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Does the LAP Band Really Keep the Weight Off?

Dilan Patel

10 October 2008

                                

Here are just some of the things being said…

“The impact on my life has been nothing short of a total reinvention…and my sex life has gone through the roof” (http://thinforlife.med.nyu.edu/news/testimonials/moller.html). 

“She went from size 26 to size 12 in just one year” (http://www.thecentersforminimallyinvasivesurgeryofsouthernnj.com/wst_page8.html)

“Before…she did not recall a time in her life when she was thin or when she felt pretty.  “Now… [She] enjoys her life much more because she has the freedom of getting around without the restrictions associated with morbid obesity.  She has a new found confidence and feels that her inner beauty has been brought to the surface” (http://www.thecentersforminimallyinvasivesurgeryofsouthernnj.com/wst_page8.html)

 “I lost weight many, many times and of course, regained it plus more.  This is the first time in my life where I’ve broken the cycle…I just feel empowered…and it runs all the way through me” (http://www.lap-bandforlife.com/testimonials.html)

“In only 8 months I had lost 100 pounds. Now after losing 130 pounds and at a weight of 139, it is so great for the weight to be off and stay off.  Going from a size 26 to a size 6 is like a miracle to me…additionally, I no longer have to take medicine for arthritis or my blood pressure” (http://www.coastalbariatrics.com/test_linda.htm)

            What could possibly cause so many people to lose great amounts of weight in just a short period of time? Why the LAP band of course.  Laparoscopic banding is the latest bariatric procedure that is used to help obese people lose weight.  By reading the amazing testimonial accounts of people effortlessly losing weight by laparoscopic surgery, it is easy to get the impression that the LAP band can potentially be used to cure the obesity epidemic in the world today.  However, the question is not whether people lose weight with the lap band, but whether they keep it off over the long term.  In this paper, I will attempt to answer this question through a literary review by analyzing studies that have focused on the long term effects of the LAP band. 

Obesity Overview- Why is it a problem?

Obesity has become a major epidemic in society in recent years.  The prevalence of obesity has risen tremendously in the past thirty years.  People who are classified as obese have a ratio of weight to height, also known as body mass index, which is greater than or equal to 30 kg / m2.  Those classified as morbidly obese have a BMI between 40 and 50 kg / m2.  The highest classification of obesity is super obesity, which is a BMI greater than 50 kg / m2.  Obesity is such a big problem because it is a risk factor for many diseases and health problems such as heart disease, type two diabetes, hypertension, cancer, and osteoarthritis (http://www.cnn.com/HEALTH/library/DS/00314.html).  It is also known to decrease life expectancy (Favretti et al, 2007).  Certain factors, such as genetics, age, family history, and sex, can predispose people to obesity (http://www.cnn.com/HEALTH/library/DS/00314.html).  A person’s metabolism, which is the rate that food is broken down in the body, can be similar to that of a close family member or relative.  It is also known to decrease with age.  Even though the predisposing factors are important and explain why some people naturally weigh more than others, they do not fully explain the rapidly increasing prevalence of obesity in developed countries throughout the world.

Lifestyle is perhaps the main reason that obesity is becoming such an epidemic.  People are simply not as active as they used to be.  This sedentary lifestyle often begins in childhood.  Many kids prefer to play video games rather than exercise and play outside.  People are also driving more places, rather than walking or riding a bike.  In addition, people are eating at restaurants more than at home.  These restaurant meals contribute to the obesity epidemic because they have more calories and fat than meals that are cooked at home.  These are just a few of the reasons that obesity is classified as a chronic disease.  It can persist throughout someone’s lifetime.  More and more people are now turning to bariatric surgery techniques in order to prevent the health complications that result from long term obesity.  In many cases, surgery is seen as the only option to cure obesity.     

 

 

What is LAGB and how does it work?

