The Gastric Band: First-Choice Procedure for Obesity Surgery

The Gastric Band: First-Choice Procedure for Obesity Surgery

Franco Favretti Æ David Ashton Æ Luca Busetto ÆGianni Segato Æ Maurizio De Luca

� Societe Internationale de Chirurgie 2009

Abstract The advent of laparoscopic adjustable gastric

banding (LAGB) during the latter part of the 20th century

represents a watershed in the management of chronic

obesity. In this paper we provide an overview of LAGB

with respect to its development, clinical outcomes, and

future role. We also address current controversies, includ-

ing a comparison of LAGB with Roux-en-Y gastric bypass

(RYGBP). At present LAGB seems to be increasing in

popularity in the United States, whereas in Europe there

seems to be a trend away from gastric banding toward

RYGBP. Optimal outcomes after LAGB are a function of

correct laparoscopic technique, an experienced surgical

team, a well-engineered device, and intensive long-term

follow-up. The majority of studies show that LAGB is an

extremely safe and effective procedure, with an operative

mortality of 0–0.1% and excess weight loss (%EWL) of

50–60%. Commensurate with this degree of weight loss,

almost all studies show substantial improvements in

obesity-related co-morbidities, such as hypertension, type

II diabetes, and dyslipidemia. In addition, LAGB has been

shown to be both safe and effective in the super-obese, in

adolescents, and in older patients and can be delivered as

an ambulatory procedure. Operative mortality and early

complication rates are significantly higher for RYGBP and,

whilst gastric bypass results in greater weight loss than

LAGB in the first 2 years, at 3 years and beyond the dif-

ference appears to be less marked. Overall, LAGB provides

a safe, effective intervention for obese patients and remains

our first-choice procedure for bariatric surgery.

Introduction

The development of the laparoscopic adjustable gastric

band (LAGB) during the latter part of the 20th century,

represents a watershed in the management of chronic

obesity. Previously, treatment options for obese patients

comprised dietary, pharmacological and/or cognitive

interventions with generally poor results, or major surgical

procedures such as vertical banded gastroplasty and Roux-

en-Y gastric bypass (RYGBP) which, whilst effective,

were associated with significant morbidity and mortality.

The advent of LAGB offers an effective, durable, and safe

alternative, which has revolutionized obesity management

throughout the world.

This article provides an overview of LAGB with respect

to its development, clinical outcomes, and future role. We

also address some current controversies, including a com-

parison of LAGB versus RYGBP.

History and development

Adjustable band

The modern adjustable gastric band is a tribute to both the

vision and perseverance of early pioneers such as Kuzmak

F. Favretti � G. Segato � M. De Luca

Department of Surgery and Obesity Center, Regional Hospital,

36100 Vicenza, Italy

D. Ashton (&)

Healthier Weight Centre, 3 Vicarage Road, Edgbaston,

Birmingham B15 3ES, UK

e-mail: [email protected]

L. Busetto

Obesity Unit, Department of Medical and Surgical Sciences,

University of Padua, Padua, Italy

123

World J Surg

DOI 10.1007/s00268-009-0091-6

and Hallberg, and a sustained collaborative effort on the

part of bioengineers, scientists, and surgeons [1]. Early

research on the concept of an adjustable band can be traced

to the work of Szinicz and Mueller in Austria, who

experimented with an adjustable band connected to a

subcutaneous port in animals [2]. In 1986, Lubomyr Kuz-

mak reported on the clinical use of an adjustable silicone

gastric band (ASGB) via open surgery; results showed

improved weight loss and reduced complication rates

compared with the non-adjustable version that he had

begun using in 1983 [3]. Independently, Hallberg and

Forsell in Sweden also developed an adjustable gastric

band, later known as the Swedish Adjustable Gastric Band

(SAGB) and, more recently, as the REALIZETM

band

(Ethicon Endo-Surgery Inc, Cincinnati, OH) [4].

Laparoscopic era

Surgical laparoscopy transformed the field of bariatric

surgery and made the gastric band an even more appealing

option for the surgical management of obesity. In 1992,

Cadiere was the first to apply the ASGB via laparoscopy [5].

In 1993, Broadbent in Australia [6] and Catona in Italy [7]

also implanted non-adjustable gastric bands by laparoscopy.

