Gastric Banding or Bypass? A Systematic Review Comparing the Two Most Popular Bariatric Procedures

Article (PDF Available)inThe American journal of medicine 121(10):885-93 · November 2008with73 Reads
DOI: 10.1016/j.amjmed.2008.05.036 · Source: PubMed
Abstract
Bariatric surgical procedures have increased exponentially in the United States. Laparoscopic adjustable gastric banding is now promoted as a safer, potentially reversible and effective alternative to Roux-en-Y gastric bypass, the current standard of care. This study evaluated the balance of patient-oriented clinical outcomes for laparoscopic adjustable gastric banding and Roux-en-Y gastric bypass. The MEDLINE database (1966 to January 2007), Cochrane clinical trials database, Cochrane reviews database, and Database of Abstracts of Reviews of Effects were searched using the key terms gastroplasty, gastric bypass, laparoscopy, Swedish band, and gastric banding. Studies with at least 1 year of follow-up that directly compared laparoscopic adjustable gastric banding with Roux-en-Y gastric bypass were included. Resolution of obesity-related comorbidities, percentage of excess body weight loss, quality of life, perioperative complications, and long-term adverse events were the abstracted outcomes. The search identified 14 comparative studies (1 randomized trial). Few studies reported outcomes beyond 1 year. Excess body weight loss at 1 year was consistently greater for Roux-en-Y gastric bypass than laparoscopic adjustable gastric banding (median difference, 26%; range, 19%-34%; P < .001). Resolution of comorbidities was greater after Roux-en-Y gastric bypass. In the highest-quality study, excess body weight loss was 76% with Roux-en-Y gastric bypass versus 48% with laparoscopic adjustable gastric banding, and diabetes resolved in 78% versus 50% of cases, respectively. Both operating room time and length of hospitalization were shorter for those undergoing laparoscopic adjustable gastric banding. Adverse events were inconsistently reported. Operative mortality was less than 0.5% for both procedures. Perioperative complications were more common with Roux-en-Y gastric bypass (9% vs 5%), whereas long-term reoperation rates were lower after Roux-en-Y gastric bypass (16% vs 24%). Patient satisfaction favored Roux-en-Y gastric bypass (P=.006). Weight loss outcomes strongly favored Roux-en-Y gastric bypass over laparoscopic adjustable gastric banding. Patients treated with laparoscopic adjustable gastric banding had lower short-term morbidity than those treated with Roux-en-Y gastric bypass, but reoperation rates were higher among patients who received laparoscopic adjustable gastric banding. Gastric bypass should remain the primary bariatric procedure used to treat obesity in the United States.

Figures

CLINICAL RESEARCH STUDY
Gastric Banding or Bypass? A Systematic Review
Comparing the Two Most Popular Bariatric Procedures
Jeffrey A. Tice, MD, Leah Karliner, MD, MS, Judith Walsh, MD, Amy J. Petersen, PhD,
Mitchell D. Feldman, MD, MPhil
Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco.
ABSTRACT
OBJECTIVE: Bariatric surgical procedures have increased exponentially in the United States. Laparoscopic
adjustable gastric banding is now promoted as a safer, potentially reversible and effective alternative to
Roux-en-Y gastric bypass, the current standard of care. This study evaluated the balance of patient-oriented
clinical outcomes for laparoscopic adjustable gastric banding and Roux-en-Y gastric bypass.
METHODS: The MEDLINE database (1966 to January 2007), Cochrane clinical trials database, Cochrane
reviews database, and Database of Abstracts of Reviews of Effects were searched using the key terms
gastroplasty, gastric bypass, laparoscopy, Swedish band, and gastric banding. Studies with at least 1 year
of follow-up that directly compared laparoscopic adjustable gastric banding with Roux-en-Y gastric bypass
were included. Resolution of obesity-related comorbidities, percentage of excess body weight loss, quality
of life, perioperative complications, and long-term adverse events were the abstracted outcomes.
RESULTS: The search identified 14 comparative studies (1 randomized trial). Few studies reported
outcomes beyond 1 year. Excess body weight loss at 1 year was consistently greater for Roux-en-Y gastric
bypass than laparoscopic adjustable gastric banding (median difference, 26%; range, 19%-34%; P .001).
Resolution of comorbidities was greater after Roux-en-Y gastric bypass. In the highest-quality study,
excess body weight loss was 76% with Roux-en-Y gastric bypass versus 48% with laparoscopic adjustable
gastric banding, and diabetes resolved in 78% versus 50% of cases, respectively. Both operating room time
and length of hospitalization were shorter for those undergoing laparoscopic adjustable gastric banding.
