E. McLaughlin, P. D. Chakravarty, D. Whittaker, E. Cowan, K. Xu, E. Byrne, D.M. Bruce, J. A. Ford University of Aberdeen.

E. McLaughlin, P. D. Chakravarty, D. Whittaker, E. Cowan, K. Xu, E. Byrne, D.M. Bruce, J. A. Ford

University of Aberdeen

ContentsBackground ObjectivesMethodologyResultsDiscussionOther ConsiderationsConclusions

Obesity- A Growing Problem

The Scottish Government. The Scottish Health Survey. Volume 1: chapter 7; Adult obesity; 7:225-261.

Obesity- CostCosts NHS Scotland £171 million annuallyMain risk factor for diabetes and cardiovascular

diseaseCurrent management involves lifestyle and

behavioural interventions

Bariatric SurgeryNumber of bariatric procedures

performed in the UK is increasing.

3 types of procedure: Restrictive - Gastric banding,

Sleeve gastrectomy, Vertical banded gastroplasty (VBG)

Malabsorptive - Duodenal switch, Biliopancreatic diversion

Malabsorptive and Restrictive -Gastric bypass

Laparoscopic adjustable gastric banding (LAGB) represents 30.3% of bariatric procedures

SIGN GuidelinesRecommends bariatric surgery for

patients who:Have a BMI > 35Have one or more co-morbidities expected to

improve with weight lossHave completed a weight management program

with no improvement in co-morbiditiesNo recommendations on procedure

ObjectiveExamine evidence for the effectiveness of

LAGB compared with other bariatric procedures

MethodologyA systematic review of RCTs was performed in

accordance with the PRISMA statement.Inclusion criteria - All RCTs comparing

LAGB and other surgical proceduresExclusion criteria - Non-adult studies, open

gastric banding procedures and trials that reported surrogate end points

Primary Outcomes - Co-morbidity improvement

Secondary Outcomes – QOL improvement, mean change in BMI or percentage excess weight loss (%EWL), complications, length of hospital stay and operation time

MethodologyDatabases used - MEDLINE, EMBASE,

CENTRAL and clinicaltrials.govStudies included from 1988- June 2011Literature search performed by 2 authors

independentlyData extracted by one author and checked by

secondStudy quality was assessed using Cochrane

risk of bias criteria

The TrialsLiterature search uncovered 801 studies5 RCTs (7 published articles) includedTrials carried out between 2003 and 2010Comparative surgeries: Laparoscopic roux-en-Y gastric bypass (LRYGB) Vertical banded gastroplasty (VBG) Sleeve gastrectomy (SG)

Follow up ranged from 6 months to 7 yearsThe largest sample size was 197 and the smallest

was 51 Baseline characteristics were comparable

throughout

Effect on Co-morbiditiesPoor reporting of co-morbidities

Van Dielen 2004Sample size of 100 Number of co-morbidities in both LAGB and VBG groups

decreased No difference between groups Co-morbidities had increased at 7 year follow up (10% of

the LAGB group and 0% of the VBG suffered from diabetes)

Angrisani 2007Sample size of 51 Co-morbidities had resolved after 5 years in both LAGB

and LRYGB groups (only 4 patients in each group)

QOLPoor reporting of QOL

Nguyen 2009Sample size of 197Improvement of QOL 12 months post surgeryDid not differ significantly between armsTime to resume normal daily activities and

time to return to work were both significantly increased with LRYGB compared to LAGB.

Weight LossMean reduction in BMI and % EWL greater in

the non LAGB arms in all 5 studiesStatistically significantGreatest weight loss in first post-operative

yearWeight loss negligible beyond three years

Operative time and length of hospital stayOperative timeMean operative time was shorter in the LAGB

group in each trial Hospital StayMean hospital stay was shorter in the LAGB

group in each trial

ComplicationsEarly complicationsLower incidence of early complications in the

LAGB armLate complicationsEvidence conflictedTwo trials reported a decrease in late

complications in LAGB compared with other procedures (one significant)

Two trials reported increase in late complications in LAGB compared with other procedures (one significant)

Study QualityTwo studies failed to

report sequence generation

Two studies failed to describe method of allocation concealment

No studies adequately described blinding

Up to 20% lost to follow up

Strengths and LimitationsStrengthOnly level 1 studies usedRobust literature search Careful data extractionConsistent baseline characteristicsStudy design and primary outcome similar

throughout studiesLimitations Only involved comparisons with LRYGB, SG

and VBGNo meta-analysis

Limitations of Evidence BaseLack of trialsOnly 5 trialsOnly 2 assessing Co-morbiditiesOnly 1 assessing QOL

RCTs flawedSmall sample sizesMissing dataLack of blinding (blinding assessors)No expertise based randomization model used

Interpretation of ResultsReduction in co-morbidities similar between

groups Increased QOL similar between groupsChange in mean BMI and %EWL was superior in

all comparative surgeriesOperative time and hospital stay are considerably

longer in the LRYGB, SG and VBG groupsEarly complications were more frequent in the

comparative surgeries than LAGBEvidence on late complications is unclear

Other ConsiderationsCostVBG, LRYGB and LAGB were found to be cost

effective when compared with no treatmentEconomic analysis does not appear to

strongly support one procedure over anotherPatient ChoicePatients often feel strongly about the choice

of procedures

ConclusionsData on co-morbidity reduction and QOL

improvement lackingLAGB may not be the most effective

procedure in terms of weight lossFewer complications and shorter operation

time and hospital stay may counteract thisCurrent evidence base is limitedSurgery should be tailored to the patient’s

own choice and health status