Laparoscopic adjustable gastric banding, which is also known as LAGB or the lap band, is a bariatric procedure that is used to help people lose weight.  Basically, it involves placing an adjustable band around the upper portion of the stomach.  The band has a balloon inside that is filled with a sterile salt water saline solution.  A wire is connected from the band on the stomach to a site that is just under the skin.  From the subcutaneous spot, physicians can alter the size of the band by injecting or removing the saline solution (http://www.webmd.com/diet/weight-loss-surgery/gastric-banding-surgery-for-weight-loss).  Inflating the balloon with saline solution causes the band to tighten (http://www.asbs.org/html/patients/banding.html).  This promotes weight loss.  The reverse is also true.  Removing some of the saline solution causes the balloon to deflate (http://www.webmd.com/diet/weight-loss-surgery/gastric-banding-surgery-for-weight-loss).  This loosens the band, which allows more food to enter the stomach.  The band splits the stomach into two parts, the upper small pouch and the larger portion beneath the band.  The upper pouch, which is the portion that limits food intake, can only hold close to one ounce of food (http://www.webmd.com/diet/weight-loss-surgery/gastric-banding-surgery-for-weight-loss).  This means that only about six ounces of food can be taken in at one sitting.  The band can be adjusted depending on how much weight that the patient wants to lose.  Individuals will generally feel full much quicker than they would without the band.  The band also helps to slow the passage of food from the stomach to the small intestines, where the nutrients and proteins are absorbed into the body.

 

 

Why should people use the LAP band over other bariatric procedures such as gastric bypass?

There are a couple of reasons why surgeons chose to perform laparoscopic banding rather than gastric bypass surgery.  First, laparoscopic banding is less invasive than gastric bypass.  This means that the small intestine is not cut out and removed or rerouted, and the stomach is not partially stapled (http://www.obesityhelp.com/content/wlsurgery.html#LapBand).  The surgeon goes in through the throat and makes small incisions in the upper part of the stomach in order to fit the band.  This is not an open procedure, which means that the risk of surgical complications is not as great.  Also, malabsorption does not occur because the stomach and intestines remain intact (http://www.lapband.us/lap-band-advantages.html).  This means that patients will still be able to absorb all of the necessary nutrients through the small intestines without impairment.  Malabsorption often occurs in gastric bypass because the part of the small intestines that absorbs the most nutrients is cut out (http://www.obesityhelp.com/content/wlsurgery.html#LapBand).  Second, the procedure typically only lasts between thirty minutes to an hour.  This is much less than the time that is needed for gastric bypass.  In addition, patients only have to stay in the hospital for a couple of days.  They also experience less post-surgical pain during their stay.  Finally, the most important reason for the increasing popularity of the lap band is that the procedure is reversible (http://www.lapband.us/lap-band-advantages.html).  The band can simply be removed if complications occur at any point after surgery.  The removal of the band also does not cause irreversible damage to the stomach and small intestines. 

 

 

What claims are being made about the LAP band?

            There are many claims being made on the web about laparoscopic banding.  Many companies that produce different types of LAP bands advertise their products on the internet.  These companies often leave out the side effects of the band in portray their band in the best possible light.  After conducting an internet search, two promotional sites in particular stand out by making erroneous and unrealistic claims.  For example, the web site for the Obesity Control Center has testimonial evidence from a thirteen year old that had gastric banding procedure (http://www.obesitycontrolcenter.com/success.php).  This is an example of extremely false promotion because surgeons will only operate on patients who are at least eighteen years of age (http://www.lapband.com/get_informed/about_lapband/risk_information/).  More importantly, the health risk of performing bariatric surgery on teenagers is still not fully understood; severe complications could occur later in life.  The website also only shows the testimonials of those who successfully lost weight, and it does not list potential side effects of the surgery.

            Another company that promotes LAP band surgery over the internet is called My Lap Band Surgery (http://www.mylapbandsurgery.com/).  This company offers a variety of bariatric and cosmetic surgeries, including gastric bypass, laparoscopic banding, liposuction, and face lift.  The website lists various features of the LAP band, including how it works and how much weight people tend to lose while wearing it.  There is also a list that shows how many more lifestyle opportunities that people who wear the LAP band have.  These opportunities include, but are not limited to improved job prospects, better dating life, great confidence, and increased energy level (http://www.mylapbandsurgery.com/).  These claims can create unrealistic hopes and expectations for patients who undergo LAGB.  Another problem with these claims is that they are not supported by evidence on the website.  One of the links connects to a comparison between the LAP band and gastric bypass (http://www.mylapbandsurgery.com/comparesurgery.index.html).  Below the table, there is a list of the benefits after bariatric surgery.  The results from the table show that diabetes mellitus, asthma, sleep apnea, hypertension, stress, and osteoarthritis are all decreased greatly after bariatric surgery (http://www.mylapbandsurgery.com/comparesurgery.index.html).  These claims are difficult to believe because they are not based on any kind of study.  The website does not even explain where the results came from.  People who are looking to have bariatric surgery must be aware of these claims.  These sites can be very misleading and harmful because they do not accurately inform people of the risks and benefits that are associated with the surgery.  The websites Obesity Control Center and My Lap Band Surgery are just a few of many that exaggerate the benefits and hide the risks of bariatric surgery.  These companies simply want to make as much money as possible from people who do not know all of the facts and evidence regarding the surgery.   