Adverse events were inconsistently reported. Operative mortality was less than 0.5% for both procedures.
Perioperative complications were more common with Roux-en-Y gastric bypass (9% vs 5%), whereas
long-term reoperation rates were lower after Roux-en-Y gastric bypass (16% vs 24%). Patient satisfaction
favored Roux-en-Y gastric bypass (P .006).
CONCLUSION: Weight loss outcomes strongly favored Roux-en-Y gastric bypass over laparoscopic ad-
justable gastric banding. Patients treated with laparoscopic adjustable gastric banding had lower short-term
morbidity than those treated with Roux-en-Y gastric bypass, but reoperation rates were higher among
patients who received laparoscopic adjustable gastric banding. Gastric bypass should remain the primary
bariatric procedure used to treat obesity in the United States.
© 2008 Elsevier Inc. All rights reserved. The American Journal of Medicine (2008) 121, 885-893
KEYWORDS:
Bariatric surgery; Laparoscopic adjustable gastric banding; Obesity; Roux-en-Y gastric bypass;
Systematic review
Obesity is rapidly increasing in the United States, with the
prevalence of class 3 obesity approaching 8% in some popu-
lations.
1,2
Class 3 obesity, defined as a body mass index (BMI)
of greater than 40 kg/m
2
, is associated with premature death
and an increased risk for diabetes, hypertension, hypercholes-
terolemia, heart disease, osteoarthritis, sleep apnea, and gall-
bladder disease. Previous research has shown that weight loss
improves both social functioning and quality of life.
3,4
Care-
fully controlled studies have demonstrated between 25% and
60% reductions in all-cause, cardiovascular, and cancer mor-
tality associated with significant weight loss.
5-7
This work was in part supported by funding from the Blue Shield of
California Foundation, San Francisco, Calif.
Requests for reprints should be addressed to Jeffrey A. Tice, MD,
Division of General Internal Medicine, Department of Medicine, Univer-
sity of California, San Francisco, 1701 Divisadero Street, Suite 554, San
Francisco, CA 94143-1732.
E-mail address: jtice@medicine.ucsf.edu
0002-9343/$ -see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjmed.2008.05.036
Current treatment options for morbid obesity include phar-
macologic agents, low-calorie diets, behavioral modification,
exercise, and surgery.
8
Dietary treatments produce an initial
weight loss of less than 15% of the starting weight, and weight
reductions generally decay to zero at 5 years.
9
More aggressive
therapy with medications (eg, orl-
istat, sibutramine) may be indicated
for patients who have medical com-
plications of obesity. However,
drug therapy is limited by side ef-
fects, and systematic reviews of be-
havioral and drug therapy have re-
ported average long-term weight
loss of only 4 to 7 kg.
8,10-12
In mor-
bidly obese patients, there is no
evidence that these interventions
result in either significant, sus-
tained weight loss or a reduction
in medical complications.
13
BARIATRIC SURGERY
The failure of most current ap-
proaches to control morbid obesity
has led to the development of sur-
gical procedures of the upper gas-
trointestinal tract designed to induce
weight loss (bariatric surgery).
14
Current guidelines from the National Institutes on Health rec-
ommend consideration of bariatric surgery for patients with a
BMI of greater than 40 kg/m
2
and for those with a BMI greater
than 35 kg/m
2
who also have serious medical problems that
may improve with weight loss, such as diabetes and obstruc-
tive sleep apnea.
15
A recent systematic review concluded that
patients achieved effective weight loss of approximately 40 kg
after bariatric surgery and that most had complete resolution or
improvement of their diabetes, hypertension, hyperlipidemia,
and obstructive sleep apnea.
16
Furthermore, recent studies re-
ported that bariatric surgery reduced long-term mortality.
6,7
There are 2 commonly performed bariatric surgery pro-
cedures: Roux-en-Y gastric bypass, the predominant ap-
proach used in the United States,
17,18
and laparoscopic ad-
justable gastric banding, the most common bariatric surgery
in Australia and Europe.
19
Both Roux-en-Y gastric bypass
and laparoscopic adjustable gastric banding are primarily
restrictive procedures. Laparoscopic adjustable gastric
banding is marketed as a less-invasive, potentially reversible
alternative to Roux-en-Y gastric bypass, because the procedure
does not require gastrointestinal bypass and reanastomosis.
Gastric banding functions by limiting food intake after the
placement of an inflatable tube around the stomach just below
the gastroesophageal junction, which allows for adjustment of
the size of the outlet via the addition or removal of saline
through a subcutaneous port.
