Op-Med is a collection of original articles contributed by Doximity members.
As bariatric surgeons who have devoted our careers to the care of the morbidly obese and who continue to offer lap band surgery in great numbers to our patients, we are most disappointed with the one-sided report published by Vox. In response to this report, we would like to offer our collective perspective.
Successful band patients tell us that combination of three factors lead to highly successful results:
- A patient who is willing to make some changes to their relationship with food.
- A physician who understands the band, promotes it positively, and makes him/herself available to their patients all the time.
- A band that is in an appropriate position and offers an appropriate amount of restriction.
The Vox report starts with quotes from a highly dissatisfied patient. Most of us recognize such a patient as one that feels abandoned and deserves better care. Experience tells us that struggling patients are doing everything they can to succeed with their band. At worst, this patient should have been offered to have her band removed, but not after 7 or 8 years as the report suggests. And at best, the patient’s band would have been properly adjusted so that she would have been able to enjoy small portions of healthy food, not feel hungry, and certainly, not live miserably.
It is true that the number of gastric banding procedures has declined over the past several years; however, this is best explained by an artificially high number of procedures done by surgeons who didn’t have the necessary comfort with, or commitment to, a seemingly simple surgical procedure which requires a highly complex aftercare regimen. Early on, the simplicity of the procedure turned many surgeons and patients on to the prospects of a very safe, adjustable, and easily reversible procedure. However, the complexity of the aftercare necessary to make such patients successful ultimately led to many surgeons willingly walking away from lap band surgery and in the process leaving many patients totally abandoned, resulting in a number of unnecessary explantations of gastric bands.
The Vox article refers to a recent report in JAMA (May 2017) as the “best study” on this subject. A quick review of this misguided report suggests that more than 81% of all Medicare recipients who underwent adjustable gastric banding (AGB), with a mean follow-up of more than 4 years, still had their bands and had no further surgical interventions. This might be the only part of this report that would qualify it as the “best study.” As a group of surgeons and scientists, we consider this component of the report to be unparalleled by any other bariatric surgical procedure. Further review of the JAMA article suggests that subsequent operative care of AGB patients is an expensive endeavor. What the authors of the JAMA article failed to provide us with is a comparative analysis for patients who underwent other bariatric interventions during the same time period. Furthermore, the authors failed to analyze the potential savings enjoyed by Medicare as a result of significant improvement in comorbidities, especially among the more than 81% of the patients who did not require any further operative interventions in more than 4 years of follow-up.
The Vox article appears to simplify the advantages of stapling procedures over AGB. What the Vox article fails to acknowledge is that with the current options available to the morbidly obese individuals, less than 1% seek bariatric intervention. The main reason for this small number is the patients’ fear of serious complications associated with stapling procedures and the lack of durability of the most commonly performed stapling procedures beyond the first few years. Stapling procedures are most successful on the day of initial surgery; thereafter, our bodies will do what they can to overcome the effects of the operation. Given enough time, our bodies will ultimately succeed.
The Vox article offers an inflammatory quote that “as long as there are patients who will pay, doctors will probably keep doing them.” We would like to remind the colleague who offered this statement that compensation for AGB (whether by insurance companies or by patients themselves) is a fraction of that for the stapling procedures. Therefore, to assert that it is simply the financial reward that encourages bariatric surgeons to continue to offer AGB to their patients is insulting and outrageous.
In conclusion, in the era of “alternative facts,” journalists need to be extremely careful before publicizing one-sided information. We urge the author of the Vox article, and all others who doubt the effectiveness of the gastric band, to reach out to any of the authors of this response and seek a second opinion. It is worth noting that many of the authors of this response are leaders in the field of bariatric surgery, locally, regionally, and nationally, and their strong opinions should be taken seriously.