Lap-Band Adjustable Gastric Banding

What Is Lap Band®?

In bariatric surgery, the term “Lap-Band” is short for Laparoscopic Gastric Band. It is the latest type of adjustable gastric banding. Surgeons use ‘keyhole’ surgical techniques to implant a medical device composed of silicone rubber around the upper portion of the stomach in order to reduce the amount of food it can hold. The Lap-Band® surgical procedure is adjustable and reversible, and for some obese patients long term weight loss results are comparable with those from gastric bypass, like Roux-en-Y. In general, however, although Lap Band® is more convenient, most bariatric surgeons regard the procedure as less effective for obesity treatment than stomach bypass. The Lap Band® procedure was approved by the FDA in June 2001, as a bariatric method to reduce the health problems connected with severe clinical obesity.

How Does Lap-Band Cause Weight Reduction?

Lap-Band is a restrictive bariatric operation, meaning, it shrinks the stomach to reduce food consumption and thus calorie intake. Unlike gastroplasty – the other main restrictive procedure – Lap-Band is less invasive (no stapling of the stomach walls), adjustable to suit the digestive needs of the patient, and fully reversible. Lap-Band contains no malabsorptive element and does not alter the anatomy of the intestinal digestive tract.

How Does Lap-Band Reduce Stomach Size?

The gastric band is placed around the stomach creating an hourglass shape, with an upper and lower pouch linked by a narrow channel. The upper pouch is very small – about the size of an egg – the lower pouch is much larger. Food first enters the upper pouch, filling it almost immediately. Food then exits the upper stomach pouch into the lower pouch, through the narrow channel (like sand through an hourglass). But the narrow diameter of the channel delays this process, so the upper stomach stays full for longer.

How Does Lap-Band Cause A Reduction In Calorie Intake?

First, the tiny size of the upper pouch limits the quantity of food that the patient can physically eat. Second, the narrow exit slows down emptying, thus maintaining a feeling of satiety for longer. In simple terms, you feel full after eating much less food. The combination of these effects forces patients to eat less food and consume fewer calories.

Does Lap-Band Surgery Guarantee Weight Loss?

No. One key drawback of restrictive procedures, like Lap-Band, is that the gastric volume restrictions may be circumvented by patients who consume high-calorie liquid foods such as sports drinks or milk shakes, since these calorie-dense liquids pass easily through the exit channel from the upper stomach. Consuming these foods reduces weight loss and may even lead to weight gain.

How Does Lap-Band Compare With Other Obesity Surgeries?

Lap-Band is always performed laparoscopically, a “keyhole” surgical method, which reduces pain, reduced surgical trauma, reduced hospitalization and recovery period. Lap-Band placement requires no cutting or stapling of the stomach or bypass of the intestines. If the band needs to be removed, the patient’s stomach usually reverts to its original form.

Where Are Lap-Band Operations Performed?

For higher risk patients, whose health or comorbidities warrant it, Lap-Band procedures are typically performed in a hospital with an intensive care unit. Other patients may be operated on in a bariatric surgery center.

What Happens After The Lap-Band Operation?

Some patients are discharged within 24 hours, others within 2-3 days. Outpatient follow-up is typically scheduled for 5-7 days after the procedure. Bariatric surgeons recommend most patients to avoid vigorous activity for about 6 weeks after surgery, although most patients may return to work or ‘most’ normal activities within about 7-10 days. Post-op check-ups are a normal part of the Lap-Band process. Typically, surgeons see their patients once a week during the first month post-op, and every 4-12 weeks during year 1. Adjustments to the band may be performed during these consultations. In years 2 and 3, follow-up visits are normally scheduled every 3-6 months. These timetables vary from patient to patient.

How Are Gastric Band Adjustments Made?

Adjustments to the lap band usually take minutes and are performed by nursing staff. Usually, Lap-Band patients need 3-4 adjustments during year 1. Before and after Lap-Band surgery, patients receive comprehensive instructions on band management, together with specific advice on diet, nutrition and exercise. Compliance with these post-operative guidelines is essential to ensure healthy weight loss. Further post-op help is usually offered via local patient support groups, or online services.

