Adjustable gastric band

A laparoscopic adjustable gastric band is a restrictive device implanted via bariatric surgery and designed for obese patients with a body mass index (BMI) of 40 or greater—or between 35–40 in cases of patients with certain comorbidities that are known to improve with weight loss, such as sleep apnea, diabetes, osteoarthritis, or metabolic syndrome, among others. The gastric band is an inflatable silicone prosthetic device that is placed around the top portion of the stomach, usually via laparoscopic surgery.

Theory of gastric banding

According to the American Society For Bariatric Surgery, gastric reduction surgery is not an easy option for obesity sufferers. It is a drastic step, and carries the usual pain and risks of any major gastrointestinal surgical operation.Some patients who undergo adjustable gastric band surgery lose more than 100 pounds in weight - some lose as much as 200 pounds weight. Typically, patients who undergo adjustable gastric banding procedures, such as Lap-Band lose less weight than those who have gastric bypass like Biliopancreatic Diversion (BPD) or Duodenal Switch (BPD-DS). Some patients reach a normal weight, while others remain overweight, although less overweight than before. However, in order to maintain this type of weight reduction, patients must follow carefully the post-operative guidelines relating to diet and exercise.

The placement of the band causes the creation of a small pouch at the top of the stomach that holds approximately 4 oz to 8 oz of food each meal. This pouch fills with food quickly and the band slows the passage of food from the pouch to the lower part of the stomach. As the upper part of the stomach registers as full, the message to the brain is that the entire stomach is full and this sensation helps the person to be hungry less often, to feel full more quickly, to eat smaller portions, and lose weight over time.

The band is inflated/adjusted via a small access port placed just under the skin. Radiopaque isotonic solution or saline is introduced into the band via the port. A specialized needle is used to avoid damage to the port membrane. There are many port designs and they may be placed in varying positions based on the surgeon’s preference. The port is sutured in place. When fluid is introduced the band expands, placing pressure around the outside of the stomach. This decreases the size of the passage between the pouch and the lower stomach, and restricts the movement of food.

Over the course of several visits to the doctor, the band is filled such that the patient feels s/he has hit a “sweet spot” where optimal restriction has been achieved, neither so loose that hunger is not controlled, nor so tight that food cannot be consumed. This is an individual experience and cannot be predicted. There are approximately 7–8 adjustable bands on the market. The amount of fluid required and total content varies.

Pregnancy

If considering pregnancy, ideally the patient should be in optimum nutritional condition prior to conception; deflation of the band may be required prior to planned conception. Deflation should also be considered should morning sickness be present. The band may remain deflated during pregnancy and once breast feeding is completed, or if bottle feeding, the band may be gradually re-inflated to aid postpartum weight loss if needed. Fact|date=February 2007

Comparison with other bariatric surgeries

Gastric band placement, unlike malabsorptive weight loss surgery (e.g. Roux-en-Y gastric bypass surgery (RNY), Biliopancreatic Diversion (BPD) and Duodenal Switch (DS)), does not cut or remove any part of the digestive system. It is also usually easy to remove the band and reverse the surgery, requiring only a laparoscopic procedure, after which the stomach usually returns to its normal pre-banded state. Unlike those who have procedures such as RNY, DS, or BPD, it is unusual for gastric band patients to experience any nutritional deficiencies or malabsorption of micro-nutrients. Calcium supplements and Vitamin B12 injections are not routinely required following gastric banding (as they are with RNY, for example). Gastric dumping syndrome issues also do not occur since no intestines are removed or re-routed.

Initial weight loss is slower than with RNY, generally 1-2 pounds per week; however, statistics indicate that over a 5-year period, weight loss outcome is similar.Fact|date=February 2007 Weight regain is possible with ANY weight loss procedures including the more radical procedures that initially result in rapid weight loss. The World Health Organization recommendation for weight loss is ½ to 1 kilogram per week and an average banded patient may lose this amount.Fact|date=February 2007 Clearly this is variable based on the individual and their personal circumstances, motivation, and mobility.