20
Roux-en-Y gastric bypass also
creates a small stomach pouch to restrict food intake, but a
portion of the jejunum is attached to the pouch to allow food to
bypass the distal stomach, duodenum, and proximal jejunum.
Bypassing this segment of the gastrointestinal tract might con-
tribute to the clinical success of Roux-en-Y gastric bypass by
altering the secretion of hormones that influence glucose reg-
ulation and the perception of both hunger and satiety.
21-25
Roux-en-Y gastric bypass is currently the standard bariatric
procedure in the United States.
19
Given the rapid increase in bariatric
procedures in the United States,
26
it
is important for internists to under-
stand the relative strengths and
weaknesses of each procedure, such
that patients and their doctors can
make informed, evidence-based de-
cisions. Conclusions about the com-
parative efficacy and safety of
Roux-en-Y gastric bypass and lapa-
roscopic adjustable gastric banding
procedures are best made on the ba-
sis of comparative trials using con-
current, ideally randomized, con-
trols. Randomized trials have
demonstrated the superiority of
Roux-en-Y gastric bypass to sev-
eral gastroplasty procedures.
27-31
However, only 1 small random-
ized trial comparing Roux-en-Y
gastric bypass with laparoscopic
adjustable gastric banding has been published to date.
32
The
present systematic review of all studies directly comparing
Roux-en-Y gastric bypass with laparoscopic adjustable gastric
banding was conducted with the aim of evaluating the relative
safety and efficacy of the 2 procedures.
Data Sources and Study Selection
The MEDLINE database, Cochrane clinical trials database,
Cochrane reviews database, Google Scholar, EMBASE, and
Database of Abstracts of Reviews of Effects were searched
using any combination of the following key terms: gastro-
plasty, gastric bypass, laparoscopy, Swedish band, and gastric
banding. The MEDLINE search was performed for the period
from 1966 to January of 2007. The bibliographies of system-
atic reviews and key articles were manually searched for ad-
ditional references, and input was solicited from bariatric sur-
gery specialists. The abstracts of citations were reviewed for
relevance, and all potentially relevant articles were reviewed in
full. Articles chosen for inclusion compared laparoscopic ad-
justable gastric banding and Roux-en-Y gastric bypass patient-
oriented outcomes (eg, weight loss, resolution of obesity-re-
lated illnesses, mortality, procedure-specific complications) in
subjects followed for a minimum of 1 year. Two investigators
independently extracted the data from each article using a
standard form. Differences were resolved through consensus.
Quality was rated according to the GRADE criteria for indi-
vidual studies.
33,34
The primary health measure driving the demand for surgical
intervention is weight loss. When comparing across studies
CLINICAL SIGNIFICANCE
There has been a 10-fold increase in bari-
atric surgeries during the past decade.
In comparative trials, weight loss, resolu-
tion of obesity-related comorbidities, and
patient satisfaction are greater after gas-
tric bypass than gastric banding.
Despite widespread marketing of gastric
banding, no subgroups have been iden-
tified in whom it performs better than
gastric bypass.
Gastric bypass should remain the pri-
mary bariatric procedure used to treat
obesity.
886 The American Journal of Medicine, Vol 121, No 10, October 2008
with differences in baseline characteristics, the percentage of
excess body weight loss is the most useful measure of weight
loss because average changes in both weight and BMI are
greater in studies enrolling patients with higher presurgical
BMI, whereas excess body weight loss is relatively consistent
across studies regardless of initial BMI. We focused on excess
body weight loss at 1 year, given the paucity of data for
patients beyond 1 year of follow-up. Additional beneficial
outcome measures included changes in obesity-related condi-
tions, such as diabetes, hypertension, sleep apnea, dyslipide-
mia, sleep apnea, arthritis, and gastroesophageal reflux disease,
as well as long-term patient satisfaction and quality of life. The
most important harms included 30-day morbidity and mortality
after the procedure, as well as long-term complications, par-
ticularly those requiring additional surgical interventions or
causing significant patient morbidity. We did not use meta-
analytic techniques to combine the results across studies be-
cause of significant heterogeneity in study design, different
definitions for the outcomes, and different methods for assess-
ing the outcomes. Measures of central tendency were summa-
rized using the median value across studies to minimize the
effect of outliers.
RESULTS
Search Results
The literature search identified 14 trials that directly compared
laparoscopic adjustable gastric banding with Roux-en-Y gas-
tric bypass.
32,35-47
One additional comparative trial did not
report weight loss outcomes or complications and was not
included in this review.
48
There have been many randomized
trials comparing laparoscopic adjustable gastric banding and
Roux-en-Y gastric bypass with other bariatric proce-
dures,
27,49-55
but only one
32
directly compared Roux-en-Y
gastric bypass with laparoscopic adjustable gastric banding.