What Are The Weight Loss Results Of Lap-Band?

An average weight reduction of 2-3 pounds a week during the first 12 months after the operation is possible, but an average of one pound a week is more likely. During the period 12-18 months after Lap-Band, weekly weight loss is less. In general, since June 2001, preliminary indications from America suggest that patients can lose about 40-50 percent of their initial excess body weight by having Lap-Band surgery. By comparison, patients who undergo gastric bypass, such as Biliopancreatic Diversion, Duodenal Switch or Roux-en-Y, typically lose 50-80 percent of their initial excess weight.

How Do Long Term Weight Loss Results Compare?

Bariatric surgeons have reported that stomach bypass patients lose weight faster during the first 12 months. After five years, however, evidence from Australia where Lap-Band is the most common type of obesity surgery, suggests that Lap-Band patients may achieve weight reduction close to or equal to that of Roux-en-Y gastric bypass patients.

Bariatric Study By the University of Minnesota

This study reviewed 136 studies (1990-2003), involving 22,094 patients who had obesity surgery including gastric banding, gastric bypass, gastroplasty, biliopancreatic diversion or duodenal switch, and others. The researchers found that the average percentage of excess weight loss for biliopancreatic diversion or duodenal switch was 70.1 percent, compared to 47.5 percent for gastric banding. Note however, that due to increased surgical expertise and data relating to laparoscopic banding, the above results may not accurately reflect current levels of weight reduction.

How Is The Lap-Band Operation Performed?

The Lap-Band is placed with the assistance of a laparoscope, using general anesthesia. To begin with, a few small incisions (access ports) are made in the abdominal wall. A narrow camera is then inserted through one of these ports to enable the surgeon to view the site of the operation on a video monitor.

A small tunnel is created near the top of the stomach through which to insert the band, which is then wrapped around the upper part of the stomach about 20 mm below the gastro-esophageal junction. The silicone elastomer band contains an inner balloon and is connected by a tube to a subcutaneous access port in the abdominal wall during surgery. Saline solution is introduced via the tubing to the inner balloon, in order to inflate the band, compressing the stomach into an hourglass shape, although it is not fully inflated until 4-6 weeks after the operation.

The diameter of the channel or passageway (stoma) between the upper and lower stomach pouches can be reduced or enlarged by adding or removing saline solution. These adjustments determine the rate of weight loss. If the gastric band is not tight enough, the upper stomach will empty too fast, reducing satiety and inducing higher calorie intake. If the band is too tight, it can cause regurgitation and gastroesophageal reflux, even vomiting.

How Are Adjustments Made To The Lap-Band?

Adjustments to the band are made either in hospital or in a doctor’s office that has x-ray equipment (fluoroscopy). Sometimes adjustments are performed in an outpatient clinic, and local anesthesia may or may not be needed. The clinician may utilize fluoroscopy to help pinpoint the position of the access port. Typically, adjustments are performed using a thin needle to inject or remove saline solution from the inner balloon. Only a small amount of solution is added/removed at each adjustment. An ideal “fit” of your band means you should be able to eat a sufficient amount of food to obtain the nutrients you require without veering from the restricted calorific regime needed to lose weight.

Who May Qualify As A Candidate For Lap-Band Surgery?

A Body Mass Index (BMI) of 40+, or a BMI of 35+ with severe comorbid conditions is essential. At present, lap-band surgery is not recommended for patients with end stage obesity (BMI 60+). In general, qualification for a Lap-Band operation is similar to that for any laparoscopic obesity surgery.

What Are The Advantages Of Lap-Band?

Here is a short summary of the benefits of Lap-Band adjustable gastric banding for the treatment of severe overweight.

