By Nicolas Earl, PhDWeight-loss surgery has gained considerable public and medical acceptance because it is one of the few treatment approaches that succeeds in helping severely obese individuals lose enough weight to significantly reduce their risk of other health problems, including diabetes, arthritis, cardiovascular disease, high blood pressure, high cholesterol, and a shortened life expectancy.Weight-loss diets, drug therapies, and diet and exercise programs enable overweight people to lose 9 to 15 pounds on average - not enough to make a difference in the overall health risks of people with Class 3 or higher obesity (body mass index over 40). Patients who undergo bariatric surgery, on the other hand, lose an average of about 90 pounds. For many, this is weight loss that can actually cure obesity-related diabetes, hypertension, and sleep apnea.Once an individual and his or her physician have reached the conclusion that weight-loss surgery is the preferred treatment approach, a major decision still remains regarding the type of procedure to choose. Two primary options exist: Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding.Roux-en-Y Bypass vs. Laparoscopic Gastric BandIn gastric bypass surgery, the stomach is surgically stapled to create a smaller stomach pouch at the top. This smaller stomach is then surgically attached directly to part of the small intestine, so that food bypasses the main stomach compartment and the upper part of the intestinal tract. The result is that food consumption is physically restricted by the size of the stomach compartment, and because the topmost portion of the intestinal tract is bypassed, fewer calories (and nutrients) are absorbed from the food that is consumed.Gastric band surgery involves the placement of a saline-filled silicone band around the top of the stomach, creating a narrow passage between the upper and lower stomach compartments. As with gastric bypass, the upper stomach compartment holds a relatively small amount of food, and the patient cannot eat more than a few ounces at one time without discomfort. The band can be adjusted to control how quickly food passes into the stomach. The digestive system and process remain essentially intact, but the stomach holds less, digestion is slower, and patients feel full sooner and longer.The two procedures are quite different, and a certain amount of disagreement has arisen about their contrasting advantages and disadvantages. Dr. Jeffrey Tice and colleagues from the University of California at San Francisco published a review of the research that had been done to todate comparing bypass and banding in terms of safety, effectiveness, and patient satisfaction [1].Advantages of Gastric Bypass SurgeryAfter reviewing the existing research comparing outcomes of the two procedures, Dr. Tice and his colleagues found that patients who undergo gastric bypass surgery tend to lose significantly more weight. The studies under review found that one year after surgery, Roux-en-Y bypass had led to 26 percent more weight loss on average than gastric banding.In the studies reviewed, 78 percent of gastric bypass cases resulted in elimination of the patient's diabetes compared to 50 percent resolution in gastric banding cases. Fewer gastric bypass patients required reoperation (16 percent vs. 24 percent for banding cases).Drawbacks of Gastric Bypass SurgeryGastric bypass is a more complex surgical procedure--it is more invasive in nature, takes more time, requires a longer hospital stay and recovery period, and involves a somewhat higher risk of complications during and immediately after surgery than the gastric banding procedure. Gastric bypass patients require lifelong nutritional supplements and nutritional supervision due to the change in their digestive process. They have a 30 percent chance of developing vitamin B12 and iron deficiencies, which can lead to anemia. Approximately 5-15% of patients develop ulcers, and about the same percentage are subject to a narrowing of the passage between the stomach and intestines that can cause nausea and vomiting after eating [2]. Bypass patients sometimes develop food intolerances and an unpleasant dumping syndrome.While mortality rates are very low for both procedures, they were slightly higher for gastric bypass.Advantages of the Gastric BandGastric band surgery is performed laparoscopically, through 5 small incisions. There is no internal cutting, and the digestive tract remains intact. For this reason, banding does not interfere with food absorption and rarely leads to the vitamin deficiencies common with bypass surgery. The surgery itself takes only about an hour and an overnight hospital stay. Many patients can resume their normal activities in less than