Study Characteristics
Patients in these studies were on average approximately 40
years old and had an initial BMI of 45 m/kg
2
(Table 1); 80%
were female. In general, the quality of the comparative
studies was low. With the exception of 1 randomized, con-
trolled study, all studies were retrospective. There were no
propensity score analyses or standard outcomes assessments.
Only 2 of the studies
37,46
matched patients for the known
predictors of poor surgical outcome: age, sex, and BMI. In
Table 1 Characteristics of Studies Comparing Laparoscopic Adjustable Gastric Banding with Roux-en-Y Gastric Bypass
Study
(First Author, Year) Design Arm N Age BMI, kg/m
2
FU, mo
1-y
FU, % Quality
Hell 2000 Retrospective, no matching SAGB and LapBand 30 36 47 40 Very low
RYGB 30 41 45 60
Biertho 2003 Retrospective, no matching SAGB 805 42 42 82 Very low
RYGB 456 40 49 31
Weber 2004 Matched by age, sex, BMI LapBand 103 40 48 42 Low
RYGB 103 40 48 18
Jan 2005 Retrospective, no matching LapBand 154 46 51 Very low
RYGB 219 42 50 24 60
Mognol 2005 Retrospective, no matching LapBand 179 40 54 24 Very low
RYGB 111 40 59 24
Parikh 2005 Retrospective, no
matching, BMI 50
LapBand
RYGB
197
97
43
42
55
55
NR, 24 80
74
Very low
Bowne 2006 Retrospective, no
matching, BMI 50
LapBand
RYGB
60
46
42
43
55
57
18
13
92
85
Very low
Cottam 2006 Matched on age, sex, BMI,
date of surgery
LapBand
RYGB
181
181
42
43
47
47
NR, 23% at 36
months
Low
Galvani 2006 Retrospective, no matching LapBand 470 41 47 Very low
RYGB 120 41 46 NR
Kim 2006 Retrospective, no matching LapBand 160 42 47 Very low
RYGB 232 39 47 NR
Parikh 2006 Retrospective, no matching LapBand 480 42 46 12 Very low
RYGB 235 41 47 12
Rosenthal 2006 Retrospective, no matching LapBand
RYGB
152
849
54
47
40
56
77% with
“complete” FU
Very low
Angrisani 2007 Randomized trial LapBand 27 33 43 60 96 Moderate
RYGB 24 35 44 60 100
Jan 2007 Retrospective, no matching LapBand 406 47 51 12 65 Very low
RYGB 492 44 49 16 48
BMI body mass index; FU follow-up; NR not reported; RYGB Roux-en-Y gastric bypass; SAGB Swedish adjustable gastric band (Obtech
Medical AG, Zug, Switzerland).
887Tice et al LapBand Versus Gastric Bypass
most of the studies, the 2 surgical groups were far from com-
parable. For example, patients who received laparoscopic ad-
justable gastric banding in 2 of the studies were treated in
Europe, whereas those who received Roux-en-Y gastric bypass
were treated in the United States.
35,39
It is impossible to de-
termine whether the observed differences in outcomes reflect
differences in the respective health care systems and patient
populations, or true differences between the procedures. Sim-
ilarly, the patient groups in 2 of the studies had age differences
of 4 to 5 years at the time of surgery.
39,40
Two other studies
had differences in baseline BMI that ranged from 7 to 15
kg/m
2
.
35,45
The median follow-up time was less than 18 months,
a relatively short period for the assessment of long-term benefits
and harms of procedures intended to last for 30 to 50 years.
Weight Loss and Resolution of Comorbidities
Weight loss outcomes consistently favored Roux-en-Y gas-
tric bypass by a substantial margin (Table 2). The median
absolute difference in excess body weight loss between the
2 groups across the 12 studies reporting weight loss out-
comes at 1 year was a large and clinically significant dif-
ference of 25%. In several of the studies, these differences
tended to narrow over time, although in others, the differ-
ences remained stable. In the only randomized trial, weight
loss differences seen at 1 year were preserved through 5
years of follow-up. These results were mirrored in the data
for the resolution of comorbidities (Figure 1). The results of
the 2 studies that matched patients
37,46
strongly favored the
Roux-en-Y gastric bypass group, with absolute differences
in the resolution of comorbidities of 25% or more (number
needed to treat 4). Thus, on average, for every 4 patients
with an obesity-related condition treated with Roux-en-Y
gastric bypass rather than laparoscopic adjustable gastric
banding, 1 additional patient will be cured of the disease.
