Safety and efficacy of the LAP-BAND AP® adjustable gastric band in the treatment of obesity: results at 2 years

Subcutaneous placement of lap band port without fascial fixation provides safe and durable access

BACKGROUND

Laparoscopic adjustable gastric band access port has been routinely sutured to the anterior fascia of the abdominal wall using nonabsorbable sutures. We present our technique demonstrating that nonfascial fixation with using a mesh allows for a safe and durable placement of the port in the superficial subcutaneous tissue.

METHODS

Retrospective chart review included 102 consecutive patients who had Lap band surgery performed by single surgeon (EA) from June 2011 until April 2013. The port was sutured to a piece of polypropylene mesh and tunneled in the subcutaneous tissue away from the incision. Patients' demographics were analyzed as well as the following parameters: OR time for port placement, follow-up, port complications requiring revision, difficult access facilitated by fluoroscopy imaging, port infection, and skin erosion.

RESULTS

The study included 102 consecutive patients (23 males and 79 females), mean age was 49 years old, mean weight was 284.7 lb, mean height was 66.2 in., and mean body mass index (BMI) was 46.3 kg/m(2). The average operative time for port placement was 4 min, mean follow-up was 12 months, port complications occurred in 2 % of the patients while fluoroscopy for difficult port access was required in 3 %. No cases of port infections or skin erosions occurred.

CONCLUSIONS

Superficial subcutaneous placement of Lap Band Port using mesh fixation without anchoring the port to the fascia provides safe and durable access. Deep incisions to secure the port directly to the fascia might not be necessary.

Effect of adjustable gastric banding on quality of life and weight loss in the Helping Evaluate Reduction in Obesity (HERO) registry study: 2 year analysis

OBJECTIVE

This report from the Helping Evaluate Reduction in Obesity (HERO) Study investigated weight loss, health-related quality of life (HRQOL), and factors predictive of HRQOL improvement during a 2 year period following Lap-Band AP implantation (post-LBAP).

RESEARCH DESIGN AND METHODS

This prospective, observational study included patients with 1 and 2 year follow-up data post-LBAP (N = 585). Changes in body mass index (BMI), percentage of weight loss (%WL), excess weight loss (%EWL) and HRQOL (Impact of Weight on Quality of Life [IWQOL]-Lite measure), and differences between <30% EWL and ≥30% EWL subgroups were assessed at 1 and 2 years post-LBAP. Multiple linear regression examined association of %EWL groups with IWQOL-Lite scores controlling for age, gender, region (US vs outside US), household income, employment status, and comorbidities.

RESULTS

Most patients were female (80.2%) and from the US (64.8%); overall mean (SD) age was 43.6 (11.28) years and 65.8% of patients had ≥30% EWL at year 2. At 2 years post-LBAP, mean %EWL was 43.5%; %EWL was 12.4% in the <30% EWL group and 59.6% in ≥30% EWL group (P ≤ 0.0001). Changes in IWQOL total and subscores were significantly greater in ≥30% EWL versus <30% EWL patients (all P < 0.0005) at years 1 and 2; Self-Esteem and Physical subscores had the largest changes. Multiple regression analysis showed that patients with ≥30% EWL had clinically meaningful improvements in HRQOL compared with patients having <30% EWL (P ≤ 0.001). Similarly, US patients and females had a clinically significant change in IWQOL score versus their counterparts (P ≤ 0.001). Conversely, income, comorbidities and employment status were not significant predictors of change in IWQOL scores at year 2.

CONCLUSIONS

These results support and extend findings regarding the effectiveness of LBAP for weight loss and illustrate the importance of ≥30% EWL as a significant factor in predicting clinically significant improvement in HRQOL 1 and 2 years post-LBAP.

CLINICAL TRIAL REGISTRATION

NCT00953173.

