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AUSTRALIAN experts have dismissed as flawed a US study finding that suggests gastric bypass surgery is superior to lap banding for weight loss and control of type 2 diabetes, with one surgeon saying it is a “no brainer” to prefer lap banding.
One obesity expert, Associate Professor John Dixon, has called for greater access to bariatric surgery in public hospitals, based on the successful outcomes of surgery performed in Australia.
Professor Dixon, head of the Obesity Research Unit in the Department of General Practice at Monash University, said that currently in Australia “we neglect Australians suffering from” obesity and type 2 diabetes.
The matched-cohort study in the Archives of Surgery looked at 1-year outcomes for 93 patients who underwent laparoscopic adjustable gastric banding (LAGB) and 92 who had laparoscopic Roux-en-Y gastric bypass (RYGB).(1)
The overall rate of complications was similar in both groups (12% for LAGB versus 15% for RYGB), with a higher rate of early complications after RYGB (11%) versus LAGB (2%) and a higher rate of reoperations after LAGB (13%) versus RYGB (2%). No deaths occurred in either group.
After 1 year the RYGB group had better measures for excess weight loss (64% versus 36% for LAGB), resolution of diabetes (76% versus 50%) and quality-of-life outcomes.
Professor Paul O’Brien, a bariatric surgeon and emeritus director of the Centre for Obesity Research and Education at Monash University, Melbourne, said LAGB required a commitment to good patient care after placement of the band. Without that, results were poor.
“This group [of researchers] are RYGB surgeons who are not that familiar with the band,” he said.
Surgeons in Australia would expect patients to have 50% excess weight loss at 12 months with LAGB, Professor O’Brien said.
“RYGB is at its best at 12 months, tends to stay steady for another year and then fades in effectiveness,” he said.
“LAGB is only halfway to its peak at 12 months, generally is best at 2–3 years and remains durable beyond because it is adjustable. RYGB is not.
In a randomised, controlled trial published in JAMA in 2008, a 73% remission rate for type 2 diabetes at 2 years was achieved using LAGB compared with 13% in conventional diabetes care, Professor O’Brien said.(2)
He said cost effectiveness had not been properly measured for RYGB. However, LAGB-induced weight loss to manage type 2 diabetes in obese patients had been shown to increase quality-adjusted life years at a decreased cost to the health care system.
“It is a no-brainer,” he said.
Medicare statistics show that the number of LAGB procedures in Australia increased from 5287 in 2005 to 11 015 last year, while the number of RYGB procedures rose from 208 to 289 over the same time.
Medicare pays an $800 rebate for banding and $988 for RYGB. Out-of-pocket cost of LAGB averages $11 000–$15 000 for patients without private health insurance and $4000 for those with it. The average cost of RYGB is estimated at $25 000.
Professor Dixon said the US data were short term and it was already known that the early weight loss with RYBG was far more extensive and rapid than with LAGB.
“RYGB is technically challenging, more dangerous in both its early and late complications and has significant long-term nutritional issues,” he said.
He said Australian surgeons preferred LAGB because of its excellent results.
“Of course, lifestyle programs need to be tried first but to do this over and over again is not needed. Surgery should be seen as an effective, safe and cost-effective therapy for a serious chronic disease,” he said.
WA surgeon Professor Jeff Hamdorf, head of surgery at the University of WA and director of the Clinical Training and Education Centre (CTEC), the medical and surgical skills training centre at UWA, said RYGB was often done as a salvage procedure rather than a primary procedure.
“The Americans just can’t seem to get results [with LAGB] which match Australian groups. Weight loss of 36% to 38% is actually OK at 12 months [because the weight loss] keeps on going.”
In Australia, gastric banding can be used to treat people with a BMI of at least 30 and an obesity-related disease such as diabetes.
Professor Dixon said the new indication filled a necessary gap in treating the disease.
