Kate Johnson

July 16, 2012

July 16, 2012 (San Diego, California) — Bariatric surgeons should abandon gastric banding in favor of sleeve gastrectomy or gastric bypass procedures, several researchers reported here at the American Society for Metabolic and Bariatric Surgery 29th Annual Meeting.

In the United States, the use of gastric banding is still "peaking," but elsewhere in the world it has largely fallen out of favor, said Michel Gagner, MD, in an interview with Medscape Medical News.

Dr. Gagner, from Hôpital du Sacré-Coeur in Montreal, Quebec, Canada, is a world-renowned bariatric surgeon who has established several bariatric surgery centers of excellence in the United States. He said he has virtually abandoned gastric banding, and performs sleeve gastrectomy in 90% of his cases.

His approach matches that of Luigi Angrisani, MD, director of the general and laparoscopic surgery unit at Giovanni Bosco Hospital in Naples, Italy.

Dr. Angrisani presented 10-year follow-up data from a prospective randomized trial comparing gastric bypass with banding, and said the evidence is clearly in favor of bypass.

"There is no point in doing further study comparing bypass with banding at this point," he told meeting attendees. "If you consider the revisions and the failures, only 26% of the banding patients had the band successfully implanted and a successful weight loss," he told Medscape Medical News in an interview. "That is not a nice result."

The study by Dr. Angrisani and colleagues involved 51 patients who were randomized from January to November 2000 to either laparoscopic adjustable gastric banding or laparoscopic Roux-en-Y gastric bypass.

In the banding group, mean age was 33.3 years and mean body mass index (BMI) was 43.4 kg/m²; in the bypass group, mean age was 34.7 years and mean BMI was 43.8 kg/m².

Of the 27 banding patients, 3 had hypertension and 1 had sleep apnea. Of the 24 bypass patients, 2 had hyperlipidemia, 1 had hypertension, and 1 had type 2 diabetes.

Ten years after surgery, 81.4% of the banding group and 87.5% of the bypass group remained in follow-up, reported Dr. Angrisani.

Of the 22 remaining banding patients, 9 (41%) had had their bands removed, leaving 13 for weight-loss evaluation.

The BMI of 6 of these 13 patients exceeded 35 kg/m², so the procedures were considered "failures"; only 7 patients in the banding group were successful in losing weight, he said.

In contrast, of the remaining 21 bypass patients, mean BMI dropped from 43.8 to 30.4 kg/m²; only 20% of the procedures in this group were considered failures.

There were no deaths in the study, and improvement in baseline comorbidities was similar in the 2 groups. However, reoperation rates were higher in the banding group than in the bypass group (41% vs 29%).

In the banding group, reasons for reoperation were pouch dilations (n = 3), band migration (n = 1), unsatisfactory weight loss (n = 4), and untreatable reflux (n = 1).

Reasons for reoperation in the bypass group were potentially life-threatening, said Dr. Angrisani — internal hernia (n = 1), cholecystectomy (n = 4), and incisional hernia (n = 1).

"The complications of bypass are iatrogenic," he told Medscape Medical News. "There is inadvertent bowel injury during manipulation of the bowel. When you do banding, you do not manipulate the bowel."

Like Dr. Gagner, Dr. Angrisani has virtually abandoned gastric banding, reserving it for a select group of smaller patients. An analysis of the Bariatric Outcomes Longitudinal Database (BOLD), presented separately at the meeting (as reported by Medscape Medical News), showed that from 2007 to 2010, banding and bypass surgery were performed in almost equal numbers in 540 hospitals in the United States (117,365 vs 138,222).

Europeans are ahead of the game, having started banding procedures before North America, and therefore detecting problems earlier, said Dr. Angrisani. "This is a very common story. While we as Europeans accept the messages from the US world of surgery, the US community does not accept data coming from Europe. So they are now living the experience we had in the last few years."

"It's a complete disaster, when you think that banding in the United States, based on the BOLD data, is the second-most common procedure," said Dr. Gagner. "Europeans are abandoning banding and the Americans are not getting the message. This abandonment that we see in Europe — we are probably going to see this in the next few years in the United States."

Although there is already a trend toward replacing banding with sleeve gastrectomy, lack of insurance coverage for the sleeve procedure remains a major barrier, he said. In the BOLD analysis, 21% of sleeve procedures were self-paid, compared with 5.7% of band procedures and 1.9% of bypass procedures.

"The European experience is more mature than the US experience with gastric banding," agreed John Morton, MD, from Stanford University in California, who reported the BOLD data at the meeting.

In an email to Medscape Medical News, Dr. Morton said that "although 6-year data for sleeve gastrectomy indicate that it is safe and effective, the potential long-term complications for the sleeve may not be fully apparent yet, and gastric banding may still be preferred due to it's favorable short-term safety profile."

Dr. Angrisani has disclosed no relevant financial relationships. Dr. Gagner reports being a speaker for Covidien, Ethicon, and Gore. Dr. Morton reports being a consultant for Vibrynt and Ethicon.

American Society for Metabolic and Bariatric Surgery (ASMBS) 29th Annual Meeting: Abstract PL 103. Presented June 20, 2012.

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