A laparoscopic adjustable gastric band also known as a Lap-Band , is an inflatable silicone device that is placed around the top portion of the stomach, via laparoscopic surgery, in order to treat obesity. Adjustable gastric band surgery is an example of bariatric surgery 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, GERD, Hypertension (high blood pressure), or metabolic syndrome, among others.
Theory of gastric banding
According to the American Society For Metabolic 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 60% of excess body weight. Typically, patients who undergo adjustable gastric banding procedures, such as Lap-Band or RealizeBand lose less weight over the first 3.5 years than those who have gastric bypass, or other surgeries such as Biliopancreatic Diversion (BPD) or Duodenal Switch (BPD-DS). However, over 7 to 8 years weight loss from gastric banding and bypass are essentially equal according to the American College of Surgeons. Most patients reach 65 to 90% of their ideal weight. However, in order to maintain this type of weight reduction, patients must follow carefully the post-operative guidelines relating to diet, exercise, and band maintenance.
The placement of the band creates a stoma, or small pouch at the top of the stomach that holds approximately 110 to 220 grams 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 and for a longer period of time, to eat smaller portions, and lose weight over time.
The gastric band is inflated/adjusted via a small access port placed just under the skin. Saline solution is introduced into the gastric band via the port. A specialized non-coring needle is used to avoid damage to the port membrane. There are many port designs (such as high profile and low profile) and they may be placed in varying positions based on the surgeon’s preference but are always attached to the muscle wall in and around the diaphragm. The port is sutured or stapled, in case of the RealizeBand into place. When saline is introduced into the band it expands, placing pressure around the outside of the stomach. Gastric Bands usually can hold 8 to 10 cc of saline. This decreases the size of the passage between the pouch created from the upper part of the stomach and the lower stomach, and further 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 found what is colloquially known as the “sweet spot” or "green zone", 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 2 brands of gastric band on the market with approximately 4–5 varieties of each. The total volume of saline each can hold varies.
Pregnancy
If considering pregnancy, ideally the patient should be in optimum nutritional condition prior to, or immediately following conception; deflation of the band may be required prior to a 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 as needed.
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 450 - 900 grams per week; however, statistics indicate that over a 5-year period, weight loss outcome is similar. 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. 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). 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.
Other complications include:
- Ulceration
- Gastritis (irritated stomach tissue)
- Erosion - The band may slowly migrate through the stomach wall. This will result in the band moving from the outside of the stomach to the inside. This may occur silently but can cause severe problems. Urgent treatment may be required if there is any internal leak of gastric contents or bleeding.
- Slippage - An unusual occurrence in which the lower part of the stomach may prolapse through the band causing an enlarged upper pouch. In severe instances this can cause an obstruction and require an urgent operation to fix.
- 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.
- Band was not placed on the stomach - (very rare - especially with an experienced bariatric surgeon) However, in two asymptomatic patients, the band had not enclosed the stomach but only perigastric fat.
The psychological effects of any weight loss procedure also should not be ignored.
The Lap-Band
The Lap-Band is one of the two main gastric banding devices currently available (the other being the Swedish Adjustable Gastric Band or SAGB).
History and development
Non-adjustable bands
At the end of the 1970s, Wilkinson developed several surgical approaches whose common aim was to limit food intake without disrupting the continuity of the gastro-intestinal tract.
In 1978 Wilkinson and Peloso were the first to place, by open procedure, a non-adjustable band (2 cm Marlex mesh) around the upper part of the stomach.
The early 1980s saw further developments, with Kolle (Norway), Molina & Oria (US), Naslund (Sweden), Frydenberg (Australia) and Kuzmack (United States) implanting non-adjustable gastric bands made from a variety of different materials, including marlex mesh, dacron vascular prosthesis, silicone covered mesh and gore-tex, amont others.. In addition, Bashour developed the “gastro-clip” a 10.5 cm polypropylene clip with a 50cc pouch and a fixed 1.25 cm stoma, which was later abandoned due to high rates of gastric erosion
All these early attempts at restriction using meshes, bands and clips showed a high failure rate due to difficulty in achieving correct stomal diameter, stomach slippage, erosion, food intolerance, intractable vomiting and pouch dilatation. Despite these difficulties, an important ancillary observation was that silicone was identified as the best tolerated material for a gastric device, with far fewer adhesions and tissue reactions than other materials. Nevertheless, adjustability became the “Holy Grail” of these early pioneers.
Adjustable bands
The development of the modern adjustable gastric band is a tribute both to the vision and persistence of the early pioneers, particularly Lubomyr Kuzmak and a sustained collaborative effort on the part of bio-engineers, surgeons and scientists.
Early research on the concept of band “adjustability” can be traced back to the early work of G. Szinicz (Austria) who experimented with an adjustable band, connected to a subcutaneous port, in animals.
In 1986, Lubomyr Kuzmak, a Ukrainian surgeon who had emigrated to the United States in 1965, reported on the clinical use of the “adjustable silicone gastric band” (ASGB) via open surgery. Kuzmak, who from the early 1980s had been searching for a simple and safe restrictive procedure for severe obesity, modified his original silicone non-adjustable band he
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