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