Between 1991 and 1993, Belachew, Cadiere, Favretti, and

O’Brien, in conjunction with the Inamed Development

Company, further adapted the original Kuzmak ASGB to

make it suitable for laparoscopic implantation, eventually

emerging with the modern Lap-Band� (Allergan Inc,

Irvine, CA). The first human laparoscopic implantation of

the newly developed Lap-Band� was performed by Bela-

chew and Le Grand on September 1, 1993 in Huy, Belgium,

followed on September 8, 1993 by Cadiere and Favretti in

Padua, Italy [8, 9]. In 1994, the first international Lap-

Band� workshop was held in Belgium and the first on the

SAGB in Sweden. The Lap-Band� obtained FDA approval

in June 2001and the SAGB in September 2007.

Both the original Lap-Band� and the SAGB have

undergone considerable modification; the latest models

have largely eliminated the earlier problems related to

tubing fracture and leakage. Other band manufacturers have

now emerged, producing devices of their own, including the

AMI Band (Austrian Agency for Medical Innovations Ltd),

the MIDBAND (MID, Lyon, France), BIORING (Cousin,

France), and the HELIOGAST (Helioscopie, Lyon).

Current trends in gastric banding

It is impossible to determine the precise numbers of gastric

bands being implanted worldwide due to reluctance on the

part of manufacturers to divulge detailed sales volumes and

projections. Nevertheless, from a worldwide perspective, it

is clear that there has been an exponential growth in the

application of the LAGB for the treatment of obesity

(Fig. 1). In 1998, approximately 2,000 gastric band pro-

cedures were performed; by 2007 there had been an

approximately 50-fold increase to 100,000 procedures

worldwide [10–12]. There are wide variations in the use of

LAGB: in France it is estimated that 87.3% of bariatric

procedures are LAGB; in Australia 96%; in the United

Kingdom 50%; in the United States 23%; and in Israel 87%

[12–15]. It is anticipated that the growth in bariatric sur-

gery will continue for the foreseeable future, with LAGB

representing approximately 50% of all procedures, perhaps

250,000 annually [12].

The overall growth in the use of LAGB masks important

differences in trends between the United States and Europe.

In Europe, the gastric band has been in use since 1993 and

many countries experienced a rapid growth in band

implantations. In 2007, the gastric band accounted for 74%

of all bariatric procedures in Europe, with RYGBP

accounting for 20.6% [16]. However, there are several

reasons why RYGBP is likely to become more popular in

the near future. In some European countries there has been

adverse publicity regarding occasional deaths after LAGB,

as well as media stories featuring television personalities

who have either failed to lose weight or experienced other

problems after band implantation. In addition, the majority

of surgeons simply do not have the resources to provide the

intensive behavioral support required to achieve optimal

post-operative outcomes with LAGB. Finally, there is a

growing perception among bariatric surgeons that long-

term complications are more frequent with the gastric band

than with RYGBP. So whilst bariatric surgery in general

will see a significant increase in Europe during the next 3–

5 years, the proportion of LAGB is likely to decline.

In the United States we see the converse of the European

trends, primarily because the Lap-Band� device did not

receive FDA approval until 2001 and the SAGB (REAL-

IZETM) band until 2007. Before the LAGB became avail-

able, the ‘‘gold standard’’ for obesity surgery in the United

Fig. 1 Worldwide trends in all bariatric procedures with proportion

(%) of gastric bands

World J Surg

123

States had been RYGBP. However, since the LAGB

became available there has been a rapid growth in its use.

A recent study showed that between 2004 and 2007 there

was a threefold increase (7–23%) in gastric banding among

academic medical centers in the United States [15]. This

trend is likely to continue, so that the gastric band will

continue to increase in popularity among patients and

surgeons in the United States, in parallel with a small

decline in Europe.

Outcomes after LAGB

Optimal outcomes after LAGB are a function of correct

laparoscopic technique, an experienced surgical team, a

well-engineered device, and intensive long-term follow-up.

Even though LAGB is the safest and least invasive of the

available surgical options for obesity, it is not a simple

procedure. Laparoscopic positioning of the adjustable

gastric band falls within the category of advanced laparo-

scopic procedures and close attention to correct surgical

technique is probably more important in LAGB than in any

other bariatric procedure. Errors in band placement may

have serious downstream consequences for the patient in

terms of slippages, pouch dilatation, and erosions. Details

of the optimal technique for band implantation have been

described elsewhere and will not be repeated here [17–19].