Who qualifies for the procedure?    

            There are general criteria that can help people determine if they qualify for LAGB.  Laparoscopic banding is typically not used for people under 18 years of age.  People who have a BMI that is greater than or equal to 40, and who have been overweight for more than five years can generally qualify for the procedure (http://www.lapband.com/get_informed/about_lapband/risk_information/).  However, physicians also consider critically important factors such as lifestyle and motivation.  Typically, patients must have tried very hard to lose weight for a long time without success in order to attempt any type of bariatric procedure.  In addition, the patient who is considering the procedure must be mentally stable and willing to change his or her lifestyle for the better.  This includes a better diet and more exercise (http://www.lapband.com/get_informed/about_lapband/risk_information/).  Some patients, however, just do not qualify for the procedure.  People with ailments such as Crohn’s disease, heart disease, lung disease, cirrhosis, and pancreatitis do not qualify for the procedure (http://www.lapband.com/get_informed/about_lapband/risk_information/).  Women who are pregnant are also not allowed to have the procedure; those women who already have the LAP band in place before becoming pregnant may have to have the band deflated (http://www.lapband.com/get_informed/about_lapband/risk_information/).  In addition to the aforementioned factors, bariatric surgeons do not favor operating on patients who have a sweet tooth.  Patients who enjoy high calorie sweets such as candy and milkshakes are not good candidates for the lap band because they can gain weight by not eating a lot of food.  The food that they eat just happens to be calorie rich and very high in fat (http://www.lapband.com/get_informed/about_lapband/risk_information/).  Overall, the lack of a strict set of criteria indicates that physicians evaluate patients on a case by case basis.

What is the scientific evidence and proof that the LAP band works long-term?

There have been many studies conducted on patients with LAGB.  However, only a number of these studies have focused on the long term results of band usage.  The goal of most of the studies is to see what complications develop from the procedure, as well as to see if the weight is kept off over the long term.  Most of the scientific literature regarding LAGB originates in Europe.  The first lap band was implanted in Europe in 1993 (http://www.lapband-blog.com/lap-band-history).  The procedure then started to be used in the United States, where it was approved by the Food and Drug Administration in 2001 (http://www.lapband.us/lap-band.html).  As a result, there have not been as many long term studies on LAGB conducted in the U.S.  This is also perhaps the reason that weight loss results have been better in Europe than in America.  Bariatric surgeons in Europe have been performing the procedure much longer than American surgeons.  This has allowed them to alter their techniques based on patient results.

The results of several important studies regarding the long term effects of gastric banding are shown below.  The data from the studies has been summarized.  Although the authors in each study have different definitions of success and failure, there are several measures that are consistent in each study.  Each study took the average age and BMI of the patients before surgery.  They then measured the drop in BMI during follow up visits in subsequent years.  In addition, the authors listed the percentages of patients who experienced adverse side effects both during and after the procedure.  The various side effects are commonly listed in these studies.

Study 1

The study entitled The Outcome of Adjustable Gastric Banding- 8 years experience was published by Weiner et al. (2003).  This study is one of the few regarding LAGB that actually had long term patient follow ups; in this case, the follow up was eight years.  The surgeons in Germany operated on a total of 984 patients from May 1994 to June 2002.  The patients averaged 38 years of age and had an average BMI of 46.8 kg / m2.  It is important to note that only the first one hundred patients were included in the data for the long term results.  These patients were tracked for the longest period of time, since the other procedures occurred sequentially until 2002.  97 percent of the 984 patients were able to be examined after the procedure. The results indicate that the mean BMI fell to 34 kg / m2 after just one year.  This precipitous weight loss, however, leveled off as the mean BMI after three years was 32 kg / m2.  The median BMI after the eight year follow up was also 32 kg / m2.  The mean excessive weight loss for these patients was 59 percent, with 19 percent losing between 61 and 100 percent of excessive weight and another 19 percent losing between 0 and 30 percent of excessive weight.  The authors also produced a table of pre-operative and post-operative co-morbidities.  The post-operative co-morbidities, which include diabetes type two, hypertension, asthma, sleep apnea, arthritis, and depression, all dropped from the pre-operative rates.  The authors of the study listed complications such as gastric perforation and slippage that occurred during the procedure.  However, they also noted that none of the complications resulted in death or conversion to open surgery.  A total of thirty six patients out of 984 had re-operations to fix the band.  Overall, the results indicate that LAGB is an effective way for obese patients to lose weight over the long term (Weiner, et al., 2003).   

