High lap band surgery revision

AN Australian pioneer of bariatric surgery says laparoscopic adjustable gastric banding remains preferable to gastric bypass as a primary bariatric procedure, despite findings that almost 20% of patients will require revisional surgery within 3 years.

Professor Paul O’Brien, emeritus director of Monash University’s Centre for Obesity Research and Education, said he would like the revision rate to be lower, but the procedure was “still good health care”.

“You can’t expect to treat a chronic disease — a lifetime disease — with a single treatment and then walk away and never have to worry about it again”, he said.

An Australian analysis of Medicare data for more than 6000 patients undergoing laparoscopic adjustable gastric band (LAGB) surgery in 2005–2006, published in JAMA Surgery, found that the rate of revisional surgery was 18.9 events per 100 patients, comprising 11.4 intra-abdominal and 7.5 subcutaneous surgical procedures. (1)

JAMA Surgery also published the findings of a French retrospective review of 831 patients who had a primary gastric bypass and 177 patients who had a secondary gastric bypass after failed LAGB. The researchers found similar rates of major adverse outcomes in both groups — 7.8% in the primary procedure group and 8.5% in the secondary procedure group. (2)

A commentary accompanying  the French study said that a higher rate of revisions required after LAGB compared with Roux-en-Y gastric bypass was driving an increase in the number of conversions from LAGB to other interventions, including sleeve gastrectomy, gastric bypass and duodenal switch. (3)

Professor O’Brien said the French study made the important point that there was no difference in safety for a patient having a revision of a gastric bypass or a patient having a primary gastric bypass. However, he said, in Australia it was far more common for LAGB patients requiring revision to have the problem with the band fixed rather than having more invasive gastric bypass.

“Every operation will have a revisional surgery rate and it becomes a surgical decision as to whether you revise to fix it up … or you go to something else”, he said.

The Australian analysis found that conversions to other bariatric procedures (1.3 events per 100 patients) and LAGB reversals (1.9 events per 100 patients) were uncommon here.

Professor O’Brien said the French study showed that for primary gastric bypass as well as secondary gastric bypass after failed adjustable gastric banding, there were some serious risks.

“You’ve got a [hospital] length of stay of 5–6 days, you’ve got a leak rate of 12 patients [n = 1008], you have a total of five deaths. You’ve got rate of abdominal reoperation within 30 days of 6%. This is serious stuff”, he said.

LAGB revision could be a day procedure with “a high probability of being very safe and, in our experience, a high probability of as good a weight loss as you get with the other procedures”, said Professor O’Brien, citing research, on which he was lead author, which found that 47% excess weight loss was maintained 15 years postprocedure, regardless of whether revision surgery was required. (4)

Professor John Dixon, head of clinical obesity research at Baker IDI Heart and Diabetes Institute, said there had been “tremendous advances” in the safety of bariatric surgery in recent years, but the reoperation rates for all procedures remained too high.

“All [bariatric procedures] are associated with what we can say is a high reoperation rate that we would like to reduce so that it minimises people’s risk of having to have multiple operations”, he said.

However, he said, while the reoperation rate was “a nuisance”, it should not detract from the overall improvement to health and quality of life provided by these procedures.

“We have to recognise that these are surgical procedures that are essential for many of our patients, they produce a total change in their life”, he said.

Professor Dixon advised GPs to keep a close eye on patients who have had bariatric surgery for any gastrointestinal symptoms and for nutritional deficiencies, which could also result from the procedures.

“If you’re seeing symptoms that worry you … always involve a bariatric surgeon. There have been some major issues when patients have gone to a general surgeon or a gastroenterologist for symptoms that are related to complications of their bariatric surgery”, he said.

1. JAMA Surg 2014; Online 18 June
2. JAMA Surg 2014; Online 18 June
3. JAMA Surg 2014; Online 18 June
4. Ann Surg 2013; 257: 87-94