Evolution in bariatric surgery
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 appeared in the late 1970s and early 1980s.
But these procedures didn’t gain widespread mainstream use until gastric band procedures gained full Food and Drug Administration approval in 2001. Clinical trials have found people who have bariatric surgery have a significantly lower risk of heart disease and other obesity-related health problems.
In the decade that followed the FDA’s approval of gastric 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, [gastric] band was the most commonly performed procedure for bariatric surgery worldwide and in the United States,” Dr. Aminian said. “It was very easy 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 were 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 [gastric] band is a foreign body that we place inside the body, many patients had complications related to that foreign body,” Dr. Aminian said.
The band can sometimes move or be displaced, causing blockage of the stomach, experts noted. Other common complications include nausea, vomiting, acid reflux, and esophageal issues (such as a hard time 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 that is connected to the band, which doctors use to make adjustments after surgery.
“Scar tissue can also form around the [gastric] band that can cause a blockage in the stomach,” Dr. Aminian said. “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 have been found to be safer, result in longer-lasting weight loss, carry fewer complications, and require fewer patient reoperations. Dr. Aminian estimates that 2%-3% of patients need second operations.
Another key factor: Metabolic ‘reset’
Sleeve and bypass procedures offer another critical advantage over band operations: They help reset the body’s metabolism better, changing appetite- and weight-related hormones in the body.
Those hormones can affect food cravings, help people feel full after eating, or boost weight gain in ways that can trump willpower, experts say.
“The [gastric] band doesn’t change the hormones in the body, it’s just a restrictive band around the esophagus or the upper part of the stomach, so it limits the patient’s ability to eat too much,” Dr. Aminian said. “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, Dr. Aminian said.
“And that’s why it’s very effective. The problem with the [gastric] 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 said.
“They change the setpoints,” Dr. Aminian said. “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 temperature inside.
“When a patient goes on a diet or goes on the [gastric] 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, then the thermostat will change and you’re not going to regain the weight that you have lost.”
Sachin Kukreja, MD, a surgeon and CEO at DFW Bariatrics and General Surgery in Dallas, said he believes these metabolic changes are the biggest things behind successful surgeries.
“People synonymize bariatric surgery with weight loss surgery, but really the metrics we should be using are more related to metabolic measures,” said Dr. 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 [gastric] band.”
David Arterburn, MD, agrees that resetting metabolism is important but said the issue is “controversial and challenging” among bariatric surgeons.
“The metabolic setpoint is the idea that we have a biologically controlled set body weight that we will always return to. Clearly, this is not the case for everyone, as some people lose and maintain long-term weight loss,” said Dr. Arterburn, a general internist and bariatric surgery researcher at Kaiser Permanente Washington Health Research Institute in Seattle.