Gastric bypass superior to lap banding finds study

By Dr. Ananya Mandal, MDJan 17 2012

A new study evaluates the best option in terms of weight loss surgery for those who need it. Researchers found gastric bypass patients lose more weight than gastric banding patients and keep it off longer. Even though banding is a simpler operation, nearly half of those patients were still obese after six years.

Many doctors aren't surprised by those results. The study also determined patients who have gastric bypass surgery have a greater risk of deadly complication compared to banding. Researchers think the benefits outweigh the risks.

A gastric bypass operation called Roux-en-Y involves reducing stomach size with staples and connecting the smaller “pouch” directly to the small intestine. It is irreversible. Gastric banding, as its name implies, involves placing a band around part of the stomach to reduce its size. This procedure is reversible, the researchers noted. Dr. Mitchell Roslin, Head of Obesity Surgery, Lenox Hill Hospital said, “When we actually remove part of the stomach we change the hormones that control hunger and fullness and we change people's relationship with food.” “Both gastric banding and gastric bypass are currently performed for morbid obesity,” said Suter. “Bypass is more effective in terms of directs results such as weight loss, but a bit more dangerous immediately than banding,” he said.

However, banding often leads to long-term complications requiring some sort of major re-operation, Suter said. “In addition, many bands are not going to stay in place for much more than 10 years; hence, banding is unlikely to be the only weight-loss procedure the patient will be submitted to,” he said. “Patients should make a choice knowing this, and decide whether they accept a slightly higher early risk to improve their results, or if they want the least invasive procedure, but then accept a high risk of further surgery at a later time.”

The report was published in the Jan. 16 online edition of the Archives of Surgery. For the study, Suter's team followed for six years 442 patients who had either gastric bypass surgery or banding.

Although there were more early surgical complications among those who had Roux-en-Y surgery, these patients lost more weight faster than those who had gastric banding, the researchers found. After bypass surgery, about 17 percent of the patients had complications, compared with more than 5 percent of those who underwent banding, the researchers noted. But at six years there were more problems with gastric banding, including about 48 percent who had weight gain or the procedure reversed, compared with about 12 percent who had bypass surgery, the study found.

Gastric banding was associated with more long-term complications (more than 42 percent versus 19 percent) and more new procedures than bypass surgery (about 27 percent vs. 13 percent). Cholesterol levels among those who had gastric bypass surgery were consistently lower than among those who had gastric banding, who saw no change over time, the researchers add. This finding implies that blood sugar levels were also lower among those who underwent gastric bypass surgery, the study authors said.

“The prevalence of morbid obesity has been growing exponentially over the past 20 years,” the researchers wrote. “A recent survey showed that bariatric procedures have more than doubled between 2003 and 2008. In the United States, the increase was much greater for gastric banding than for gastric bypass.”

Suter is concerned that many patients are only offered banding and not told of its drawbacks. “There is, in the United States, an extensive campaign promoting gastric banding as 'the solution' for obesity, which is far from being true,” he said. It can result in significant weight loss, but it remains a surgical procedure, and is certainly associated with significant risks, both in the short and long term, Suter said. “Patients must be informed that surgery alone is not sufficient to achieve significant weight loss, and they must be instructed about other things they have to do such as changing their eating and lifestyle habits,” he said.

In addition, Suter said, “Patients calling or referred for gastric banding must be informed about the other available procedures for morbid obesity, and not offered band only, as is the case in several places.” Depending on the actual operation, both procedure costs between $10,000 and $20,000 plus follow-up costs, and insurance coverage is very inconsistent, according to Dr. Edward Livingston, who serves as the Dr. Lee Hudson-Robert R. Penn Chair in Surgery at the University of Texas Southwestern Medical Center, in Dallas. Hospital stay for bypass is usually two days, and banding usually one day, but this can vary depending on surgeon, hospital and complications.

Dr. Jacques Himpens, from the European School of Laparoscopic Surgery at Saint Pierre University Hospital in Brussels and author of an accompanying journal editorial, is less concerned with a particular procedure than with the specific surgeon. “Not all surgeons can do bypasses,” he said. “Maybe they don't have the skills or the experience, but in any case it's not the best option because they are not up to it,” he said. “That's the case for many surgeons.”

Also, while a gastric bypass causes changes in metabolism, banding does not, Himpens said. “But the good thing is that it is reversible. When you take out the band, no harm has been done and you can still do another procedure if you need to,” he said. However, among patients who receive bands, only 40 percent retain them after 10 years, either because of complications or the desire to have it removed, Himpens said. “Notwithstanding these words of caution, Suter et al must be commended for their scientific rigor and zealous follow-up,” he wrote. “Both constitute an enlightening example for all of us bariatric surgeons.”