustments can continue to be made years after implantation and patients can still lose weight years later if they utilize the band restriction and follow the recommended guidelines.
3). The LAGB is more easily reversible since it involved no stapling or cutting of the stomach and there is less scarring.
4). Loss of as little as 10% of body weight can result in improvements in health. Diabetes has been shown to improve in 65% of patients after LAGB and hypertension, hyperlipidemia, sleep apnea, acid reflux and joint issues are often improved or resolve. The improvements seen after LAGB however, are totally dependent on patients losing weight and do not occur otherwise (compared to Gastric Bypass with a metabolic effect independent of weight loss).
Outcomes of Laparopscopic Gastric Bands Procedures:
The LAGB patients average losing 50% of their excess weight (their preop body weight
minus their ideal body weight) and 50% are “successful” long term (means they keep
50% of their excess weight off for 5 years).
The results of both FDA Clinical Trials on the two current brands of LAGB over a 3 year
study were nearly identical with average weight loss of 40% of excess weight.
Who Should Consider A Laparoscopic Adjustable Gastric Band?
The LAGB is most appropriate for patients whose BMI is less than 50. The lower the BMI initially (35-49) and the closer patients are to being only 100 pounds over their ideal body weight has the most success in my experience. The other category which does well with a LAGB are the “big” meal eaters. This means they aren’t snackers and don’t graze on junk food all day and night until they go to bed, but instead tend to eat meats and vegetables three times a day but in large quantities or amounts. This group tends to do well with any Restrictive Procedure.
Patients who tend to do poorly with the LAGB are patients with a “sweet tooth” who frequently eat ice cream, candy, cookies and simple carbohydrates like potatoes, bread, rice and pasta; or patients who graze all day by eating small handfuls of nuts, chips and other convenience and junk foods. They never over eat and feel full or vomit so they get no benefit from the band, but there is a steady stream of calories through out the day which add up quickly. Keep in mind you must reduce your intake to 1200 calories or less and it can be done and you be satisfied if you make better food choices after Restrictive Operations like the LAGB.
Who is NOT the best candidates for Laparoscopic Adjustable Gastric Bands?
Patients with BMI’s greater than 50 or who weigh more than 350 pounds are generally unhappy with their weight loss from a Laparoscopic Gastric Bands.
I strongly advise any patient with Adult Onset Type 2 Diabetes or with high cholesterol or triglycerides to have a Roux-En Y Gastric Bypass.