Band width

What's the best way to lose weight? Stop eating. Or, shrink your stomach. A new less non-invasive procedure called lap band surgery - that ties up a part of the stomach - is proving to be quite effective as well as a boon for obese patients, says Sandra G Boodman

After his weight ballooned to 285 pounds, John Bischoff, a veteran of failed diet and exercise programmes, figured he had no alternative to a gastric bypass that would permanently shrink his stomach. His internist suggested it.

A surgeon told him the operation might alleviate his hypertension and lower his worrisome cholesterol level as well as his weight. The retired America Online executive was about to schedule the surgery when he mentioned it to his daughter, a nurse practitioner.

"She looked at me like, 'What, are you crazy?' " recalls Bischoff, 56, who lives in Loudoun County, Virginia. "She said it was radical surgery, life-altering, and there's no reversing it."

Bischoff's daughter instead suggested a new, less invasive and reversible weight-loss operation called adjustable laparoscopic banding, which restricts food intake without cutting or stapling the stomach or permanently rerouting the intestines, as does bypass surgery.

That appealed to Bischoff, who had the "lap band" surgery in June this year. Surgeon Eric D. Pinnar made a series of one-inch cuts in Bischoff's abdomen, through which he inserted an inflatable hollow silicone band around the top of Bischoff's stomach.

The band reconfigured the organ into an hourglass shape, drastically shrinking the top. This serves a dual purpose: it limits the quantity of food Bischoff can eat and quickly triggers a feeling of fullness that lasts for several hours.

Four hours after the 60-minute procedure, Bischoff was walking around his hospital room. The next day he went home. A week later he was back on the golf course. So far he has lost about 22 pounds, at a rate of one to three pounds per week, the amount Pinnar recommends.

"I think this surgery is a great option," says Bischoff, who says he has suffered no complications, isn't hungry and eats a fraction of what he used to. "The big thing for me is that it's controllable."

Bischoff says he was willing to trade the possibility of lesser weight loss for the band's adjustability.

Plus points

As Bischoff loses weight, the device can be periodically tightened or loosened to allow more or less food to pass through it. Adjustments are made by controlling the amount of saline Pinnar inserts into it through a portal implanted under the skin of Bischoff's abdomen. The port is connected to the band by a slender plastic tube.

In the two years since it was approved by the U.S. Food and Drug Administration, the adjustable band, widely used in Europe and Australia, has emerged as a kinder, gentler - and less effective - alternative to gastric bypass. Although bypass patients usually lose more weight rapidly - sometimes a pound a day - the operation carries a higher risk of death and permanent complications than the band.

The reason lies in the nature of the gastric bypass procedure: the most common operation, known as the Roux-en-Y, not only reduces the amount of food that can be eaten, but also causes significant malabsorption of calories and nutrients. Malabsorption places patients at greater risk of anaemia, osteoporosis and bone disease, problems that can usually be prevented by taking high doses of vitamins.

About 20 per cent of bypass patients also require further surgery to correct complications, which can be life-threatening; the mortality rate from bypass is estimated to be about one per cent. The mortality rate after the band is roughly 0.1 to 0.2 per cent.

Some band-related complications can be reversed by removal of the device, which requires another operation. An USFDA official says manufacturer Inamed has reported seven deaths and 97 serious injuries associated with the band between 1999 and 2002.

An Inamed official said that about 15,000 U.S. patients have received bands. Recipients include U.S. television personality Sharon Osbourne, singer Ann Wilson of Heart and actor Brian Dennehy.

Whether the lap band will become popular enough to compete with gastric bypass surgery remains to be seen, particularly because bypass operations are increasingly being performed laparoscopically rather than through a single large incision, enabling patients to recover more quickly with less pain.

Both band and bypass procedures are recommended by federal health officials only for selected patients who are morbidly obese: those approximately 100 pounds or more above their healthy weight. That description fits nearly five per cent of American adults.

In the past two years, the number of Americans turning to weight loss, or bariatric, surgery has skyrocketed. The American Society for Bariatric Surgery, the trade association for weightloss surgeons, estimates that 103,000 Americans, most of them women, will undergo obesity surgery this year, compared with approximately 40,000 in 2001.

This explosive growth reflects the accelerating epidemic of obesity, which affects more than 25 per cent of the U.S. population coupled with growing media coverage of the problem and of celebrities' surgeries (most recently the laparoscopic gastric bypass performed on Today show weatherman Al Roker). It's also spurred by the lack of viable long-term weight-loss alternatives for the morbidly obese.

There is also growing evidence that surgery works: A recent analysis by the Cochrane Review, a respected British collaborative that disseminates research about the safety and efficacy of medical practices, examined 18 clinical trials involving nearly 1,900 morbidly obese patients.

The group found that bypass surgery resulted in greater weight loss and more improvement in health problems like Type 2 diabetes than conventional diet and exercise programmes.

What's best?

But which surgery works best for what kind of patient? And what are the long-term risks and benefits? So far no one knows. The U.S. National Institutes of Health is poised to fund a $15 million programme in which investigators at several medical centres will spend five years attempting to answer these and related questions.

Months-long waiting lists, particularly for bypass surgery, are common, because fewer than 1,000 surgeons in the U.S. are believed to be performing gastric bypass. Although patients are seeking out doctors who perform gastric bypass laparoscopically, there's a dearth of evidence to show that laparoscopy is superior - and widespread agreement that it makes a difficult operation even tougher to perform.

"This is very, very hard surgery," says New York laparoscopic surgeon Christine J. Ren, an assistant professor of surgery at New York University School of Medicine. Ren, who has performed more than 300 laparoscopic bypasses, notes that proficiency varies widely.

Laparoscopic training is now usually part of residency training for surgeons, and advanced skills can be acquired during a one-year post-residency fellowship.

But most doctors older than about 45 typically have little or no training in laparoscopic techniques, which require a surgeon to manipulate special ins