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Canadian study

Publically-funded LAGB results in effective weight loss

Results demonstrate achievable weight loss through safe and least complex obesity surgery option

Adapting bariatric surgery in the Canadian public health care system has the potential to alleviate on-going health care burden from obesity-related disease, according to a study published in the Canadian Journal of Surgery.

The data suggest that the weight loss achieved with laparoscopic adjustable gastric banding (LAGB) in a sustainable public programme is substantial and successful, the authors note, and that the safety of the procedure was clearly demonstrated.

Although they acknowledge that long term data are still required to ‘ultimately decide the true cost-effectiveness of LAGB in our system’, the study of the short-term results ‘represents a realistic view of achievable weight loss through this safe and least complex obesity surgery option’. 

The researchers undertook the study as there is no uniform long-term data on public bariatric surgery programmes or consensus currently on patient selection criteria for LAGB.

“These controversies are reflected in that not all Canadian provinces fund LAGB as a treatment for obesity,” they note. “The publicly funded obesity treatment program at our institution is a referral-based, multidisciplinary clinic providing tertiary medical, psychological and surgical interventions.”

The investigators performed a retrospective study involving patients who underwent LAGB during a six-year period from 2005 to 2010 and the short-term weight loss results at one-, two- and three-year follow-up were analysed.

They calculated the weight loss results as both percentage total body weight loss (%TBWL) and percentage excessive body weight loss (%EBWL) based on an ideal body weight generated using a normal BMI of 24.9.

The analysis of complications were separated into two categories: short (postoperative period before discharge from hospital) and medium term (the period from discharge up to three-year follow-up).

In addition, they also reported the operational costs for on-going LAGB care, we assessed the duration of surgery, length of stay (LOS), frequency of clinic visits and band fillings, and methods of investigation used during the follow-up period.

They included two generations (Real 1 and 2) of the REALIZE adjustable gastric band (manufactured by Ethicon Endo-Surgery) and reported the differences in performance between the two devices.

Outcomes

They identified 178 patients who underwent LAGB during the study period: 153 women (86%) and 25 men (14%). The average age was 42.8 years, and the average preoperative BMI was 44.2 (SD -/+7).

The trends of weight loss over the 3 years are illustrated in Figure 1. Three patients’ weight data were not included in the weight loss analysis owing to early removal of band (n=1) and complication or pregnancy affecting weight (n=2) before one-year follow-up. The preoperative conservative weight management achieved a %TBWL average of 4.4%.

Figure1: Percentage total body weight loss and percentage excess body weight loss among patients who underwent laparoscopic adjustable gastric band surgery.

The most common short-term complications were postoperative nausea (19%) and non–surgical site infections, such as pneumonia and urinary tract infections (1%). The reoperation rate was 4.5%.

In an analysis of operational costs, the average duration of surgery was 56 minutes, and the average LOS was 1.4 days. Clinic visits occurred most frequently in the first year, with an average of seven visits, and dropped to four visits in the next two years. The average number of band fillings required was three fills in year one, and one fill only in the other two years.

They noted that 36% of our patients required at least one investigation postoperatively. Fluoroscopy was the most common method (86%), followed by computed tomog raphy (9%) and upper endoscopy (4%).

REALIZE comparison

The comparison between Real 1 and 2 gastric bands is presented in Table 1. They found significant differences in preoperative BMI, weight loss and duration of surgery. The weight loss analysis was based on one-year follow-up data because not enough patients who received the newer Real 2 band had complete two-year follow-up data.

Table 1: Comparison between the first (Real 1) and second generation (Real 2) of the REALIZE adjustable gastric band at one-year follow-up.

The weight loss achieved through LAGB in the short-term plateaued between the second and third year reaching a %TBWL of 20% and %EBWL of 44%.

Regarding the comparison between the first and second generations of the REALIZE gastric band, the investigators claim the data suggest significant differences in the duration of surgery and weight loss at one-year follow-up. The surgery was three minutes longer in the newer Real 2 band group, which likely represents a small learning curve using the new product.

The %EBWL was higher in the Real 1 group; however, the preoperative BMI between the 2 groups was also significantly different, with the Real 1 group having a higher BMI.

“Since the 2 groups’ baseline characteristics were not identical, especially with respect to preoperative weight, it is difficult to determine whether the observed difference in %EBWL is truly significant,” the write. “More data collection with longer follow-up will be needed to further investigate the difference in weight loss observed between patients who received the different bands.”

“Our patients may represent a distinct population that differs from that in the private system,” the researchers conclude. “Long-term data are necessary to determine the cost-effectiveness of this important surgical option for severe obesity.”

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