OBES SURG (2007) 17:1608–1613 DOI 10.1007/s11695-007-9263-3
Who Benefits from Gastric Banding? Marco Bueter & Andreas Thalheimer & Caroline Lager & Marion Schowalter & Bertram Illert & Martin Fein
Published online: 21 November 2007 # Springer Science + Business Media B.V. 2007
Abstract Background In the present study, criteria were investigated to predict major benefit after laparoscopic adjustable gastric banding (LAGB). Materials and Methods 85 morbidly obese patients were operated with LAGB between 1999 and 2005. Seventy-one of these patients were analyzed according to several possible predictive characteristics for success as the primary endpoint. Success was defined as excess body weight loss (EBWL) >50% and no band removal. Median follow-up was 27 months (range 8–90 months). Results In total, median EBWL was 43% (−41 to 171.5%) with a decrease in BMI of 8.0 kg/m2 (−9 to 35 kg/m2). Success rate was 37% (n = 26). These patients were compared to all other patients (n=45). Significant success predictors were baseline absolute BW, EBW, BMI (p< 0.01), BMI with a threshold value of 50 kg/m2 (p=0.02), and female sex (p=0.02) as well as postoperative vomiting (p=0.02), eating behavior and physical activity after LAGB (p<0.01). Baseline EBW and change in eating behavior after surgery were identified as independent predictors in multivariate analysis.
M. Bueter (*) : A. Thalheimer : B. Illert : M. Fein Department of Surgery I, Julius-Maximilians-University of Wuerzburg, Oberduerrbacher Strasse 6, 97080 Wuerzburg, Germany e-mail:
[email protected] C. Lager : M. Schowalter Institute of Psychotherapy and Medical Psychology, Julius-Maximilians-University of Wuerzburg, Klinikstrasse 3, 97070 Wuerzburg, Germany
Conclusion Patients with a lower excess body weight who improve especially their eating behavior after surgery have the highest chance of success after LAGB. Keywords Morbid obesity . Bariatric surgery . Laparascopic adjustable gastric banding . Predicting outcome
Introduction Morbid obesity is a major healthcare problem in western countries reducing quality of life. It is supposed to be a major public health challenge during the upcoming years [1]. Nonoperative means of weight loss have inconsistent success and a high rate of failure to sustain even a 10% long-term weight loss [2]. Thus, surgery is considered the treatment of choice in morbid obesity at the present time and has been demonstrated to reduce obesity related morbidity and mortality [3]. Among these, LAGB as a purely restrictive procedure has been found to provide significant weight loss in morbid obesity and a good reduction in comorbidities with a very low mortality rate. However, the outcome of this procedure is variable and absence of weight loss or weight regain may occur in the long-term postoperative period [4]. Differences in success of LAGB were observed for patients’ characteristics such as sex and weight [5]. It has been hypothesized, that success of LAGB is not only a function of the surgical procedure alone and other criteria like physical activity, social and familiar circumstances also play a role in achieving and maintaining weight reduction after surgery [6]. In addition, different personality traits may also be relevant to eating behavior and adjustment after surgery, and may lead to difficulties in adapting to the demands imposed by the band resulting in inadequate weight loss [7].
Who benefits from gastric banding?
The aim of this study was to examine which individual pre- and postoperative criteria predict weight loss after gastric banding.
