Transcript with other bariatric procedures

E. McLaughlin, P. D. Chakravarty, D. Whittaker, E. Cowan,
K. Xu, E. Byrne, D.M. Bruce, J. A. Ford
University of Aberdeen
Contents
 Background
 Objectives
 Methodology
 Results
 Discussion
 Other Considerations
 Conclusions
Obesity- A Growing Problem
The Scottish Government. The Scottish Health Survey. Volume 1: chapter 7; Adult obesity; 7:225261.
Obesity- Cost
 Costs NHS Scotland £171 million annually
 Main risk factor for diabetes and cardiovascular disease
 Current management involves lifestyle and behavioural
interventions
Bariatric Surgery
 Number 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 Guidelines
 Recommends bariatric surgery for patients who:
 Have a BMI > 35
 Have one or more co-morbidities expected to improve with
weight loss
 Have completed a weight management program with no
improvement in co-morbidities
 No recommendations on procedure
Objective
 Examine evidence for the effectiveness of LAGB
compared with other bariatric procedures
Methodology
 A systematic review of RCTs was performed in accordance with
the PRISMA statement.
 Inclusion criteria - All RCTs comparing LAGB and
other surgical procedures
 Exclusion 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
Methodology
 Databases used - MEDLINE, EMBASE, CENTRAL and
clinicaltrials.gov
 Studies included from 1988- June 2011
 Literature search performed by 2 authors
independently
 Data extracted by one author and checked by second
 Study quality was assessed using Cochrane risk of bias
criteria
The Trials
 Literature search uncovered 801 studies
 5 RCTs (7 published articles) included
 Trials carried out between 2003 and 2010
 Comparative surgeries:
 Laparoscopic roux-en-Y gastric bypass (LRYGB)
 Vertical banded gastroplasty (VBG)
 Sleeve gastrectomy (SG)
 Follow up ranged from 6 months to 7 years
 The largest sample size was 197 and the smallest was 51
 Baseline characteristics were comparable throughout
Effect on Co-morbidities
Poor reporting of co-morbidities
Van Dielen 2004
 Sample 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 2007
 Sample size of 51
 Co-morbidities had resolved after 5 years in both LAGB and
LRYGB groups (only 4 patients in each group)
QOL
Poor reporting of QOL
Nguyen 2009
 Sample size of 197
 Improvement of QOL 12 months post surgery
 Did not differ significantly between arms
 Time to resume normal daily activities and time to
return to work were both significantly increased with
LRYGB compared to LAGB.
Weight Loss
 Mean reduction in BMI and % EWL greater in the non
LAGB arms in all 5 studies
 Statistically significant
 Greatest weight loss in first post-operative year
 Weight loss negligible beyond three years
Operative time and length of
hospital stay
Operative time
 Mean operative time was shorter in the LAGB group in
each trial
Hospital Stay
 Mean hospital stay was shorter in the LAGB group in
each trial
Complications
Early complications
 Lower incidence of early complications in the LAGB
arm
Late complications
 Evidence conflicted
 Two 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 Quality
 Two 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 Limitations
Strength
 Only level 1 studies used
 Robust literature search
 Careful data extraction
 Consistent baseline characteristics
 Study design and primary outcome similar throughout
studies
Limitations
 Only involved comparisons with LRYGB, SG and VBG
 No meta-analysis
Limitations of Evidence Base
Lack of trials
 Only 5 trials
 Only 2 assessing Co-morbidities
 Only 1 assessing QOL
RCTs flawed
 Small sample sizes
 Missing data
 Lack of blinding (blinding assessors)
 No expertise based randomization model used
Interpretation of Results
 Reduction in co-morbidities similar between groups
 Increased QOL similar between groups
 Change in mean BMI and %EWL was superior in all
comparative surgeries
 Operative time and hospital stay are considerably
longer in the LRYGB, SG and VBG groups
 Early complications were more frequent in the
comparative surgeries than LAGB
 Evidence on late complications is unclear
Other Considerations
Cost
 VBG, LRYGB and LAGB were found to be cost effective
when compared with no treatment
 Economic analysis does not appear to strongly support
one procedure over another
Patient Choice
 Patients often feel strongly about the choice of
procedures
Conclusions
 Data on co-morbidity reduction and QOL
improvement lacking
 LAGB may not be the most effective procedure in
terms of weight loss
 Fewer complications and shorter operation time and
hospital stay may counteract this
 Current evidence base is limited
 Surgery should be tailored to the patient’s own choice
and health status