OCTOBER 30, 2007
VOLUME 4 NO. 18

PATIENTS & PRACTICE

Weighing the options:
gastric bypass or lap band

Co-morbidities, risks inform bariatric op choice



Physicians can help patients choose between gastric bypass or lap band surgery, pictured right
Illustration courtesy of Allergan

When dieting and exercise fail, your severely obese patients turn to surgery to help them lose weight. But the question is: which surgery to recommend? Gastric bypass and laparoscopic banding (lap band) both lead to significant weight loss and improve patients' overall health. But that's where the similarities end.

Deciding which one to go for is the patient's prerogative, but some facts may tip the scale either way. "My job is about presenting the advantages and disadvantages of both," Harvard University chief of minimally invasive surgery Dr Daniel B Jones told NRM. Dr Jones gave a talk on the subject during International Surgical Week in Montreal in August.

HOW THEY WORK
During the two-hour gastric bypass surgery, the stomach is divided with a stapler and stitched to create a small upper pouch. That upper part is linked up to the middle of the small intestine with a stapler and again reinforced with stitches. The patient ends up with a stomach the size of a golf ball. The lower part of the stomach is left in place in case the operation needs to be reversed — but that's very rare and only done in case of serious complications.

Lap banding is a shorter operation and offers patients a flexibility that bypass can't. A donut-shaped device with an inflatable balloon on the inside, is placed around the upper part of the stomach to restrict the passage of food to the rest of the digestive tract. It can be tightened or loosened as desired with a simple needle injection of saline solution in the balloon, done through a subcutaneous "access port."

Lap band patients can be back on their feet the same day or the next morning, and return to their normal lifestyle within a week after surgery. The bypass procedure on the other hand requires two to three days of recovery in the hospital and up to three weeks of down time before resuming regular lifestyle.

SHEDDING POUNDS
"Gastric bypass patients on average lose a little more weight," says Dr Jones. "So heaviest patients would benefit most. As do patients with diabetes, because they end up on less insulin within days of the bypass," he adds. Patients lose weight dramatically within the first year of bypass, so those with very high BMIs, who need to shed the pounds urgently, are better off with this method, he says.

Weight loss with lap band is more gradual, but banding has advantages among younger and more fragile patients. "Young adults have their whole lives ahead of them, so there's a tendency with many of us to favour the band," Dr Jones says. The fact that it is adjustable and reversible mean it's safer and easier to accommodate life changes like pregnancy. "For patients who are sick or elderly, I prefer the band because it is easier to put in," he adds.

FOOD FOLLOW-UP
Patients need to know that their eating habits have to change after either operation. The lap band works by decreasing the amount of food the stomach can handle, so patients have to change the way they eat — taking smaller portions, eating slowly, chewing carefully.

Gastric bypass patients have to examine what they eat instead. The surgery cuts the ability to absorb nutrients, since food spends less time in the gut, and patients will need life-long supplements of vitamins and minerals.

Patients have to understand that the surgeries are a treatment not a cure and longterm success depends on other life choices they make, including eating habits and exercise.

RISKY BUSINESS
"At the time of operation, lap band is safer," Dr Jones says. "There's no cutting or connecting involved." But complications may come up after both operations, he says. Band erosion — where part of the band goes through the gastric wall and into the lumen — or slippage are the complaints with lap bands. In fact, Health Canada has recently issued a warning against the Swedish Adjustable Gastric Band, saying there have been 36 incidents of band erosion reported in the past five years, all but one of which required the band's removal.

Gastric bypass carries a risk of infection and internal hernia, says Dr Jones. Longterm risks include a breakdown of the staple line and obstruction of the bowel. "And leaks," adds Dr Jones, "if that goes undiagnosed, it can be a serious a problem."

In the end, your patient's choice of operation may depend more on the wait time than actual risks. Gastric bypass patients in this country have to wait anywhere between six to eight years to go under the knife, while lap band waits range in weeks. Lap band isn't covered by most provincial insurance plans, so most are done in private clinics. Some provinces are sending patients to the US for gastric bypass, where the wait is only a few months.

 

 

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