Quality of life after laparoscopic adjustable gastric banding (LAP-BAND): APEX interim 3-year analysis

BACKGROUND

Obesity is often associated with diminished health-related quality of life (HRQOL), but significant gains in HRQOL have been observed after bariatric surgery. Laparoscopic adjustable gastric banding has been established as a safe, effective treatment to reduce weight in patients with obesity. This report summarizes interim 3-year changes in HRQOL and body weight, as well as safety postimplantation of the LAP-BAND AP (LBAP) system.

METHODS

The LAP-BAND AP EXperience (APEX) trial, an ongoing, prospective, 5-year, open-label study, assessed changes in HRQOL (Obesity and Weight-Loss Quality of Life [OWLQOL] questionnaire) and body weight, and safety after placement of LBAP. This interim analysis represents patients with evaluable OWLQOL data at baseline and at 3 years (n = 183).

RESULTS

The OWLQOL total score and individual scores significantly improved within 6 months post-LBAP and continued to improve during a 3 year period (P < 0.0001, both). Total score improved from 71.0 to 34.0 (mean improvement from baseline, 52%; range, 18%-65%); mean change in individual scores was -2.2 (range, -0.7 to -3.0). Percent weight loss was maintained through 3 years (19.4%; n = 174). Improvement in OWLQOL was associated with percent weight loss at 3 years (r = -0.5407; P < 0.0001). Revisions and explants were performed in 7 (3.8%) and 20 (10.9%) out of 183 patients, respectively.

CONCLUSIONS

Meaningful improvement in quality of life occurred through clinically significant weight loss after LBAP placement, extending throughout the 3 years of this analysis.

Control of type 2 diabetes after 1 year of laparoscopic adjustable gastric banding in the helping evaluate reduction in obesity (HERO) study

AIMS

The 5-year, open-label, prospective, observational helping evaluate reduction in obesity (HERO) study (N = 1106) examines efficacy and safety of the LAP-BAND AP(®) laparoscopic adjustable gastric band (LAGB) in obese patients. This interim analysis assessed the control of type 2 diabetes (T2D), 1 year after the implantation of the LAGB.

METHODS

Baseline T2D was defined by chart review or use of antidiabetic medications or haemoglobin A1c (HbA1c) ≥ 7.0%. Control of T2D at 1 year was defined as A1c <7.0% (with or without antidiabetic medications).

RESULTS

After 1 year, 187 of 273 patients with T2D at baseline had adequate data available to assess T2D status, of which 135 patients (72.2%) achieved target control of T2D compared with 42.8% control rate at baseline. Independent predictors of achieving target control at 1 year included the following: (i) shorter diabetes duration odds ratio (OR) 0.914 [95% confidence interval (CI), 0.839, 0.995, p = 0.038], (ii) not using insulin therapy OR 0.16 (95% CI, 0.06, 0.47, p < 0.001) and (iii) greater mean % weight loss OR 1.176 (95% CI, 1.093, 1.266, p < 0.001). Patients using insulin at baseline were 84% less likely to achieve control of T2D after 1 year; each additional year of diabetes at baseline reduced the likelihood of good control by 9%; and each 1% of weight loss increases the likelihood of good control by 18%. Rates of device-related adverse events and reoperations were low and were not significantly different between patients with and without baseline T2D at 1 year.

CONCLUSIONS

Greater % weight loss, not using insulin therapy, and shorter disease duration predicted increased likelihood of target control of T2D, 1 year after implantation of the LAGB.

Efficacy and safety of the adjustable gastric band - pooled interim analysis of the APEX and HERO studies at 48 weeks

OBJECTIVE

This 48 week combined analysis reports safety and clinical effectiveness of the LAP-BAND AP * laparoscopic adjustable gastric band (LAGB) in severely obese patients enrolled in the 5 year, prospective, observational, open-label APEX (NCT00501085) and HERO (NCT00953173) studies.

METHODS

The studies enrolled 1620 patients (APEX: N = 514; HERO: N = 1106), 1140 patients in the US (including all APEX patients), and 480 patients in the European Union (EU), Canada or Australia. APEX and HERO are non-randomized, non-comparator, open-label studies with differences in study management practices and follow-up. Notably, laboratory data were not collected during the APEX study.

