LGBP vs LASGB

LGBP vs LASGB

Abstract & Commentary

By Richard Peterson, MD, MPH, Clinical Instructor of Surgery, Department of Surgery, USC. Dr. Peterson reports no financial relationship relevant to this field of study.
This article was peer reviewed by Peter Crookes, MD, FACS

Synopsis: Although LGBP patients experienced more complications compared to LASGB patients (5.6 vs 4.3%, respectively; P < 0.56), this did not reach statistical significance. Early after surgery, LGBP patients lose more weight than LASGB patients but have similar improvements in comorbidities. Further follow-up is needed to determine the relative long-term efficacy of these procedures.

Source: Kim TH, et al. Early US outcomes of laparoscopic gastric bypass versus laparoscopic adjustable silicone gastric banding for morbid obesity. Surg Endosc. 2006;20:202-209.

Laparoscopic gastric bypass (lgbp) is the gold standard operation for long-term weight control in the United States. Laparoscopic adjustable silicone gastric banding (LASGB) is the preferred operative method for morbid obesity worldwide. Limited data are available comparing the 2 procedures in the United States.

This study compares weight loss, complications, and early outcome of comorbidity resolution in patients who underwent LGBP vs LASGB. A review of prospectively collected data was performed on 392 patients undergoing primary LGBP (n = 232) and LASGB (n = 160) procedures between February 2001 and July 2004. Differences in percentage excess weight lost (%EWL) at 3, 6, 12, 18, and 24 months post-op, improvement or resolution of comorbidities, and complications across procedure types were evaluated. Mean initial body mass index between groups was not significantly different (LGBP 47.2 vs LASGB 47.1, p < 0.53). There were significant differences in age, gender, and self-reported sweet-eating behavior between operative groups. There was a significantly greater %EWL in patients who underwent LGBP compared to patients of the LASGB groups 3, 6, 12, and 18 months after surgery. There were no significant differences in resolution or improvement of comorbidities between the groups. Although LGBP patients experienced more complications compared to LASGB patients (5.6 vs 4.3%, respectively; P < 0.56), this did not reach statistical significance. Early after surgery, LGBP patients lose more weight than LASGB patients but have similar improvements in comorbidities. Further follow-up is needed to determine the relative long-term efficacy of these procedures.

Commentary

Kim and colleagues compared 2 techniques that are being widely utilized in the treatment of morbid obesity. LGBP has become the standard bariatric operation at many centers in the United States. In contrast, Kim et al point out that the LASGB is the most commonly performed procedure worldwide. The LASGB is a purely restrictive operation that induces early satiety in the patient by means of a small gastric pouch. In contrast, the LGBP is both a restrictive and malabsorptive operation that induces satiety with minimal intake, creates hormonal alterations in response to a meal, and impairs intake of high osmolar foods due to dumping syndrome. They took on the task of identifying early results of LASGB in the United States compared with LGBP.

With the approval of the Lap-Band by the FDA in 2001, there has been an increase in the number of these procedures offered by bariatric surgeons to their patients. Additionally, patients have become their own advocates, with respect to choice of surgery. Many patients spend a lot of time prior to initial consultation with a bariatric surgeon doing research on the surgical options available to them. Kim et al cite another report in their study that shows that the reported safety and "least invasive" aspect of banding as the factors that most influenced the patient's decision. The few studies that have compared LGBP and LASGB are primarily in Europe. There is little data in the United States and, hence, controversy remains regarding the indication for one procedure over the other.

Kim et al ultimately evaluated a total of 392 patients undergoing LGBP or LASGB from February 2001-July 2004. There were 232 LGBP and 160 LASGB patients. BMI was similar in the 2 groups. Characteristics that were significantly different (P < 0.05) were that the patients in the LASGB were older (41.7 vs 38.5), more likely to be male (25% vs 11%), and were less likely to be sweet eaters (47.8% vs 61%). Additionally, Kim et al evaluated the differences in improvement/resolution of comorbidities between the 2 groups, and found that in the 6 comorbidities they identified (hypertension, diabetes mellitus, hyperlipidemia, arthritis, GERD and stress urinary incontinence), there were no statistically significant differences. No mortalities were reported in either group. The complications noted were broken into early and late complications. The LGBP group had a significantly greater rate of early complications, ie, anastomotic leak, intraabdominal abscess, wound infection, and pneumonia (5.2 vs 0.63; P < 0.05). The LASGB had a significantly higher rate of late complications, ie, tubing leak/break, incisional hernia, and small bowel obstruction (3.7 vs 0.43; P < 0.05). However when comparing their overall complication rate, there was no significant difference between LGBP and LASGB (5.6 vs 4.3%). There was significantly more percentage of excess weight loss (%EWL) for all time points in the LGBP group compared to the LASGB except at 24 months.

Kim et al put together a nice study comparing LGBP and LASGB. Their data suggest that even with a slower %EWL, as seen in LASGB resolution of comorbidities, occurs. However with the recent utilization of LASGB in the United States, more long-term follow-up is necessary to realize the sustainability of these results. Additionally, they commented on the fact that their study was non-randomized and, because of the patient numbers, small differences that do not appear significant in this study may be if the number of patients was increased. Overall, Kim et al have added a valuable beginning in the literature to the understanding of LGBP and LASGB, and why one modality may be better than another for patients. Larger series are needed to truly evaluate which technique will provide the most benefit to specific groups.