The Weight Loss Options: When Should You Choose the Lap Band? by Dr. Paul O’Brien

So you have decided to lose some weight. Congratulations. Accepting that you have a problem is the critical first step to solving the problem.

Let's assume, by the fact that you are visiting this website, you have a relatively serious problem with your weight. Let's assume that you are obese. By convention we restrict the term obese for those with a Body Mass Index (BMI) above 30 kg/m². And let's assume that today is the first day you even started thinking about weight loss. What should you do?  What are your options? Which will you do first? Which will be your last resort?

I have made a list of your options and I have put the list in order of the combination of risk, cost and complexity. Common sense dictates that the simplest and safest option that works should be your first choice.

Let me make some comments on each of the options on the list.

1. Lifestyle change

This option covers the standard and well known programs of dieting, exercise and behavioral modification. In essence, it means eating smaller amounts of food, eating less frequently, not snacking or grazing, increasing your activity throughout the day, exercising and changing the habits that lead you to eat too much. We include all the commercial weight loss groups, such as Jenny Craig and Weight Watchers and the health professionals such as dietitians, psychologists, naturopaths etc.  Almost everyone who visits this website will have been trying these for many years but nevertheless we include it as we have assumed that today is your first attempt at weight loss.

The long term outcome from lifestyle change is quite disappointing. Most who are obese have not really started to try to change their lifestyle. Most who have started, don't try it properly; they aren't committed to a program.  Most, who do try hard, don't lose weight. Most who do lose weight, regain it. You quickly realize there are not many left for whom lifestyle is worthwhile. But there are a few. Some people do lose a substantial amount of weight and keep it off over several years. You may be one of these fortunate people. Therefore you must test this option before moving down the list.

Score on the RCC scale - 1

2. Drugs and very low calorie diets

We have very few drugs that are available for the treatment of obesity. We certainly need more and I can assure you that "big pharma", the drug manufacturers are working as hard as they can at finding such a drug or combination.  They would love it and their shareholders would love it. But it has not been easy.

The three drugs currently available are sibutramine, phentermine and orlistat.  They don't not exactly make you melt away. You will lose a little weight while you are taking them - usually less than 10lblbs. If losing 10 lb would solve your problem, you certainly should try for it. But most who are obese need to lose 50 lb or 75lbs. If that is what you need, you will not find a solution with current drug therapy. And, as soon as you stop the drug, the little guy who is up in your brain setting your weight will be calling you back to where you were.  In the meantime you are suffering all the side-effects of these drugs and paying quite a steady cost for each month's supply. Short term weight loss is no value and potentially it is harmful. There seems little benefits is this option at this stage.  Let's wait and see what Big Pharma can come up with in the future.

Very low calorie diets (VCLDs) can lead to a worthwhile weight loss if they are used properly but they are at best a short term solution. There are a range of products on the market with Optifast being the best known, best studied and most widely used. The VCLDs are not much fun but they do work. If you stick to the rules, you can lose 20-30 lbs over a 3 month period. But don't underestimate how hard it is to stick to the rules. Most people cannot do it but it may well be worth a try. You are not allowed to continue beyond 3 months. Once you are back on normal food, the hard-earned weight loss starts to disappear. You can have a second course of Optifast later on but very few can get the enthusiasm up for this second round. Obesity is a long-term problem and this is not a long-term solution.

Score on the RCC scale - 2

3. Endoscopic options:

These options involve passing a gastroscope (a flexible tube with a light source that enables us to look inside the stomach) and doing something that could lead to weight loss. There are lots of ideas about what would work, including special stapling devices, sleeves that divert the food further down the gut and ways of stopping food getting out of the stomach. So far almost all are experimental. The intragastric balloon is the only endoscopic procedure in current use. The attraction of the endoscopic procedure over surgery is the reduced invasiveness.  Endoscopic procedures will usually be performed as an outpatient, are reasonably safe and do not hurt much. However, so far they are not known to be effective, are unlikely to give a durable effect and will probably cost as much or more than far more attractive procedures such as the Lap-Band.

The intragastric balloon was first introduced in the 1980s. It was shown not to be any better than just pretending to place a balloon. Further, they caused major problems if they burst and then blocked the gut further down. Newer versions are now available but have yet to be proven to be worthwhile. They are used in Europe and South America but are not yet approved for use in the United States.

Score on the RCC scale - 4

4. The Lap-Band:

The Lap-Band, also known also as the laparoscopic adjustable gastric band, LAGB and gastric banding, is as safe and almost as gentle as an endoscopic procedure but is as effective as more radical and invasive forms of surgery.

