BAND vs SLEEVE vs BYPASS: What are the differences?
Trying to work out which procedure is best for you can all be a bit confusing. Here is a brief overview of the differences between the band, sleeve and bypass weight loss procedures. If you’re still unsure, don’t worry, we will advise you when you meet with Dr Taylor after carefully going through your medical, dietary and weight loss history.
The Gastric Band
The Gastric band is a soft silicon collar that is placed at the top of the stomach. Unlike the Sleeve, the band does not make your stomach smaller; rather it changes the way signals are sent along the nerves to your brain when you eat. Our stomachs are lined with nerve endings which sense when we eat and how much we eat. These nerve endings join together to form two nerves called the Vagus nerves, which carry this information to the part of our brain called the Hypothalamus – this is the control centre for appetite. The Gastric Band appears to modify these signals so that we feel less hungry and become satisfied with smaller portions. This effect can be fine-tuned through adjustments.
Unlike the Sleeve, the Band does not reduce the physical size of the stomach. Instead it modifies the signals that are sent to the brain so you feel less hungry and become satisfied with smaller portions.
However, because the stomach still has the same overall size, the Band will not prevent you from consuming too many calories. This is especially true if the calories are soft or liquid, which will just slide through the band, even if it is made very tight. And because weight loss will only occur if your calorie intake is reduced, the Band will not work well if you continue to consume a large amount of liquid calories. The Sleeve on the other hand will restrict all types of calories to some degree, which may be more suitable if you have trouble reducing your intake of soft drinks, ice-cream, chocolate or alcohol.
The Band does not restrict soft or liquid calories. It is just a tool that reduces hunger and the amount of solid food needed to feel satisfied.
The Band is essentially just a tool that makes you less hungry and satisfied more quickly. It’s still up to you to watch your portions, make better food choices, and exercise regularly. It requires effort and commitment toward lifestyle improvement. In our experience, the Band is most suited for people who can usually lose weight quite easily but just have trouble maintaining it, and generally make good food choices but have a problem with being hungry all the time or needing big meals to feel full.
The Band has some advantages over the Sleeve: it is simple to insert, can be adjusted or even emptied completely if ever required, and can be removed. However, just because it can be removed does not make it any less permanent than the Sleeve. It is designed to be left in place for long term.
The Band is the safest form of weight loss surgery, and although it can be removed, it is intended for long term use.
The main downside of the Band is that it is powerless to stop a person consuming too many liquid and soft calories, which therefore leads to poor weight control in such circumstances. It also can lead to difficulties swallowing meats, breads, and some fibrous vegetables, particularly if the band is adjusted too tightly (perhaps in a misguided attempt to get more weight loss). Other issues include the need for regular adjustments (every 4-8 weeks in the first year), and the small risk of long-term device-related problems such as slippage or erosion or port/tubing issues, which may occur in up to 20% of patients. Fortunately, these problems are usually quite straightforward to fix, and have reduced significantly in recent years due to improvements in Band design, surgical technique and aftercare.
Although device-related problems can occur long-term with the Band, these are usually easily corrected and have become less common.
The Gastric Sleeve
Unlike the Band, the Sleeve does not involve having a man-made device (a prosthesis) inside your body. Rather, the stomach is simply reduced in size by cutting a part of it away. Gastric Sleeve is simply the name given to the tubular shape of the part of your stomach that is left behind. Although approximately 80% of the stomach is removed, the remaining 20% (about the size of a cup) still functions as the stomach should: it’s just smaller. Removing a significant portion of the stomach also results in the reduction of the hunger hormone Ghrelin. Gastric acid and Pepsin still continue to be produced to assist in the breakdown of food, and Intrinsic Factor still continues to assist in the absorption of Vitamin B12. The Sleeve is completely different to the old ‘stomach stapling’ operation of the past. And, unlike the Gastric Bypass, the small intestine is not altered; therefore, there is virtually no risk of malabsorption of protein, vitamins or minerals.
