Women of childbearing age who undergo gastric bypass should avoid pregnancy in the first 2 years after surgery "because they’re going to compete nutritionally with the growing fetus," he said. And patients should keep postoperative alcohol consumption in check. "If you drink half a glass of wine after gastric bypass surgery, you may be legally drunk because alcohol gets absorbed so fast in the reconfiguration of the stomach," he explained. "It may also be easier to get addicted to alcohol after the surgery because the levels get so high so fast. Alcohol needs to be on the back burner if you’re thinking about gastric bypass surgery."
According to the ASMBS, the gastric bypass procedure costs between $14,000 and $26,000, but Dr. Jones puts the cost of this and other weight loss procedures in the range of $30,000.
• Laparoscopic adjustable gastric banding (LAGB). In this procedure, surgeons place a silicone band filled with saline around the upper part of the stomach, creating a small pouch which causes restriction. The band can be tightened or loosened through a port.
Ideal candidates include patients with a body mass index of 40 kg/m2 or more, or those with a BMI of 35 kg/m2 plus a serious medical conditions such as diabetes that might improve with weight loss.
"The band operation itself is not that difficult to perform, yet you’re still around some real estate," said Dr. Jones, coauthor with Dr. Mark J. Watson of the "Lap-Band Companion" handbook (Woodbury, Conn.: Cin?-Med Inc., 2007), which is intended for patients. "There’s the esophagus, the aorta, the stomach, and the diaphragm. There are plenty of opportunities for very serious, life-threatening complications. The band is deceptively simple, but there is plenty of room for problems. Many severely overweight people who come to us have other significant comorbid conditions: coronary artery disease, hypertension, sleep apnea. All of these things may put patients at very high risk for heart attacks or respiratory arrest, or [deep vein thrombosis]."
Slippage ranks as the most common reason for needing to remove bands. Dr. Jones tells patients that there is a 40% chance that their band may need to be repaired, revised, or removed at some point in their lives. "That band may be there forever, or it may come out because they have prolapse and it’s in the wrong spot, or maybe they had an appendicitis and the band was getting infected," he said. "The things I see the most are breakdowns in the tubing or hub from, say, a needle stick during the port adjustment. Early on, a port can flip over, and long term, these bands can get out of position."
On Dec. 3, 2010, the Food and Drug Administration’s Gastroenterology and Urology Devices Panel recommended the use of the Lap-Band procedure for people who don’t meet the clinical criteria for obesity. Allergan Inc., which makes the device, proposed that the Lap-Band adjustable gastric banding system be approved for weight reduction in people aged 18 years and over with no comorbidities and a BMI of at least 35 kg/m2, or a BMI of at least 30 kg/m2 and one or more comorbid conditions. Eight out of 10 FDA panel members agreed that there was "reasonable assurance" that the device was safe and effective for this population.
Such patients may find it difficult to convince their health insurers to pay for the operation in the near future. "[Insurance companies are] probably going to hang tight at BMIs of 35-40 kg/m2. It may be that a BMI of 30-35 kg/m2 is going to be a cash-pay cost."
Patients who undergo LAGB generally go home by noon the next day. Dr. Jones believes an overnight stay for these patients is advisable, whereas most gastric bypass patients leave the hospital on the second or third day. Because more cutting and connections are involved with that procedure, there are more opportunities for leaks, stenosis, or bleeding, he noted.
• Sleeve gastrectomy. During this procedure, surgeons remove about 85% of the fundus and body of the stomach, creating a vertical sleeve that restricts the amount of food that can be consumed. The operation is generally reserved for patients who cannot tolerate LAGB or gastric bypass. As an example, Dr. Jones cited a patient whose size rendered him unable to roll over. "He was getting a hernia eroding through his belly button, so he had the beginnings of infection, so I didn’t want to put in a Lap-Band. He wasn’t a candidate for the bypass because he couldn’t tolerate the fluid shifts we might expect during the procedure. We did the sleeve procedure, and he lost 200 pounds."