RESULTS

After 48 weeks, mean (SD) percentage weight loss (%WL) was for APEX: 18.7% (7.9); HERO-US: 17.9% (8.5); HERO-EU: 16.5% (10.3); HERO-Canada: 13.4% (8.9); and HERO-Australia: 12.3% (6.9). After 48 weeks, there were no significant differences in %WL for APEX vs. HERO-US. After 48 weeks in the combined analysis (APEX + HERO): (1) patients without vs. with type 2 diabetes at baseline had greater %WL (18% [8.7] vs. 16% [8.5], p = 0.002); (2) female patients had greater %WL vs. male patients (17.9% [8.5] vs. 15.9% [9.3], p = 0.003); (3) younger patients had greater %WL vs. older patients (<50 years: 17.8% [8.7] vs. ≥50 years: 16.7% [8.6], p = 0.035); (4) baseline BMI did not affect %WL (≤35 to ≤45 kg/m(2): 17.7% [8.4] vs. >45 kg/m(2): 17.1% [9.1], p = 0.272). Device-related serious adverse events and adverse events were reported in 1.9% and 17.7% of patients, respectively. Revision and explantation surgeries were carried out on 3.4% and 2.3% of patients, respectively during the 48 weeks of follow-up.

CONCLUSIONS

This analysis demonstrates the effective weight loss and safety profile of the current LAGB system, with US patients achieving better weight loss than patients from outside the US.

An evaluation of the knowledge of the surgical treatment of obesity among surgeons

INTRODUCTION

Surgical treatment of obesity is currently the only effective treatment option for patients with excess body weight, especially morbid obesity and diseases caused by it. There are no studies evaluating the knowledge of surgeons in the field of bariatric surgery.

AIM

To assess the knowledge of surgeons regarding bariatric surgery.

MATERIAL AND METHODS

An anonymous questionnaire was conducted among 143 surgeons in 2010-2011 during local educational conferences. The survey consisted of 10 questions dedicated to the fundamental problems of the surgical treatment of obesity.

RESULTS

Theoretical and practical knowledge connected to the so-called "epidemiological awareness" in the surgical treatment of obesity was possessed by 25% of the respondents. Knowledge of surgical techniques is known to most surgeons. Reducing the "oncological risk" after bariatric surgery is known to only 27% of surgeons. Almost 80% of surgeons indicated a necessity of their further education regarding the surgical treatment of obesity.

CONCLUSIONS

Knowledge of Polish general surgeons in the surgical treatment of obesity is not high, with a high number of surgeons who possess knowledge of the operating technique, whereas only a quarter have a basic knowledge of the indication for surgical treatment. Most surgeons who participated in our study are awaiting educational programmes focused on this issue.

Safety and effectiveness of LAP-BAND AP System: results of Helping Evaluate Reduction in Obesity (HERO) prospective registry study at 1 year

BACKGROUND

Laparoscopic adjustable gastric banding has several distinctive features, including band adjustability, easy reversibility, and lack of malabsorption, which contribute to its widespread use. The LAP-BAND AP System (LBAP; Allergan, Inc.), a redesigned and improved version of the original device, was approved by the US Food and Drug Administration in 2006. Because of limited information on LBAP, this study prospectively assesses the efficacy and safety of LBAP in real-world settings at clinical centers located in North America, Europe, and Australia.

STUDY DESIGN

This interim report of the ongoing 5-year prospective, observational, international, multicenter registry, Helping Evaluate Reduction in Obesity (HERO) Study (NCT00953173), describes clinical efficacy and safety of LBAP in real-world settings at 1 year.