Materials and Methods Patients Between 1999 and 2005, a number of 85 patients were operated for morbid obesity with gastric banding. The laparoscopic approach was standardized in all patients and has been described before [8, 9]. In all cases, the Swedish adjustable gastric banding (SAGB) was used (Obtech, Ethicon Endo-Surgery, Germany) and positioned through the pars flaccida technique. All the patients were carefully selected and always seen by a multidisciplinary team consisting of a surgeon, an endocrinologist, and a psychologist. The patients were considered as candidates for LAGB when the following conditions were met: age >18 years and body mass index (BMI)>40 kg/m2 or BMI>35 kg/m2 with obesity related comorbidities, no endocrine disease causing overweight like hypothyreoidism or hypercortisolism, no binge-eating disorder and no history of any kind of drug or alcohol addiction. Ideal body weight was determined according to the Metropolitan Life Insurance Company’s 1983 height/weight tables. Excess weight (EW) was defined as the difference between the patient’s weight and the theoretical medium-frame ideal body weight. In total, there were 69 women and 16 men (sex ratio=0.25) with a median age of 40 years (18–64 years). Preoperative median body weight (BW) was 136 kg (88–202 kg) with a BMI of 49 kg/m2 (37–73 kg/m2) and an excess body weight (EBW) of 52 kg (17–110 kg). A total of 213 comorbidity conditions related to overweight were recorded in 83 patients (97.6%) with a mean number of 2.4 comorbidities per patient. These included hypertension (70.7%, n=58), diabetes (30.5%, n=25), sleep apnea (13.4%, n=11), degenerative joint disease (81.7%, n=67), and dyspnea (63.4%, n=52). Study Design Primary endpoint of this retrospective study was a success after gastric banding defined as excess body weight loss (EBWL) more than 50% and no band removal. A secondary endpoint was failure after gastric banding defined as EBWL below 20% or band removal. Data Collection All the patients were compared in terms of general features, comorbidities, postoperative complications, social and
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familiar circumstances, eating behavior, and physical activity. Data were collected by a personal interview according to an unvalidated, standardized questionnaire developed by the multidisciplinary team at any visit during preoperative and postoperative care. In exceptional cases, a telephone interview was performed instead. Eating behavior and eating attitudes were evaluated according to the following patterns: Sweet eating was diagnosed when the patient continuously craved simple carbohydrates and carbohydrate craving could be triggered by emotional and physiological situations. Stress eating was diagnosed when any food ingestion other than carbohydrates could be triggered by emotional and physiological stress situations. To identify other forms of misbehavior like nibbling or gorging, number of meals per day (<3 vs >3) and meal size (<2 bagels vs >2 bagels) were also evaluated. Finally, patients were asked for events of vomiting of food remnants after eating and considered positive if this happened more than once a day. The patients were considered as physical active when endurance sports (e.g., swimming, running, power walking, aerobic, cycling) was performed more than three times a week for more than 30 min. Statistical Analysis All data are presented as median (range) unless otherwise stated. Statistical evaluations used Fisher exact test, χ2 tests and nonparametric tests (Mann–Whitney U test, Kruskal– Wallis test). Multivariate analysis was done using logistic regression with backward elimination of variables with SAS® software (SAS Institute, Cary, NC, USA). P<0.05 was considered significant.
Results Follow-up Median follow-up was 27 months (8–90 months). Eleven of the eighty-five patients were lost to follow-up (13%). Two patients were excluded due to band infection as this
Table 1 General outcome Total median (range) Body weight (kg) BMI (kg/m2) Excess weight (kg) EWL (kg) EBWL (%) Loss of BMI (kg/m2)
115 (70–200) 38 (24–66) 28 (−17 to 102) 23 (−30 to 100) 43.2 (−41 to 171.5) 8.0 (−9 to 35)
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Who Benefits from Gastric Banding?
Fig. 1 Course of EBWL%, failure and success rate per year
complication was considered independent from postoperative compliance or misbehavior. Another patient was excluded after band removal and switch to gastric bypass at patient’s request leaving 71 patients (84%) for the analysis in this study. Groups for statistical comparisons were success (n=26, 37%) versus no success (n=45, 63%) and failure (n=14, 20%) versus no failure (n=57, 80%). General Outcome General outcome including weight loss after LAGB is summarized in Table 1. In total, median excess body weight loss (EBWL) was 43.2% (−41 to 171.5%) with a decrease in BMI of 8.0 kg/m2 (−9 to 35 kg/m2). Course of EBWL%, individual success and failure rates per year are shown in Fig. 1. Course of comorbidities is listed in Table 2. The patients with success had a significant higher chance of improvement or total recovery of arterial hypertension, degenerative joint disease, and dyspnea than patients with failed LAGB. Although not significant, diabetes mellitus and sleep apnea showed a similar trend towards improvement for successful patients.
Overall, there was no mortality. Morbidity rate was 21.9%. A total number of 18 patients experienced one or more complications. Band migration and port site infection were noted in two patients (2.4%), band leakage and pouch dilatation were found in three patients respectively (3.7%), port dislocation was seen in six patients (7.3%), and band slippage was observed in seven patients (8.5%). Among the above-mentioned complications, 17.1% of all patients (n=14) required one or more reoperations under general anesthesia including band replacement (9.8%) and band removal (4.9%). There was no correlation between the complication rates and weight loss. Outcome Predictors for Success Mean values of baseline BMI, EBW, and BW were significantly lower in successful patients than in unsuccessful patients after LAGB (Table 3). All other relevant factors for success are listed in Table 4. Female sex predicted success [Relative Risk (RR) 5.5; confidence interval 95% (CI95%): 1.2–26.1]. BMI of 50 kg/m2 was identified as cutoff value as a predictor of success with a relative risk of 3.0 (CI95%: 1.2–7.7) for patients with BMI with a BMI cut-off value below 50 kg/m2.
