Adjustable Gastric Banding – A Review:
Many of our patients with type 2 diabetes struggle daily with the food part of their new lifestyle. Unfortunately we live in a world where bad choices are available 24/7. Supermarkets are stocked with processed foods full of unhealthy amounts of fat, salt and/or sugar. Restaurants and even recipes in the news can be extremely unhealthy. It can be difficult if not impossible to lose weight in such an environment.
Is surgery for obesity a viable option for some of our patients?
This article will follow one patient’s experience (I will call her Gail) with the adjustable lap band procedure at a clinic in Toronto two years ago. Gail was 54 years old when she made the call to the clinic. Her weight was 226 lbs with a BMI of 42 (100 lbs above her ideal body weight). Her M.D. had told her that she was at high risk for type 2 diabetes. She was taking three drugs for hypertension and had just started a lipid lowering medication. She had chronic pain in her back and hips and became short of breath on exertion. Travelling on an airplane was becoming impossible and she felt that people judged her because of her weight. As Gail told the surgeon “If I don’t do something now, I won’t live to see my grandchildren”. Gail had contemplated whether she should have a gastric bypass or the lap band procedure. Her best friend, a pathologist, raised concerns regarding the long-term safety of the bypass and she opted for the lap banding.
The Allergan Lap-Band is approved by Health Canada as a treatment option for type 2 diabetes. Currently there are three companies that manufacture lap bands but only the Allergan band has this approval. The cost is $16,000 and in most provinces this is not covered by government health plans. Alberta is an exception but there is a long waiting list and so many of the patents go outside of the province for the surgery. In Quebec the surgery and device are paid for but there is limited funding for follow-up care. I will return to the importance of follow-up. Gail feels that it is critical both to choose a surgeon who does hundreds of these surgeries per year and a clinic which provides adequate follow-up visits.
I had the opportunity to observe the procedure and it is a minimally invasive procedure that takes about 30 minutes. It is done under a general anesthetic and the patient goes home the same day. The patient is back to all their normal activities within four to five days. The surgeon told me that there are about 1500 of these procedures per year in Canada and he performs 400 -500 of them. The lap-band is placed around the top part of the stomach creating a very small pouch which is less than 5% of the total stomach volume. It works on the principle of feeling satisfied or not hungry after eating a small amount of food. The stimulation of the vagus nerve in this part of the stomach leads to this satiety.
About 28% of his patients have type 2 diabetes and 60% have at least one health issue related to their weight. Complications are uncommon but the most common (<2% of patients) occurs when the pouch stretches due to overeating. The solution is fairly simple and includes repositioning of the band which is another out-patient procedure.
Gail stressed over and over the importance of the follow-up visits. The purpose of these visits is to adjust the band or to adjust the eating habits. A port is placed under the skin and saline can be easily added to the port and band to inflate a balloon on the inside of the band. This tightens the band slightly and allows her to feel satiety at smaller portions. Gail returned for saline adjustments 4-6 times in both the first and second year after surgery. She described the “sweet spot” where the band is adjusted to allow her to feel satiety for 2-4 hours after a meal. If too much saline is put into the band and the band is too tight the patient may end up having problems with vomiting and inability to keep solid food down. As she said “slow and steady paves the way to success”. The goal is to eat a healthy diet and lose 1-2 lbs per week.
The dietitian is an important part of the team. The diet progression is as follows:
- High protein diet for 2-3 weeks pre-surgery. This helps to shrink the liver.
- Clear fluid diet with beverages low in sugar and free of carbonation, caffeine and alcohol for the first 1-2 days after the surgery.
- Full fluids with high protein beverages for the next 12 days or so
- Soft foods diet – moist , minced, diced, ground or pureed for a few weeks to a few months
- Solid foods – the key is to eat small amounts of good food and chew each bite slowly. If food is not chewed well it will not pass through the opening between the pouch and the lower stomach. The dietitian can also suggest eating times, frequency and volumes (1).
- Post adjustment protocol – Isom (1) suggests going back on protein drinks for a day, then soft foods for a day before starting solids after the band adjustment.