It is useful to consider the rapid evolution of gastric

banding in two distinct phases: pre- and post-millennium

(Table 1). Between 1993 and 2000, there were rapid

improvements in surgical technique and in the design of the

band itself, i.e., the development phase. After 2000, the

established phase, surgical technique has become largely

standardized and widely disseminated among specialised

bariatric centres worldwide. Studies on outcomes after

gastric banding can be similarly divided; those where

recruitment and surgery were performed before 2000 and

studies initiated in the new millennium. Improvements in

laparoscopic technique and band technology would be

expected to translate into more favorable outcomes;

Table 2 provides information on some key studies. How-

ever, it is important to note that the definition and reporting

of even basic outcomes in these studies is not standardized

and, consequently, exact comparisons are difficult [20–44].

As can be seen from Table 2, even in earlier studies the

operative mortality for LAGB was consistently zero or

close to zero. Recent studies confirm that LAGB is by far

the safest of the available bariatric procedures. Before

2000, a significant proportion of gastric bands were

implanted using the perigastric technique, which later

evolved into the pars flaccida. This is important because

the latter approach is associated with dramatically lower

slippage rates. For example, Ponce et al. reported a 20.5%

slippage rate with the perigastric approach, which

decreased to 1.4% after adopting the pars flaccida tech-

nique [38], and O’Brien et al. have shown the risk of

anterior slippage to be almost four times higher for the

perigastric approach compared with the pars flaccida [45].

After 2000, complications due to port/tubing problems and

erosions are less common due to improved band design and

surgical technique. Band slippage continues to be an

unwelcome complication, although the overall rates appear

to have declined compared with the outcomes before 2000.

Finally, it is worth noting that the duration of the procedure

and length of hospital stay have decreased dramatically in

recent years. In earlier studies, the length of the procedure

ranged from 60 to 150 minutes with a hospital stay of 3 to

4 days [21, 22, 46]. Nowadays, the procedure may take no

more than 40 minutes [47] and some centers perform

gastric band surgery on an ambulatory basis, with patients

discharged within 2 hours after the procedure [43].

Weight loss and impact on co-morbidities

Despite improvements in outcome associated with recent

advances in surgical technique and bioengineering, Table 2

shows that the 50–60% excess weight loss achieved with

the LAGB is remarkably consistent across the 15-year

Table 1 Two phases of LAGB development

Development phase (before 2000) Established phase (after 2000)

Significant numbers (50%?) received perigastric implants All pars-flaccida

Laparoscopic surgery in its infancy—few surgeons with

experience

Advanced laparoscopic techniques well established and widely

disseminated

No specialist obesity surgery centers Many internationally recognized centers of excellence

Early band technology—high failure rates due to leakage,

erosions, and tubing/access port problems

Improved band engineering and design, eliminating previous

problems and offering innovations – e.g., development of rapid

fixation technology for access port

Little experience with band adjustment, erosion, pouch dilatation,

prolapse, etc.

Greater recognition of perils of overadjustment and need for close

follow-up and early intervention when problems arise

World J Surg

123

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World J Surg

123

period. This has been confirmed in a recent meta-analysis

of 4,273 patients in 33 SAGB studies and 24,707 patients

in 104 LAGB studies, which found an early mortality rate

of 0–0.1% and a mean 3-year excess weight loss of 53.3%

[48]. Commensurate with this degree of weight loss, almost

all studies show substantial improvements in obesity-rela-

ted co-morbidities, such as hypertension, type II diabetes,

and dyslipidemia, although the magnitude of the reported

improvement differs significantly between studies [49, 50].

In addition, LAGB has been shown to be both safe and

effective in the super-obese [47], adolescents [51], and

older patients [52].

The impact of LAGB on type II diabetes has been

extensively reported in the scientific literature. In the sys-

tematic review and meta-analysis by Buchwald et al., res-

olution of diabetes in patients who underwent LAGB was

47.9% [49] and the systematic review by Cunneen et al.

found that diabetes resolved in 60% of patients after LAGB

[48]. Improved diabetes control produced by gastric

banding is probably less than that achieved by other higher

risk procedures, at least in the short-term, but it is sub-

stantially better than that produced by the best medical

therapy [53, 54]. Moreover, improvement in diabetic con-

trol after gastric banding is particularly marked in patients

in whom type II diabetes is more related to insulin-resis-

tance than to irreversible b-cell failure, and optimal bene-

ficial effects on diabetes outcome might be achieved if

gastric banding is performed early in the course of the

disease [55, 56].