The Most Convenient Surgery
Lap-Band is ideal for qualified patients who need to return quickly to full activity. With only 1-2 days in hospital and a possible return to most normal activities within 7-10 days, it involves less recovery time.

The Least Invasive Form Of Bariatric Surgery
Lap-Band is inserted laparoscopically, without major incisions or scarring. There is no stomach stapling involved, so no chance of staple line breakage. There is no interference with the gastrointestinal tract (duodenum, jejunum), therefore no risk of leakage and less chance of infection. And post-op pain after Lap-Band is greatly reduced

Adjustable To Suit Patient Needs
One of the major advantages of the Lap-Band procedure is its adjustable nature. If illness requires you to eat more food, the gastric ring can be loosened until you recover. If you want to reduce your calorie intake further the band can be tightened.

Fully Reversible
Because Lap-Band uses no staples (as in gastroplasty), involves no gastrectomy or surgical alteration to the digestive tract, it is removeable using the same laparoscopic technique by which it was inserted. After removal, the stomach usually reverts to its pre-op condition, although weight gain is common.

Less Danger Of Nutritional Deficiencies
Gastric bypass reduces nutritional uptake as well as food intake. Lap-Band only restricts food intake. Therefore, while it is important for patients to adhere to the post-op dietary guidelines, Lap-Band carries a much lower risk of nutritional deficency. During your post-op check-ups, your specialist will assess your nutritional needs – eg. if you are getting sufficient vitamin B12, folic acid, and iron – and will advise you on the need for supplementation.

Lowest Mortality Rate
The consensus among bariatric surgeons in Australia, Europe and the United States, is that Lap-Band has the lowest rate of hospital deaths, or post-op deaths, than any other type of obesity surgery. The risk is there, but much lower than after gastric bypass. Current statistics indicate a mortality rate of 1 in 2000 for Lap-Band patients compared to 1 in 200 for Roux-en-Y stomach bypass patients.

Lowest Rate Of Perioperative And Postoperative Health Complications
Although not problem-free, Lap-Band has the lowest rate of serious health complications of all bariatric procedures. The most common health complication seems to be slippage of the stomach through the band, leading to the enlargement of the upper stomach pouch and problems of obstruction. This affects 10-20 percent of patients, most of whom require revisional laparoscopic surgery to correct the problem.

Lap-Band is convertible to another operation, if weight loss is inadequate, although conversion surgery (like all revisional procedures) carries higher risks.

What Are The Disadvantages Of Lap-Band?

The drawbacks of Lap-Band involve health problems inherent in the operation, post-op health problems, and problems concerning weight reduction.

Operation Problems
The Lap-Band is an implanted medical device placed around the stomach. It can slip and it can induce problems like infection or erosion. Also the access port used to inject saline into the band may leak and require minor surgery. In general, patients who undergo Lap-Band obesity surgery appear to have a higher need for corrective operations than other bariatric patients. As many as 1 in 5 patients may need revisional surgery after theie initial Lap-Band procedure.

Post-Op Problems
All Lap-Band patients require several band adjustments (at least 3 or 4). Some people require many more corrections. In addition, some patients find it impossible to achieve the optimum position for their band, leading to reduced weight loss. Another common occurrence for band patients is regurgitation of food from the upper pouch. To avoid this, the patient should consume less, eat more slowly and chew food more thoroughly. Also, in rare cases, the narrow passageway beween the two stomach pouches may become blocked by unchewed food, bones or other solid matter.

Weight Loss Problems
Evidence varies as to weight loss results after Lap-Band. But most bariatric experts would agree with the following general propositions:

– Lap-Band offers slower initial weight loss than stomach bypass.
– The Lap-Band procedure enables patients to cheat more easily.
– Long term Lap-Band weight loss results depend on post-op care and support.
– If post-op support is good, long term weight loss is comparable with gastric bypass.

What Can Patients Eat After Lap-Band?