The Sleeve simply reduces the size of the stomach organ. It does not interfere with the absorption of nutrients.
Because the physical capacity of the stomach is reduced, the Sleeve restricts the intake of virtually all calories, both solid and liquid. This makes it more powerful than the Band, and weight loss is more consistent and reliable. However, regular consultations with experienced psychologists and dieticians are still needed to address the underlying dietary and lifestyle factors.
The Sleeve can even restrict the intake of soft and liquid calories which makes it more suitable for emotional eaters, especially when combined with the help from experienced psychologists and dieticians to overcome the underlying issues.
The main disadvantage of the Sleeve is that the internal pressure within the stomach increases; this may lead to reflux in approximately 20% of patients. In most cases this is quite manageable with acid lowering medication such as Somac, but occasionally corrective surgery (such as hiatus hernia repair or conversion to roux-Y bypass) might be necessary if reflux is severe (approx 1-3%). The sleeve will also stretch over time (for the same reason that the internal pressure is higher), leading to reduced portion control and the possibility of some weight regain, especially if sufficient behavioural and lifestyle improvements have not been made.
Disadvantages of the Sleeve include reflux, and stretching in the long term, which could lead to some weight regain.
An advantage of the Sleeve over the Band is that is does not require any adjusting. This means clinic appointments after the surgery can be less frequent- once every 3 months rather than once a month. This may make the Sleeve more suitable if you live outside of Sydney, or foresee difficulties in getting back to the clinic. Another advantage is that there are virtually no dietary restrictions with the Sleeve- most types of food can continue to be eaten, just in smaller quantities.
Although the sleeve does not need adjusting, on-going medical, dietary and psychological support remain just as important.
Because the Sleeve restricts soft and liquid calories better than a Band, the Sleeve usually results in a more consistent reduction in calorie intake overall. This means that the average amount of weight loss after a Sleeve is usually a little bit better than for a Band – in our clinic the average excess weight loss at 12 months after a Sleeve is 76% vs. 62% after a Band. (The “excess weight” is the number of kilograms you are carrying over the ideal body mass index of 25).
Regardless of their differences, both the Band and the Sleeve are far more effective than diets and exercises alone for people with a long-term weight problem. Ongoing participation in multi-disciplinary follow-up after surgery and a commitment toward lifestyle improvement remain the most important factors.
The Gastric Bypass
The Roux-Y gastric bypass has the longest track record of any of the modern bariatric procedures. For this reason it is often referred to as the ‘Gold Standard’ procedure, which newer procedures are compared against. However, despite being an excellent and reliable weight loss tool, it does have a number of side effects. One of these is the risk of intestinal obstruction related to herniation through the mesentery windows that are necessarily created during a roux-Y. This has lead to the development of modern, improved versions of the bypass, such as the “Omega Loop” procedure, which have substantially reduced this risk. Other side effects, such as ‘dumping syndrome’ are also less frequent.
All forms of gastric bypass involve dividing the stomach into two sections, and then creating an ‘anastomosis’ or join between the smaller stomach pouch and the small intestine. This arrangement gives a strong sense of portion control, and diverts food straight into the lower intestine, preventing food from entering the duodenum. This rearrangement causes favourable changes to the gut hormones, leading to suppression of appetite, and improvement in diabetes.
The gastric bypass may provide greater weight loss and also better long term results than other types of bariatric surgery. In addition, type-2 diabetes improves or resolves in most cases. As with all types of surgery, ongoing participation in multi-disciplinary follow-up, and a genuine patient commitment toward improving dietary behaviours and lifestyle remain important.
Generally the risks and side effects of the bypass are greater than other types of bariatric surgery. The main long term risks of the bypass include potential nutritional deficiencies (particularly iron), anastomotic ulcers (especially in smokers), increased frequency or looseness of bowel movements, and loss of endoscopic access to the duodenum and bile duct. To balance these risks, the bypass may be more suited to the following patients:
- BMI > 50
- Patients with severe reflux such as Barretts Oesophagitis
- Patients with weight regain after other types of surgery