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Placement of a Lap-Band® is a fairly straightforward procedure
that is accomplished by placing the Band, which is a belt-like section
of plastic, around the upper stomach to create a tiny stomach pouch.
The Band creates a calibrated narrowing at the bottom of this tiny
new stomach, so that it is easy to fill up with small amounts of
food. This good sensation of fullness is called "satiety."
The key thing about the Band that is placed around the stomach is
that it is adjustable. Adjustment is accomplished by means of a balloon
that lines the inside of the Band. On the day of surgery, when the
Band is placed, the balloon is empty and this provides only a slight
restriction to eating. Over the weeks and months following surgery
the balloon within the Band is gradually filled (outlet is tightened)
to provide progressively increasing restriction that is matched or "tuned" to
each patient.
The balloon adjustment is accomplished using an access port (which
is buried under the skin) to increase or decrease the amount of saline
fluid contained in the balloon. The Band is pictured in its normal
position on the upper stomach at right.
There are several key features that make the Lap-Band an attractive
surgical technique for weight loss:
- laparoscopic placement
- no division or anastomosis of stomach or bowel
- removable
- adjustable
The first two of the features above probably reduce the risk of
surgery, which is especially important when operating on patients
who suffer from morbid obesity. The fact that there is no cutting
or repositioning of any intestine brings the risk of leak or obstruction
to very low levels (not impossible, as outlined in the risks section
below). The fact that the procedure is almost always done laparoscopically
may allow decreased stress on the vital organs (heart, lungs, etc.)
and may allow quicker recovery in comparison to open procedures.
"Removable" in the list of key features refers to the fact that the
Lap-Band can be removed from the patient with little residual impact on the
stomach. This seems to be true even when the band has eroded into the stomach,
or become infected, or slipped out of position. This is possible because the
silastic substance from which the band is made creates essentially no tissue
reaction, so that the Band is not stuck in place over time. This feature also
means that the Lap-Band procedure is "reversible" in a certain sense.
We hasten to clarify that the Band would only be removed in our practice because
of medical necessity, and that if it were not replaced by some other weight
loss procedure that the patient would be guaranteed to experience significant
weight regain.
The feature of the Band that deserves the most attention is that
it is adjustable. This is the feature that makes the Band (in many
published reports) successful in helping patients achieve significant sustained
weight loss. After all, if the Lap-Band were not successful, then the decrease
in operative risk would not mean much. As long as the patient and surgeon
continue to work together, it is usually possible to adjust the Band to the
patient's needs at that time.
There are several other potential advantages claimed by advocates
of the Lap-Band, which deserve mention.
- Slower weight loss - the Lap-Band aims to create slower
and steadier weight loss than the results seen after most other
surgical procedures. Most weight loss operations create very rapid
weight loss in the first few months, which then slows and stabilizes
at 10-18 months after surgery. On the other hand, Lap-Band patients
begin with a relatively loose Band that allows ongoing intake of
nutrition, and the Band is gradually "tightened" according
to the patient's weight progress and satiety symptoms. This approach
aims to achieve a weight loss of 1-2 pounds per week, that continues
up to or beyond 30 months after surgery. Lap-Band advocates promote
this difference as "gentler" or "safer" or "more
physiologic," but we have frankly seen very few nutritional
problems in our many gastric bypass patients related to rapid weight
loss.
- Nutrient Absorption - operations that involve rearrangement
of the small intestine such as the gastric bypass or the BPD-DS
create a deficiency of absorption of Iron, calcium and B12. Purely
restrictive procedures such as the Lap-Band should theoretically
not cause such problems because no intestine is bypassed. Caution
is needed, however; almost all VBG patients (outmoded operation)
we see for surgical repair are deficient in Iron and B12. It may
well turn out that the reduction in overall intake is more important
than the specific bowel anatomy. In our practice for the time being,
we are recommending exactly the same supplements after either the
gastric bypass or the Lap-Band.
Open questions
The Lap-Band system has only been in use since the early/mid-1990's,
so there is no data on really long-term outcomes. Unbiased observers
have raised several questions about the Lap-Band as outlined below:
- Weight loss results & maintenance - early studies
from Europe reported weight loss results that were less substantial
than the Gastric Bypass. However, more recent studies from Australia
(especially from Dr. Paul O'Brien and Dr. George Fielding) have
put out reliable-appearing results in which weight loss after Lap-Band
is essentially equivalent to GBP. Comparative studies done between
GBP and Lap-Band by surgeons in the US have shown somewhat less
weight loss with the Lap-Band. The course of weight over
many years after Lap-Band points in the direction of long term
maintenance of weight, but the actual long term results do not
yet exist.
- Band erosion - all surgeons who perform the Lap-Band have
found erosion of the Band into the patient's stomach in a small
percentage of cases. It appears that this event (which requires
removal of the Band) occurs most frequently in the first year or
so after surgery, but can occur at any time after Band placement. Almost
surprisingly, erosion usually does not create serious illness.
Even though it is not likely to be an emergency, erosion of the
Band does always require surgical removal of the Band.
- Esophageal function - some patients have experienced failure
of normal esophageal peristalsis (swallowing function) after Lap-Band.
If this occurs, it causes painful swallowing, reflux, or regurgitation.
Band deflation or removal is required. More recent studies suggest
that the occurrence of esophageal failure arises from tightening
the Band too aggressively, and that this complication can be almost
completely avoided.
- Silastic reaction - it is possible that the material of
the Band could create some type of body immune reaction that stimulates
a separate disease process such as arthritis or Systemic Lupus
Erythematosis (SLE). However the Band is made of a silicone elastomer
which is completely non-reactive to the body tissues, as far as
it has been possible to determine. The same type of material has
been in use in a number of implanted medical devices over time,
and no problems with tissue reaction have been demonstrated. Here
again, the early data is reassuring but no true long-term information
exists.
Risks specific to Lap-Band
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