It is surprising to come across procedures such as “Weight Loss Tongue Patch” that are being performed now. Chugay et.al. (American Journal of Cosmetic Surgery, Vol.31, No. 1, 2014 26-33) reported a series of 81 patients with a mean weight loss of 16 lbs. (range 0-16.8). They concluded “While maintaining a strict low-calorie diet plan and adhering to a regular exercise regimen, patients using a tongue patch can achieve significant weight loss over a 30-day period, with relatively minimal procedural risk.

The “logic” of this procedure is that placing a mesh on the tongue makes swallowing painful and difficult. The patient is forced to maintain a liquid diet and this causes thus weight loss reported above.

The science and research of weight loss surgical procedures has centered around the metabolic aspect of obesity. Over the years we have moved away from the simple notion of obesity being only a function of over eating and lack of physical activity. The premise that obesity is a disease of energy imbalance is unproven to say the least.

In my opinion, this is a step backward in the surgical treatment of obesity.  I always tell my patients to do their research before signing up for a procedure. This procedure is similar to tried and failed wiring of the jaws. It only created a short-term weight loss that is no more effective than any diet. The notion that a patient should be punished with pain to loose weight should not be tolerated by anyone.

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

The gastric emptying is shorter after Duodenal Switch than after Sleeve Gastrectomy. This has been studied by having volunteers consume a known amount of measured food that contained trace amounts of medical nuclear markers. Using special imaging cameras, the amount of radiation collected in the stomach was measured over time. In the case of the Duodenal Switch patients, the emptying half time was 28 +/- 16 minutes, with the normal non-operated patient be at 91 +/- 20 minutes(i). The Gastric emptying after sleeve gastrectomy has been reported to be 38 +/- 19(ii) minutes and 57 +/-19(iii) minutes in two different studies.

(i) J. Hedberg et al., Gatric Emptying and Postprandial PYY resposnce after Biliopancreatic Diversion with Duodenal Switch. Obesity Surgery, (2001) 21:609-615.

(ii) Braghetto et al., Scintigraphic evaluation of gastric emptying in obese patients submitted to sleeve gastrectomy compared to normal subjects. Obesity Surgery, (2009); 19:1515-21

(iii) Bernstine et al. Gastric emptying is not affected by sleeve gastrectomy, without removal of the gastric antrum. Obesity Surgery, 2009;19:293-8.

Band to band revision is never a good idea, in my opinion. Please let me explain. There are many reasons why an adjustable gastric banding (AGB) revision may be needed, which include but not limited to complications of the surgery, inadequate weight loss or both. These complications are a lot more common than publicized. (i)

Over time the incidence of band failure, as defined to EBWL (Excess body weight loss) <25% or band removal increases from 13.2% at 18 months (the best mark) to 36.9% at 7 years(ii).The source that this date comes from has lowered the EBWL to 25% and although it’s been lowered, the success rate is still not impressive.

If the patient has had complications such as slippage, erosion, ulceration or perforation and the adjustable gastric banding needs to be removed, the procedure should then be revised to an alternative such as a Sleeve Gastrectomy or the Duodenal Switch operation. Revising to either of the two procedures, in my opinion, serve as better alternatives than to revise to a Gastric Bypass.

If the patient has developed physiologic and functional complication of the adjustable gastric banding, such as reflux, difficulty with swallowing or esophageal dysfunction, then removing and replacing the band will not solve the underlying problem. I would argue that the band itself would likely be the cause of the complication(s).

If the patient has an infection of the injection port side, then the port will needs to be removed and replaced in a subsequent operation.

The only time that I can possibly think that a revision of a band to band is an option is if the band was one an earlier model placed many years ago. You may question why this would be important. The value behind this is that it will not only determine what type of band was used for placement but also were it has been placed.

So the only question of importance would be: when was the adjustable gastric banding placed? This question is only significant if the AGB was placed at a time prior to the recommendation of a “pars flaccida” dissection. The first technique recommended for adjustable gastric banding placement was the “perigastric” technique. This meant that the band was placed sitting right on the stomach. In order to perform this, all the tissue around the stomach specifically on the medial aspect was dissected and the band was wrapped around the tissue of the stomach itself. This provided a tighter grip of the stomach. However, it became evident that this also resulted also in a high erosion rate because there was no tissue protecting the stomach from the foreign body wrapped around it. A second problem with this technique was that the top part of the stomach, again on the medial aspect, had a near straight extension line to the distal esophagus and thus resulted in a higher slippage rate. Additionally, the design of the band itself evolved during the same time frame, as the techniques were refined. So, if a patient has complications that a surgeon can directly contribute to the older “model” or the early technique of the placements of the AGB, one can argue revising and AGB to AGB.

I would like to raise the following question that all patients need to ask themselves; If some of the overwhelming reasons for choosing the AGB was its perceived “least invasive” nature, and the “low complication rate” as it is advertised so much, then wouldn’t the need for a revision itself prove both of those fact to be incorrect. The data demonstrates that the complications of the AGB are much more prevalent than initially thought, or reported.

It is my opinion that the AGB should not be the default procedure of choice and that there should be very good indications as to why a patient cannot have any of the other procedures.

