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BOMSS 2013

Prepare for revisional band operations, says surgeon

Mr James Brown, presenting at the BOMSS 2013 conference.
James Brown projects that his centre will have to perform more than 150 gastric band removals over next three years
Brown - "There are better operations"

Following a large rise in the number of gastric band removals performed at his centre, a British surgeon has said he considers the operation to be an “historical” procedure, and that that surgeons should make preparations for significant numbers of revisional operations over the next few years.

Mr James Brown, of City Hospitals Sunderland, UK, told the British Obesity and Metabolic Surgery Society’s Annual Meeting in Glasgow, Scotland that if current rates of attrition continued, he expected his centre to remove 153 gastric bands over the next three years.

“The purpose of the paper was to point out the fact that we’ve taken out a lot of bands,” Brown told Bariatric News, “but that’s the tip of the iceberg if you consider the number of bands placed in other units and in the independent sector. If they aren’t for life in a significant proportion of people, someone’s going to have to take them out, and for a proportion of those people we’re going to have to think of something different for them.”

Out of the 674 bands that the hospital placed between 2000 and 2012, 143 – 21% – have had to be removed. The mean period of time for a gastric band to be implanted before needed to be removed was 1200 days – just over three years.

Brown noted that there was a linear progression in the number of bands that have been removed over time. While every single band implanted at the hospital in 2000 has now been removed, half of the bands implanted in 2005 have been removed, and less than 10% of the bands implanted in 2010-2012.

The hospital has overseen what Brown describes as a “precipitous drop” in the number of gastric band operations, peaking at about 190 procedures in 2009, before falling to around 50 in 2011 and less than 20 in 2012.

“It’s not something we routinely offer,” he said. “The reason we don’t routinely offer it is that there are better operations.”

The total number of bariatric operations performed in the hospital has continued to rise, however, mostly due to an increase in gastric bypasses.

Brown noted that his hospital served a relatively deprived population in the north east of England, and was publicly funded, which limited its ability to offer as extensive follow-up services as some other centres.

“I think it’s apples and pears comparing privately funded affluent people with NHS patients who are non-fee paying and from an entirely different social demographic,” he said. “Poor people tend to do badly whether they’ve got cancer and heart disease or, in this case, bariatrics. Deprivation has a very pervasive effect on how things work.”

“I think that within the population we serve, I can’t see banding have any form of resurgence.”

In comparison to Brown’s results, Professors Paul O’Brien and Wendy Brown, of Monash University, Australia, recently released a study covering 15 years of outcomes from gastric banding operations in his centre, which showed that only 5.6% of his patients required explantation.

“There is a setting in which you can make bands work, where you’ve got intensive follow-up and very motivated patients,” said Brown. “Unfortunately we don’t have primary care physicians who are doing band fills and defills and reviewing, as they might do in the Australian model. So whether you could make bands work in this way in the UK and the NHS, I’d be a little sceptical.”

Brown also noted that O’Brien’s centre did not offer other treatments, meaning that they were more likely “find a way to make it work” rather than what he described as “a slightly more pragmatic approach” of considering removal or revisional surgery.

“Within that you have to accept the fact that in 10 years’ time we might find that there’s an inherent problem with Roux-en-Y bypass,” said Brown.

“What occurs to me is that in bariatric surgery we’ve invented a whole new specialty in the last decade, and we don’t have any particular cornerstones of research on which to base this. We’re kind of feeling our way in the dark – a bit like driving looking through the rear-view mirror to try and work out which way we’re going.”

Brown’s talk was awarded the BOMSS Council Prize for best oral presentation at their annual meeting.

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