Durability Of Bariatric Surgery
Tuesday, August 3, 2010
For most patients with severe obesity, the decision to undergo bariatric surgery is one of the most important decisions they will make in their lifetime.
But once they have decided to go down this route, several important issues need to be considered, not least the choice of operation.
Apart from the surgical risk (complications at the time of surgery), patients are of course interested in how much weight they will lose. Many patients also consider the long-term outcomes (will the weight stay off?).
Interestingly, however, few patients appear well aware that if the surgery does not work, their only option may be to have another operation performed (often another type of surgery).
As of course very few patients want to have more than one operation, the question of whether or not a given operation is indeed a “definitive” procedure, that will last them a lifetime, is of considerable significance.
And this is where there are indeed important differences between the various types of bariatric surgery.
For e.g., in a paper from our group just published in OBESITY SURGERY, we review the literature on the laparoscopic sleeve gastrectomy (LSG) and note, based on a systematic review of 15 studies (940 patients), that despite sustained weight loss up to 3 years, it is presently not clear if weight loss following LSG is sustainable in the long term. We conclude that it is, therefore, not possible to determine what percent of patients may require further revisional surgery following LSG (e.g. conversion to gastric bypass).
Similarly, a paper just published in the same issue of OBESITY SURGERY by Monika Lanthaler and colleagues from Innsbruck, Austria, suggests that a significant proportion of patients undergoing laparoscopic adjustable gastric banding (LABG) may need reoperation.
In their experience with 276 patients, who underwent LABG a minimum of 9 years ago, despite good initial weight loss, 146 (52.9%) patients had at least one complication requiring reoperation.
Presently, only 148 (53.6%) patients still have their original band, 49 (17.8%) had their original band replaced with a new one, and 79 (28.6%) had their band removed. A Roux-en-Y gastric bypass was eventually done in 39 patients, and 6 patients underwent sleeve gastrectomy.
What makes this study important is the fact that the investigators managed to collect outcomes on 80% of their study population. Most surgical centres lose track of their patients and frankly have no idea what proportion of patients they operate on experience weight regain, have long-term complications, and/or end up having revisional operations.
I wonder how many patients would opt for a procedure, which although safe and relatively simple, is also associated with a 1 in 3 chance of requiring a reoperation?
Health professionals likely need to tell their patients that certain procedures may be less “definitive” than others – something that certainly must be considered in the overall risk (and cost) of any given procedure.
AMS
Duchesnay, Quebec
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Shi X, Karmali S, Sharma AM, & Birch DW (2010). A review of laparoscopic sleeve gastrectomy for morbid obesity. Obesity surgery, 20 (8), 1171-7 PMID: 20379795
Lanthaler M, Aigner F, Kinzl J, Sieb M, Cakar-Beck F, & Nehoda H (2010). Long-term results and complications following adjustable gastric banding. Obesity surgery, 20 (8), 1078-85 PMID: 20496124
Wednesday, August 4, 2010
Dear Arya:
As usual we read your daily blog with great interest. However from time to time I have concerns about your message and appreciate the opportunity to provide a rebuttal. As you can imagine, your discussion about the durability of bariatric surgery caught my attention and I have reviewed the papers you reference in today’s blog.
The paper by Lanthaler et al is interesting because it documents long term follow up after LAGB (Laparoscopic Adjustable Gastric Band) surgery and shows excellent weight loss at 10 years that compares favourably with the limited long term data available for gastric bypass. This study supports the review of medium term data provided by Drs. Dixon and O’Brien from Australia in their “Systematic Review of Medium-term Weight Loss after Bariatric Operations” (Obes Surg. 2006 Aug;16(8):1032-40) which showed comparable long term weight loss between RYGB (Roux-en-Y Gastric Bypass) and LAGB.
