Candidates for weight-loss surgery accept a level of risk and uncertainty about the outcome with any procedure. Many do so because having a body mass index of 35 or more with obesity-related health conditions from diabetes to high blood pressure — or 40 or higher, when an individual is considered morbidly obese, even without any other conditions — can put a person at risk of having a whole host of health problems, and ultimately dying earlier. A man standing 5 foot, 10 inches weighing 280 pounds, for example, would have a BMI — which is based on one’s weight in relation to height — of 40.
Bariatric surgery procedures help many shed substantial pounds they couldn’t have otherwise — assuming they use the surgery as a tool, rather than a fix in itself, along with lifestyle changes, including proper diet and physical activity to lose weight and keep it off. In 2015, about 196,000 bariatric procedures were performed, according to the latest annual estimates from the American Society for Metabolic and Bariatric Surgery. (The figure includes revision surgeries, when patients have complications from an initial bariatric surgery or fail to lose significant weight, and have another bariatric procedure to try to address those issues.) That’s up from 158,000 procedures just a few years prior in 2011.
But while total bariatric procedures are up, one of the most commonly performed procedures is now on a sharp, steady decline. Once the most popular weight loss surgery option, laparoscopic gastric band procedures dropped from 35 percent of the procedures done in 2011 to less than 6 percent in 2015. Lap-band surgery involves placing a band around the upper part of the stomach that creates a pouch, restricting how much food the stomach can hold, so that a person will feel fuller sooner. By comparison, the two other most common bariatric surgeries, gastric bypass and sleeve gastrectomy, accounted for 23 percent and nearly 54 percent of estimated weight-loss procedures in 2015.
[See: 10 Ways to Prepare for Surgery.]
Highlighting one possible reason why lap-band procedures are plummeting, research published in JAMA Surgery in May finds nearly 1 in 5 Medicare patients studied who underwent the procedure had reoperations done during the average four-and-a-half-year period in which they were followed. In some cases, reoperations are done to address a device malfunction, like when the band “either erodes into the stomach or it slides out of place and causes a bowel obstruction,” says lead study author Dr. Andrew Ibrahim, a Robert Wood Johnson Clinical Scholar in the department of surgery at the University of Michigan. Those patients who had reoperations on average had nearly four done. “Between 18 and 19 percent of patients were undergoing additional operations that were specific to the device, which is high — much higher than the reoperation rates for other bariatric procedures,” Ibrahim says. “That also gave us a lot of insight into why so many bariatric surgeons were moving away from it.”
The study also found that of the $470 million Medicare paid for gastric band procedures reviewed in the research, nearly half that — $224 million — was for reoperations. The researchers concluded that insurers “should reconsider their coverage of the gastric band device.”
In fact, other countries have already taken the lap-band option off the surgical table. “In Canada, the lap band’s not covered by the public system. In New Zealand it’s not covered by the public system,” notes Ibrahim.
One limitation of the research in JAMA Surgery is that it relies on Medicare data — and the Medicare population skews older. However, the researchers noted that many who undergo bariatric surgery are Medicare beneficiaries because of disability, not age. Ibrahim says on average those studied were in their 50s (rather than 65 and up). In subsequent research which hasn’t yet been published, using the National (Nationwide) Inpatient Database, an all-payer inpatient care database with Medicare, Medicaid, private insurance and self-pay patient data, he notes that he’s found similarly high reoperation rates with the lap-band.
“If you’re a student of history, especially of bariatric surgery, you will see that there’s been many procedures that have arrived with great fanfare … become widely adopted, and then been subsequently abandoned,” says Dr. Vadim Sherman, medical director of bariatric and metabolic surgery at Houston Methodist Hospital. He cites vertical banded gastroplasty — also called stomach stapling — as one example. “It was introduced in the early ’80s as an alternative to gastric bypass. We don’t do it anymore. It’s fallen out of favor,” he says, one reason being that it failed to produce so-called durable weight loss, or essentially results that last.
“Whether the gastric band has been effective in facilitating weight loss has also been debated,” note the researchers in JAMA Surgery, citing previous research. “A meta-analysis of 48 studies (randomized clinical trials and 39 observational trials) between 2003 and 2012 compared the gastric band with either Roux-en-Y gastric bypass or a sleeve gastrectomy. At 1-, 3-, and 5-year follow-up, the gastric band was the least effective in facilitating weight loss compared with the other bariatric procedures.” Yet some surgeons and patients still say it can be quite effective for lasting weight loss.
[See: 8 Weird Ways Obesity Makes You Sick.]
But Sherman no longer sees the lap-band as a viable option for patients. “I’m a proponent of stopping band surgeries in our hospital,” he says. “We haven’t done any in over five years.”
However, other experts emphasize that success with the lap-band depends greatly on the surgeon doing the procedure — and follow-up care, including adjusting the band as needed (for instance, to tighten it) to improve effectiveness.
“I think the take home message should be not to take out a procedure which is going to be good for a smaller group of people than we originally thought,” says Dr. Scott Cunneen, director of bariatric surgery at Cedars-Sinai Medical Center in Los Angeles. “One of the problems with weight-loss surgery if you look at it over the last 15 to 20 years is that we pick a procedure and we try to use that procedure for everyone.”
Instead, clinicians recommend those who are candidates for weight-loss surgery talk over all options, including non-surgical ones, to find the right fit. Experts emphasize that no surgery is a fix, but rather a tool to help with weight loss; and that lifestyle changes, such as improving diet and exercising, are critical for long-term success.
[See: 6 Ways Obesity Can Weigh on the Brain.]
Risks for weight-loss surgery range from infection to malnutrition — with some variations depending upon the procedure. While safety has improved, deaths still sometimes occur with weight-loss procedures. According to a 2014 review and meta-analysis in JAMA Surgery comparing different bariatric procedures, “Adjustable gastric banding had lower mortality and complication rates; yet, the reoperation rate was higher and weight loss was less substantial than gastric bypass. Sleeve gastrectomy appeared to be more effective in weight loss than adjustable gastric banding and comparable with gastric bypass.”
There’s a lot to consider. But at the end of the day, Ibrahim hopes that research like his will help patients make an informed decision.
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Is Lap-band Surgery Still a Viable Option for Weight-Loss Surgery? originally appeared on usnews.com
