Abandon Gastric Banding? Two Sides to Every Story

A Medscape article, “Abandon Gastric Banding Bariatric Surgery, Experts Say,” covers the opinion of two surgeons who believe – as the title states – that gastric banding (most often the lap band) should generally not be performed. They believe that the gastric sleeve and gastric bypass are superior operations, and are performing those operations almost exclusively. We spoke with several nationally and internationally recognized bariatric surgeons about their take on the article. Dr. George Fielding said “the recent article, featuring comments by Dr Michel Gagner and Dr Luigi Angrisani, suggesting the imminent demise of the band obviously raises concern and some alarm. My first thought is to be reminded of the quote: ‘the reports of my death are greatly exaggerated.’ There are many centers in the US and Australia presenting ongoing excellent long term results with the lap band.” Although Dr. Angrisani cites a study that resulted in only 26% of banding patients have a ‘successful’ result, surgeons we spoke to have very different outcomes. Dr Fielding said, “We at NYU have shown very small band removal rates at 7 years, and sustained weight loss and reduction of associated diseases.” Another criticism presented in the Medscape article is that “Europeans are ahead of the game, having started banding procedures before North America, and therefore detecting problems earlier.” However Dr Fielding points out, “My old mentor, Dr. Paul O’Brien in Australia, who put my own band in over 12 years ago, has very similar data. Both Dr O’Brien and myself have been doing gastric banding at least as long as the Europeans. There are many many thousands of happy patients years out from their lap band surgery in Australia and the US. And at NYU we don’t just do bands; we also perform gastric sleeves, bypasses, and revisional surgeries on bands, bypasses, and sleeves. We – and many other bariatric surgeons – have learned how to make the band work.”

Last year at the World Congress for the International Federation for the Surgery of Obesity, Dr. O’Brien presented follow-up data on over 2600 gastric banding patients from the last 15 years.  For patients receiving the most recent gastric banding technique, O’Brien reported a slip rate of 2.6%, and an erosion rate of 0.6%.  Including patients undergoing banding as far back as 1994, O’Brien had a 5% band removal rate. This is substantially different from data that Angrisani spoke about, showing a 41% band removal rate.  Dr. Vafa Shayani in Chicago gave one potential reason such differences are seen in success data: “We are learning more and more that gastric banding results are quite variable among centers and surgeons. Unlike other ‘fixed’ surgical procedures (gastric bypass and sleeve gastrectomy), gastric banding requires appropriate aftercare which is not provided to the same extent by all healthcare providers.” For example, during his oral presentation at the ASMBS meeting where Dr. Angrisani presented his data, he was asked by Dr. Emma Patterson – who served as discussant – about his follow up. “Angrisani admitted that most of his follow up was completed over the phone”, Patterson said, “which is not a standard followed by me or my colleagues”. Patterson also pointed out that Angrisari admitted during her questioning, that he has largely abandoned the bypass now, in favor of the sleeve. Dr. Fielding adds, “Sleeve gastrectomy is the operation de jour. It is relatively simple and works very quickly. However, if it leaks – and they do – the leaks are disastrous, often taking months to heal and sometimes needing total gastrectomy to fix them. Numbers of these same vaunted European surgeons have described weight regain and a need for reoperations at rates of up to 30% at 5 years. Once again, as Angrisani said, ‘this is not a good thing’. And once again I will add that there are plenty of very happy sleeve patients.”

Dr. Gagner, who has been critical of gastric banding for approximately 10 years and who has published little data about his experiences with it, says it is a “complete disaster” that gastric banding is the second most common bariatric surgery in the United States. But the real disaster, Dr Shayani says, “is for any authority to believe that she/he has bariatric surgery totally figured out. It is true that with regards to bariatric surgery, we have come a long way over the past 2 decades, both in the U.S. and around the world. But truthfully, we are only scratching the surface. Over the next few decades we will continue to learn about the shortcomings of every surgical procedure and when we do, we will appreciate that the least invasive and the least involved procedures should be considered the first-line treatment for the majority of patients.” In fact, gastric banding is so different of a procedure from other bariatric surgeries, that many question the validity of trying to choose one over the other. Gastric bypass does lead to more rapid, and more dramatic weight loss. However, the safety associated with gastric banding, and the fact that it’s significantly less invasive (involves no cutting, stapling, or removal of any part of the stomach or intestines), make it a procedure that will likely be the preferred choice of many patients.

As for the severity of Gagner’s statements and stance on gastric banding, Dr Fielding says “Strangely enough, I met a woman today who had her band inserted by Dr Gagner in 1999.  She lost 105 pounds, has kept it off, and feels wonderful. Dr Gagner is a brilliant surgeon, but has long been an opponent of the band. Scare-mongering comments like ‘complete disaster’ from him serve little purpose. It is simply false to say that having a band is a disaster. Sure, some people don’t do well with them. Ditto for the gastric bypass and the gastric sleeve. But a disaster? No.”

Correction: Nov 29, 2012
An earlier version of this article mis-attributed reported data to Dr Gagner. That has been corrected.

by Emma Squillace

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