Table 2 Improvement of comorbidities after LAGB
Hypertension Diabetes Sleep apnoea Degenerative joint disease Dyspnoea
Success (n=26)
No success (n=45)
P values
79.6% 90% 57.1% 88.2% 97.7%
22.2% 33.3% 0% 15.4% 11.1%
0.002 0.07 0.20 0.0001 0.0001
Percentage of patients in whom comorbidities were gone or improved. Success after LAGB is a precondition for improvement of comorbidities.
Table 3 Relevance of preoperative weight characteristics Criteria
Success (n=26)
No success (n=45)
P values
BMI (kg/m2) EBW (kg) BW (kg)
45 (37– 63) 44 (17– 83) 128 (93–173)
51 (40 –73) 56 (22 –110) 145 (88 –200)
0.021 0.004 0.002
Success, excess body weight loss >50% and no band removal; No success, excess body weight loss <50% or band removal; EBW, excess body weight, BW: body weight
Who benefits from gastric banding?
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Table 4 Predictors of success after LAGB (Success vs. No Success)
Table 5 Predictors of failure after LAGB (Failure vs. No Failure)
Criteria
Criteria
RR (Odds ratio)
General features Female sex 5.5 BMI<50 3.0 Complications after LAGB Port dislocation 3.3 Re–OP 4.5 Replacement 1.9 Eating behavior after LAGB Sweet eating 0.2 Stress eating 0.1 Vomiting 3.9 Physical activity after LAGB Yes 4.2
95% Confidence interval
P
1.2 – 26.1 1.2 – 7.7
0.023 0.024
0.37 – 29.3 0.9 – 21.5 0.4 – 10.2
0.401 0.068 0.704
0.05 – 0.7 0.02 – 0.5 1.3 –11.7
0.008 0.003 0.015
1.5 –11.7
0.007
RR (Odds ratio)
General features Male sex 3.9 BMI>50 1.9 Complications after LAGB Port dislocation 8.9 Re–OP 5.2 Replacement 0.5 Eating behavior after LAGB Sweet eating 0.6 Stress eating 0.4 Vomiting 3.1 Physical activity after LAGB No 4.0
95% Confidence interval
P
1.2 –12.7 0.7 – 5.5
0.038 0.291
1.5 – 53.3 1.5 –17.7 0.06 – 4.2
0.019 0.011 0.678
0.2 – 2.0 0.1 –1.2 0.6 –15.1
0.530 0.121 0.204
1.0 –15.7
0.045
Success: excess body weight loss >50% and no band removal (n=26). No Success: excess body weight loss <50% or band removal (n=45).
Failure: excess body weight loss <20% or band removal (n=14). No Failure: excess body weight loss >20% and band removal (n=57).
While the preoperative eating behavior showed no significant influence on success, presence of sweet and stress eating behavior after LAGB was associated with a low chance on successful weight loss (RR 0.2, CI95%: 0.05–0.7 and RR 0.1, CI95%: 0.02–0.5). As expected, both the number of meals per day and meal size were reduced after band placement due to the restrictive character of the procedure. Noteworthy, patients reporting to have events of vomiting after food ingestion more than once a day were more likely to loose weight (RR 3.9, CI95%: 1.3–11.7). General physical activity after LAGB had also statistically significant predictive power on success after LAGB (RR 4.2, CI95%: 1.5–11.7). Multivariate analysis showed that baseline EBW (RR 0.962, CI95%: 0.932–0.993) and eating behavior (RR 8.62, CI95%: 1.75–42.4) were identified as the only independent predictors of success ( p=0.008). The patients’ age and length of postoperative follow-up period showed no significant prediction of success after LAGB. Personal and familiar history of obesity including early onset of overweight, obese parents or siblings had no statistically significant predictive power on success after LAGB. No difference was observed for rate of marriage, employment or level of school education between successful patients. Preoperative presence or absence of obesity-related comorbidities was also no predictor of success of LAGB. None of the peri-operative complications had statistically significant predictive power on success (data not shown).
LAGB (RR 3.9, CI: 1.2–12.7). Occurrence of port dislocation was correlated with an elevated risk of failure (RR 8.9, CI95%: 1.5–53.3). In addition, the association of reoperation and failure was also statistically significant (38.9 vs 10.9%, p=0.01). However, this can be related to the fact that band removals were considered as failures and required a reoperation. Differences became insignificant when band removals were excluded from the failure group (26.7 vs 14.9%, p=0.275). Of the analyzed postoperative characteristics, being physical inactive was statistically significant associated with failure (RR 4.0, CI95%: 1.0–15.7). Multivariate analysis showed that only baseline EBW was identified as the main predictor of failure after LAGB (RR 0.952, CI95%: 0.920–0.984, p=0.005).
