New Jersey Governor Chris Christie's choice of gastric banding has prompted questions about why he opted for a weight-loss procedure less favored by bariatric surgeons and patients.
Lap-Band stirred excitement a decade ago when the anti-obesity device was introduced in the United States. The adjustable silicone cuff filled with saline is placed around the upper part of the stomach. That creates a small pouch less than 1 inch across that limits how much food one can consume at a sitting. The patient also feels full sooner, and can thereby shed weight.
In early 2011 the U.S. Food and Drug Administration extended the approved use of Lap-Band to include use by some people who are barely obese. At the time, manufacturer Allergan Inc, better known for its Botox wrinkle treatment, said the new criterion would make 26 million Americans eligible for the product.
The company's high hopes were quickly dashed, however, when sales plunged from almost $300 million in 2008 to $160 million in 2012 because of concerns about Lap-Band's effectiveness. Most studies find that although some gastric-band patients lose 100 pounds or even more, in general gastric bypass produces more, and more enduring, weight loss. Allergan is now trying to find a buyer for the product line and earlier this year said it considered Lap-Band a "discontinued operation.
Another important reason for Lap-Band's decline is growing evidence that a form of bypass surgery called Roux-en-Y may be more effective in treating Type 2 diabetes, which typically develops in adulthood and is linked to obesity.
Christie has not explained why he chose banding instead of a bypass, but experts who were not involved in his case pointed out several possibilities, including that he may not have needed to treat diabetes. In the past, Christie has described himself as healthy despite his weight.
"If he didn't have any other medical problems, that could have come into the decision-making," said Dr Jaime Ponce, president of the American Society for Metabolic & Bariatric Surgery.
Gastric banding is also a simpler procedure. Its rate of major complications is 0.9 percent, reports the American Society for Metabolic & Bariatric Surgery, compared to 3.6 percent for gastric bypass. That means less likelihood of post-operative infection, blood clots, blood loss or other serious problems.
About 200,000 people in the United States had weight-loss surgery in 2009, the last year for which data are available, according to the bariatric surgery society. Gastric bypass accounted for about half of the procedures and lap banding for about one-quarter.
REROUTING THE DIGESTIVE SYSTEM
The three main forms of bariatric surgery cost $11,500 to $26,000, according to the surgery society. Medicare, the federal government's health insurance program for the elderly and disabled, pays for them in patients who have a body mass index (BMI) of 35 or greater plus one additional obesity-related condition, such as diabetes or sleep apnea, and who meet certain other requirements. Many commercial insurers have similar policies.
In gastric bypass, a surgeon reroutes the digestive system so that the stomach empties directly into the middle of the small intestine, bypassing a section called the duodenum and jejunum. That has the effect of limiting the absorption of calories. And since the surgery also makes the stomach much smaller, it limits how much someone can eat at a time.
In sleeve gastrectomy, a surgeon staples the stomach vertically. That has the effect of decreasing its volume by more than 85 percent, creating a tube- or banana-shaped pouch that, like banding, reduces the amount of food that can be consumed and absorbed.
Complications from the banding cuff include the possibility that it will erode the stomach or slip out of place, requiring corrective surgery, said Ponce, who is also the co-medical director for bariatric surgery at Memorial Hospital in Chattanooga, Tennessee.
Banding can reduce the severity of Type 2 diabetes only if it leads to significant weight loss. But Roux-en-Y targets the underlying metabolic causes of diabetes, and blood glucose levels improve even before there is significant weight loss, said Dr Francesco Rubino of Catholic University in Rome, a pioneer in Roux-en-Y.
The more modest procedure also often fails to produce the significant and enduring weight loss that patients hope for. "One of the unfortunate reactions the body has to (smaller intake) is to decrease its energy expenditure," said Rubino.
As the body adjusts its metabolism to near-starvation conditions, it burns fewer calories to maintain basic metabolism. That can cause weight to plateau before patients reach their ideal size.
Even more distressing to gastric-band patients, they can regain weight. That can happen if they force too much food into the stomach, stretching it and thereby loosening the band, or if they eat mostly calorie-dense foods.
By contrast, with gastric bypass "there are more mechanisms at work that counter the body's reaction to weight loss," said Rubino. In particular, a study released this year found, the re-plumbing of the gastrointestinal tract alters the microbes that live in the gut, increasing the population of bacteria associated with leanness and decreasing those that contribute to obesity.
Christie, seen as a possible 2016 contender for the White House, told the New York Post on Monday that his decision to undergo the procedure was motivated by his family's concern for his health, not political ambition.
Because the risks and benefits of weight-loss surgery need to be assessed individually for each patient, experts caution that people considering one of the procedures should not be swayed by Christie's decision.
When public figures undergo bariatric surgery it can affect perception of the procedures for good and for ill. "Some patients may understand that this is a medical necessity and not a shameful thing so these examples may help more patients get proper care," said Rubino. But "some patients may decide to seek the same operation as the VIP when it may or may not be the best surgical option for their own case."
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