Surgery for Obesity and Related Diseases ] (2014) 00–00
Editorial comment
Comment on: High failure rate of the laparoscopic adjustable gastric band as primary bariatric procedure In this paper Dr. Kindell et al. evaluated the mid-term (approximately 5-year) outcomes of adjustable band gastroplasty (LAGB) in their practice. They concluded that the LAGB procedure should no longer be performed, predominantly because of insufficient weight loss. Others, including us [1,2], came to a similar conclusion, but merely because of the high incidence of reoperations, including band removals in up to 50% of patients. Conversely, across most publications [1–3], long-term excess weight loss (EWL) appeared to remain just under an acceptable 50% for patients who managed to keep their band. In the present study, however, whereas a remarkable 87% of the patients kept their band within a 5-year span, the mean EWL was a disappointing 30.8%. Unfortunately, the outcomes in terms of weight loss are unclear or unknown for a substantial number of patients. Approximately one third (32%) of the 104 patients with a supposedly intact band dropped out of follow-up within 5 years. Additionally, about one fourth of the available final weight data were obtained from the electronic records of the patients and not from the obesity department charts. Consequently, the study is substantially exposed to type 2 bias. Interestingly, despite being the primary outcome of the study, defective weight loss did not appear to influence the decision to convert the procedure. Thus, whereas in this cohort of 120 patients 13 patients had their band permanently deflated and 9 patients had their band “terminally” removed, none of these 22 (18% of the cohort) underwent another weight loss procedure, even with a documented substantial weight gain, and only 7 patients (6%) were converted. Many questions concerning the long-term value of LAGB remain unanswered by this study. For instance, it is not clear to what extent the subgroup of individuals with a relatively low BMI, who suffer fewer failures than the heavier patients, actually performed well with LAGB, as others previously have reported [4]. In addition, concerning
possible alternatives for LAGB, nobody knows the longterm outcomes, in terms of weight loss, of the sleeve gastrectomy procedure, the alleged successor of the gastric band [5]. Thus, based on weight loss data, the authors concluded that LAGB should be abandoned as bariatric operation. Even if this were the case, the limitations of this study do not allow us to draw this conclusion. Hence, rather than definitely condemning LAGB because weight loss is insufficient, we should wait for unbiased long-term data, preferably obtained by large-scale prospective randomized trials. General statements based on retrospective analyses exclusively focusing post hoc on the weight loss outcomes of a procedure should be avoided, especially when the number of patients is small and the follow-up time relatively short. Prof. Jacques Himpens, M.D., Ph.D. St. Pierre University Hospital, European School of Laparoscopic Surgery, Brussels, Belgium References [1] Victorzon M, Tolonen P. Mean fourteen-year, 100% follow-up of laparoscopic adjustable gastric banding for morbid obesity. Surg Obes Relat Dis 2013;9(5):753–7. [2] Himpens J, Cadière GB, Bazi M, et al. Long-term outcomes of laparoscopic adjustable gastric banding. Arch Surg 2011;146(7):802–7. [3] O’Brien PE, MacDonald L, Anderson M, Brennan L, Brown WA. Long-term outcomes after bariatric surgery: fifteen –year follow-up of adjustable gastric banding and a systematic review of the bariatric surgical literature. Ann Surg 2013;257(1):87–94. [4] Chevallier JM, Paita M, Rodde-Dunet MH, et al. Predictive factors of outcome after gastric banding: a nationwide survey on the role of center activity and patients’ behavior. Ann Surg 2007;246(6):1034–9. [5] Himpens J, Dobbeleir J, Peeters G. Long-term results of laparoscopic sleeve gastrectomy for obesity. Ann Surg 2010;252(2):319–24.
1550-7289/14/$ – see front matter r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved. http://dx.doi.org/10.1016/j.soard.2013.12.001
Editorial comment
Comment on: High failure rate of the laparoscopic adjustable gastric band as primary bariatric procedure In this paper Dr. Kindell et al. evaluated the mid-term (approximately 5-year) outcomes of adjustable band gastroplasty (LAGB) in their practice. They concluded that the LAGB procedure should no longer be performed, predominantly because of insufficient weight loss. Others, including us [1,2], came to a similar conclusion, but merely because of the high incidence of reoperations, including band removals in up to 50% of patients. Conversely, across most publications [1–3], long-term excess weight loss (EWL) appeared to remain just under an acceptable 50% for patients who managed to keep their band. In the present study, however, whereas a remarkable 87% of the patients kept their band within a 5-year span, the mean EWL was a disappointing 30.8%. Unfortunately, the outcomes in terms of weight loss are unclear or unknown for a substantial number of patients. Approximately one third (32%) of the 104 patients with a supposedly intact band dropped out of follow-up within 5 years. Additionally, about one fourth of the available final weight data were obtained from the electronic records of the patients and not from the obesity department charts. Consequently, the study is substantially exposed to type 2 bias. Interestingly, despite being the primary outcome of the study, defective weight loss did not appear to influence the decision to convert the procedure. Thus, whereas in this cohort of 120 patients 13 patients had their band permanently deflated and 9 patients had their band “terminally” removed, none of these 22 (18% of the cohort) underwent another weight loss procedure, even with a documented substantial weight gain, and only 7 patients (6%) were converted. Many questions concerning the long-term value of LAGB remain unanswered by this study. For instance, it is not clear to what extent the subgroup of individuals with a relatively low BMI, who suffer fewer failures than the heavier patients, actually performed well with LAGB, as others previously have reported [4]. In addition, concerning
possible alternatives for LAGB, nobody knows the longterm outcomes, in terms of weight loss, of the sleeve gastrectomy procedure, the alleged successor of the gastric band [5]. Thus, based on weight loss data, the authors concluded that LAGB should be abandoned as bariatric operation. Even if this were the case, the limitations of this study do not allow us to draw this conclusion. Hence, rather than definitely condemning LAGB because weight loss is insufficient, we should wait for unbiased long-term data, preferably obtained by large-scale prospective randomized trials. General statements based on retrospective analyses exclusively focusing post hoc on the weight loss outcomes of a procedure should be avoided, especially when the number of patients is small and the follow-up time relatively short. Prof. Jacques Himpens, M.D., Ph.D. St. Pierre University Hospital, European School of Laparoscopic Surgery, Brussels, Belgium References [1] Victorzon M, Tolonen P. Mean fourteen-year, 100% follow-up of laparoscopic adjustable gastric banding for morbid obesity. Surg Obes Relat Dis 2013;9(5):753–7. [2] Himpens J, Cadière GB, Bazi M, et al. Long-term outcomes of laparoscopic adjustable gastric banding. Arch Surg 2011;146(7):802–7. [3] O’Brien PE, MacDonald L, Anderson M, Brennan L, Brown WA. Long-term outcomes after bariatric surgery: fifteen –year follow-up of adjustable gastric banding and a systematic review of the bariatric surgical literature. Ann Surg 2013;257(1):87–94. [4] Chevallier JM, Paita M, Rodde-Dunet MH, et al. Predictive factors of outcome after gastric banding: a nationwide survey on the role of center activity and patients’ behavior. Ann Surg 2007;246(6):1034–9. [5] Himpens J, Dobbeleir J, Peeters G. Long-term results of laparoscopic sleeve gastrectomy for obesity. Ann Surg 2010;252(2):319–24.
1550-7289/14/$ – see front matter r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved. http://dx.doi.org/10.1016/j.soard.2013.12.001
