Very Obese Bypass Patients in Study Lost More Weight, Kept it Off Longer
By Salynn Boyles
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Reviewed by Brunilda Nazario, MD
Jan. 16, 2012 -- Gastric banding doesn't work as well as bypass surgery, according to a new study in the journal Archives of Surgery.
More than 200,000 weight loss surgeries are performed annually in the U.S. and more people are choosing banding procedures over gastric bypasses. Banding procedures are marketed as a safer and simpler alternative, but new research suggests that it may not achieve better and lasting results.
Over six years of follow-up, obese people who had Roux-en-Y gastric bypass surgeries lost more weight and kept it off longer than people who chose gastric banding.
Although the complication rate was higher in the bypass group immediately following surgery, banding patients had more long-term complications and more surgical failures.
Several bariatric surgeons who spoke to WebMD called the study long overdue, while another questioned the conclusion that bypass is the best choice for most patients.
"Bypass surgery is not a miracle treatment and many surgeons do not perform it well," says Jacques Himpens, MD, of the European School of Laparoscopy in Brussels, Belgium. "Surgical competency is a big issue with Roux-en-Y gastric bypass." Himpens wrote an editorial of the study.
Banding, Bypass, and Sleeve Gastrectomy
About 15 million Americans are morbidly obese, meaning that they are 50 to 100 pounds over their ideal body weight or have a body mass index (BMI) of 40 or greater.
Over the past two decades, the number of bariatric surgeries performed in the U.S. has increased more than 10-fold.
With a Roux-en-Y gastric bypass surgery, the stomach is reduced in size by 90% to 95% -- from that of a football to a golf ball. The surgery also bypasses a section of the small intestine, which limits calorie absorption.
With a gastric banding procedure, the stomach size is restricted with an adjustable ring, or band.
A third type of weight loss surgery, known as gastric sleeve procedure, reduces the size of the stomach through surgery.
Obesity and Weight Regain
The new study compared outcomes among severely obese patients who had gastric banding and gastric bypass surgeries.
Among the major findings:
- Three years after surgery, 22% of the banding patients were still severely obese (BMI of 35 or greater), compared to 7% of bypass patients.
- Six years post-op, nearly three times as many banding patients had a BMI of 35 or greater (33% versus 12%).
- Fourteen percent of the banding patients remained morbidly obese (BMI of 40 or greater), after six years, compared to 2.4% of bypass patients.
- The complication rate immediately following surgery was 17% in the bypass patients, versus 5% in the banding patients. Six years later, 41% of the banding patients and 19% of the bypass patients reported long-term complications.
Forty-seven of the 221 patients who initially had the banding procedure (21%) ended up having the bands removed.
"At the present time, Roux-en-Y gastric bypass seems clearly superior to gastric banding when treating morbidly obese patients ... researcher Sebastien Romy, MD, and colleagues wrote.
Ronald H. Clements, MD, who directs the bariatric surgery program at Vanderbilt University Medical Center in Nashville, Tenn., says the findings come as no surprise.
"Our experience and that of many others is that close to 25% of these bands end up being removed for some reason such as slippage, erosion, or failure to lose weight," Clements says.
Role of Consumer Marketing
Clements adds that aggressive marketing by the gastric banding industry has been largely responsible for the dramatic increase in gastric banding procedures.
"It's common for patients to tell me they want gastric banding because they have seen a commercial for it," he says. "When I explain the pros and cons of banding, bypass, and sleeve procedures, they often change their minds."
American Society for Metabolic and Bariatric Surgery (ASMBS) president Robin Blackstone acknowledges that aggressive marketing of gastric banding is an issue.
"The Society does not favor the direct-to-consumer type of advertising that we are seeing with gastric banding," she says. "We recommend that patients seek out a center which offers a variety of procedures and also offers counseling to address the risks and benefits of each one."
Himpens says gastric banding can be a better option than bypass if patients do not have access to surgeons who specialize in bypass surgery or if they will not be followed closely after surgery.
Clements, Blackstone, and Himpens agree that gastric bypass or sleeve surgeries are generally preferable to banding for one group of patients -- people with type 2 diabetes.
Because bypass and sleeve procedures change a person's metabolism in addition to promoting weight loss, in many cases diabetes improves or goes away before weight loss occurs.
Banding Industry Weighs In
Allergan, Inc., markets the Lap-Band gastric banding system, which is the most widely used gastric band in the U.S.
In a written statement, an Allergan spokesperson highlighted what the company called "specific weaknesses" in the study, including:
- The fact that the patients received an older version of the banding system, which is no longer used. The insertion method used has also been replaced since the patients in the study had the procedures, and the new method has a much lower re-operation rate. The researchers did acknowledge that some of the patients in the study used an older system.
- The researchers failed to include many complications that have been associated with bypass surgery in their analysis, including small bowel obstructions, osteoporosis, anemia, and long-term nutritional complications.
- Migration of the band through the stomach wall into the stomach, known as erosion, was much higher in the study participants -- 7.7% -- than has been typically reported (0.2-0.5%).
"Although we applaud the high six-year follow-up rate of these bariatric patients, it would be inappropriate to draw conclusions regarding the relative risks and benefits of either procedure based on this single study," according to Allergan.
SOURCES: Romy, S., Archives of Surgery, Jan. 16, 2012.Ronald H. Clements, MD, professor of surgery and director of bariatric surgery, Vanderbilt University Medical Center, Nashville, Tenn.Robin Blackstone, MD, president, American Society for Metabolic and Bariatric Surgeons; medical director, Scottsdale Healthcare Bariatric Center, Scottsdale Healthcare, Scottsdale, Ariz.Jacques Himpens, MD, European School of Laparoscopy, Brussels, Belgium.Naziah Lasi-Tejani, senior manager, corporate affairs and public relations, Allergan, Inc.News release, JAMA Media, Jan. 16, 2012.American Society for Metabolic and Bariatric Surgery: Metabolic and Bariatric Surgery Overview.
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