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LAGB in private centres

Private centre in UK finds LAGB safe and durable

The researchers note that weight loss in the first 12-months was greater in those with a pre-operative BMI<50 than those in the BMI≥50 group, but there was no difference for 2-,3- and 4 years.

Laparoscopic adjustable gastric band (LAGB) is a safe procedure, which delivers significant and durable weight loss with acceptable complications rates and low re-operation rate, according to a retrospective study from more than 2,200 patients who underwent the procedure at a private clinic in the UK between June 2004 and October 2014. The study is believed to be the first such report from the private sector in the UK. The paper, ‘Medium and long-term results of gastric banding: outcomes from a large private clinic in UK’, by researchers from Heart of England NHS Foundation Trust and Healthier Weight Centres, Birmingham, UK, was published in BMC Obesity.

The number of LAGB procedure, like elsewhere in the world has declined significantly over the last few years in the UK, particularly as a procedure provided by the NHS. Nevertheless, LAGB is still a popular procedure in the UK’s private sector, although the NHS will often deal with complications from the proceed. As a result, the study authors undertook this study to examine the weight loss outcomes and complication rates in a large cohort of LAGB patients from a single, private provider in the UK.

This retrospective study included 2,246 patients who underwent LAGB by a private weight management clinic in the UK over a ten-year period. All patients benefited from a two-year aftercare programme as part of their LAGB package including unlimited adjustments, access to a dietetic team and surgical consults if required. Follow up consisted of an initial six weeks, three months and six months follow up, followed by six monthly follow up until two years by a team consisting of bariatric nurses, dieticians and surgeons.

Therefore, data was available for the first two years and for another two years as a result of contact via email and telephone. Data collection included basic demographics, date of surgery, pre-operative weight, height, BMI, post-operative complications and most recent weight. Patients who required further revisions/ reoperations following their initial procedure were excluded from our weight loss analysis but reported separately. A variety of saline filled LAGBs were used including Swedish Adjustable Gastric Band, LAP-BAND AP, AMI and Bioring.

Outcomes

Between June 2004 and October 2014, 2,246 patients underwent primary implantation of a LAGB, 81% of cases were performed by three experienced consultant bariatric surgeons. The mean age of these patients was 45.6±11.5 years and 84.6% (1,945) of patients were female. The mean baseline weight was 110.6±22kg and the baseline BMI was 39.7±6.6. The baseline BMI range was 28.5–73.4.

At the time the study began, 1,334 patients were beyond 36 months post-procedure and were contacted via email or phone depending on the patients indicated preference. A total of 1,640 patients were over 12 months from their initial procedure and had not reported any complications. Their mean pre-operative weight and BMI were 111.2±22.1kg and 39.9±6.7, respectively. In total, 80.48% of patients had complete follow-up 24 months post operatively.

The researchers divided the patients into two groups depending on age (<50 (1,305 patients) and ≥50 years (762 patients). Mean excess % BMI loss figures were compared between these two groups and there was no statistically significant difference in their baseline mean BMIs (Age < 50–40.1 +/− 6.8 vs. 39.5 +/− 6.6, p=0.05). Between the groups, mean excess % BMI loss was initially better in patients who were over the age of 50 for up to three months following their procedure (Figure 1). However, there was no statistically significant difference following this.

Figure 1: Mean % excess BMI loss according to BMI groups with statistical significance at each time point/p>

Patients were divided into two groups of BMI (BMI<50 vs BMI≥50) for analysis and there were 1,504 patients with a BMI<50 and 134 patients with a BMI≥50. The mean baseline BMIs were 38.5±5.0 and 54.9±4.6 respectively (p=0.02). Statistically better mean excess % BMI loss was achieved for patients with a baseline BMI<50 for the first 12 months (p<0.05). However, this difference lost statistical significance after this.

From 2,246 patients had a saline filled LAGB implanted, of which a total of 130 complications were identified (5.8%). Of the major complications, 39 (1.7%) experienced a slippage or pouch dilatation which required 33 re-operations (1.5% re-operations for slippages); removal - 12; replacement - 13; repositioning - four and conversion to Roux-en-Y-gastric bypass (RYGB) or SG - four. It is to be noted that only nine slippages were diagnosed within two years of follow up (1.3%). Two patients had erosions with one resulting in a conversion to RYGB (0.04%), the second patient was lost to follow-up.

In total, 76 (3.4%) patients had problems related to the tubing or port including infections with 63 patients undergoing reoperations; seven LAGB or port removals, 49 LAGB or port replacements, six conversions to RYGB or SG and one tubing repair. One further patient had a foreign body left in situ from their primary operation and which required a reoperation for removal.

Twenty-eight (1.2%) patients underwent a conversion from their LAGB to either RYGB or SG. This was due to inadequate weight loss in nine patients (between 21 and 112 months after the initial procedure) and individual choice in 12 (between 5 and 81 months). There was no data available to account for conversion in the remaining six (12–68 months).

A further 29 (1.3%) patients had their LAGBs removed, replaced or repositioned. Of these, 16 were removed for no obvious reason, seven due to patient choice and one due to a fracture of the LAGB tubing secondary to a road-traffic accident. Three LAGBs were replaced and two were repositioned for reasons unknown.

The researchers note that weight loss in the first 12-months was greater in those with a pre-operative BMI<50 than those in the BMI≥50 group, but there was no difference for 2-,3- and 4 years.

“Based on these findings, we believe that sub-optimal outcomes for the LAGB are primarily a function of low volume surgeons or facilities and an inadequate LAGB aftercare programme…The fact is that LAGB requires a long-term commitment to the patient and whilst this is obviously true for all bariatric patients, it is an indispensable requirement for success with the LAGB,” they write.

The authors acknowledge that patients with poor outcomes or those who developed complications may have avoided contact and as patients were self-paying their motivation to succeed is likely to be greater than NHS patients -  therefore the results may not be completely extrapolated to NHS practice. Moreover, they state that the co-morbidities for these private patients are probably less severe compared to NHS patients.

“Overall, we feel that it is likely that most LAGBs implanted in the UK will continue to be in the private sector,” they conclude. “Assuming that this is the case and that the LAGB survives the current fashion for more aggressive procedures, our results should be reassuring to both patients and regulatory authorities alike.”

To access this paper, please click here

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