Study 2

The objective of the second study was to evaluate the weight loss and complications of patients who underwent laparoscopic gastric banding procedure.  The initial group of patients was able to be tracked for eight years in this study.  All of the surgeries were performed in Switzerland.  The authors defined successful weight loss as losing more than 50 percent of excessive weight.  Failure was defined as losing less than 25 percent of excessive weight, and the major complication was defined as eventual band removal.  A total of 317 patients were operated on between June 1997 and June 2003.  The average age of the patients was 38, and their average BMI was 43.5 kg / m2.  The number of patients with pre-operative co-morbidities was 258 out of 317.  Almost 98 percent of patients were followed up after three years.  Subsequently, 89 percent were followed up after four years, and 75 percent were followed up after five years.  Reasonable conclusions can be drawn from this data because the follow up percentages are relatively high.  The results show that 105 patients, which are 33 percent of the total number of patients, developed long term complications such as port infection, leak, band infection, esophageal dilation, severe food intolerance, pouch dilation, slippage of the band, and band erosion into the stomach.  The authors also concluded that the seven year success rate was 43 percent, meaning that only 43 percent of the patients lost most than 50 percent of excessive weight.  The success rate was at its peak of 54 percent after two years, but proceeded to drop to the 43 percent mark after seven years.  The results of this study indicate that the LAP band does not help people to lose weight and keep it off in the long term.  The high percent of post-operative complications is also a reason for concern (Suter, et al., 2006). 

Study 3

Belachew, Belva, and Desaive (2002) conducted a study using the data from three bariatric centers in Belgium.  All three centers used the same surgical technique and band, as well as the same follow up procedure.  763 patients had the procedure, and 686 of them were able to attend the follow up four years later.  Of the 763 patients, 168 were male and 595 were female.  The average age of the patients before the surgery was 34, and the average BMI was 42 kg / m2.  The average BMI after four years was 30 kg / m2, which translates to a drop in BMI of 12 kg / m2.  The authors also note that the mean BMI of patients who were measured after five years was less than 30 kg / m2.  This is a positive sign because it means that these patients kept their weight off after surgery.  The early complications of the surgeries include gastric perforation, large bowel perforation, bleeding, port infection, death, and conversion to open procedure.  The percentage of patients with these early complications was around two percent.  However, this relatively low percentage is likely not a cause for concern because the study was conducted with a large sample of patients.  The overall results of the study show that the lap band is effective over the long term (Belachew, Belva, and Desaive, 2002).

Study 4

            A different study, published in the 2007 edition of the journal Obesity Surgery, focused on the results of 1,791 patients who underwent laparoscopic adjustable gastric banding between September 1993 and December 2005.  The same team of surgeons performed all of the operations using the same type of band.  The mean age of the patients before the procedure was 38, and the mean BMI was 46.2 kg / m2.  The average follow up rate for 12 years was 90 percent.  However, similar to the first study, it is important to note that only four patients had the procedure in 1993.  These patients were able to be tracked for the entire twelve year period.  Each subsequent cohort has been tracked for less than twelve years.  This can be a misconception because the title of the study seems to indicate that 1,791 patients were tracked for twelve years.  A total of 106 out of 1,791 patients had major complications from the surgery that required re-operation.  These complications include pouch dilation, band erosion, psychological intolerance, miscellaneous infections, and gastric necrosis. 

