A laparoscopic adjustable gastric band, commonly called a lap-band, A band, or LAGB, is an inflatable silicone device placed around the top portion of the stomach to treat obesity, intended to decrease food consumption.
Adjustable gastric band surgery is an example of bariatric surgery designed for obese patients with a body mass index (BMI) of 40 or greater—or between 35 and 40 in cases of patients with certain comorbidities that are known to improve with weight loss, such as sleep apnea, diabetes, osteoarthritis, GERD, hypertension (high blood pressure), or metabolic syndrome, among others.
In February 2011, the United States Food and Drug Administration (FDA) expanded approval of adjustable gastric bands to patients with a BMI between 30 and 40 and one weight-related medical condition, such as diabetes or high blood pressure. However, an adjustable gastric band may be used only after other methods such as diet and exercise have been tried.
Working principle
The inflatable band is placed around the upper part of the stomach to create a smaller stomach pouch. This slows and limits the amount of food that can be consumed at one time, thus giving the opportunity for the sense of satiety to be met with the release of peptide YY (PYY). It does not decrease gastric emptying time. The individual achieves sustained weight loss by choosing healthy food options, limiting food intake and volume, reducing appetite, and progress of food from the top portion of the stomach to the lower portion digestion.
According to the American Society for Metabolic Bariatric Surgery, bariatric surgery is not an easy option for obesity sufferers. It is a drastic step, and carries the usual pain and risks of any major gastrointestinal surgical operation. However, gastric banding is the least invasive surgery of its kind and is completely reversible, with another "keyhole" operation. Gastric banding is performed using laparoscopic surgery and usually results in a shorter hospital stay, faster recovery, smaller scars, and less pain than open surgical procedures. Because no part of the stomach is stapled or removed, and the patient's intestines are not re-routed, they can continue to absorb nutrients from food normally. Gastric bands are made entirely of biocompatible materials, so they are able to stay in the patient's body without causing harm.
However, not all patients are suitable for laparoscopy. Patients who are extremely obese, who have had previous abdominal surgery, or have complicating medical problems may require the open approach.Bariatric Surgery for Severe Obesity , National Institutes of Health. 2009;08-4006. Retrieved 2010-07-30.
Placement via laparoscopic surgery The surgical insertion of an adjustable gastric band is often referred to as a lap band procedure or band placement. First, a small incision (typically less than 1.25 cm or 0.5 in.) is made near the belly button. Carbon dioxide (a gas that occurs naturally in the body) is introduced into the abdomen to create a work space for the surgeon. Then a small laparoscopic camera is placed through the incision into the abdomen. The camera sends a picture of the stomach and abdominal cavity to a video monitor. It gives the surgeon a good view of the key structures in the abdominal cavity. A few additional small incisions are made in the abdomen. The surgeon watches the video monitor and works through these small incisions using instruments with long handles to complete the procedure. The surgeon creates a small, circular tunnel behind the stomach, inserts the gastric band through the tunnel, and locks the band around the stomach.
Clinical studies of laparoscopic (minimally invasive) bariatric surgery patients found that they felt better, spent more time doing recreational and physical activities, benefited from enhanced productivity and economic opportunities, and had more self-confidence than they did prior to surgery.
Mechanics The placement of the band creates a small pouch at the top of the stomach. This pouch holds approximately of food, whereas the typical stomach holds about of food. The pouch fills with food quickly, and the band slows the passage of food from the pouch to the lower part of the stomach.Lee C, Zieve, D. Laparoscopic gastric banding. National Institutes of Health. Retrieved 2010-07-08. As the upper part of the stomach registers as full, the message to the brain is that the entire stomach is full, and this sensation helps the person to be hungry less often, feel full more quickly and for a longer period of time, eat smaller portions, and lose weight over time.
As patients lose weight, their bands will need adjustments, or "fills", to ensure comfort and effectiveness. The gastric band is adjusted by introducing a saline solution into a small access port placed just under the skin. A specialized non-coring needle is used to avoid damage to the port membrane and prevent leakage.Surgical Procedures & Innovations: Gastric Bandings Columbia University, Center for Metabolic and Weight Loss Surgery; New York, NY: 2007. Retrieved 2010-07-09. There are many port designs (such as high profile and low profile), and they may be placed in varying positions based on the surgeon's preference, but are always attached (through sutures, staples, or another method) to the muscle wall in and around the diaphragm.
Adjustable gastric bands hold between 4 and 12 cc of saline solution, depending on their design. When the band is inflated with saline solution, it places pressure around the outside of the stomach. This decreases the size of the passage between the pouch created from the upper part of the stomach and the lower stomach and further restricts the movement of food. Over the course of several visits to the doctor, the band is filled until the optimal restriction has been achieved – neither so loose that hunger is not controlled, nor so tight that food cannot move through the digestive system. The number of adjustments required is an individual experience and cannot be accurately predicted.
