OBES SURG (2012) 22:773–776 DOI 10.1007/s11695-011-0526-7

CLINICAL RESEARCH

The Effect of Gastric Band Slippage on Patient Body Mass Index and Quality of Life Shaheel M. Sahebally & John P. Burke & Donal O’Shea & Justin Geoghegan

Published online: 20 October 2011 # Springer Science+Business Media, LLC 2011

Abstract Background Laparoscopic adjustable gastric banding (LAGB) is a popular surgical procedure for the management of morbid obesity. Gastric band slippage (GBS) is the most common long-term complication. In this study, the effect of GBS on body mass index (BMI) and quality of life (QOL) were assessed. Methods This was a retrospective, case-controlled study. Patient demographics and BMI were prospectively recorded, and QOL was assessed via telephone questionnaire using the medical outcomes study short-form-36 (SF-36). The QOL of the GBS group were compared with an age, sex, and duration of follow-up matched control group who underwent uncomplicated LAGB (n=10). Results Seventeen patients with GBS who underwent surgery were identified. Ten patients underwent band removal, and seven underwent revision surgery (six band repositioning and one Roux-en-Y gastric bypass); all were managed laparoscopically. Mean follow-up since re-operation was 17.2± 2.9 months. A significant increase in BMI occurred following GBS surgery (29.0±1.5 vs. 33.8±1.0, P=0.035), which did not differ between the removal or revision groups. Overall, there was no difference in QOL between the GBS and

Shaheel M. Sahebally and John P. Burke contributed equally to this work. S. M. Sahebally : J. P. Burke : J. Geoghegan (*) Department of Surgery, St. Columcille’s Hospital, Loughlinstown, Co, Dublin, Ireland e-mail: [email protected] D. O’Shea Department of Endocrinology, St. Columcille’s Hospital, Loughlinstown, Co, Dublin, Ireland

control groups. On subgroup analysis, those who underwent revision surgery had a worse score in limitations in social activities because of physical or emotional problems than those who underwent band removal (92.0±3.9 vs. 70.8± 10.0, P=0.046). Conclusions Following surgery for GBS, patients experience a rise in BMI. Overall, this does not affect patient QOL but may limit social activities because of physical or emotional problems in those who have band revision surgery. Keywords Laparoscopic adjustable gastric band . Band slippage . Band revision . Band removal . Quality of life

Introduction Laparoscopic adjustable gastric banding (LAGB) is the most popular restrictive procedure for morbid obesity in Europe. It is characterized by low mortality, possible reversibility, and good weight loss in the long term and a reduction in obesity related co-morbidity [1, 2]. Although LAGB has been shown to be a safe technique with a low incidence of perioperative morbidity, there is a relatively high re-operation rate in comparison to other bariatric procedures [3, 4]. The most common long-term complication is gastric band slippage (GBS) occurring in 4.5% of patients [4]. This can result in total dysphagia, prolonged vomiting, or gastric strangulation [5, 6]. Surgical management options include band release, band repositioning, alternative procedures, or band removal without further operative therapy [7]. Following surgical intervention for GBS, the effect on patient body mass index (BMI) is equivocal [7–10], and the effect on quality of life (QOL) is unknown. The purpose of the current study was to assess the effect of GBS on patient BMI and QOL.

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Methods

Results

Obesity surgery has been slow to gain widespread acceptance in the Republic of Ireland. The public health system has been reluctant to support the introduction of bariatric surgery. However, it has been forced to provide a safety net for patients who have procedures performed in the private sector, often overseas, who develop problems postoperatively. A case-control study was performed comparing all patients referred to our institution for the management of GBS to a control group. All patients who had sustained GBS and had undergone surgery for its correction were included and identified from a prospectively maintained, institutional weight management database and operating theatre records. GBS was defined as total food and liquid intolerance after complete band disinflation without any passage through the band on gastrografin swallow. A control group was identified consisting of ten patients matched for age, sex, and duration since initial band placement who had undergone uncomplicated LAGB insertion in our institution. The Swedish adjustable gastric band system (Ethicon-Endo-Surgery, Le Locle, Switzerland) was inserted into all patients via a laparoscopic, pars flaccida approach. Data on age, sex, type and date of procedure, and preand postoperative BMI were retrieved from our database, patient records, operative notes, and patient interviews. Each patient was contacted by telephone and invited to participate in the study by answering questions read directly from the short form (SF)-36 health status questionnaire [11, 12]. A single interviewer (SMS) administered all telephone questionnaires, to both control and GBS patients, in an identical fashion. The SF-36 health status questionnaire is one of the most widely accepted and best validated QOL instruments currently available [13]. SF-36 assesses eight health concepts: (1) limitations in physical activities because of health problems (PF); (2) limitations in social activities because of physical or emotional problems (SF); (3) limitations in usual role activities because of physical health problems (RP); (4) physical pain (PP); (5) general mental health, psychologic distress, and well-being (MH); (6) limitations in usual role activities because of emotional problems (RE); (7) vitality, energy, and fatigue (VT); and (8) perception of general health (GH). Scores in each category were standardized to a range of 0 (worst possible) to 100 (best possible). Data is presented as mean±standard error of mean (SEM). Statistical analysis was performed using Chi-squared test for categorical variables and analysis of variance (ANOVA) for continuous variables using SPSS v12.01 (SPSS Inc., Chicago, IL, USA).