Unfortunately the paper by Lanthaler does not represent the current state of affairs in regards to the technique and devices available for LAGB surgery. All of the LAGB procedures in this paper were performed prior to 2001 and thus used the older peri-gastric technique of band placement. This technique led a very high rate of posterior band slippage (20%) and has now been replaced with the pars flaccida technique. Posterior band slippage has essentially been eliminated by the pars flaccid technique. This paper describes 20% rate of band “migration”. It is unclear whether the authors are using the term migration to describe erosion or slippage. If they mean erosion, this is an extremely high rate and would likely indicate problems with either surgical technique or with band adjustments. If they mean slippage (I suspect this is the case), this would fit with the expected rate of posterior slippage with the now abandoned peri-gastric technique. The majority of the other complications (port disconnection, band leakage) they describe are now unusual because of advances in the design of the current generation of banding devices.
Lanthaler et al opted to remove the band and provide an alternative bariatric procedure in most patients who developed a complication. This reflects the current trend in Europe where funding for follow up care after LAGB has been reduced. This may be one of the reasons why many bariatric centres in Europe prefer conversion to RYGB or sleeve rather than band replacement. However the majority of centres in Australia and in clinics like ours in Canada will reposition slipped bands and repair port problems, rather than remove the device. Patients have been shown to maintain successful weight loss after band revision with appropriate follow up. It is likely the high rate of band removal reported in this paper is due to surgeon preference rather than clinical necessity.
You chose not to include a discussion of the durability of weight loss, or incidence of complications after RYGB. As mentioned there are few long term studies of the sustainability of weight loss after RYGB, but the issue of weight regain is well known. Dr. Christou from Montreal published a paper in the Annals of Surgery (2006) (attached) documenting the weight regain that can be an issue with RYGB in clinics that document long term follow up. The lack of long term studies is an issue with all bariatric procedures, including RYGB.
I am also concerned that the “complications” after LAGB need to be kept in perspective. Some authors included problems with nausea and vomiting as “complications” after LAGB which are not comparable to other problems. Complications after LAGB are rarely life threatening in comparison to the early complications after other bariatric procedures, which can be serious and lead to significant morbidity and prolonged hospital stay. Reoperation in LAGB patients is usually required for device specific problems, such as band slippage or minor port/tubing complications and can be usually be performed on an outpatient basis. Surgery for the complications of other bariatric procedures is generally for more complex problems, such as internal hernia, stomal ulceration, fistulas, anastomotic leaks or stenosis. Long term nutritional issues are rarely an issue with LAGB in contrast with other weight loss operations.
Parikh et al. (J Am Coll Surg, 2005) 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 complication rates were 9% for LAGB, 23% for RYGBP, and 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 LAGB group had an almost three and a half times lower likelihood of a complication compared with the gastric bypass group.
Once again, I thank you for your commitment and the very thought provoking blogs. I also appreciate the opportunity to respond.
Best Wishes
Chris Cobourn
Wednesday, August 4, 2010
@Chris: Your comments are very helpful in terms of putting these papers into perspective. As you point out – better long-term data for all procedures (including RYGBP would certainly be valuable to help guide both clinicians and patients (and funders?) in deciding the best surgical approach for a given patient.
AMS
Wednesday, August 4, 2010
Hi Arya,
Congratulations on your review article on sleeve gastrectomy. Another perspective can be found at http://bariatrictimes.com/2010/07/22/sleeve-gastrectomy-failure-just-when-we-thought-we-had-the-perfect-operation/ . There definitely seems to be some excitement about the sleeve gastrectomy operations, so these articles are very timely. Hopefully more data will become available soon.
nana
Friday, June 24, 2011
Is the glass 2/3 full or 1/3 empty. I think a lot of patients battling with obesity would be prepared to accept an operation which had a 2/3 chance of long term success. There is no ‘perfect’ obesity surgery procedure and surgeons should discuss the various merits of bypass, sleeve or band surgery with their patients.
Thursday, September 1, 2011
Dr. Arya,
I am so satisfied after I got a biatric bypass,it has changed my life,from 178 to 98 kegs in seven months,and ur articles give so much comfort that my decision was right.