Poor outcomes after LAGB

Unsatisfactory outcomes after LAGB have been reported

by several groups and have been used by some to argue that

the gastric band is an unreliable intervention with an

unacceptably high re-operation rate [57–60]. For example,

Suter et al. implanted 317 bands during a 6-year period

with an average follow-up of 72 months. A total of 105

(33.1%) patients developed at least one complication and

69 (21.7%) had the band removed [58]. However, the poor

results observed in this and other studies can be accounted

for in terms of a combination of factors: small patient

numbers; relatively small numbers of procedures per-

formed over long-periods; inferior surgical technique;

perigastric approach and old design gastric bands that were

much more susceptible to leakage, tubing fracture, and

erosion. A further contributory factor to poor outcomes

may be sub-optimal follow-up, because there is evidence to

suggest that patients who do not attend regular post-oper-

ative review lose significantly less weight than more fre-

quent attenders [61].

These studies clearly represent the outliers in the totality

of the experience of the gastric band and should not be

allowed to inform decisions about the role of LAGB in the

modern management of obesity.

LAGB versus RYGBP

There is considerable debate and controversy among sur-

geons as to whether gastric banding or gastric bypass

should be the procedure of choice in the management of

morbid obesity. A major impediment to providing a

definitive answer to this question is that whilst the stated

goal of surgery is to achieve sustainable weight loss over a

long-period, the published literature is dominated by short-

term data. The average follow-up of gastric bypass surgery

compared with LAGB in published trials often comprises

less than 2 years, which is obviously insufficient to assess

the long-term risks and benefits of procedures intended to

last 30–50 years.

Nevertheless, given that LAGB and RYGBP together

account for more than 90% of bariatric procedures world-

wide, it is important to attempt a comparison of the two

options, focusing on operative mortality and morbidity, re-

operation rates, weight loss, effects on diabetes, and impact

on long-term mortality. The available evidence comes from

systematic reviews and (primarily) retrospective studies

from single centers that have compared outcomes for both

procedures.

Operative mortality and complications

Mortality and morbidity for bariatric procedures is pri-

marily determined by the volume of patients and the sur-

gical experience of the treatment center [62]. Buchwald

et al. reported an operative mortality (mortality at

B30 days) of 0.1% in 2,297 patients who underwent gastric

banding and 0.5% in 5,644 patients who underwent gastric

bypass [49]. However, recent reports from high-volume

centres of excellence show mortality rates for RYGBP to

be significantly lower than this [63, 64]. A systematic

review by Tice et al. directly compared outcomes for

RYGBP and LAGB in 14 studies, with a minimum follow-

up of 1 year [65]. In general, the quality of these com-

parative studies was low and most were retrospective.

Despite methodological limitations, reported mortality for

both groups was low: 0.06% and 0.17% for LAGB and

RYGBP, respectively. Overall, the reported difference in

major early complications ranged from 1.1–6.3% in favor

of gastric banding. Parikh et al. performed a retrospective

review of 780 procedures to compare early morbidity/

mortality rates for LAGB, RYGBP, and biliopancreatic

diversion with duodenal switch (BPD/DS). Total compli-

cation rates were 9% for LAGB, 23% for RYGBP, and

World J Surg

123

25% for BPD/DS. Complications resulting in organ

resection, irreversible deficits, and death (grades III and

IV) occurred at rates of 0.2% for gastric banding, 2% for

gastric bypass, and 5% for BPD/DS. Overall, the gastric

banding group had an almost three and a half times lower

likelihood of a complication compared with the gastric

bypass group [66].

Re-operation rates

A number of comparative studies have found overall re-

operations rates to be higher for LAGB than RYGBP [67–

69], whereas several others have reported similar rates [70–

72]. Such differences may be partly attributable to length

of follow-up. For example Jan et al. found a greater re-

operation rate for the gastric band (20% vs. 10%) at 3 years

but an identical re-operation rate (17%) at 5 years [73, 74].

These data suggest that with longer-term follow-up, initial

differences in outcomes between gastric band and gastric

bypass become less pronounced. Furthermore, whereas re-

operation in LAGB patients is usually required for device-

specific problems, such as band slippage or minor port/

tubing complications, in bypass patients it is often required

for more complex problems, such as internal hernia and

anastomotic stenosis.

Effects on weight loss

In their systematic review, Buchwald et al. determined that

the mean EWL% was 47.5% for patients who underwent

gastric banding and 61.6% for gastric bypass [49]. Tice

et al. found weight loss at 1 year to be consistently greater

for RYGBP; in the highest quality study EWL% was 76%

for RYGBP versus 48% for LAGB [65].