It works by controlling appetite, by taking away the feeling of hunger. Because it squeezes the top of the stomach for 24 hours a day there is a background control of appetite. Then as food is squeezed past the band extra signals go to the appetite center turning down the desire to eat more.

It has the further great advantage of being adjustable so that the level of saline in the band can be titrated against the effect. The adjustments can be regarded as equivalent to having a dial where we can increase or decrease the appetite by taking out or adding saline to the system. This is a real strength with the band but it can also be a weakness. You must come back to aftercare or we cannot adjust that dial. Without good aftercare the band is much less attractive as an option. At True Results we have created the best aftercare program available. But you must come back or we cannot help you.

Reversibility is another important advantage of the band. If some better treatment comes along in the next 15 or 20 years, you can have the band out, everything goes back to normal and you can start on the new treatment. That cannot happen after other surgical procedures.

Score on the RCC scale - 5

5. Sleeve gastrectomy:

This procedure started life as the first stage of the biliopancreatic diversion/duodenal switch (BPD-DS) operation which is discussed below. Then surgeons found that there was good weight loss with the sleeve and did not need to go on with the BPD-DS. Figure 2 shows what happens.

About 90% of the stomach is removed and the part that is left is shaped into a tube. You cannot eat as much and you lose weight, quite rapidly. You will lose as much weight with the sleeve as you will lose with a gastric bypass in the first year. There is not usually much weight loss after that. On average people will lose about 55% of their excess weight.

There are two major concerns with sleeve gastrectomy. First, it carries the risks of bypass and yet just gets no better weight loss than the band. Second, as there is no reinforcement of the tube of stomach, it will inevitably expand and so, after a few years, you will be putting weight back on. Short term weight loss, even for 4-5 years, is just not worth it.

Score on the RCC scale - 7

6. Roux-en-Y gastric bypass:

This is the oldest of the current forms of weight loss surgery having been in use since the late 1970s. The stomach is totally divided into a very small top bit and all the rest is closed off and no longer involved in digesting food. The tiny top bit of stomach is joined to a straight piece of small intestine that has been taken out of the loop. The picture shows what it looks like.

It is rather complex but it does lead to reasonable weight loss at least in the short term. As it is not adjustable, there tends to be weight gain after 5 years but it is slow and many get a good medium term result. However the weight loss is probably no better than the band at 5 years and onwards if the band patient is coming back to aftercare.

Score on the RCC scale - 8

7. Biliopancreatic diversion/duodenal switch: 

This group of procedures are even more complex than bypass. The stomach is reduced markedly and the gut is rearranged as shown in figure 4 so that the food you eat does not meet up with the digestive juices until the food has nearly reached the lower bowel.

It generally, but not always, leads to major weight loss but at a price of some unpleasant side effects and a serious risk of a range of nutritional deficiencies. It has never been popular and is even less so now being less than 2% of all weight loss surgery.

Score on the RCC scale - 9

So, after all that, what you should do?

First of all, make a commitment to find a solution. Don't start at level one and then stop when that doesn't work. Make the commitment to do whatever it takes to solve a very real problem. And make the commitment that you will do your part as well as possible.

I recommend you always start with the simple and safe and move towards the complex and risky. Start with lifestyle measures. Try hard and see if you are one of the lucky few who not only succeed but also succeed for a good period of time. Most of you visiting this website have been there and done that.

Next consider the drugs and VLCD. Again it is likely that you have already tried these options. If not consider at least one course of VLCD. If you do it according to the rules you should get a fairly rapid and acceptable weight loss. Then see if you can keep it off for as long as possible.

The current drugs are probably not worth the effort, the costs and the side effects. You could wait and see what new drugs appear. There are always candidates being assessed but you may have to wait several years and then be disappointed.

There is no endoscopic method currently available in the USA. The intragastric balloon could become available but I would not recommend waiting for it. It offers only a short term solution for a long term problem. You can lose as much weight with VLCD and with the balloon and there are fewer hassles, less complications and lower costs.

The next option is gastric banding. This is a great option and will solve most people's problems. It is safe; it is effective. It is well established. It does require a commitment to the aftercare process. Make that commitment. It is worth it.

There will be very few who are not adequately treated by gastric banding.  A few will go on to the more invasive procedures, maybe 2%, maybe 3%. It should not be more than that.  And once you get to this point, a sleeve or a bypass will often do no better, so you suffer he risks and the permanent changes and do not get a worthwhile return. This can be one of the few settings where BPD-DS is worth considering.

Thankfully, the vast majority will never have to worry about taking this last step.