It is essential for all patients to adhere to their post-op eating and drinking instructions. These diet guidelines permit the new stomach structure to heal completely and the band to remain in the right position. For instance, eating too much after surgery can cause vomiting which can lead to stretching of the small stomach pouch. In time, patients move gradually to solid food. Note that during the first few weeks, patients may be able to eat to eat certain types of food that will be off-limits later because these foods are too high in calories. Point is, it is more important immediately after the operation to let the stomach adjust to the gastric band than it is to reduce weight. Here are some general diet guidelines after Lap-Band surgery.

Immediately After Lap-Band Surgery (First few days)

Immediately following surgery, patients may have an occasional sip of water or suck on an ice cube. Do not drink more than this. The day after the operation, you may take a little more fluid, but only a small amount at any one time, otherwise you risk nausea and vomiting. Try to choose liquids with an adequate amount of calories.

1-4 Weeks After Lap-Band Surgery

During this period you may enjoy the following liquids and very soft foods:

– Clear broth or soup (without vegetables or meat or cream)
– Low-fat yogurt
– Skimmed milk
– Jello
– Fruit juice or pureed soft fruit

4-6 Weeks After Lap-Band Surgery

During this period, you may start introducing thicker, or creamier soups. This helps you transition to more solid food. It is safer to consume softer foods that are easier to digest. At the end of this period you might include foods such as fish or moist white meat like chicken and pork. If you have any problems with solid foods and suffer from nausea or vomiting, return to the liquid diet immediately. Then slowly add soft foods to help you move on to solid foods later. Always ask for advice from your doctor or dietician.

What Are The Health Benefits Of Lap-Band?

The health benefits of adjustable stomach banding procedures, like Lap-Band, depend upon the amount of excess weight lost. Current evidence indicates that 70-80 percent of Lap-Band patients with hypertension will no longer need medication to reduce blood pressure; 9 out of 10 patients with type 2 diabetes mellitus will no longer need medication; other health conditions that are dramatically improved, if not cured, include: obstructive sleep apnea, respiratory problems, asthma, joint pain and arthritis. Risks of heart disease and stroke, as well as other circulatory disorders, are significantly reduced, as is insulin sensitivity and associated metabolic problems.

Is Lap-Band Covered By Medical Insurance?

Morbid obesity (BMI > 40) is a life threatening disease which triggers a range of comorbid conditions. As a result, gastric bypass and other obesity surgeries – that are medically necessary – are covered by many (but by no means all) health insurance companies. In any event, to gain approval for bariatric surgery, patients are required to supply details of their medical condition as well as a documented weight history.

How Do You Gain Approval For Lap-Band Obesity Surgery?

A Letter of Medical Necessity is the first requirement to obtain prior authorization for obesity surgery like Lap-Band. Health insurance policies only pay for obesity surgery if it is medically necessary. A Letter of Medical Necessity explains why significant weight loss is medically necessary for the patient and usually contains the following:

Patient’s Weight
The patient must be 100+ pounds above their ideal weight. Generally, this equates to BMI > 40, or BMI > 35 with associated weight-related medical problems.

List of Comorbid Conditions
This means the patient’s medical problems which are caused by their obesity. Examples: type 2 diabetes, sleep apnea, hypertension.

A documented weight history of the patient is also essential. This includes: the number of years that patient has been overweight (at least 5+); the number and types of failed attempts at losing weight, with details of weight loss programs or commercial diets followed.

How Can You Appeal A Failed Prior Authorization Request For Obesity Surgery?

If the insurance company denies your request for Lap-Band surgery, you can appeal by contesting the validity of the reasons why your request has been denied. Your bariatric surgeon and his staff can assist you in this process.

Which Health Insurance Companies Pay For Obesity Surgery?

For informational purposes only, here is a provisional list of health insurers that cover Lap-Band surgery, either partially or completely. Do NOT assume that these companies will cover you: you must consult your individual policy.

American Family Insurance, Blue Cross (in some states), First Health, Humana, Medicaid,
One Health, Oxford Health Plan, Tufts Health Plan, United Healthcare.