Types of adjustable bands
In the U.S. market, one adjustable gastric band is currently approved by the FDA: Lap-Band. The Lap-Band System obtained FDA approval in 2001.FDA Approval: LAP-BAND Adjustable Gastric Banding (LAGB) System - P000008, fda.gov 2001-06-05. Retrieved 2010-01-21. The Realize Band lost FDA approval in 2016. The device comes in five different sizes and has undergone modification over the years. The latest models, the Lap-Band AP-L and Lap-Band AP-S, feature a standardized injection port sutured into the skin and fill volumes of 14 mL and 10 mL respectively.Laparoscopic Adjustable Gastric Banding: Surgical Technique, thinforlife.med.nyu.edu
Two other adjustable gastric bands are in use outside of the United States—Heliogast and Midband. Neither band has been approved by the FDA. The Midband was the first to market in 2000.Médical Innovation Développement , Médical Innovation Développement . Retrieved 2010-01-21. In order to preserve the gastric wall in event of rubbing, the device contains no sharp edges or irregularities. It is also opaque to x-rays, making it easy to locate and adjust.Laparoscopic Adjustable Gastric Banding Using the Midband , Monkhouse, S., Johnson, A., Bates, S., Sawyer, L., Lord, K., Morgan, J. Departments of Surgery, Endocrinology and Dietetics, Southmead Hospital, Bristol. UK. Retrieved 2010-01-21. The Heliogast band entered the market in 2003. The device features a streamlined band to ease insertion during the operation.Dr. Jacob Haiavy and Dr. John Olsofka (25 May 2021). Lap band surgery Healthroid.
Surgical indications In general, gastric banding is indicated for people for whom all of the following apply: Body Mass Index above 40, or those who are 100 pounds (7 stone/45 kilograms) or more over their estimated ideal weight, according to the National Institutes of Health, or those with a BMI between 30 and 40 with co-morbidities that may improve with weight loss (type 2 diabetes, hypertension, high cholesterol, non-alcoholic fatty liver disease and obstructive sleep apnea.)Metabolic Surgery Expected to Play Bigger Role in Treating Type 2 Diabetes And Other Metabolic Diseases , American Society of Metabolic & Bariatric Surgery 2007. Retrieved 2010-08-26. Age between 18 and 55 years (although there are doctors who will work outside these ages, some as young as 12). Failure of medically supervised dietary therapy (for about 6 months). History of obesity (up to 5 years). Comprehension of the risks and benefits of the procedure and willingness to comply with the substantial lifelong dietary restrictions required for long-term success. Gastric banding is usually not recommended for people with any of the following: If the surgery or treatment represents an unreasonable risk to the patient Untreated endocrine diseases such as hypothyroidism Inflammatory diseases of the gastrointestinal tract such as ulcers, esophagitis or Crohn's disease. Severe cardiopulmonary diseases or other conditions which may make them poor surgical candidates in general. An allergic reaction to materials contained in the band or who have exhibited a pain intolerance to implanted devices Dependency on alcohol or drugs People with severe learning or cognitive disabilities or emotionally unstable people.
Special considerations for pregnancy If considering pregnancy, ideally the patient should be in optimum nutritional condition prior to, or immediately following, conception; deflation of the band may be required prior to a planned conception. Deflation should also be considered should the patient experience morning sickness. The band may remain deflated during pregnancy and once breast feeding is completed, or if bottle feeding, the band may be gradually re-inflated to aid postpartum weight loss as needed.Dixon J, Dixon M, O’Brien P. Pregnancy after Lap-Band Surgery: Management of the Band to Achieve Healthy Weight Outcomes. Obesity Surgery. 2001 Feb;11(1):59-65. Retrieved 2010-08-26.
It is highly advised to take extra precautions during intercourse after surgery, as rapid weight loss increases fertility. Effective birth control methods must be used at all times to avoid unwanted pregnancies. Two factors have been pointed out by experts that may help explain this increase in fertility: reversal of PCOS (polycystic ovary syndrome) and reduction in the excess of estrogen, which is produced by fat cells.Can weight loss increase fertility?, Discovery Fit & Health. Retrieved 2013-12-06.
Comparison with other bariatric surgeries Unlike more open forms of weight loss surgery (e.g. Roux-en-Y gastric bypass surgery (RNY), Biliopancreatic diversion (BPD) and Duodenal Switch (DS)), gastric banding does not require cutting or removing any part of the digestive system. It is removable, requiring only a laparoscopic procedure to remove the band, after which the stomach usually returns to its normal pre-banded size so it is not unusual for a person to gain weight after having a band removed. However, it is not entirely reversible as adhesions and tissue scarring are inevitable. Unlike those who have procedures such as RNY, DS, or BPD, it is unusual for gastric band patients to experience any nutritional deficiencies or malabsorption of micro-nutrients. Calcium supplements and Vitamin B12 injections are not routinely required following gastric banding (as is often the case with RNY, for example). Gastric dumping syndrome issues also do not occur since intestines are not removed or re-routed.