Potential complications

A commonly reported occurrence for banded patients is regurgitation of non-acidic swallowed food from the upper pouch, commonly known as Productive Burping (PBing).Fact|date=February 2007 Productive Burping is not to be considered normal. The patient should consider eating less, eating more slowly, or chewing their food more thoroughly. Occasionally, the narrow passage into the larger / lower part of the stomach may become blocked by a large portion of unchewed or unsuitable foodstuff. Fact|date=February 2007

Other complications include:

*Ulceration
*Gastritis (irritated stomach tissue)
*Erosion—the band may wear away a small area on the outside of the stomach which can lead to migration of the band to the inside of the stomach.Very severe treatment required and very dangerious if internal bleeding happens.
*Slippage—an unusual occurrence in which the lower part of the stomach may prolapse over the band and cause an obstruction. Fact|date=February 2007
*Band placement - (high or low on stomach) - Extensive vomiting during the early postoperative period - This complication can be caused by lack of experience of the surgeon. Patients must undergo a second operation to reposition the band. The Swedish Laparoscopic Adjustable Gastric Banding for Morbid Obesity: Radiologic Findings in 218 Patients
*Band was not placed on the stomach - However, in two asymptomatic patients, the band had not enclosed the stomach but only perigastric fat - The Swedish Laparoscopic Adjustable Gastric Banding for Morbid Obesity: Radiologic Findings in 218 Patients

The psychological effects of any weight loss procedure also should not be ignored.

History of the procedure and device

In early 1985, Dr. Dag Hallberg applied for a patent for the Swedish Adjustable Gastric Band (SAGB) within Scandinavian countries. In late March, Dr. Hallberg presented his idea of the "balloon band" at the Swedish Surgical Society and started to use the SAGB in a controlled series of 50 procedures. During this time, laparoscopic surgery was not common and Dr. Hallberg and his assistant, Dr. Peter Forsell, started performing the open technique to implant the SAGB.

In 1992, Dr. Forsell was in contact with different surgeons in Switzerland, Italy and Germany who began to implant the SAGB with the laparoscopic technique. Dr. Forsell fully owned the patent at this time. In 1994, Dr. Forsell presented the SAGB at an international workshop for bariatric surgery in Sweden, and from then on, the SAGB started to be implanted laparoscopically. During this time, the SAGB was manufactured by a Swedish company, ATOS Medical.

Indications

In general, gastric banding is indicated for people for whom all of the following apply:
*Body Mass Index above 40, or those who are 100 pounds (45 kg) or more over their estimated ideal weight according to the 1983 Metropolitan Life Insurance Tables or those between 30 to 40 with co-morbidities which may improve with weight loss (high blood pressure, diabetes, sleep apnea, and arthritis).
*Age between 18 and 55 years (although there are doctors who will work outside these ages, some as young as 12 [ [http://www.kitsapsun.com/news/2007/jul/02/the-kid-i-want-to-be/ The Kid I Want To Be, July 2007] ] ).
*Failure of dietary or weight-loss drug therapy for more than one year.
*History of obesity (generally 5 years or more).
*Comprehension of the risks and benefits of the procedure and willingness to comply with the substantial lifelong dietary restrictions required for long term success.
*Acceptable operative risk.It is usually contraindicated for people with any of the following:
*If the surgery or treatment represents an unreasonable risk to the patient.
*Untreated glandular diseases such as hypothyroidism.
*Inflammatory diseases of the gastrointestinal tract such as ulcers, esophagitis or Crohn’s disease.
*Severe cardiopulmonary diseases or other conditions which may make them poor surgical candidates in general.
*An allergic reaction to materials contained in the band or who have exhibited a pain intolerance to implanted devices.
*Dependency on alcohol or drugs.
* [People with severe learning or cognitive disabilities] or emotionally unstable people.

Benefits of gastric banding when compared to other bariatric surgeries

*Lower mortality rate: only 1 in 2000 versus 1 in 200 for Roux-en-Y gastric bypass surgery
*Fully reversible: stomach returns to normal if the band is removed
*No cutting or stapling of the stomach
*Short hospital stay
*Quick recovery
*Adjustable without additional surgery
*No malabsorption issues (because no intestines are bypassed)
*Fewer life threatening complications (see complications table for details)

Losing weight after surgery

Correct and sensitive adjustment of the band is imperative for weight loss and the long term success of the procedure. Adjustments (also called "fills") may be performed using an X-ray fluoroscope so that the radiologist may assess the placement of the band, the port and the tubing that runs between the port and the band. The patient is given a small cup of liquid that contains a radio-opaque fluid similar to barium—clear or white. When swallowed, the fluid is clearly shown on X–ray and is watched as it travels down the esophagus and through the restriction caused by the band. The radiologist is then able to see the level of restriction in the band and to assess if there are potential or developing issues of concern. These may include dilation of the esophagus, an enlarged pouch, prolapsed stomach (when part of the stomach moves into the band where it does not belong), erosion or migration. Reflux type symptoms may indicate too great a restriction and further investigation may be required. In some circumstances fluid is removed from the band prior to further investigation and re-evaluation. In some cases further surgery may be required (e.g. removal of the band) should gastric erosion or similar be detected.

