Lap Band Surgery vs Tube Gastrectomy vs Gastric Bypass Surgery - How to choose between these types of surgeries?

The essential part in the decision making process is a discussion of the individual patient’s weight problem and how weight loss surgery might affect that. There are multiple operations available for the patients to choose to treat their obesity problem. In Australia those operations are classified as primarily restrictive and combination procedures which involve restrictive and malabsorbtive (reduced food absorption) components. Before choosing an operation and speaking to your surgeon it might be useful to speak to other people who had similar procedures. One can have a feel of the range of experiences about different surgical operations from various surgical blogs and social media. Lap band and sleeve gastrectomy operations belong to the restrictive surgical procedures group and Gastric bypass belongs to a combination procedure group. In my practice all those operations are performed laparoscopically (keyhole technique). As the patients differ in the extent of their overweight – the operation has to be carefully chosen to address the individual patients needs.
Lap Band is an adjustable prosthetic device implanted around the upper part of the stomach. The advantages of this procedure are that it is least invasive, reversible and no stapling or cutting is involved. It leads to approximately 40-50% of excess weight loss.
Sleeve gastrectomy involves partial removal of the fundus and the body of the stomach, reducing gastric volume from approximately 1 litre down to 150 mililiters. No intestines are removed or bypassed. No foreign body is inserted. It has a better patient compliance excellent hunger control and is often called “sleeve and leave” procedure. Weight loss process is much faster and compliant patients loose on average 60 – 70% of their excess weight within the two year period.

Gastric bypass involves creation of small gastric pouch and rearrangement of small intestine in a “Y” configuration to limit absorption of food to some extent. Gastric bypass gives approximately 70-80-% of excess weight loss and is an ideal operation for the diabetic patients as it reverses diabetes in up to approximately 80% of cases.

I will briefly describe the essential points of difference between the 3 most commonly offered bariatric surgeries.  When deciding which surgery you will have, you have to decide which positive and negative points about each operation are most relevant or important to you.  The decision should be made with thorough assessment and discussion with your surgeon and care team.

Gastric banding
  Positives
  - it is reversible
  - the stomach is left intact
  - has the lowest serious morbidity and mortality rates of all three
     procedures
  - can achieve up to 50-60% excess weight loss if follow up and band fills
      performed appropriately and patient follows ‘post-band’ dietary advice
  - in situations where you may need your dietary intake to increase, it is
     possible to temporarily reverse the restriction on the diet by deflating the
     band through the port
  Negatives
  - generally does not achieve as much excess weight loss as the gastric
     bypass
  - insertion of a prosthesis (silicone), and any prosthesis or foreign body
     has the potential for developing infection
  - patients need follow up forever and needs frequent appointment during
     which the fluid in the band needs to be changed to optimise weight loss
  - problems may occur any time in future which may need reoperation or
     even removal of the band including 1. slippage of band, 2. erosion of
     band into stomach, 3. dilation (stretching) of small pouch or oesophagus
     above the band, 4. port or tubing problems such as flipping over of port or
     hole and leakage of tubing.
  - If the band needs to be removed for some reason, then most of the
     weight lost is often regained.

Sleeve/tube gastrectomy
  Positives
  - there are no anastomoses (joins) required to be performed or to heal in
     the gut
  - may be possible in severely obese patients if bypass is not technically
     feasible due to massive intra-abdominal fat
  - These patients may potentially not need to be followed up as frequently
     as the gastric band or gastric bypass patients
  Negatives
  - There is a lack of long-term data of this operation as it is newer than the
     gastric bypass and gastric band
  - There is some concern that the tube of stomach can stretch over time and      
     cause less restriction to the diet
  - There is a long staple line where a large part of the stomach is removed,
     and this staple line has the potential risk of leaking, which can be a very
     serious complication

Gastric Bypass
  Positives
  - It probably achieves the greatest excess weight loss at about 60-70%
     (hence it tends to be the operation recommended for the massively
     obese patients with BMI >50).
  Negatives
  - It has the highest peri-operative morbidity and mortality rates (although
     fairly low, these are is still higher than the gastric band)
  - It has the potential risks of leakage from the staple lines or the (two) joins
     or narrowing of one join in particular, there are risk of bowel twisting
     around each other, higher risks potentially of malabsorption of important
     nutrients and vitamins. Some of these surgical risks can be very serious
     or even fatal
  - It is essentially not reversible
  - Still need relatively frequent follow up by your surgeon and/or dietician to
     make sure you are not developing any serious malabsorption syndromes

All surgeries have the risk of failure of loss of weight or risk of regaining lost weight for one reason or another and all surgeries require patient compliance in following the recommended dietary changes. They all also carry the increased risks of surgery that occur with obese patients compared with non-obese.

I hope this helps you to understand what needs to be considered when making your decision but again I stress that you should have a thorough discussion with your surgeon and care team when making this decision.