In addition to publishing the long term results of the weight loss study, the authors also conducted a separate case control epidemiological study in order to determine the effect of weight loss on life expectancy.  The case control study matched 821 patients who had LAGB with 821 patients who received only medical treatment.  The results indicate that the treatment group had a 60 percent reduction in total mortality.  After analyzing the data, it is reasonable to conclude that the lap band is an effective way for obese and morbidly obese people to safely lose weight and live longer (Favretti et al., 2007).   

Conclusion

          All of the studies mentioned used similar criteria to evaluate weight loss in patients who underwent LAGB.  Although the majority of the long term studies seem to indicate the effectiveness of the LAP band, there is still not enough evidence to conclusively prove that the LAP band is the cure for obese and morbidly obese people.  While the results from studies one, three, and four show successful patient drops in BMI and co-morbidities, the results from study two show a large percentage of post-surgical complications.  The LAP band can potentially be a very safe and effective way for patients to lose weight; however, as of now, there is not enough evidence that conclude that the LAP band will help keep weight off in the long term.  Most, if not all of the authors of the studies also indicated the need to further test the effectiveness of the lap band over longer periods of time and with greater patient groups.  This conclusion is based on the results of long term studies conducted in Europe, mainly because the long term effectiveness of the LAP band in the U.S. is still being tested.  It is also important to note that the results of LAGB depend on the proficiency of the surgeon, the clinic in which the procedure takes place, and the motivation of the patient to lose weight.  Patients must be motivated to exercise, eat healthy foods, and avoid sweets in order to have the best chance at losing weight after the surgery. 

What can people do to avoid having laparoscopic surgery?

             The prevalence of obesity has risen dramatically in developed countries around the world.  There are approximately 60 million obese adults in America, and obesity has become the second leading cause of preventable death in the U.S.  (http://www.obesityinamerica.org/bythenumbers.html).  As a result, researchers and scientists are fervently searching for ways to help people quickly and safely lose weight.  Obesity can be a debilitating disease because it forces people to make great changes in their everyday lives.  Some people have genes that pre-dispose them to becoming obese.  While there is no doubt that this is true, it is critical to note that obesity does not develop overnight.  It can be controlled with proper diet and exercise.  In effect, obesity is a problem that is linked to lifestyle.  The best way to prevent obesity and the problems associated with it is to lead a healthy and active life.

Literature Cited

Belachew, M., Belva., P.H., & Desaive, C. (2002). Long-term Results of Laparoscopic Adjustable Gastric Banding for the Treatment of Morbid Obesity. Obesity Surgery, 12, 564-568.

Favretti, F., Segato, G., Ashton, D., Busetto, L., De Luca, M., Mazza, M., Ceoloni, A., Banzato, O, Calo, E., & Enzi, G. (2007). Laparoscopic Adjustable Gastric Banding in 1,791 Consecutive Obese Patients: 12 Year Results. Obesity Surgery, 17, 168-175.

Suter, M., Calmes, J.M., Paroz, A., & Giusti, V. (2006). A 10-year Experience with Laparoscopic Gastric Banding for Morbid Obesity: High Long-Term Complication and Failure Rates. Obesity Surgery, 16, 829-835.

Weiner, R., Blanco-Engert, R., Weiner, S., Matkowitz, R., Schaefer, L., & Pomhoff, I. (2003). Outcome after Laparoscopic Adjustable Gastric Banding – 8 years experience. Obesity Surgery, 13, 427-434.

Additional Resources

http://health.ucsd.edu/specialties/lapband/about/options.htm

http://www.asbs.org/html/patients/banding.html

http://www.content4reprint.com/health/medicine/lap-band-surgery-what-are-the-risks-of-lap-band-surgery.htm

http://www.cnn.com/HEALTH/library/DS/00314.html

http://www.lapband.com/get_informed/about_lapband/risk_information

http://www.lapband.us/lap-band-advantages.html

http://www.lapband-blog.com/lap-band-history

http://www.lapband.us/lap-band.html

http://www.mylapbandsurgery.com

http://www.newhopetoday.com/default.aspx?newhope=108

http://www.obesitycontrolcenter.com/success.php

http://www.obesityhelp.com/content/wlsurgery.html#LapBand

http://www.obesityinamerica.org/bythenumbers.html

http://www.webmd.com/diet/weight-loss-surgery/gastric-banding-surgery-for-weight-loss

 

Pictures

http://www.lapband.com/get_informed/about_lapband/how_it_works/

http://www.lapband.us/qualify-lap-band.html

 

 

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