Not All Surgeons Subscribe to Weight-loss Surgery

The adjustable gastric band (AGB) procedure, like all obesity surgeries, is not without controversy and detractors.

Allan Wittgrove, the current head of the American Society of Bariatric Surgery, who was part of an early AGB clinical trial in the USA, doesn't perform the procedure anymore.
"My patients didn't experience the same level of satiety, the feeling of fullness after eating a small amount of food, as my gastric bypass patients, and that is key to success," Wittgrove says. His patients who got the AGB, also called the lap band, lost much less weight than his bypass patients, and he has operated on several to change them to the bypass. Wittgrove subscribes to the theory, still being studied, that bypass surgery suppresses the hormone ghrelin, which stimulates food intake, while the AGB does not.

On the other hand, Jaime Ponce at Hamilton Medical Center in Dalton, Ga., who has done more than 600 lap bands, doesn't perform any other kind of obesity surgery. He says studies show lower complication and death rates than for gastric bypass.

In two studies of more than 700 patients, death rates of 0.1% and complication rates of 2.2% to 10% were reported. A survey of several studies of bypass patients in the American Journal of Surgery shows reported death rates 10 times greater at 1%, with some complications, such as 5.6% developing a gastrointestinal leak that can lead to serious infection and 24% developing a hernia.

Ponce thinks U.S. surgeons, whose success rate in many cases hasn't been as good as that of more experienced Australian and European AGB surgeons, struggle to cope with the amount of follow-up required with lap-band patients, making the mistake of treating them the same as bypass patients.

"It's not the right procedure for every patient or every surgeon," Ponce says.
Both Ponce and Wittgrove say experience suggests that the best band patients are AGB patients who eat healthy and who would be active if not for their weight, whose obesity seems driven more by genes than sloppy eating, and those who are emotionally stable. Bypass, they believe, achieves weight loss for a greater variety of patients.
U.S. studies of AGB patients show 41% to 53% excess weight lost on average after three years. Long-term studies of bypass patients over five to 14 years show an average of 49% to 62% of excess weight lost.

Studies on both the lap band and gastric bypass in the USA show that about 20% of patients need second surgeries because of complications.

A recent article in the Journal of the American Medical Association, though, questions whether weight-loss surgery of any kind is prescribed too easily.

In the article, Walter Pories, professor of surgery and biochemistry at the Brody School of Medicine at East Carolina University, says that explosive demand by obese patients and huge earnings for surgeons make screening patients haphazard at best.

Edward Livingston, a professor of surgery at the University of Texas Southwestern MedicalCenter in Dallas, who has done more than 1,500 weight-loss surgeries, says a planned long-term study may show that "we've overestimated the benefits of surgery compared with medical treatment" such as medications and behavior modification.
Paul Ernsberger, associate professor of nutrition at Case Western Reserve School of Medicine, a critic of weight-loss surgery, is skeptical of published studies.

"Patients who fail or develop complications after two years aren't often followed by their doctors, because those who fail are too embarrassed to go back," Ernsberger says.

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