The technique of adjustable gastric banding has become the gold standard in the surgical treatment of morbid obesity in Western Europe and in Australia. It is now rapidly gaining popularity in the US as well. The procedure is rather easy to perform, even in massively obese patients, and the band itself is adjustable. Since the band is placed around the stomach, no changes are made to the existing anatomy, which renders the procedure fully reversible. As the main goal in obesity surgery is not to harm, the adjustable gastric band could appear as an ideal solution, yet some caveats exist. We will not focus here on the numerous material failures of the procedure that have emerged with the different types of bands, such as tubing-port disconnection, tubing decay and band chamber leakage, as these problems have been mostly addressed in recent band development.
Some of the effects of the band are not reversible. Permanent damage to oesophageal motility has been reported.1
Band-induced gastro-oesophageal reflux may facilitate the development of distal oesophageal cancer.2
Gastro-oesophageal reflux is a logical consequence of high gastric stenosis. In fact, since the stomach proximal to the band is highly distensible, some unavoidable dilation of the pouch must be anticipated. If, on the other hand, the band is placed very high on the stomach (i.e
. in the so-called oesogastric position) oesophageal dilation will very often ensue.3
Not surprisingly, the average number of vomiting episodes in patients reported as successes in terms of weight loss is more than once a day. The questionable quality of life caused by this frequent emesis condition, however, does not always translate in quality of life studies such as the BAROS score in band patients.4
This phenomenon can only be explained by the psychological reward patients obtain with significant weight loss, which renders all other symptoms negligible in their opinion. Nonetheless, if one keeps in mind the potential risk of oesophageal cancer possibly enhanced by marked reflux and frequent vomiting, one should assume that at least annual oesogastroscopies should be performed in this patient population. Also, in order to avoid vomiting and if not managed properly, a significant number of patients will change their eating habits and switch to an often highly caloric semi-liquid diet.5
Poor food selection, particularly avoidance of protein-rich food, more often than not results in protein malnutrition, anaemia, and vitamin depletion. Lack of compliance with postoperative dietary regulations is the principal cause of failure of any restrictive procedure. Band patients experiencing this turn in eating habits can, and should, be treated by temporary loosening of the band, but this implies patient discipline which, as a rule, is not prevalent amongst the bariatric patients.6
Despite this lack of patient discipline, the need for frequent doctor's visits is very likely the most important key to success or failure with this technique. Most studies performed in Australia (but not elsewhere) report excellent results (i.e
. a permanent weight loss of 50% of excess weight) in almost all patient groups, regardless of their initial body mass index (BMI). The Australians have established a very well-organised follow-up system, involving dieticians, physician assistants, nurses, etc
. who are willing to help patients, even if treated elsewhere.7
Similar empathy is hard to find elsewhere in the world and European patients appear to have a lower tolerance for frequent follow-up visits. As a result, the clinical results of most Australian groups remain unmatched. The need for thorough follow-up, however, cannot be over-emphasised as detection of dangerous symptoms and their adequate treatment can be life-saving. In the rare, but extremely serious, condition of pouch necrosis,8
for example, symptoms often are deceivably mild.
The most serious challenge to a bariatric operation is time. Indeed, many patients will experience weight regain starting some 2 years after the procedure. Few series report on results beyond 5 years; those that have, report dismal longterm results. Re-operation rates continue to rise after 10 years or more.9
In fact, this high incidence of re-operations has pushed researchers into developing a biodegradable band, with the intention of complete disappearance of the band before dreadful delayed complications can occur. Besides material breakdown, the most frequent causes of re-operation are: insufficient weight loss, intractable gastro-oesophageal reflux, pouch dilation or band slippage, and intragastric migration of the band. Whereas some authors can treat this latter complication by endoscopic means,10
most surgeons still rely on a laparoscopic or even ‘open’ approach for band removal. Replacement of a band after slippage or migration is, in our experience and in most others,11
quite unsatisfactory. Some surgeons, however, do not hesitate to replace a band once, twice, or even three times. The therapeutic attitude of some authors towards adjustable band complications is sometimes quite surprising; achalasia-like malformations of the oesophagus, for example, are now judged acceptable by some.12
This disturbing evolution is hardly compatible with the prime intention of the procedure itself, namely minimal aggression to the body.
Many band patients will need another bariatric operation at some point in the future, be it for obesity recidivism or for adverse effects of the technique. There is substantial evidence that re-do operations are technically more demanding, more prone to complications, and less effective than primary ones. Quite logically, the number of conversions into laparotomy will be markedly higher in the re-do situation. The incidence of complications in re-do bariatric surgery is significantly higher than in first comers.13
The pouch is more difficult to construct and will often end up being too large because excessive scarring obscures the view and renders dissection hazardous. Quite often, surgeons will be forced into adapting their technique to the anatomical changes induced by the band and switch to an operation they are not accustomed to, like biliopancreatic diversion.
Can the band be used as a rescue strategy after other failed bariatric procedures? Some authors have had good results by adding an adjustable band after previous failed procedures.14
Whilst in the latter case adding restriction may sound logical, it contradicts Scopinaro's principle. Also, placing an adjustable band proximal to the vertical staple line of the VBG involves placement of the band in the aforementioned oesogastric position, prone to oesophageal dilation. Moreover, it implies replacing a failed restrictive construction with another one, which appears illogical to most of us. Indeed, there is substantial evidence in literature that the best way to treat a failed restrictive procedure is a malabsorptive operation. The adjustable band has also been used in conjunction with gastric bypass, in an effort to render the bypass reversible and allow for endoscopic access to the greater stomach and to the biliary tree. A committee of experts, however, recently determined this technique to be unsuitable due to its grave side effects.16
Adjustable band gastroplasty in the treatment of obesity appears to be extremely operator (or country) dependent. The excellent results obtained by some are in sharp contrast to the experience of most others. A good procedure should be easily replicable, not only considering the technique itself, but also considering the approach to follow-up. As long as this is not the case, the adjustable band will remain a questionable tool for many bariatric surgeons, including ourselves.