Cami Ridley

            Obesity is a growing problem in America.  Despite the abundance of diets, weight loss drugs, and miracle exercise products Americans continue to gain weight.  Most obese individuals have tried each of these weight loss methods before without any success.  What, if any, are their options?  This paper will review new surgical treatments for obesity and weight management; gastric banding and vertical banded gastroplasty.  It will look at the procedure, the rationale, effectiveness, complications and lifestyle changes that follow gastric banding procedures.

            Gastric banding and vertical banded gastroplasty seek to promote weight loss in the same fashion, but they go about this in slightly different ways.  In gastric banding, a small synthetic band is placed around the curvature at the top of the stomach, just below the end of the esophagus.  This band is tightened around this tube to create a small food pouch at the top of the stomach.  The pouch typically holds between 1-3mL of food or liquid at a given time.  The pouch is connected to the stomach through a small opening ¼ an inch wide through which food is permitted to past through the rest of the digestive system.  In vertical banded gastroplasty, a synthetic band is placed around the lesser curvature of the stomach and tightened.  The food pouch is created by this band and the same amount of food is allowed to collect and then pass through the same size opening as the previous procedure.  Where the procedures differ is that in vertical banded gastroplasty this pouch is then attached to the wall of the stomach with a series of staples.  This is done to help prevent slippage of the band around the stomach opening.  Both procedures are minimally invasive and require only a day and a half of hospitalization.

            These surgical procedures seek to advocate weight loss through the severe restriction of food intake.  The food pouch only hold between 1-3 ml of food, which is equivalent to about ½ of a cup at any one meal.  This amount of food can be ingested without discomfort and will give a feeling of satiation.  Any amount of food over this limit will be expelled from the person almost immediately and cause great feelings of discomfort.  The theory is that by restricting food intake and providing the feeling of satiation much more quickly, that obese people will be able to finally lose the weight necessary to maintain good health.  After the first several weeks on a liquid diet, the person can resume normal eating habits that are within the intake range.

            Many Internet sites and doctors who perform these procedures tout these gastric banding procedures as the most effective way to lose weight and maintain weight loss for the obese patient.  They claim that there are few if any complications and that almost all patients are able to meet and sustain their weight loss goals.  On the surface it looks like these new surgical procedures are the best method of weight loss for the obese patient, but it sound like this is too good to be true.  The next sections of this paper will try and determine whether these claims about effectiveness and complications are true, and whether there are significant lifestyle changes that must take place after a surgery such as this.

            In a study by the Mayo Clinic (1997), they followed seventy patients that had undergone gastric banding or gastroplasty from 1985-1989.  They monitored these patients post-operatively at one year and three years following surgery.  At the one-year interval they found that patients had lost about 60% of the excess weight that they had hoped to lose by undergoing the procedure.  At the three-year interval they found that only 38% of patients were able to maintain half of their desired weight loss.  They monitored the weight progress through weigh-ins at the clinic.  A reason they cite for their low results in maintained weight loss is the fact that 50% of the patients had devised a way to beat the restrictive intake system.  These individuals discovered that they could eat milkshakes, ice cream, and puddings and that these foods would rapidly slip through the restrictive pouch thus defeating the restrictive food intake system designed by the surgery.

            In another study conducted by G.A. Fielding and associates (1999), they monitored 335 patients who had undergone gastric banding procedures.  They monitored patients weight loss over the course of eighteen months, as well as monitoring for any side effects or complications that may arise from surgery.  All patients in their study had previously tried many different dieting methods without success and were between 34-86 on the body mass index scale.  The results in terms of weight loss showed differing results through the 18-month period.  For the first three months after surgery, patients averaged an excess weight loss of 24%.  At the year follow up, patients averaged an excess weight loss of 52%, and at the 18-month follow-up patients were able to lose an average of 62% of their excess weight.  This study also monitored for the occurrence of complications following surgery.  They found that only 12 patients out of the original 335 had complications that required another surgery.  Among these patients the most common problem was gastric herniation through the band and into the stomach.  Other problems included port-hole (into the stomach) obstruction and band slippage.

            One last study, which provided an evaluation of both weight loss and complications following the procedure, was conducted by Belachew and colleagues (1998).  This study followed 350 patients over the course of 41 months.  They monitored for excess weight lost and any recent of late developing complications tied to the surgical procedure.  They found that over the course of a fifteen-month period, patients continued to lose weight and at the end of this period had lost an average of 57% of their excess body weight. After this time period the marked weight loss tapers off to an average of 80% of excess weight lost, and after the 33^rd month patients actually started to gain weight back.  At the end of the 41-month period, patients had lost 64% of their excess weight but were on an upward weight path.  In terms of complications, about 10% of patients suffered from staple line disruption, which necessitated another surgery, and food intolerance was common but needed no surgical attention.