Many programs suggest 60-80 grams of protein per day in early weight loss phase, although the daily reference value of 46-56 grams should be sufficient in later post-operative phases (1).
Patient reports have suggested this may cause some abdominal discomfort (1).
Minerals and vitamins
A complete multivitamin is advised containing fat soluble vitamins, B vitamins, thiamin, copper, zinc and selenium, 18mg iron, 400 ug folate and calcium and vitamin D (1). Aim for 1200-2000 mg of calcium and 800-1000 IU of vitamin D.
Expected weight loss
Most studies show that the average % weight loss with lap band surgery is 20-30%. Another way to measure results is percentage of excess of body weight (%EWL). Gail has lost 70% of this weight over 2 years. Patients must have a good understanding of the surgery and the lifelong dietary changes necessary to achieve weight loss (2). Weight loss will be limited if the patient consumes large amounts of high calorie liquids. Results will also be limited by eating soft mushy foods that slide through easily. Gail checks in with Weight Watcher’s once per week for support. Physical activity is also recommended to enhance overall health but Gail finds it hard to be active. One of the unique issues that Gail notes is that the band gets a little tighter when she flies. “I don’t eat anything solid when taking a long flight and have to be really careful afterwards”.
Gail’s diet before and after surgery
Gail said that before surgery she never felt “full” with meals. She was not a breakfast eater but would eat a healthy lunch and dinner which included vegetables, protein and some kind of starch. Snacks and treats were the big problem and she might have cookies and a tub of ice cream on a weekend.
Lunch and dinner are similar but portions are much smaller and the food is chewed well before being swallowed. Her treat might be one scoop of ice cream. She noted big differences in her behaviour at parties. In the past she might consume about 15 appetizers and now only 3 or 4.
Lap band surgery and the effect on type 2 diabetes
There have been many studies that compared gastric banding and conventional therapy for type 2 diabetes. In a randomized prospective trial (3) the patients had a mean duration of diabetes of less than 2 years and the mean A1c was 7.7%. At 2 years the rate of diabetes remission was 13% in the conventional therapy group compared to 73% in the banding group. Diabetes remission was judged by a fasting glucose of less than 7.0mmol/L and an A1c of less than 6.2%. The study has been criticized as the conventional therapy was not as aggressive as that in the Diabetes Prevention Program and the small sample size (n=55 patients) was not considered adequate. However the conventional treatment received treatment consistent with established clinical practice.
Lap band surgery is considered the safest of all the obesity surgical procedures. The CDA suggests that bariatric surgery should be discussed with all Type 2 patients with a BMI > 35 who have not been able to lose weight with other weight-control approaches. Some physicians believe that it should be done early in the course of the disease as diabetes is a progressive condition with beta cell deterioration over time. Lap band surgery works best if done before patients lose significant beta cell function and require insulin therapy.
On the other hand Van Wormer (4) raises some concerns which have not yet been addressed. These include:
- How to help patients who are non-adherent to the nutrition recommendations
- How to help patients who re-gain weight
- How to prevent recurrence of the diabetes
There may be psychological issues around food that the surgery does not correct and there is no psychological screening to choose the best candidates at this time.
The diabetes educator can at least discuss the pros and cons of the surgery with appropriate patients. The surgery is not for everyone. Gail feels that it has changed her life and would go through it again. She calls it a “tool” which has helped her to gain control of her eating.
1. Isom KA. Standardizing the Evolution of the Postoperative Bariatric Diet. Diabetes Spectrum Fall 2012;25: 222-228.
2. Bagdade PS, Grothe KB. Psychosocial evaluation, preparation and follow-up for bariatric surgery patients. Diabetes Spectrum Fall 2012;25:211-216.
3. Dixon JB, Obrien PE, Playfair J et al. Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial. JAMA 2008; 299:316-323.
4. Van Wormer J. Has Research Optimized the Targeted Use of Weight Loss Surgery for Glucose Control? Diabetes Spectrum Fall 2012; 25:194-195.
The author wishes to sincerely thank Sema Schreiber and Dr. Chris Cobourn (Medical Director and Surgeon, SmartShape Weight Loss Centre) who generously shared their time and expertise.