When comparing outcomes for both procedures beyond

1 year, two apparently contradictory patterns emerge. In the

only randomized trial by Angrisani et al., differences in

EWL% between LAGB (47.5%) and RYGBP (66.6%)

persisted up to 5 years [71]. Cottam et al. performed a case-

controlled study of 181 LAGB and 181 RYGBP patients in

a single center [68]. Weight loss was consistently higher in

the RYGBP group up to three years when the EWL% was

51% and 74% for LAGB and RYGBP respectively. Similar

findings have been reported by te Riele et al. [75].

In contrast to the above, several other studies have

shown that although initial weight loss is greater after

RYGBP, after 2–5 years of follow-up, there is no signifi-

cant difference in EWL% between the two groups [70, 74,

76, 77]. These findings are consistent with a systematic

review by O’Brien et al., who found mean EWL% for

standard gastric bypass was higher than for gastric banding

at years 1 and 2, but not statistically different at years 3, 4,

5, 6, or 7 [78]. Note that this is primarily due to a fading of

the effect of RYGBP, whereas weight loss with the band

remains relatively stable (Fig 2).

Effects on diabetes

Buchwald et al. describe a gradation of effect for diabetes

resolution from 98.9% for BPD/DS to 83.7% for gastric

bypass and 47.9% for gastric banding [49]. These differ-

ences may be attributed to the corresponding differences in

short-term weight loss observed with the three procedures,

but may also be related to the existence of specific meta-

bolic effects, independent of weight loss [79]. However, no

prospective, randomized studies have directly compared

the effects of different surgical procedures on outcomes for

diabetes.

Bowne et al. performed a retrospective analysis of 106

super-morbidly obese patients who underwent LAGB or

RYGBP; after 16 months of follow-up, 100% of patients

who underwent gastric bypass showed resolution of dia-

betes compared with 40% of those who received the gastric

band [69]. Cottam et al. observed resolution of type II

diabetes in 78% and 50% of diabetic RYGBP and LAGB

subjects respectively, after a 3-year follow-up [68]. How-

ever, in a study comparing resolution of diabetes after

LAGB, RYGBP, and BPD/DS, after 2 years follow-up,

Parikh et al. found no significant difference between the

three groups [80]. Two other large studies also have shown

no significant difference between LAGB and RYGBP in

terms of improvement/resolution of diabetes [70, 77].

Impact on long-term mortality

Several studies have looked at long-term mortality after

obesity surgery. In the Swedish Obese Subjects (SOS)

Fig. 2 EWL% for LAGB and RYGB (O’Brien et al., with permission

[17])

World J Surg

123

Study, the adjusted 10-year mortality rate was found to be

significantly (31%) lower in the surgical group versus the

control group [81], although many of the subjects in this

study were treated during the 1990s with procedures that

are now largely abandoned [82]. Two retrospective studies

examined the effect of RYGBP on long-term mortality.

Christou et al. used an observational two-cohort study in

which 1,035 surgically treated patients were matched with

5,746 severely obese, non-surgically treated control sub-

jects. Both cohorts were followed for a maximum of

5 years at which time the mortality rate in the surgically

treated cohort was 0.68% compared with 6.17% in the

control subjects. This translates into a highly significant

(89%) reduction in the relative risk of death for the sur-

gically treated patients [83]. A more recent retrospective

study by Adams et al. found that during a follow-up period

of 7 years, adjusted long-term mortality from any cause in

the RYGBP group decreased by 40% compared with that in

the control group [84].

Two retrospective studies analyzed long-term mortality

in obese patients treated with the gastric band. A study that

compared LAGB versus non-surgical treatment showed that

during a mean follow-up of 5.7 and 7.2 years, respectively,

a statistically significant 60% reduction in total mortality in

favor of the LAGB group was found (Fig. 3) [85]. In

addition, Peeters et al. compared the mortality rate in 1,468

morbidly obese patients treated by gastric banding with

5,960 patients from an established population-based control

group. They found that the surgically treated group were

73% less likely to die than the control subjects [86].

LAGB versus RYGBP: conclusion

Despite the absence of data from randomized trials, there is

abundant evidence to suggest that both LAGB and RYGBP

produce durable weight loss and long-term reductions in

mortality in obese patients. Whilst RYGBP undoubtedly

induces greater weight loss than LAGB during the first

2 years, at 3 years and beyond the difference appears to be

much less marked, primarily due to a fading of the effect of

RYGBP. Resolution or improvement of diabetes is broadly

similar, although data from longer-term studies is required

to clarify any potential differences in their relative efficacy.

