A five year Canadian laparoscopic adjustable gastric band experience

Is bariatric surgery safe in the elderly population?

BACKGROUND

Bariatric surgery has proven to be the most effective treatment for morbid obesity in all age groups and is considered superior to medical treatment. The aim of our study was to report the outcomes of bariatric surgery in patients over 65 years of age at our institution.

METHODS

A retrospective review of a prospectively collected database was conducted of all patients > 65 years who underwent a bariatric procedure between 2005 and 2015 at our institution. We compared this group to a control group of patients < 65 years of age who were operated on during the last 5 years, from 2011 to 2015. Data analyzed included age, preoperative BMI, postoperative complications, and comorbidities.

RESULTS

Of 1613 patients studied, 1220 patients were under 65 years of age, and in Group B, 393 were >65 years of age at time of surgery. There was a significant difference in proportion of male patients among groups; 42 % in Group B were male compared to 30 % in Group A (p < 0.001). Caucasians represented the majority in both groups. Both groups had comparable preoperative BMI 42.27 kg/m² for the younger Group A population versus 41.64 kg/m² for Group B (p = 0.074). Group B had more comorbidities than Group A: hypertension (p < 0.001), sleep apnea (p < 0.001), and hypercholesterolemia (p < 0.001). No difference was found between groups in history of depression (p = 0.409) or type II diabetes (p = 0.961). Distribution of procedures was significantly different between groups, with more LSG in Group A (p < 0.001). Elderly patients had longer length of stay (LOS) by one day on average (LOS = 3 days, p < 0.001), but a lower readmission rate (10 % vs. 7 %) (p = 0.023). Complication rates were comparable in both groups, except for incidence of de novo GERD, which was higher in Group B (5 % vs. 8 %) (p = 0.005).

CONCLUSIONS

Elderly patients are usually sicker in terms of comorbidities than the younger population. However, age does not seem to represent a risk of surgical complications after bariatric surgery.

Medical tourism and bariatric surgery: who pays?

INTRODUCTION

The objective of this study was to determine the short-term cost impact that medical tourism for bariatric surgery has on a public healthcare system. Due to long wait times for bariatric surgery services, Canadians are venturing to private clinics in other provinces/countries. Postoperative care in this population not only burdens the provincial health system with intervention costs required for complicated patients, but may also impact resources allotted to patients in the public clinic.

METHODS

A chart review was performed from January 2009 to June 2013, which identified 62 medical tourists requiring costly interventions related to bariatric surgery. Secondarily, a survey was conducted to estimate the frequency of bariatric medical tourists presenting to general surgeons in Alberta, necessary interventions, and associated costs. A threshold analysis was used to compare costs of medical tourism to those from our institution.

RESULTS

A conservative cost estimate of $1.8 million CAD was calculated for all interventions in 62 medical tourists. The survey established that 25 Albertan general surgeons consulted 59 medical tourists per year: a cost of approximately $1 million CAD. Medical tourism was calculated to require a complication rate ≤ 28% (average intervention cost of $37,000 per patient) to equate the cost of locally conducted surgery: a rate less than the current supported evidence. Conducting 250 primary bariatric surgeries in Alberta is approximately $1.9 million less than the modeled cost of treating 250 medical tourists returning to Alberta.

CONCLUSIONS

Medical tourism has a substantial impact on healthcare costs in Alberta. When compared to bariatric medical tourists, the complication rate for locally conducted surgery is less, and the cost of managing the complications is also much less. Therefore, we conclude that it is a better use of resources to conduct bariatric surgery for Albertan residents in Alberta than to fund patients to seek surgery out of province/country.

Long follow-up of patients with gastric band

BACKGROUND

The adjustable gastric band laparoscopic technique is safe, reversible and potentially effective alternative to gastric bypass Y-deRoux. However, it has a high rate of reoperation and unsatisfactory weight loss.

OBJECTIVE

To present a cases series with the use of gastric banding in long term follow-up analyzing the withdrawal rate, its causes and the surgical conversions performed

METHODS

Retrospective study based on the analysis of 19 patients who underwent the procedure between November 1999 and November 2002, and reviewed with clinical follow-up until late February 2011. The patients were analyzed in the following aspects: gender, age, preoperative weight, preoperative BMI, duration of follow-up, reasons for removal of the gastric band, need for conversion to another type of surgery and failure rate of surgical method.

RESULTS

Nineteen patients underwent the procedure, four women and 15 men. The mean preoperative BMI was 41.95 kg/m² (36-54). The band was withdrawn in 13 patients (68.42%), including seven by erosion, four for unsatisfactory weight loss and two for gastroesophageal reflux. The gastric bypass was conducted in ten patients and Scopinaro operation in one. Two patients had not been reoperated till nowadays and four were lost in late follow-up.

CONCLUSION

The gastric band is technically unsatisfactory in long-term evaluation, have high withdrawal rate due to migration or unsatisfactory weight loss.

Prospective, multicenter, 3-year trial of laparoscopic adjustable gastric banding with the MIDBAND™

BACKGROUND

Although laparoscopic adjustable gastric banding (LAGB) is a popular metabolic/bariatric procedure, few prospective studies have assessed its outcomes. This study aimed to prospectively assess LAGB safety and effectiveness outcomes using the MIDBAND™ (MID, Dardilly, France).

METHODS

Between May 2005 and September 2006, 262 morbidly obese patients underwent primary gastric banding with pars flaccida technique in 13 French medical centers. Excess weight loss and change in body mass index (BMI, kilogram per square meter), percentage of patients with comorbidities, and obesity-related complications were recorded. Patients were followed at 6-month intervals for 3 years. A multivariable individual growth model was used to analyze weight change over time and determine potential predictors of weight loss.

RESULTS

The majority of patients were female (n = 233, 89%), with mean age of 36.4 ± 9.7 years. At 3 years, LAGB with MIDBAND resulted in significant decrease in mean BMI from 41.8 ± 4.2 to 30.7 ± 5.8 (p < 0.0001). Median excess weight loss and excess BMI loss were 61% and 68%, respectively. The prevalence of obesity-related comorbidities had significantly decreased from 71% to 15% (p < 0.0001). Complications were observed in 26 patients (10%); device-related complications occurred in 20 patients (8.2%), requiring band removal in 8 (3.3%), and port revision in 8 (3.3%). Individual growth analysis identified significant predictors of weight loss including the number of follow-up visits.

CONCLUSION

Prospective outcomes demonstrate the safety and efficacy of gastric banding over time using the MIDBAND. Individual growth modeling demonstrated that postoperative weight loss is strongly related to the frequency and consistency of follow-up visits.