Seventeen patients who underwent surgery for GBS were identified and compared to ten control patients (Table 1). One hundred percent data was retrieved on all patients. Fifteen of 17 (88%) of GBS patients underwent their initial LAGB placement in other institutions; all ten (100%) control patients underwent their band placement in our institution. There was no difference in sex, preoperative BMI, or time from initial band insertion to latest follow-up between the two groups (Table 1). Those who experienced GBS were younger than control patients at initial band placement (36.1±1.6 vs. 42.4±2.7 years, P=0.044, ANOVA). The mean duration to surgery for GBS was 20.4±3.3 months following initial band placement. The mean age at GBS surgery was 37.8±1.5 years, and the mean interval between GBS surgery and follow-up assessment was 17.2 ± 2.9 months. Ten of 17 (59%) patients had the band removed (plus 1 released but left in situ and repositioned 9 months later), and seven of 17 (41%) had a revision procedure (six bands repositioned and one converted to a laparoscopic Roux-en-Y gastric bypass). All were performed as laparoscopic, one-stage procedures. When surgery was undertaken for GBS at a mean 20.4± 3.3 months following initial band placement, there was a significant reduction in BMI when compared to that at initial band placement (40.4±1.2 vs. 29.0±1.5, P<0.001, ANOVA). However, at a mean of 17.2±2.9 months following revision surgery, patient BMI had significantly risen (29.0±1.5 vs. 33.8±1.0, P=0.035, ANOVA; Fig. 1a). When subgroup analysis was undertaken, there was no difference in weight loss/gain between those who had their band removed or revised (P>0.05 for all groups, ANOVA; Fig. 1b). QOL was assessed in GBS patients using the SF-36 instrument and compared to that of control patients. There was no statistical difference in any of the eight health concepts between patients who underwent surgery for GBS and control patients (Fig. 2a). However, on subgroup analysis, patients who underwent revision surgery relative to band removal had a significantly lower score in

Table 1 Patient demographics Control

GBS

P- value

Female/male (%)

7/3 (70%)

15/2 (88%)

0.249

Age at band placement (years) BMI at initial band placement (kg/m2) Time since initial band placement (min)

42.4±2.7 44.34±2.3

36.1±1.6 40.4±1.2

0.044 0.101

29.6±2.7

37.6±3.1

0.093

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Discussion

Fig. 1 Effect of GBS surgery on BMI. When surgery was undertaken for GBS, there was a significant reduction in BMI compared to that at initial band placement. Mean patient BMI rose significantly following GBS surgery (Aa) (*(single asterisk, P<0.001,; number sign, #P= 0.035, ANOVA). When subgroup analysis was undertaken, there was no difference in BMI between those who had their band removed or revised (Bb) (P>0.05 for all groups, ANOVA)

limitations in social activities because of physical or emotional problems (92.0±3.9 vs. 70.8±10.0, P=0.046, ANOVA; Fig. 2b).

Fig. 2 Comparison of SF-36 scores in control and GBS patients. 8 Eight variables were assessed: limitations in physical activities because of health problems (PF), limitations in usual role activities because of physical health problems (RP), limitations in usual role activities because of emotional problems (RE), vitality, energy, and fatigue (VT), general mental health, psychologic distress and wellbeing (MH), limitations in social activities because of physical or emotional problems (SF), physical pain (PP), and perception of general health (GH). There was no difference between the control group and GBS group (aA). On subgroup analysis, the SF score was lower in GBS patients who underwent revision surgery (bB) (*(single asterisk, P=0.046, ANOVA)

The current study examined QOL in patients who had GBS. The SF-36 has previously been demonstrated to be a robust tool in assessing patients following LAGB. An improvement in the psychosocial wellbeing of morbidly obese patients has been noted following LAGB both at 1 year and over longer periods [14, 15]. Patients who underwent band removal had better QOL than those who underwent band revision in the domain that tested limitation in social activities because of physical or emotional problems. Treatment failure occurs in 16.7% of patients who undergo LAGB [16]. The current data suggests that following surgery for GBS patients will regain weight whether the band is removed or revised. This phenomenon has been observed in two prior studies where 35% of patients experienced weight regain following revision [8, 9], but two further studies report weight loss following revision surgery [7, 10]. While some patients find weight gain after band revision disappointing, it is not surprising. A slipped band produces a degree of restriction that is not compatible with a sustainable long-term eating pattern or lifestyle. Despite some weight regain, patients who underwent removal as opposed to revision had fewer limitations in social activities because of emotional or physical problems. Removal of the band entirely following GBS may contribute to a more positive psychological outlook, which underlines this phenomenon. Longer follow-up would be needed to show if band removal is associated with greater weight regain than band revision. When patients are selected according to established criteria [17], the complication rate decreases significantly, primarily due to adequate dietetical preparation and postoperative surveillance. In our control cohort, all patients were treated by a multidisciplinary team comprising of a surgeon, endocrinologist, dietician, physiotherapist, and psychologist. All patients were given clear instruction regarding food preparation and frequency of eating and received routine postoperative follow-up. The band slippage group was treated in other institutions so the same perioperative management cannot be ensured. Bad dietetical preparation can lead to proximal pouch dilatation and eventual slippage but may also explain why patients have a better QOL after band removal than after revision. Careful patient selection, management in a multidisciplinary team environment, and adequate perioperative counseling is essential in ensuring a good functional outcome. Regarding improving patient management, only 50% of LAGB patients will recall being counseled on GBS preoperatively [18]. Given the high incidence of GBS and the potential effect on weight management goals and QOL, patients should be thoroughly counseled on this complication preoperatively. Furthermore, a number of operative techni-

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ques have been suggested to reduce GBS including the pars flaccida technique, using an 11-cm Lap-Band and suturing the gastric fundus to the left hemi-diaphragm [8, 19, 20]. In summary, this study reports a formal evaluation of BMI and QOL following surgery for GBS and, despite some limitations, suggests that while patients who suffer a GBS experience rebound weight gain, this does not profoundly affect QOL. Longer follow-up is required to determine whether patients would be better served by band removal as opposed to revision. Conflicts of interest All authors declare no conflicts of interest.

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