People used to have to be very obese to qualify for LAP-BAND surgery, a weight loss operation in which an inflatable silicon ring is wrapped around the stomach to create a small pouch, drastically limiting food consumption. Until recently, the procedure was only approved for those with a body mass index (BMI) of 40 or above, or patients with a BMI of 35 or above, plus a severe obesity-related illness, such as heart disease or diabetes. Now the FDA has expanded the criteria to include people who have a BMI of 30, along with an obesity-related disorder.
That means 37 million more Americans are potential candidates for the surgery. Yet the FDA also reports that in a US study of people with BMIs of 30 to 40 who were treated with the LAP-BAND, more than 70 percent had one or more side effects. The most common were vomiting and trouble swallowing, both of which were usually temporary. Consumer Reports recently wrote about the apparently high rate of dissatisfaction with the procedure: In a study discussed on the manufacturer’s website, of 299 LAP-BAND patients followed for three years after the operation, 25 percent underwent a second surgery to remove the band. What’s more, up to 18 percent of patients needed a repeat procedure to repair problems with the band or its access port.
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How much of a concern are these issues, and how does LAP-BAND surgery’s risks and benefits stack up to those of gastric bypass, the most commonly performed weight-loss operation? “The LAP-BAND has a similar rate of complications as gastric bypass, but that’s not an entirely fair comparison, since gastric bypass is a much bigger surgery that permanently alters the anatomy of the stomach, so complications of gastric bypass tend to be more serious,” says Ted Khalili, MD, founder of the Khalili Center for Bariatric Care in Beverly Hills, California.
As with all operations, the experience of the surgeon is a key factor in the success of weight-loss surgery, adds Dr. Khalili. “There’s a learning curve, and during the first 50 cases, it’s not unusual for a bariatric surgeon to have a complication rate of 5 percent, while one who has done 1,000 operations may have a complication rate of less than 1 percent.” If you’re considering weight-loss surgery, get a referral from your primary care doctor or another physician you trust. Most US weight-loss surgeons are members of the American Society for Metabolic and Bariatric Surgery and are also board-certified in surgery.
During your initial consultation, discuss the surgeon’s track record with the procedure you’re considering as well as the potential risks and benefits. Also ask what sort of follow-up program the surgeon offers, advised Dr. Khalili. “You don’t want the doctor to leave you on your own without any support program to help make the procedure a success.” Here’s an overview of the pros and cons of the two operations. (Another procedure, called sleeve gastrectomy, is seldom used and had inferior weight-loss results to gastric bypass in a recent clinical trial in China.)
What is it? LAP-BAND is the brand name of a FDA-approved device used for an operation called gastric banding. The procedure is performed through small incisions in the abdomen. It involves placing an inflatable silicone ring around the upper portion of the stomach to create a small pouch. The band can be tightened by adding saline solution, like blowing up a donut-shaped balloon. It’s connected to an access port positioned underneath the skin of the abdomen, which is used to add or remove fluid to adjust the tightness.
Who is an ideal candidate? To meet medical criteria for gastric banding, you must have a BMI of 40 (about 100 pounds overweight for an average man, or 80 pounds overweight for an average woman), or a BMI of 30 plus a serious obesity-related disorder, such as sleep apnea, heart disease, type 2 diabetes, high blood pressure, or hypercholesterolemia. To be an ideal candidate, you should also have tried dieting without success, says Dr. Khalili. “Your eating patterns are also important, since someone who grazes with frequent small meals or drinks a lot of sugary beverages may not have much weight loss with banding.”
