Gastric Lap-Band Weight-Loss Surgery vs. Gastric Bypass Weight-Loss Surgery vs. a Rigorous, Medically Supervised Diet, Prescription Medicine, and Exercise Program for Long Term Weight Loss in the Chronically & Severely Adult Obese

Weight loss surgery is becoming vastly more common, and the number of cases is well over a quarter of a million annually worldwide, with about 200,000 in the US alone. 

Great as these figures are, the number of these surgeries almost doubles each year.

The number of hospitals in the US   where they are performed is probably about 400, although the number of them that qualify as “Centers of Excellence,” is currently 351.

The closest thing that this still new surgical specialty has to a certification board is the American Society for Metabolic and Bariatric Surgery, which has 607 surgeons it considers particularly qualified to do these procedures.

This patient-to-surgeries ratio would be worrisome, excepting for the universally recognized fact that the best results seem to come from surgeons who do a lot of these procedures in places where a lot of these procedures get done. 

It is a kind of circular logic, but it actually proves true in this case.

The only thing growing faster it seems, are the number of television ads for adjustable lap band weight-loss surgery.

Adjustable lap band weight-loss is trying to make up lost ground since it was approved for wider use by the FDA  (which has the power to regulate surgical devices in addition to drugs) about 5 years after Roux-en-Y gastric bypass surgery took off.

Both procedures   (and several less-used variants) have flourished with the advent of minimally-invasive approaches. Consequently,   acronyms like  Laparoscopic Roux-en-Y gastric bypass (LRYGB)  and Laparoscopic Adjustable Gastric Banding  (LAGB) are becoming quite a bit more common in memos from surgeons and nurses to their biomedical librarians.

How do these two competing surgical procedures compare to a rigorous, medically supervised regimen  of dieting, exercise, and weight-loss prescriptions for the long term maintenance of weight loss in the chronically obese?

And of the two most commonly performed surgical approaches, which is better?

What does the evidence say?

An important article (O’Brien et al, 2006) in the Annals of Internal Medicine, scarcely a vehicle for promoting surgery of any type when non-surgical medical interventions might do as well,  admitted quite bluntly that the treatment of mild to moderate obesity with LAGB  was significantly, statistically superior to an intensive medical program of dieting, multiple visits to the internist’s  office, psychotherapy,  and weight-loss drug prescriptions (Orlistat™). 

This does not mean that the dieting/exercise/prescriptions school of thought   has abandoned continuing research.

ClinicalTrials.gov  reports 159 ongoing studies on weight loss, with a preponderance dealing with some combination of medical supervision, restricted eating , exercise and overall behavioral modification,  most with the hope, but rarely proven  result, of  sustaining that weight loss over several years in the majority of their human subjects.

But there still remain some serious unanswered questions (see Frank, 2006).

For the time being, the evidence for long term maintenance of weight loss favors surgery over attempts at remaking human nature and physiology for the vast majority of chronically obese individuals.

Both of the most common laparoscopic procedures have valid claims to advantages relative to each other, supported by some of the literature.

It is fairly clear, for example, that the LAGB procedure is less drastic and is more readily reversible, in the sense that the surgical band is made to be loosened or tightened fairly easily.

Hospital stays with LAGB are generally quite short and a 24 hour cycling through is not unusual.

And, up until 2006, based largely on European and Australian case histories (since the procedure was used earlier and more widely there) LAGB appeared to better for the super obese; those with BMI over 60.

But a 2006 article  by Bowne et al. reported that LAGB patients had more late complications, reoperations, less weight loss and decreased overall satisfaction when compared to a match group having a LRYGB.

Of particular note was that some patients had as many as 15 “adjustments” in order to attain the right size of stomach for them to have consistent weight loss. However, most of these can be done on an office visit or day surgery basis.

This is not to say that LRYNGB   patients were without mishaps or complications. In fact, these occurred earlier in the post operative period, and contributed to adding up to 3-5 days to the typical hospitalization.

Up until this very month, the only clear-cut advantage that every study agreed upon was that LRYGB procedures resulted in more weight loss, and intriguingly seemed to have much better results for patients with adult onset (Type II) diabetes much more often, although the causal mechanism was not well   understood.

But a spate of studies and reviews (e.g. Bult et al. 2008, Holdstock et al., 2008, and most notably a lab animal study, Troy et al. , 2008, in the prestigious journal Cell Metabolism) have suggested that the reason for this weight loss with diabetes resolution is very likely to be  that LRYGB fundamentally changes, in a decisive and quite favorable way, the hormonal and regulatory peptide flux that involves weight-related  substances like ghrelin and glucagon-like peptide-1.

Perhaps an even bigger surprise than the study in Cell Metabolism was a report this month (September, 2008) in the American Journal of Managed Care (Cremieux et al. 2008). 

The Analysis Group, an economic, financial, and strategy planning consulting firm in Boston reported that, while they admittedly could not know all the variables in advance and suggested prospective trials to test their hypotheses,  their calculations suggested that the $17,000-$26,000 paid out per person on average, for bariatric surgery by insurance companies, seemed quite likely to pay for itself in reduced medical claims after two years for the more frequently encountered case of laparoscopic weight-loss surgeries, and after four years for the less common case “open” weight-loss surgeries.

