Adjustable Gastric Banding (AGB) procedures have been presented and promoted as innocuous and low risk in nature. AGB still carries significant risks although its perioperative complication rate appears to be less compared to other weight loss surgical procedures. Such risks include permanent and potentially life-threatening damages or other complications if proper treatment isn’t sought in an urgent manner.

Often times a patient’s complaints are minimized and blamed on behavior or their presumed non-compliance. Quite frequently they are only referred to a surgeon after exhaustive workup has been completed and mostly reported back as normal. These workups include upper GI series and endoscopic studies. Nevertheless, the complication(s) with which a patient may have been presented with still continue.

I would like to discuss two such examples in which patient care may have been delayed.

The first patient was a 45-year-old male who had the AGB procedure completed approximately two years prior to her first visit to our office. He presented complaints of abdominal pain and worsening reflux. He had had multiple adjustments at his primary surgeon’s office and was told to be in the optimal “green zone” for the band. He had lost approximately 45% of his excess weight, but continued to have significant debilitating reflux.

An upper endoscopy was reported to be normal and consistent with a properly placed band. An upper GI performed months later identified a dilated esophagus, requiring the band to be removed. In hindsight, the band should have been completely emptied upon the patient’s first complaints of abdominal pain and reflux.

The next patient visited a local emergency room with acute onset of nausea and vomiting. She was sent home with a diagnosis of gastroenteritis and instructed to follow up with her primary care physician. She returned back to the emergency room within 36 hours with a progressively worsening nausea and vomiting. She was admitted and underwent an upper endoscopy after which a surgical consultation was obtained. The patient was taken to the operating room with a diagnosis of “slipped band”, and had to have the band removed emergently. Looking back at this case, the abdominal x-ray was suspicious for a slipped band. She should have been referred for surgical care at the time of her first emergency room visit.

Ultimately, the burden of proof is on the medical provider treating the patient with an AGB to ensure that there is no slippage when the patient presents with acute changes in his or her condition. The AGB may still “appear” to be in the proper place and adjusted with the patient still having symptoms of reflux, inadequate weight loss, and abdominal pain. These patients would require surgical intervention and probably removal of the band.

As indicated earlier, the patients’ complaints should not be discounted as being a compliance issue and instead should be referred for surgical evaluation.

Dr. Papaconstantinou of White Memorial Hospital in Temple, Texas has studied the relationship between the presence of colonized nares with Methicillin Resistant Staphylococcus Aureus (MRSA) and the incidence of the type of the infection after a gastrointestinal surgery.

He studied 1137 patients. He compared the postoperative infection rate of patients that were positive for MRSA, Negative for MRSA and a third group that was Methicillin Sensitive Staphylococcus Aureus (MSSA). He found that the infection rate for MRSA group was 14%, the highest of all the groups. There was no correlation however when other risk factors were accounted for.

The most significant finding however was the type of the infection present in MRSA patients. With positive nasal swab for MRSA, the most common organism causing the wound infection was MRSA (70%). In patients that were MRSA negative for the nasal swabs, the rate of MRSA wound infection was low at only 8.5%.

An additional finding was that the finding of MRSA positive nasal swab was a predictor for prolonged hospitalization.

There was no reported difference in the postoperative death rate in the MRSA positive or negative group.

It is important, however, to remind ourselves that this is a single study and more studies are needed to look at these variables in different surgical procedures.

The initial short-term data available for Adjustable Gastric Banding (AGB- Lap Band and Realize Band in the US) was promoted as a minimally invasive procedure with an equal outcome and low risk compared to the more commonly performed gastric bypass or the most successful procedure, the Duodenal Switch operation.

Over the years the data that has been published has drawn a completely different picture. The weight loss has not been as anticipated or sustained in majority of the patients who have had the AGB. Furthermore, the incidence of complication has been far worse than initially presented.

Common complaints that the patient reported with AGB includes inadequate weight loss, symptoms of reflux, abdominal pain, and significant solid or food intolerance. The general consensus and treatments have been tailored towards adjustment of the band either by adding fluid to tighten, to hopefully promote weight loss or by removing fluid from the band to reduce the restriction and resolving the reflux and/or deep abdominal pain. This only is after a mechanical or placement issue has been ruled out.

Most recently published data (Poster presentation ASMBS 2011 San Diego, CA.) shows that majority of the patients who developed esophageal dilatation, will require conversion to a different bariatric surgery. Furthermore, the consensus developing is that the placement of band should not be performed since there are better alternatives that can yield much better results with a safety profile that is better than that of the AGB.

As I have summarized previously, if long term data is reviewed the complication rate of the AGB is much higher that initially reported. I think there has been selective reporting of the data performed to promote a procedure that in the very short term may look attractive, however, over time, complications surface. Almost all patients with AGB procedures are sent home the same day, and in the first few months some weight is lost and almost no complication of reflux, indigestion, or other esophageal motility problems are reported. Yet when the same patient data is collected past the 12 months then there is increase in the reported cases of the complication of the banding procedures. This has lead to European and South American Centers that have lead the wave of the AGB placement to make a reversal of course and now recommend that other surgical procedures be offered to patients instead of the temporary fix of the AGB.
With our own practice we have significantly reduced the AGB placements. It is impossible to recommend a procedure that its results cannot be backed up with scientific data. We also find ourselves, spending a significant amount of time correcting the information that most patients have obtained from non-medical sources and even in some cases from other health care providers that is just not correct.

These are some of the examples of the information that I would like to clarify and explain to patients since they are deceiving and inaccurate.

“The band is reversible.”
Let’s take the concept of the “reversibility”. Can anyone name a procedure that a patient may need to have it done as a cure to an ailment with a condition of reversibility? Would anyone like to have a reversible hip replacement? Appendectomy? Or Cancer surgery? The point that I am raising is that the option of reversibility all by itself is not a meaningful measure other than it can be removed. One has to ask why I would want it removed. The answer is that it has a high complication rate that surface later on and in almost all cases requires band removal.

“It has minimal risk.”
The issue of the risk is one that I also emphasize. I think is inadequate to discuss the option of the risk in vacuum with no discussion of the benefits of each procedure. In majority of the cases patients indicate that the AGB can be done as outpatient (correct) with minimal down time (correct). The long-term outcome however is not there and I would recommend that the patient have no surgery since the long term complication of the banding is significant for any marginal benefit of weight loss.

“Patients have complications with the gastric stapling.”
There is a general misunderstanding that all procedures that have to do with weight loss are either the “gastric banding or the stapling type”. It is critical that we all appreciate that there are a number of different surgical procedures, that have different outcomes and each one of them needs to be examined for suitability for each patient