Outcome Predictors for Failure All relevant factors for failure are listed in Table 5. Male gender was associated with higher chance for failure after
Discussion In accordance to other studies, a large variability in postoperative weight loss was observed after gastric banding. EBWL had a range from fair good results to complete failures [10–15]. While some authors attributed the outcome rather to physiologic and technical reasons than to comorbidities or preoperative eating behavior, it is still common belief that failure after LAGB is more related to motivational and/or psychological factors [16]. In the present study, baseline BMI and subsequently preoperative EBW and BW were found to be significantly associated with a better outcome. A BMI cut-off value predicting success was identified at BMI<50 kg/m2. This is in accordance to other studies reporting that patients with BMI>50 kg/m2 had a success rate about half that seen in patients with BMI<50 kg/m2 [17–19]. Thus, these results
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support the conclusion that super-obese patients may require more complex operations, like e.g. Roux-en-Y gastric bypass, to achieve satisfactory weight loss. In addition, female gender was significantly associated with success while male sex predicted failure. The general conclusion that patients with a BMI>50 kg/m2 or male patients cannot succeed to loose weight after LAGB should not be drawn. In the presented study, the chance for success was three times higher for patients with a BMI<50 kg/m2 and at least five times higher in women. Interestingly, multivariate analysis revealed baseline EBW as the main predictor of success after LAGB indicating that preoperative weight is of major importance for the decision that patient should be treated by LAGB or not. Postoperative eating behavior and behavioral changes after LAGB have also been shown to be relevant for outcome prediction. Some authors stated that the psychological status may be of great importance for eating behavior and adjustment after surgery and therefore cause difficulties in adapting to the demands imposed by the LAGB leading to inadequate weight loss [7]. In this regard, it has been proposed to consider bariatric surgery as a ‘forced behavior modification’ [20]. In the present study, physical activity, sweet and stress eating behavior before surgical intervention had no predictive potential. This is in accordance to the “Swedish Obese Subjects” study as sweet eating was not a predictor of poor outcome, and success rate was comparable with nonsweet eating patients [21]. In contrast, modification of eating behavior after surgery predicted statistically significant success even in multivariate analysis. Thereby, it appears to be of less importance whether the patient is a physical inactive sweet and/or stress eater before surgery as long as he is able to change his habits after surgery. This observation highlights the influence of motivational factors for weight loss after LAGB. Unfortunately, a valuable and objective tool for measuring the compliance of a patient does not exist, yet. Therefore, early predictions are difficult what patients will be able to fulfill postoperative behavior changes necessary for success. These considerations led to a modification of postoperative care in our institution: All patients who underwent weight loss surgery are given motivational and psychological support in regular meetings addressing postoperative eating behavior and physical activity among other things. Whether this will improve the outcome is a matter of ongoing research. As a matter of concern, a high vomiting frequency after LAGB was associated with major weight loss. The patients with binge eating disorders have previously been demonstrated to have a significantly higher vomiting frequency and higher prevalence of stomal stenosis than patients without binge eating during the first year after LAGB [22]. As presence of binge-eating disorder was considered as
Who Benefits from Gastric Banding?
contraindication for LAGB and binge eater were identified at screening, these patients are unlikely to be unrecognized binge eaters. Although a reserved strategy of banding adjustments is followed by the investigators, it has to be recognized that in these cases, weight loss could be due to overfilling of the band instead of change of cognition and development of satiety. In conclusion, the presented results confirm the important role of LAGB in the treatment of morbid obesity. It produced sustained weight loss in a large proportion of obese patients. Its lower efficacy in comparison to malabsorptive procedures must be balanced against its lower rate of life-threatening complications as well as the postoperative adjustability and its complete reversibility. Despite a relative small number of patients, the present analysis of outcome predictors clearly revealed that patients with a lower excess body weight who improve especially their eating behavior after surgery benefit the most from gastric banding. Besides preoperative excess body weight, personal impressions of the surgeon and patients’ requests still have significant influence on the final treatment decision. Furthermore, the presented results support the need of fundamental changes in physical activity and eating behavior of the patients in the postoperative period to augment the likelihood of sufficient weight loss. Patients are unlikely to meet all these demands on their own, and a regular motivational and psychological support as a postoperative standard procedure seems to be beneficial. Acknowledgement The authors acknowledge Mrs. Kathrin Hohl, who devotedly manages and organizes our Obesity Centre.
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