(i) Long-Term Results of a Prospective Study of Laparoscopic Adjustable Gastric Banding for Morbid Obesity – Y. Nieuwenhove et.al. Obesity Surgery-21 (5), 2011, 582-587

(ii)A 10-year Experience with Laparoscopic Gastric Banding for Morbid Obesity: High Long-Term Complication and Failure Rates – M. Suter et.al. Obesity Surgery, 16, 2006, 829-835

One of the main reasons why humans become hungry is because of the hormone ghrelin. Ghrelin is primarily secreted by the stomach, which responds to hunger and starvation. Once ghrelin gets into the blood, it circulates the body until it reaches the Vagus nerve, which sends a signal to your brain that tells you “I am hungry!” Actually, for people who have had their Vagus nerve divided (a Vagotomy), ghrelin no longer has a significant impact on hunger. This finding suggests that the Vagus nerve and ghrelin are needed for maximum stimulation of hunger. Also, ghrelin containing neurons are found in the arcuate nucleus, a region of the brain that regulates appetite. In order to stimulate hunger, these neurons send signals to other neurons that contain neuropeptide Y (NPY), which stimulates hunger. However, if the body wants to suppress hunger, it will send signals to neurons containing proopiomelanocortin (POMC). (i)

Now that we know a little about how ghrelin makes us hungry, lets see how the hormone leptin makes us full. Leptin is made in the fat cells (adipose tissue) of our body. The way leptin regulates hunger is by stimulating or not stimulating nerves in the brain. Just like ghrelin, leptin acts on the arcuate nucleus. When leptin is not present, NPY causes us to be hungry. When leptin levels are high, they block NPY and stimulate POMC nerves in the brain that make us full. However, one might ask, if we have more fat cells that produce leptin, why are we still hungry? The answer is that many obese individuals have genetic defects that block the function of leptin. The other is that too much leptin can cause negative feedback to fat cells, which tell the body “hey we have too much leptin, stop making it.” (ii)

Although the exact mechanisms of how ghrelin and leptin work are extremely complex, we see that the three main responses that are contributed to the presence of ghrelin (iii) (iv) are:

1. Stimulation of appetite
2. Reduction of metabolism
3. Reduction of fat catabolism (fat breakdown)

In contrast to ghrelin, leptin’s main responses are:

1. Suppression of appetite
2. Increase in metabolism
3. Increase immune function

The following table summarizes the information on ghrelin and leptin, its relationship with other GI hormones, and its levels after Sleeve Gastrectomy. (v)

By: Chris Tashjian BS – Ara Keshishian MD, FACS, FASMBS

(i) Sato T, Nakamura Y, et al. Structure, regulation, and function of Ghrelin. Journal of Biochemistry. Oct 31, 2011.

(ii) Friedman JM, Halaas JL. Leptin and the regulation of body weight in mammals. Nature. 1998 Oct 22; 395 (6704): 763-70

(iii) Le Roux CW, Aylwin SJ, Batterham RL, et al. Gut Hormone profiles following baraitric surgery favor an anorectic state, facilitate weight loss, and improve metabolic parameters. Ann Surg. 2006; 243:108-114.

(iv) Hansen TK, Dall R, Hosoda H. et al. Weight loss increases circulating levels of ghrelin in human obesity. Clin. Endocrinology 2002; 56:203-206

(v) Melissa Gianos, et al. Understanding The Mechanisms of Action of Sleeve Gastrectomy on Obesity. Bariatric Times 8;5: S4-S6 (Supplement)

(vi) Ariyasu H, Takaya K et al. Stomach is a major source of circulating ghrelin, and feeding state determines plasma ghrelin-like immunoreactivity levels in humans. J Clin Endrocrinology Metabolism. 20001;86:4753-4758

(vii) Liu CD, Aloia T, et al. Peptide YY: a potential proabsorptive hormone for the treatment of malabsorptive disorders. American Journal of Surgery. 1996 Mar; 62(3) 232-6.

“The LAP-BAND® System is reversible and, if necessary, can be removed — with the stomach usually returning to its original shape.”

This is a direct quotation from the manufacture’s website. It is a statement of its reversible state that is usually used to promote the adjustable gastric banding procedure compared to other surgical alternatives. In my practice I am a very strong advocate of the Duodenal Switch operation and as a distant second, I offer Sleeve Gastrectomy. I do not offer or recommend the Gastric Bypass (RNY, proximal or distal) procedures because of their well known complications of dumping syndrome, weight regain, inadequate weight loss, as well as anatomical complication of stricture or marginal ulcerations that are seen.

I would only assume that the reversibility issue is to be discussed if the procedure is expected to fail frequently . As a surgeon who performs the duodenal switch operation as a primary weight loss surgical procedure, I have rarely had to reverse the procedure. In my opinion, the physiologic reversal of the duodenal switch operation is by far the easiest of all surgical procedures. It involves creation of a side-to-side anastomosis between the alimentary and the biliopancreatic limbs.

The following are images of a Lap-Band® being removed because the patient kept suffering from persistent nausea and vomiting. The operation was performed laparoscopically. The operative finding identified a significant amount of reactive tissue (scar formation) that represented substantial difficulty in the operating room from a technical point of view. The long term damage done to organs by the Lap-Band makes it not easily reversible.

My recommendations for any individual considering a weight loss surgery is not to focus on the ease of reversibility of the procedure, but rather its long-term outcome data as the basis for choosing an operation.