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