– Cathy Saunders
1. Arch Surg 2011;146:149-155.
2. JAMA 2008; 299:316-323.
Posted 28 February 2011
I have had 2 lapband procedures, 7 and 4 years ago and not made any comment in a public forum before. Reading these other posts, I hope my experience may shed some light for others on possible other than ideal outcomes. The most weight I lost was 4 kg on the fluids only part for the first few weeks. When I started to eat food, I had frequent bouts of vomiting, to the stage I couldn’t drink water. I had the first surgery done with a surgeon in Brisbane and found follow up difficult, as I live an hour north of Brisbane, and his nurse’s advice was to stick with fluids. I had been told 1/20 lap bands ‘don’t work’, but after lots of problems, never being able to eat fish or rice (and yes ice cream did slip down, and I had rarely eaten it before). I was told my problem was a slow metabolism. He also said if I had it taken out I would probably put on another 20kg. I decided to give it another try with a different surgeon, who used the French lap band (the previous one was Swedish). It was much more comfortable, and allowed a more normal eating pattern (I could eat some salads, fish, rice and chicken). However, food still got stuck quite frequently, and it was hard to get the food mix right so that there was a feeling of satiation – just a bit soft (ie, cereal or casserole) and it slid through, meat not perfectly tender and it stuck. I also need vitamin D, fish oil and multivitamin supplement, and these are difficult to swallow too. Now 7 yrs on, with lots of enamel gone from my teeth, I am 18 kg heavier. I lost 8 kg at one stage with Weight Watchers over 4 months, but had to eat tiny amounts and felt hungry a lot of the time. I know a lot of people do lose weight with lapbands, but it is a difficult and painful process. I would say those with the biggest chance of success are those people who know they eat large volumes of food, don’t have any physical impediment to a significant amount of exercise, life is not too stressful, and you don’t work full time. If you don’t eat much more than normal, I would say this is not for you. I was never asked HOW much food I ate, just that other methods had failed. I was also told by the first surgeon, who had had the procedure himself, that exercise didn’t make much difference. I truly wanted this to work, but despite private follow up (it was very good with my second surgeon, just disappointing results) it certainly doesn’t work for everyone.
Had banding 3 yrs ago as a private patient in Adelaide. Received very poor (read nil) support post surgery. Surgeon never at appointments, only a sidekick with an attitude problem towards obese people. My band remains empty and no dr to follow up as I refuse to return to the original clinic…beware anyone contemplating this procedure…
I had LAGB more than ten years ago. Initially I did lose weight but the experience was memorable. I awoke from the anaesthetic with the surgeon standing over me saying “Now I want you to take this very seriously.” I had just paid him $7000 upfront so I was hardly expecting this advice. What I should have been told preoperatively was that I would not be permitted to drink fluids with meals. Hence I got excruciating pain if I tried to eat a teaspoon of grated carrot or a morsel of grilled fish. Previously for lunch I would have a salad roll with several glasses of water, that was now off the agenda but chocolate, cheesecake, anything rich easily slipped past the band. In public, rather than suffer the embarrassment of having to absent myself to regurgitate the smallest obstacle and relieve the pressure, returning to the table with reddened face and weeping eyes, I would order something that did slip down without a fuss. In fact the LAGB changed my dietary habits for the worse. Now it sits there unused. It certainly did nothing for my long term obesity. After the initial loss, I remain obese but feel great as I eat salads every day, drink lots of water and walk for miles. I do get mad though at the surgeons who promote LAGB as the answer to obesity. What about their long-term follow ups? How are their patients faring after 4 years and beyond? Frankly I wish I had spent the money on a personal trainer, or maybe a holiday in the Galapagos.
I see a number of patients in my clinic who have had surgery for gastric banding. They presented with significant levels of gastric discomfort and pain as a result of eating and impared digestive function. It was obvious some of these patients were not digesting food effectively and one wonders if this was a result of the surgery or if the condition existed prior to surgery. The symptoms they described indicated these conditions may have existed prior to surgery and were not addressed. Had these issues been addressed along with more time spent with the patients educating them about food choices over a period of time, they may not have required surgery in the beginning. These patients did not receive adequate support post surgery and opted for the removal of the bands. With education over a period of time along with some counseling they became self reliant in their ability to lose weight and take control of their health. The patients went back to addressing the causes of their obesity and were able to regain control of their health.
It has been my experience that overweight patients when releasing feelings and emotions from past events, coupled with getting them to come up with their own adjusted eating habits that they are happy with. Looking at creating attainable changes has been a non-surgical intervention that is able to work for them.
When patients try it over and over again without success, it tells me that what they are doing isn’t working. Yet, again and again they try the same methods that didn’t work in the first place, other than short-term using ‘willpower’.
I have had a client that underwent a gastric banding that allowed them to release 10kg, but they have since put it all back on again, only this time in the top part of the stomach that has been banded. Two of her friends also underwent the surgical procedure – one had it removed as she became very sick, the other had the band slip.
I believe everything has its place, but I would be concerned if we now endeavour to use this form of procedure as a norm, only to find out later patients are still up the creek without a paddle.
How much research has been done to validate a substantially large group of people with long-term results that show the weight stays off without complications?
I’ve come across someone who had LAGB in SA through a public hospital trial, and got very poor support and follow up – the surgeon was never there for outpatient visits and the registrars just said “Sorry I don’t know”. The GP has now emptied the adjustment reservoir due to frequent dry retching.
She is still losing weight, but I wonder what happens when she needs the excess skin removed. She was promised hospital support in that as part of the trial, but since other support proved non-existent post surgery I wonder…