Lap Band Failures Drive Many to Safer Weight Loss Surgeries

 March 29, 2022 — Jessica Furby struggled with weight most of her life, constantly dieting and exercising to shed pounds. But nothing seemed to help. By her 22nd birthday, she tipped the scales at more than 300 pounds.

So, in 2011, while a college student in Pittsburgh, she decided to have a weight loss procedure known as lap band surgery. Doctors placed a synthetic belt around her stomach to limit what she could eat. It seemed like a good option at the time, and, after her surgery, she lost about 60 pounds.

But the benefits didn’t last. In the months that followed, she had pain and other complications. Worst of all, she eventually regained all the weight she’d lost — and then some. By 2016, she weighed 350 pounds and was becoming prediabetic.

Courcoulas, chief of minimally invasive bariatric and general surgery at the University of Pittsburgh Medical Center, says there are two main reasons for the decline in lap band procedures.

“It is less effective for weight loss [than] other bariatric surgical procedures, and band intolerance often results in band removal,” she says.

Ali Aminian, MD, director of the Bariatric and Metabolic Institute at the Cleveland Clinic, agrees that lap band complications and failures and ineffective weight loss are behind the trend, driving patients and doctors to choose safer and more effective procedures.

He says the Cleveland Clinic no longer does band operations, and he has done a lot of conversions.

“Around 50-60% of [lap band] patients require reoperation to take care of the complications,” he says. “So, when you have a surgery where the patients require reoperation more than half of the time, we cannot claim that’s a safe operation.”

Evolution in Bariatric Surgery

The first bariatric surgeries for weight loss date back to the 1950s and 1960s, when surgeons at the University of Minnesota first did experimental bypass operations. Adjustable gastric banding first appeared in the late 1970s and early 1980s.

But these procedures didn’t gain widespread mainstream use until gastric band procedures gained full FDA approval in 2001. Clinical trials have found that bariatric surgery people have a significantly lower risk of heart disease and other obesity-related health problems.

In the decade that followed the FDA’s approval of lap band surgery, it became a popular weight loss procedure, accounting for more than a third of all bariatric surgeries by 2011.

“Fifteen to 20 years ago, lap band was the most commonly performed procedure for bariatric surgery worldwide and in the United States,” Aminian says. “It was straightforward to do; it was quick — it takes 20 minutes to do the procedure — recovery was short, and initially, patients had great outcomes. They would lose weight and be healthy.”

But over the past decade, surgeons found that patients often regained the weight they’d lost, and complication and failure rates rose.

“Because the lap band is a foreign body that we place inside the body, many patients had complications related to that foreign body,” Aminian says.

Experts note that the band can sometimes move or be displaced, causing blockage of the stomach. Other common complications include nausea, vomiting, acid reflux, and esophageal issues (such as difficulty swallowing). Some patients feel pain, constant food cravings, or that they can’t eat or drink anything. And painful infections and other problems can develop with the tubing or the port placed under the skin connected to the band, which doctors use to make adjustments after surgery.

“Scar tissue can also form around the lap band that can cause a blockage in the stomach,” Aminian says. “Then if the band is too tight, it can erode into the stomach tissue or even go inside the stomach and cause perforation or bleeding.”

By contrast, gastric sleeve and bypass procedures are safer, resulting in longer-lasting weight loss, carrying fewer complications, and requiring fewer patient reoperations. Aminian estimates that only 2% to 3% of patients need second operations.

Another Key Factor: Metabolic ‘Reset’

“That’s why it doesn’t have the metabolic effects.”

But other procedures, like the gastric sleeve, change the hormones in the body. Removing the source of those hormones means the patient won’t have the same appetite, Aminian says.

“And that’s why it’s very effective. The problem with the lap band is the patient always has the feeling and desire to eat — they’re always hungry. That’s why in the long run, they fail,” he says.

“They change the setpoints,” Aminian says. “When the hormones in your body change, the [metabolic] setpoint in the brain also changes.”

He likens the metabolic setpoint to a thermostat in your home that regulates the temperature inside.

“When a patient goes on a diet or goes on the lap band, the thermostat doesn’t change,” he says. “They may lose some weight, but they’re going to regain it because the thermostat is the same. But when the hormones in your body change, the thermostat will change, and you’re not going to regain the weight you have lost.”

Sachin Kukreja, MD, a surgeon, and CEO at DFW Bariatrics and General Surgery in Dallas, says he believes these metabolic changes are the biggest behind successful surgeries.

“People synonymize bariatric surgery with weight loss surgery, but the metrics we should be using are more related to metabolic measures,” says Kukreja, who hasn’t done a band surgery since 2013. “And so, the metabolic parameters that change with bariatric surgery are much more significant in the setting with sleeve and gastric sleeve, and much less significant with the lap band.”

David Arterburn, MD, agrees that resetting metabolism is essential but says the issue is “controversial and challenging” among bariatric surgeons.

“The metabolic setpoint is the idea that we have a biologically controlled set bodyweight that we will always return to.

“I feel great,” he says. “I have become more active; doing everything is a lot easier. It got to the point where it was a task to tie up my shoes!”

Should Band Patients Convert to Sleeve or Bypass?

“If a patient experiences poor weight loss or complications from a band, they can consider conversion/revision to a sleeve or bypass,” says Courcoulas, echoing the views of other doctors.

Here’s a primer, including the pros and cons of each procedure:

Lap Band

Food goes through the stomach but is limited by the smaller opening of the band.

Advantages:

• The lowest rate of complications right after surgery
• No division of the stomach or intestines
• Patients go home on the day of surgery, and recovery is quick.
• The band can be removed if necessary.

Disadvantages:

• The band may need to be adjusted from time to time, and patients must make monthly office visits during the first year.
• There’s less weight loss than with other surgical procedures.
• It comes with the risk of band movement (slippage) or damage to the stomach over time (erosion).
• The surgery means that a foreign implant has to remain in the body.
• It has a high rate of reoperation.
• The surgery can bring swallowing problems, enlargement of the esophagus, and other complications.

Gastric Sleeve 

For laparoscopic sleeve gastrectomy — often called gastric sleeve — surgeons remove about 80% of the stomach, so the remaining stomach is the size and shape.

The new, smaller stomach holds less food and liquid, reducing how much food (and calories) the patient can get. 

Advantages:

• It’s technically simple and has a short surgery time.
• It can do it in certain patients with high-risk medical conditions.
• It may be the first step for patients with severe obesity or as a bridge to gastric bypass.
• The surgery brings effective weight loss and improvement of obesity-related conditions (typically 50%-60%, Mayo Clinic estimates), with a low complication rate (2%-3%).

Disadvantages:

• Nonreversible procedure
• It may worsen or cause new reflux and heartburn.
• Less impact on metabolism compared to bypass procedures.

Gastric Bypass

Gastric bypass works by limiting the amount of food and calories a patient can consume. It also decreases hunger and increases fullness, allowing the patient to reach and maintain a healthy weight. The impact on hormones and metabolic health often results in the improvement of diabetes and helps patients with reflux.

Advantages:

• Reliable and long-lasting weight loss
• Effective for the remission of obesity-associated conditions
• Effective weight loss (60%-70%, Mayo Clinic estimates)