Some health practitioners adjust the band without the use of X-ray control (fluoroscopy). For example, this is standard practice in the main bariatric surgery clinic in Melbourne, Australia, where AGB placement has been performed for more than ten years. Some UK services, such as Bristol, also do non-fluoroscopic adjustments. In these cases, patients visiting for a regular fill adjustment will typically find they will spend more time talking about the adjustment and their progress than the actual fill itself, which generally will only take about one to two minutes..

For some patients this type of fill is not possible, due to issues such as partial rotation of the port, or excess tissue above the port making it difficult to determine its precise location. In these cases, a fluoroscope will generally be used.

No accurate number of adjustments required can be given. However, an average may be estimated to be between three and five fills (where saline/isotonic solution is inserted into the band via the subcutaneous port) for a person to reach the optimal restriction for weight loss. The amount of saline/isotonic solution needed in the band varies from patient to patient. There are a small number of people who find they do not need a fill at all and have sufficient restriction immediately following surgery. Others may need significant adjustments to the maximum the band is able to hold. Bands come in several diameters and sizes and can hold a total of between 4 cc (ml) to 12 cc (ml) of fill fluid depending on the design. Band size is usually determined by personal preference of the surgeon who places the band together with what s/he is either able to use (e.g., specific bands approved in country of surgery) or what s/he believes to be the most appropriate. In Europe, for example, it is possible for the surgeon to use many designs. The size of the band used is determined by the surgeon during surgery based on the size and thickness of the patient's stomach.

It is more common practice for the band not to be filled at surgery—although some surgeons choose to place a small amount in the band at the time of surgery. The stomach tends to swell following surgery and it is possible that too great a restriction would be achieved if filled at at that time. Clearly, this is undesirable.

The patient may be prescribed a liquid-only diet, followed by mushy foods and then solids. This is prescribed for a varied length of time and each surgeon and manufacturer varies. Some may find that before their first fill that they are still able to eat fairly large portions. This is not surprising since before the fill there is little or no restriction and this is why a proper post-op diet and a good after-care plan is essential to success. Many health practitioners make the first adjustment between 6 – 8 weeks post operatively to allow the stomach time to heal. After that, fills are performed as needed. Some practitioners may be more aggressive than others, but most appear to require a 2 – 4 week wait between fills. It is very important to discuss post-surgical care and diet plans with your weight loss team if you are considering this surgery. Recommendations can vary dramatically from team to team and it is important to find a weight loss team with a good post-surgical plan. Some teams offer support groups, but unfortunately many of them mix RNY and gastric bypass patients with gastric banding patients. Some gastric band patients have criticized this approach because while many of the underlying issues related to obesity are the same, the needs and challenges of the two groups are very different, as are their early rates of weight loss. Some gastric band recipients feel the procedure is a failure when they see that RNY patients generally lose weight faster.

Effectiveness

The average gastric banding patient loses 500 grams to a kilogram (1-2 pounds) per week consistently, but heavier patients often lose faster in the beginning.Fact|date=September 2007 This comes to roughly 50 to 100 pounds the first year for most band patients. It is important to keep in mind that while most of the RNY patients drop the weight faster in the beginning, LAGB patients will have the same percentage of excess weight loss and comparable ability to keep it off after only a couple of years. Gastric banding patients may have to work a little harder in the first couple of years, but the procedure tends to encourage better eating habits which, in turn, helps in producing long term weight stability.

A systematic review concluded "LAGB has been shown to produce a significant loss of excess weight while maintaining low rates of short-term complications and reducing obesity-related comorbidities. LAGB may not result in the most weight loss but it may be an option for bariatric patients who prefer or who are better suited to undergo less invasive and reversible surgery with lower perioperative complication rates. One caution with LAGB is the uncertainty about whether the low complication rate extends past three years, given a possibility of increased band-related complications (e.g., erosion, slippage) requiring re-operation". [cite web |url=http://www.cadth.ca/index.php/en/hta/reports-publications/search/publication/739 |title=CADTH: Laparoscopic Adjustable Gastric Banding for Weight Loss in Obese Adults: Clinical and Economic Review |accessdate=2007-09-24 |format= |work=]

Other positive effects of gastric banding

Effects on Depression

Recent studies [cite web |url=http://www.magenband-op.com/wirkung.html |title=Studien zum Thema Wirkung des Magenbandes und anderer Operationen zur Magenverkleinerung |accessdate=2007-10-01 |format=html |work=] show that the gastric band can have a positive effect on depressive patients.