a week. Complications are less common during and immediately after surgery, due to the less-invasive nature of the operation. The procedure is reversible.Drawbacks of the Gastric BandGastric banding patients are more likely to require some form of follow-up surgery in the long-term, since the device can slip out of place or develop a kink or twist.Overall weight loss was significantly less at one-year follow-up for gastric banding patients than gastric bypass patients in the studies reviewed by Tice et al. Some researchers and physicians have noted that these statistics do not reflect significant improvements in the banding procedure since it was first approved in 2001 [2,3]. A number of studies have found that loss of excess weight following banding procedures ranged from 48 percent to as much as 63 percent. Four years after surgery, 75 percent of patients had lost more than 50 percent of their excess weight [4].Some studies have found that the resolution of related health conditions following gastric banding was as much as 25 percent lower than following gastric bypass surgery. Again, however, other studies have found that the rate of resolution of diabetes was the same in patients who had a gastric band as in those who had bypass surgery [5]. One randomized clinical trial found that adjustable gastric banding led to a 73 percent cure rate for type 2 diabetes [6].ConclusionsGastric bypass surgery has been performed for more than 40 years, while gastric banding was only approved in the United States in 2001. It is not surprising that there is substantially more data on the outcomes and effectiveness of the bypass procedure.Tice et al. regard gastric bypass as "the current standard of care." Based on the evidence they gathered from available research demonstrating superior weight loss results and the fact that 80 percent of bypass patients were "very satisfied," their conclusion is that "Roux-en-Y gastric bypass should remain the bariatric procedure of choice in the United States" [1].On the other hand, proponents of the laparoscopic adjustable gastric banding procedure note that much of the comparative evidence Tice et al. rely upon is drawn from low quality studies and fails to take into account more recent advances and improvements in the newer procedure.Both sides of this debate would no doubt agree, however, that "we need to spend more time understanding the science of obesity, the mechanism of action of bariatric surgery, and stratifying the care of our patients to the procedures best suited to their illness" [3].The decision in any individual case may come down to degrees-how much weight does the patient need to lose and how quickly? How severe are the patient's other obesity-related health problems? How compliant is the patient likely to be with the different post-operative life-style adjustments required for successful weight-loss maintenance?In the meantime, there is reassurance in the fact that prospective patients and their doctors are left with the choice between two well-established procedures, both of which have been proved to be safe and effective weight-loss solutions for thousands of patients.Update: In 2014, Laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered the most effective method to treat for morbid obesity. Dr Heneghan and his colleagues are now studying a new approach: Banded Roux-en-Y gastric bypass. This is a combination of the two procedures, whereby a nonadjustable band is placed around the pouch. This is a procedure that can provide even better weight loss, especially to super obese patients.References1. Tice JA, Karliner L, Walsh J, Petersen AJ, Feldman MD. Gastric banding or bypass? A systematic review comparing the two most popular bariatric procedures. Am J Med. 2008;121:885-93.2. Brolin RE (2002). Bariatric surgery and long-term control of morbid obesity. JAMA, 288(22): 2793-27963. Bhoyrul S, Dixon J, Fielding G, Ren Fielding C, Patterson E, Grossbard L, Shayani V, Bessler M, Voellinger D, Billy H, Cywes R, Ehrlich TB, Jones DB, Watkins BM, Ponce J, Brengman M, Schroder G. (2009). Safety and effectiveness of bariatric surgery: Roux-en-y gastric bypass is superior to gastric banding in the management of morbidly obese patients: a response. Patient Saf Surg 3:17.4. Ponce, J. (2005) Laparoscopic Adjustable Gastric Banding: 1,014 Consecutive Cases.Journal of the American College of Surgeons, 201(4):529-5355. Parikh MS, Fielding GA, Ren CJ. (2005) U.S. experience with 749 laparoscopic adjustable gastric bands: intermediate outcomes. Surg Endosc. 19:1631-5.6. Dixon JB, O'Brien PE, Playfair J, Chapman L, Schachter LM, Skinner S, Proietto J, Bailey M, Anderson M. (2008) Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial. JAMA. 299:316-23