Early complications tend to be more marked and more

serious in RYGBP. Re-operation rates tend to be higher in

LAGB patients in the short-medium term; however, with

longer follow-up, a larger proportion of RYGBP patients

seem to require surgical intervention, often for more

complex problems. Finally, both procedures confer a

mortality advantage and there is no evidence to suggest that

either one is more effective than the other.

The future

The lessons from the development (before 2000) phase of

LAGB have been learned and we are currently in the

established phase in which the correct surgical technique

for band implantation is widely implemented and the band

technology advanced. It is sometimes said that the Achilles

heel of the gastric band is the significant re-operation rate,

but this problem is not unique to the gastric band. Both

surgeons and patients should recognize that a proportion of

those who undergo LAGB will require further surgical

intervention at some point, and this possibility should be

made clear at the pre-operative consultation.

It is possible that developments in surgical technique

will reduce slippage and complication rates even further

[44], but it is unlikely to eliminate them entirely. However,

it is imperative that changes in surgical technique should be

evaluated within the context of methodologically rigorous

trials, rather than on the ad hoc basis which has been such a

conspicuous feature of bariatric research to date, and which

helps to explain why there is such a paucity of long-term

data. During the next decade, we have to move away from

observational studies with descriptive statistics to a much

greater emphasis on hypothesis testing within the context

of large-scale, randomized trials.

Whilst further refinement of surgical technique may

reduce complication rates, it is unlikely to improve the 50–

60% excess weight loss, which is such a consistent feature

of the majority of long-term LAGB studies. If we are to

achieve more with the band, we need to focus more of our

efforts toward a better understanding of what should be

regarded as best practice regarding long-term follow-up

and behavioral support. It is a remarkable fact that not-

withstanding the tens of thousands of gastric bands that

have been implanted during the last 15 years, there is still

no agreement about the optimal adjustment algorithm,

although it is known that the frequency of post-operative

review predicts weight loss [61].

90

92,5

95

97,5

100

0 ,5 1 2 3 4 5years

pro

bab

ility

of

surv

ival

LAGB

no LAGB

Fig. 3 Trends in survival for LAGB vs. non-surgical controls

World J Surg

123

New surgical techniques, such as single incision lapa-

roscopic surgery (SILS), are already being deployed for

implantation of the gastric band and will accelerate the

current trend toward the use of gastric banding as an

ambulatory procedure [43, 87]. In addition, clinical trials

are currently underway with a telemetrically adjustable

gastric band (EasyBand� Allergan Medical) which, by

dispensing with the standard needle-adjusted hydraulic

system, could eliminate port/tubing problems such as

leakage and infection, while simultaneously providing

much greater adjustment precision.

The shift away from LAGB toward RYGBP in Europe is

not only due to adverse publicity but also to a perception

among some surgeons that RYGBP is more effective than

LAGB, and that bypass patients demand less in terms of

long-term support and follow-up. However, the evidence

does not suggest that RYGBP confers major advantages

compared with the gastric band. Moreover, the sustained

behavioral changes needed for success with the gastric

band are no different from those required for success after

gastric bypass. Failure to recognize the RYGBP patient’s

need for lifelong behavioral support may help to explain

why a significant proportion of bypass patients begin to

regain weight after 3–5 years [88].

During the next 5–10 years, healthcare systems in the

developed world will be confronted with an unprecedented

demand for obesity surgery. This is a unique situation

because at no other time in history have surgeons been asked

to perform mass intervention for what is, ultimately, a public

health problem. The only procedure that could plausibly be

applied on a large scale is the LAGB. It is easily the safest of

the currently available surgical options, delivers durable

weight loss and health benefits comparable with RYGBP,

and is associated with a significant reduction in long-term

mortality. Moreover, for most patients—including the super-

obese—it can safely be delivered in the out-patient surgery

setting [89]. Finally, for the band patient who fails to lose

weight, all alternative surgical options remain open, whereas

for the failed gastric bypass the alternatives are by no means

obvious. For these reasons, LAGB will remain our first

choice procedure for obesity surgery.

Acknowledgments The authors thank Ms. Debbie Jordan for her

assistance in the revision of a first draft of this manuscript and Ste-

phen Brown for help in the preparation of the figures.

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The Gastric Band: First-Choice Procedure for Obesity Surgery

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