If this projection holds up, expect more demand for searches and information on bariatric   surgery.

Neither this country, nor the world in general, is running out of obese adults who could very likely benefit from it.

Angrisani L, Lorenzo M & Borrelli  V. 2007. Laparoscopic adjustable gastric banding versus Roux-en-Y   gastric bypass: Five year results of a prospective randomized trial. Surgery for Obesity and Related Diseases 3 (2): 127-132.

Batsis J et al. 2008. Cardiovascular risk after bariatric surgery for obesity. American Journal of Cardiology 102 (7): 930-937.

Bult MJF, van Dalen T, Muller AF. 2008. Surgical treatment of obesity. European Journal of Endocrinology 158: 135-145.

Bowne WB et al. 2006. Laparoscopic gastric bypass is superior to adjustable gastric band in super morbidly obese patients: A prospective comparative analysis. Archives of Surgery 141 (7): 683-689.

Buchwald H. 2008. Introduction and current status of bariatric procedures. Surgery for Obesity and Related Diseases 4 (Supplement 3): s1-s6.

Champion JK & Pories WJ. 2005. Centers of excellence for bariatric surgery. Surgery for Obesity and Related Diseases 1 (2): 148-151.

Cheng AKS & Poon L. 2007. A comparison of four different proprietary gastric bands. ANZ Journal of Surgery 77 (May Supplement): 46-47.

Cremieux PY et al. A study on the economic impact of bariatric surgery. American Journal of Managed Care 14 (9): 589-596.

Engstrom BE et al. 2007. Meal suppression of circulating ghrelin is normalized in obese individuals following gastric bypass surgery.  International Journal of Obesity 31 (3): 476-480.

Fielding GA. 2003. Laparoscopic adjustable gastric banding for massive superobesity (> 60 BMI). Surgical Endoscopy 17 (10): 541-1545.

Frank A. 2006. Bariatric surgery: Too many unanswered questions. American Family Physician 73: 1403-1408.

Holdstock C et al. 2003. Ghrelin and adipose tissue regulatory peptides: Effect of gastric bypass surgery in obese humans. Journal of Clinical Endocrinology and Metabolism 88 (7): 2999-3002.

Holdstock C et al. 2008. Postprandial changes in gut regulatory peptides in gastric bypass patients. International Journal of Obesity  epub ahead of print.  doi: 10.1038/ijo.2008.157.

Jan JC et al. 2007. Comparative study between laparoscopic adjustable gastric banding and laparoscopic gastric bypass: Single-institution, 5-year experience in bariatric surgery. Surgery for Obesity and Related Diseases 3 (1): 42-50, follow up discussion 50-51.

Korner J et al. 2006. Differential effects of gastric bypass and banding on circulating gut hormone and leptin levels. Obesity 14 (9): 1553-1561.

Lancaster RT   & Hutter MM. 2008. Bands and bypasses: Thirty-day morbidity and mortality of bariatric surgery as assessed by prospective, multi-center, risk-adjusted ACS-NSQIP data. Surgical Endoscopy epub ahead of print.

Lyass S et al. 2005. Device-related reoperations after laparoscopic adjustable gastric banding. American Surgeon 71 (9): 738-743.

Muller MK et al. High secondary failure rate of rebanding after failed gastric banding. Surgical Endoscopy 22 (2): 448-453.

Nguyen NT  et al. 2005. Accelerated   growth of   bariatric surgery with the introduction   of minimally  invasive   surgery.  Archives of Surgery 140 (12): 1198-1202.

O’Brien PE   et al.  2006.  Treatment   of mild to moderate obesity with laparoscopic adjustable banding   or an intensive   medical program. Annals  of Internal Medicine    144: 625-633.

Rendom SE & Pories WJ. 2005. Quality assurance in bariatric surgery. Surgical Clinics of North America 85: 757-771.

Tan KY, Rao A. & Ramalingam G. 2007. A comparison    of four  different proprietary gastric bands.  ANZ Journal of Surgery 77 (May Supplement): 46-47.

Troy S et al.  2008. Intestinal gluconeogenesis is a key factor for early metabolic changes after gastric bypass but not after gastric lap-band in mice. Cell Metabolism 8: 201-211.

Tony Stankus tstankus@uark.edu Life Sciences Librarian & Professor

University of Arkansas Libraries MULN 223 E

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Fayetteville AR 72701-4002

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Comments

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[Stella]

Very informative journal!

However, as far as weight loss surgery is concerned, I tell you something from my personal experience. My sister had undergone gastric bypass 2 years back due to her excessive abdominal fat and also to avoid diabetes development earlier than expected. But the suregry didn't relieved her obesity permanently. She has started to gain weight again.
So, what I believe is effective in losing weight, it is your diet control and having good meal planning plus a properly planned fitness/work out routine.

Nice info nonetheless!

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