Dr. George Fielding weighs in on the latest research on Lap-Band surgery.
We all know what we’re supposed to do if we’re very overweight, especially if those extra pounds are starting to cause health problems. We are supposed to follow the mantra of “eat less and exercise more.” It usually works for a while, and we can lose a few pounds, sometimes hundreds of pounds, if we can stick to it long enough. But what most people can’t do is keep the weight off.
Why is that? Well, for one thing, it can be an all-consuming process, where it’s all you think about, and eventually it can exhaust us. And then there’s the hunger. Skinny people usually get hungry, eat, are satisfied, and stop. Many of us who are fat are always hungry and are never satisfied. The normal triggers in our brain that say we can stop don’t work right. We are hungry all day, all night, and it just doesn’t go away. It’s fighting that hunger that’s so hard, so all-consuming. And finally, you have to stay very dedicated to exercise to burn off even one pound of fat.
We try, it works for a while, and then it doesn’t.
It’s at this point, often after several failed attempts, that overweight people may consider the possibility of weight loss surgery. I know it’s when I did 15 years ago. I had lost 60 to 80 pounds five times and regained it every time. Then, in one year, I ended up on 11 new medications as my body collapsed under the constant strain of being 330 pounds. I was a typical fat man faced with a choice. Lose weight or die young. Ask yourself why you don’t see a lot of old fat people. It’s because most are dead, years before their time. A man with a BMI of 45 dies about 13 years before his normal weight brother or sister.
The Lap-Band has been around since 1993, and available in the US since 2001, when it was approved by the FDA. There is plenty of long-term data showing it’s an effective tool. In Australia, O’Brien recently reviewed 3,227 patients treated with Lap-Band between September 1994 and December 2011. A total of 714 patients had completed at least 10 years of follow-up. No patient died from surgery. On average, those 714 patients lost 47% of their excess weight. The band was removed in only 6%. At NYU we studied 2,909 patients and found exactly the same thing - 47% excess weight loss at six years post-surgery. Two of our patients died after surgery. If you combine the two studies, that’s two deaths in over 6000 obese patients, many of whom are ill, and very effective weight loss long-term. Most people kept their bands, and most did well.
The Lap-Band works primarily by controlling hunger. There are many pathways that go to the brain to help it work out whether we are hungry or not. Many of them come from the top of the stomach, and are manipulated by the pressure applied by the band. When it’s adjusted properly, that relentless urge to eat can fade away. If you loosen it, the hunger may quickly return. If we can make an obese person persistently not hungry, that person will likely lose weight. I eat less than my normal-weight wife, and I am not hungry. I’ve had the Lap-Band for 15 years, have lost about 110 pounds and kept it off and have come off most of my 11 meds.
The Lap-Band can help those who are not morbidly obese, too. The FDA has approved it for people with a BMI 30 to 35. In 2009, we reported on 53 patients at NYU with an average BMI of 33, nearly all of whom had a weight-related disease. At two years, their BMI was about 25 on average, and the diseases were much improved. Similarly, in 2006, O’Brien in Australia compared a group of patients with a BMI less than 35 having bands, to a group on intensive medical weight loss treatment. At two years, the Lap-Band group lost 87% of their excess weight, compared to 21% in the medical group. Fourteen of 15 patients in the Lap-Band group lost the metabolic syndrome, compared to 7 of 15 in the medical group. In 2013, O’Brien did a 10-year follow-up on those same patients. The surgery group had maintained a 64% weight loss, and the medical group none. Ten of the 14 patients stayed free of the metabolic syndrome 10 years after surgery.
O’Brien recently took this one step further and studied diabetics with a BMI of 25 to 30. At two years, 52% of the Lap-Band group had remission of diabetes, compared to 8% of the medical group. We found similar results at NYU in a study of follow-up of 95 diabetic patients who had a Lap-Band at least five years, where 40% had complete remission and improvement of their diabetes.
It’s not all rosy. The Lap-Band is a device, and devices can have complications. We have studied this very carefully at NYU. In 3876 patients, 390 needed a Lap-Band revision, to reposition the band. Their initial BMI was 45. At reoperation, it was 32. Two years later BMI was 33. Their bands were revised safely, and they maintained their weight loss. Rarely, the Lap-Band can rub its way into the stomach, an erosion. Although we found this to be very rare, the Lap-Band needs to be removed in those patients, under a general anesthetic. The port or tubing caused problems in 4%, but these can easily be fixed under local anesthetic, without needing to go to sleep.
The Lap-Band is a safe, effective tool. It provides sustainable weight loss without removing a large part of the stomach, as in the sleeve, or rerouting the intestine, as in the bypass, both of which work well, but carry much higher risk. The Lap-Band works by controlling hunger. You just eat a lot less and are a lot less hungry. It’s worth thinking about.