What to expect: Because the band prevents food from rapidly exiting the stomach, says Dr. Khalili, “you get a sensation of fullness after eating four to six ounces of food. Consuming more than that is likely to trigger vomiting.” Typically, patients he treats shed an average of 10 to 20 pounds within two months of the operation, and after that, two to five pounds a month. A recent study compared 100 morbidly obese patients (BMI above 40) who underwent LAP-BAND surgery with 100 similar patients treated with Roux-en-Y gastric bypass. After one year, the gastric bypass group had lost an average of 64 percent of their excess pounds, compared to a 36 percent reduction for the LAP-BAND group. However, LAP-BAND typically causes slower weight loss, which can continue for two years or longer, points out Dr. Khalili, so the study may not have lasted long enough to compare the full long-term weight loss of the two procedures.
Potential risks: Serious side effects of LAP-BAND surgery are relatively rare. One of the most common problems, affecting 5 to 10 percent of patients, is slippage of the band, requiring a repeat procedure to reposition it. Another risk is that the band could break, also requiring repeat surgery. A less common problem is erosion of the band into the stomach, a serious side effect that requires hospitalization. All patients are likely to need periodic adjustments of the amount of fluid in the band, which can be done in a brief outpatient visit to the doctor. As with any operation, there is a potential risk of infections, anesthesia reactions, and excessive bleeding, though these seldom occur. The most common side effects after surgery are trouble swallowing and vomiting, both of which usually disappear over time. Should you decide that you’re not happy with gastric banding, the ring can be removed, thus reversing the procedure.
What it costs and is it covered by insurance: In the past, some plans that covered gastric bypass didn’t cover gastric banding, but now plans that pay for weight loss operations typically cover both procedures, says Dr. Khalili. The average cost in the US ranges from $15,000 to $20,000.
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Gastric bypass surgery
What is it? This weight-loss operation changes your digestive tract to redirect food. There are variations of this operation, but the most common is the Roux-en-Y procedure. During this surgery, which is usually performed through small incisions, the surgeon staples your stomach, which is normally the size of a football, across the top to create a pouch the size of an egg. The pouch is then separated from the rest of the stomach and connected to small intestine, so food bypasses the rest of the stomach and first part of the small intestine (the duodenum). This procedure both restricts the amount of food you can eat and reduces absorption of calories, thus promoting weight loss in two ways.
Who is an ideal candidate? To qualify, you must have a BMI of 40 or higher or a BMI of 35 or above plus a serious obesity-related disorder, such as diabetes, high blood pressure, heart disease, sleep apnea or hypercholesterolemia. You should also be unable to lose weight through dieting and exercise. The procedure isn’t for everyone, emphasizes Dr. Khalili. “It’s an even more permanent commitment than marriage, because you can’t get a divorce from this surgery, so it’s crucial to be thoroughly evaluated to make sure you’re ready for this major procedure that will change your life forever.” This procedure has particular benefits if you have type 2 diabetes, since 76 percent of obese diabetics in a recent study had improvement or even reversal of their disease within one year after gastric bypass, compared with 50 percent of diabetic LAP-BAND patients.
What to expect: Pounds melt off more quickly with gastric bypass than with the LAP-BAND operation, with patients losing 64 percent of their excess weight in one year, according to a recent study. As with the LAP-BAND procedure, you will need to make dramatic changes in your eating habits since you will only be able to consume a few ounces of food at a time and must eat slowly, chewing thoroughly to avoid pain and vomiting.
Potential risks: While gastric bypass has a similar rate of complications to LAP-BAND surgery, they tend to be more serious. One of the most worrisome is severe infection (peritonitis) due to leakage of intestinal contents into the abdomen if the surgery to join the intestines to the stomach pouch isn’t correctly performed. This is more likely to occur if the surgeon is inexperienced with the procedure, but is relatively uncommon. Because the surgery is more extensive than LAP-BAND, the risk of blood clots is somewhat higher, but still relatively rare. A long-term risk of gastric bypass is vitamin deficiency, since fewer nutrients in food are absorbed after the surgery, so patients will typically need supplements.
What it costs and is it covered by insurance: Most plans will cover the surgery for patients who meet the medical criteria. However, some plans don’t pay for weight-loss surgery at all. The procedure costs about $20,000 to $30,000.
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