RESULTS

One thousand one hundred and six patients were implanted with LBAP and 1-year data were available from 834 patients for efficacy analysis. At 1 year, the mean (SD) percentage of excess weight loss was 39.8% (22.3%), of weight loss was 16.9% (9.0%), and the mean (SD) body mass index decreased to 37.7 (7.0) kg/m(2) from 45.1 (6.9) kg/m(2) at baseline. Patients with type 2 diabetes mellitus or hypertension showed significant improvements at 1 year post LBAP (both p < 0.005). The most common device-related complications were port displacement (n = 20 [1.8%]), pouch dilation (n = 12 [1.1%]), band slippage (n = 7 [0.6%]), and band erosion (n = 5 [0.5%]). Eighteen (1.6%) patients had the device explanted.

CONCLUSIONS

At 1 year post LBAP, progressive weight loss was associated with improvement and/or resolution of comorbid conditions and was safe and well tolerated. Patient follow-up continues.

Bariatric surgery as a treatment option in patients with type 2 diabetes mellitus

Type 2 diabetes mellitus (T2DM) is a leading cause of blindness, non-traumatic amputation and end-stage renal disease as well as a major cardiovascular risk factor. Tight glycemic control reduces the incidence of microvascular complications of T2DM whereas its effects on macrovascular complication are more controversial. However, glycemic targets are achieved by a minority of diabetic patients despite the availability of several antidiabetic agents. In the present commentary, we discuss the findings of two recent randomized studies that compared bariatric surgery with medical treatment in patients with uncontrolled T2DM. Both studies showed that bariatric surgery results in remission of T2DM in the majority of patients. However, both studies were limited to relatively young patients without comorbidities, had relatively short follow-up and did not assess the effects of surgery on T2DM complications. Moreover, the perioperative complications of bariatric surgery and its limited availability in some areas are additional barriers to the wider implementation of this therapeutic approach. On the other hand, the elucidation of the mechanisms underpinning the resolution of T2DM following bariatric surgery might result in the development of novel, more effective pharmacotherapies for this common disease.

Effect of early weight loss on type 2 diabetes mellitus after 2 years of gastric banding

OBJECTIVE

Laparoscopic adjustable gastric banding (LAGB) is an established bariatric surgical procedure that produces meaningful weight loss and improvements in patients with type 2 diabetes mellitus (T2DM) and a body mass index (BMI) ≥ 30 kg/m2. This study examined the effect of LAGB on T2DM status in severely obese patients with T2DM.

METHODS

This was a 2-year interim analysis of patients with T2DM who required daily hypoglycemic medication at baseline (N = 89) in the 5-year, open-label, prospective, observational LAP-BAND AP® EXperience (APEX) trial. Type 2 diabetes mellitus status was classified as "remission," "improved," "stable," or "worse" based on physician- and patient-reported changes in T2DM control and changes in hypoglycemic medication use.

RESULTS

At baseline, 89 (22.5%) of 395 patients required daily hypoglycemic medication; 66 patients had data available after 2 years. Remission of T2DM occurred in 32 (48.5%) patients, improvement occurred in 31 (47.0%) patients, and no change occurred in 3 (4.5%) patients. Overall, 95.5% of patients experienced remission or improvement in T2DM status. Duration of T2DM in patients with remission or improvement after 2 years was 4.0 and 6.7 years, respectively (P = 0.082 between groups), and was associated with change in T2DM status (logistic regression, P = 0.069). Baseline BMI, change in BMI, and percent weight loss were not significantly different between the T2DM response groups. Percent excess weight loss was numerically, but not statistically significantly, greater in remitted (-56.1%) compared with the improved response (-42.9%) group (P = 0.134), and was correlated with change in T2DM status (logistic regression, P = 0.052). After 2 years, patients experienced remission or improvement of other obesity comorbidities. The rate of revisional surgery or explantation was 3.4%, and it was not significantly different between patients with and without T2DM (P = 0.687).

CONCLUSION

Shorter duration of T2DM and greater percent excess weight loss were associated with an increased likelihood of remission or improvement in T2DM status through LAGB after 2 years. Laparoscopic adjustable gastric banding is a potential adjunctive treatment for obese patients with T2DM.