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For weight loss and/or diabetes control, which type of bariatric surgery do you prefer?
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Laproscopic banding is over-utilized
As far as the procedures go, there is one that I particularly do not prefer — the laproscopic band procedure. I have written a few articles on the subject. It’s probably an over-utilized procedure. The surgeon takes a foreign object, a little plastic belt, and wraps it around the stomach. It is a relatively simple procedure that takes about 45 minutes in the right hands. Putting foreign objects into patients is going to have long-term complications, however, such as band erosions and problems with the tubing. Patients might require secondary surgery to have these things fixed. It is not a very durable operation.
One of the newer operations that surgeons are talking about is the sleeve gastrectomy. This is essentially where you remove a sleeve of the stomach, thereby making it a thin tube. As with the band, it is a constrictive procedure, where decreased intake and subsequent decrease in fat mass results in weight loss and improvement in things like diabetes.
 Andrew Gumbs |
One of the benefits of the sleeve over the band, however, is that you actually remove part of the stomach. With the band, the entire stomach is left intact. When you remove part of the stomach, you remove part of the ghrelin-secreting portion of the stomach. So ghrelin levels decrease, and we think that might be one of the reasons patients may have better long-term weight loss and improvement in their diabetes after a sleeve gastrectomy when compared to a band procedure.
Andrew Gumbs, MD, is an Assistant Attending Surgeon at New York Presbyterian Hospital.
No preference for any current procedure
The two most commonly performed bariatric procedures are gastric bypass and the adjustable gastric band. I do not prefer one procedure over the other.
Gastric banding creates a gastric pouch that is actually adjusted to constrict the stomach to create a new outlet through the stomach. So when food enters the pouch, it stays in the pouch, stretches the stomach, and makes patients feel full more quickly. After surgery, we can adjust the band to make it tighter and can also loosen it if it is too tight. It is adjusted via a needle through the skin.
 Atul Madan |
There is no randomized trial comparing the bypass and the band. And the long-term data for sleeve gastrectomy do not exist at this time. However, most data suggest that with a bypass, you will lose slightly more weight than with a band. Weight loss is faster with the bypass, although weight regain may be common with this procedure. Some may have a bias against that band because initial weight loss is not as robust as in the bypass. However, the goal of bariatric surgery is not short-term weight loss but long-term maintenance. Unfortunately, the band does take more work after the surgery then before in adjustments and proper follow-up. That is the key to its success. The concerns of issues about a foreign body are real but there is also a decreased mortality after the band compared to the bypass or other procedures involving transecting the gastrointestinal tract.
As far as diabetic resolution goes, there is some suggestion that there is something about bypassing the initial part of the gastrointestinal tract that lends itself to resolve diabetes at a faster rate and higher incidence. It is well established that bariatric surgery can resolve diabetes, whether you are looking at gastric bypass or banding. Weight loss without any surgery also resolves it. Since we do not know the true mechanism of diabetes resolution after bariatric surgery, recommending one procedure over another in diabetic patients, at this time, is based on conjecture and not data.
Atul Madan, MD, is Chief in the Division of Laparoendoscopic & Bariatric Surgery at the University of Miami Miller School of Medicine.