Two groups of 600 overweight patients, each over 40kg/m², were closely watched for 5 years. Both groups had about 29% depressive patients. After 6 months, both groups of patients were less depressed. After 5 years, the number of depressive patients in the non-operated control group had returned to its origin, while members of the operated group were noticeably less depressed.

Quality of Sleep

About 38% of gravely overweight women and 48% of overweight men are suffering from severe sleep apnea. An Australian study [cite web |url=http://www.magenband-op.com/wirkung/schlafapnoe.html |title=Australische Studie zur Wirkung des Magenbandes auf die Schlafapnoe |accessdate=2007-10-01 |format=html |work=] is now trying to show that a gastric band operation can have a positive effect on the sleep apnea.Since weight loss generally has a good effect on sleep apnea, and the gastric band usually leads to weight loss, chances are that the gastric band has a positive effect on sleep apnea, reducing the tiredness during the day and therefore increasing the work-performance of the patient.

The LAP-BAND in Australia

According to an August 2006 article in "The Medical Journal of Australia" [http://www.mja.com.au/public/issues/183_06_190905/obr10369_fm.html] , over 90% of weight loss surgeries in Australia are installations of the laparoscopic adjustable gastric band. Some of the more interesting findings in the study are these:

Our group has treated more than 2700 severely obese patients with the LAGB procedure since 1994 without a single perioperative death. In contrast, mortality from RYGB is reported at between 0 and 5%, with the ASERNIP-S systematic review showing a mean short-term mortality rate of 0.5% — ten times the risk of LAGB. [...]

All bariatric procedures have been able to achieve loss of more than 50% of excess weight. The ASERNIP-S systematic review showed greater weight loss after RYGB than LAGB during the first 2 years after the procedure, but the difference in weight loss was not significant at 3 and 4 years. In a recent review, we extended the data of the ASERNIP-S review by including all studies that included at least 50 patients, reported up to March 2004. This showed a substantial weight loss after both procedures, with an initial greater weight loss after RYGB but similar effectiveness for both procedures at 4, 5 and 6 years.

Documented adverse effects

"From the [http://www.fda.gov/cdrh/mda/docs/p000008.html FDA website] "

Band- and port-specific

*Band slippage/Pouch dilation
*Esophageal dilatation/dysmotility
*Erosion of the band into the gastric lumen
*Mechanical malfunctions - port leakage, cracking of the kink-resistant tubing or disruption of the tubing connection from the port to the band
*Port site pain
*Port displacement
*Infection of the fluid within the band

Digestive

*Nausea and/or vomiting
*Gastroesophageal reflux
*Stoma obstruction
*Constipation
*Dysphagia
*Diarrhea
*Abnormal stools / Constipation

Body as a whole

*Abdominal pain
*Asthenia
*Death
*Infection
*Fever
*Hernia
*Pain
*Chest pain
*Incisional infection
*Incision pain
*Blood clots

Miscellaneous

*Abnormal healing
*Alopecia

Celebrities

As with many developments in approaches to weight loss, some high-profile and well-publicized cases amongst celebrities have increased the public awareness of gastric banding:
*Khaliah Ali (daughter of Muhammad Ali) [ [http://thinforlife.med.nyu.edu/news/stories/khaliahali.html "She floats like a butterfly, too"] , thinforlife.med.nyu.edu]
*Fern Brittoncite web| url = http://news.bbc.co.uk/1/hi/entertainment/7429561.stm | title = Britton admits to stomach surgery | accessdate = 2008-06-01 | date = 2008-05-31| publisher = "BBC Online"]
*Guillermo Del Toro
*Brian Dennehy
*Anne Diamond
*Joseph R. Gannascoli
*Harry Knowles
*Sharon Osbourne [ [http://www.usatoday.com/news/health/spotlighthealth/2003-11-14-spothlth-osbourne-_x.htm Sharon Osbourne candid about colorectal cancer] , "USA Today", 2003-11-14. Retrieved on May 30, 2007] - Osbourne has subsequently had her band removed in order to address her bulimia
*Mikey Robbins
*Caitlin VanZandt - Guiding Light actress
*Ann Wilson
*Joe Grande - Grande mentioned on his show that he has gained weight using the Lap Band.
*Courtney Love

References

External links

* [http://www.asmbs.org American Society for Metabolic and Bariatric Surgery]
* [http://www.win.niddk.nih.gov/statistics/index.htm NIH statistics on weight and obesity]
* [http://www.mja.com.au/public/issues/183_06_190905/obr10369_fm.html Medical Journal of Australia study]