            In a study by Ovrebo, MD and colleagues (1998) they investigated the occurrence of acid reflux in patients that have undergone gastric banding procedures.  They contrasted the simple gastric banding procedure with the vertical banded gastroplasty, which in addition to banding, staples the food pouch to the wall of the stomach.  They wanted to measure the incidences of acid reflux in each procedure and measure any possible differences between procedures.  They followed forty-three patients who underwent gastric banding or vertical banded gastroplasty.  The patients were followed both before and after surgery to monitor for any adverse symptoms and to measure the number of patients taking antireflux medication.  The team took pH measures both before and after surgery.  They found that when undergoing gastric banding procedures, while 14% of patients experienced acid reflux symptoms prior to surgery this increased to 63-69% of patients who experienced symptoms after undergoing the procedure.  Approximately 81% of post-operative patients of gastric banding procedures needed to take acid inhibitors by prescription.  In this same study they found that 32-33% of patients who underwent vertical banded gastroplasty experienced symptoms before surgery, these figures remained the same post-operatively.  It seems that this procedure leads to no increase in acid reflux symptoms.

            Another study examined the incidence of band erosion in patients who underwent gastric banding procedures.  Moreno, MD and colleagues (1998) followed two hundred and fifty patients who underwent a gastric banding procedure between the years 1987-1995.  They monitored the development of band erosion into the stomach, necessary reparative surgery and long-term weight loss control.  They found that band erosion occurred in 7 patients, or 2.8% of all patients served by the procedure.  Six of these patients required another operation to correct the banding problem.  Of these 7 cases, 2 were external band erosion where the band eroded through the lesser curve of the stomach, and 5 were internal band erosion, where the band eroded through the staples into the stomach.  These patients underwent another banding procedure without complication and all but 1 of the patients achieved long-term weight loss goals.

            It appears that each of the effectiveness studies is in basic agreement about the amount of excess weight lost by patients undergoing these surgical procedures.  Patients that undergo this procedure will lose approximately 60-80% of their excess weight, but after losing this amount of weight it appears that the weight loss effects may not be sustained over time.  As a greater amount of time passes the percentage of excess weight lost becomes less and less.  It also appears that the complications from these procedures are not typically severe.  While a few patients have complications that necessitate another surgery, the large majority of patients have few complications aside from acid reflux and food intolerance.

It looks like the claims made by the internet sources referring to gastric banding as the ultimately most effective weight loss procedure are not entirely true.  When examining the scientific literature, it seems that a great amount of excess weight is lost at first but that these effects may not continue for many years. The claims regarding the safety and low occurrence of side effects made on the Internet seem to be true.  Scientific studies concur with these sources on the few complications that may result for a gastric banding procedure.  While the side effects are minimal and effectiveness seems possible both long and short-term there are still changes in lifestyle that a person undergoing this procedure should be aware of.  Possible candidates for this type of surgery need to know how this procedure can effect their lifestyle and their eating habits for the remainder of their lives.  After having a gastric banding procedure, a person needs to chew food extremely well to prevent a blockage in the pouch, is unable to eat large meals or meals over one-half of a cup without discomfort for the remainder of their lives.  They also need to be committed to lifelong medical follow-up to monitor the strength and possible erosion of the band.  It is also important that people understand that this is not a miracle cure for obesity.  Without determination and commitment to success in maintaining weight loss goals, this procedure will not provide continued success.

                                                Works Cited

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Obesity: Who is an appropriate candidate?. Mayo Clinic Proceedings, 72(6), 551-558.

Belachew, M., Legrand, M., Vincent, V., Lismonde, M., Le Docte, N., & Deschamps, V.

(1998). Laparoscopic Adjustable Gastric Banding. World Journal of Surgery, 22, 955-963.

Fielding, G. A., Rhodes, M., & Nathanson, L. K. (1999), Laparoscopic gastric banding

for morbid obesity. Surgical Endoscopy, 13, 550-554.

MacGregor, Alex. (1999). Gastric Banding. The Story of Surgery for Obesity [On-line].

Available: http://asbs.org/html/story/ch_5.html

Moreno, Pau, et. al. (1998). Band Erosion in Patients who have undergone vertical

banded gastroplasty: Incidence and Technical Solutions. Archives of Surgery, 133(2), 189-193.

NIH Publications: NIDDK Weight-control information network [On-line]. Available:

http://www.niddk.nih.gov/health/nutrit/pubs/gastsurg.htm

Ovrebo, K. K., Hatlebakk, J. G., Viste, A., Bassoe, H. H., & Svanes, K. (1998)

Gastroesophageal reflux in morbidly obese patients treated with gastric banding or vertical banded gastroplasty. Annals of Surgery, 228(1), 51-58.

Sugerman, Harvey J. (2000). The epidemic of severe obesity: THe value of surgical

treatment. Mayo Clinic Proceedings, 75(7), 669-672.