Even larger differences were reported by Bowne et al
36
in
their study of patients with a BMI of greater than 50 kg/m
2
.
For instance, 100% of patients with diabetes who were
treated with Roux-en-Y gastric bypass showed blood glu-
cose normalization without medication, compared with only
40% of diabetic patients treated with laparoscopic adjust-
able gastric banding. However, 2 recent large studies reported
that improvements in comorbidities were similar between the 2
Table 2 Percentage of Excess Body Weight Loss and Resolution of Comorbidities Among Patients Entering Study with the
Condition*
Study Arm N %EBWL, 1 y DM HTN Dyslipidemia OSA GERD Arthritis Asthma
Hell 2000 LAGB 30
RYGB 30
Biertho 2003 LAGB 805 33
RYGB 456 67
Weber 2004 LAGB 103 35 59 70 0
RYGB 103 55 84 75 50
Jan 2005 LAGB 154 34
RYGB 219 64
Mognol 2005 LAGB 179 41
RYGB 1) 63
Parikh 2005 LAGB 197 35
RYGB 97 58
Bowne 2006 LAGB 60 31 40 27 40 34 14 12
RYGB 46 52 100 63 43 88 29 73
Cottam 2006 LAGB 181 48 (19) 50 56 46
RYGB 181 76 (16) 78 81 81
Galvani 2006 LAGB 470 39 68 59 55 56 60
RYGB 120 65 75 61 63 75 69
Kim 2006 LAGB 160 34 77 56 37 88 84
RYGB 232 64 72 66 48 84 75
Parikh 2006 LAGB 480
RYGB 235
Rosenthal 2006 LAGB 152 54
RYGB 849 73
Angrisani 2007 LAGB 27 35 0 100
RYGB 24 51 100 0 100
Jan 2007 LAGB 406 34
RYGB 492 65
DM diabetes mellitus; EBWL excess body weight loss; GERD gastroesophageal reflux disease; HTN hypertension; LAGB laparoscopic
adjustable gastric banding; OSA obstructive sleep apnea; RYGB Roux-en-Y gastric bypass.
*Percentages of patients with comorbidity before surgery with complete resolution after the bariatric procedure.
888 The American Journal of Medicine, Vol 121, No 10, October 2008
groups, although weight loss outcomes were better for patients
treated with Roux-en-Y gastric bypass.
38,42
Complications
Short-term complication rates generally favored laparoscopic
adjustable gastric banding (Table 3). Operative times were
shorter by a median of 68 minutes, and hospitalization length
of stay was approximately 2 days shorter. There were fewer
deaths in the laparoscopic adjustable gastric banding group
(0.06% vs 0.17%), although mortality was low in both groups.
Rates of conversion to open procedures, perforation, bleeding,
and anastomotic leaks were low in both groups. Overall, the
reported difference in major early complications ranged be-
tween 1.1% and 6.3% in favor of laparoscopic adjustable
gastric banding.
However, long-term complications were more com-
monly observed in those who underwent laparoscopic ad-
justable gastric banding (Figure 2); several studies reported
large differences in the rates of long-term complications
(Table 4). For instance, in the first trial with matched
groups,
46
early complications occurred in 21 of 103 patients
(20%) in the Roux-en-Y gastric bypass group and in 18 of
103 patients (17%) in the laparoscopic adjustable gastric
banding group, whereas long-term complications were more
common after laparoscopic adjustable gastric banding (14%
vs 44%, P not reported). Longer follow-up in the laparo-
scopic adjustable gastric banding group may partially ex-
plain this difference, although reoperation rates were higher
in the laparoscopic adjustable gastric banding group in an-
other trial in which participants were matched not only by
patient characteristics but also by date of surgery (19% in the
Roux-en-Y gastric bypass group vs 24% in the laparoscopic
adjustable gastric banding group).
37
Long-term reoperation
rates also were higher in the laparoscopic adjustable gastric
banding group than the Roux-en-Y gastric bypass group in 3 of
the 6 other comparative trials that reported reoperations.
36,40,45
Port problems or band slippage with pouch dilation counted
among the most common reasons for reoperation of patients
who received laparoscopic adjustable gastric banding, whereas
bowel obstruction was the most common problem among
patients who underwent Roux-en-Y gastric bypass. Band ero-
sion, gallbladder problems, and incisional hernias were rela-
tively uncommon late complications.
The complication rates for each procedure differ markedly
from study to study. This likely reflects different lengths of
follow-up and different definitions of significant complications
across studies. Most of the studies reported the prevalence of
complications rather than the annual rate of complications over
time. It is unclear whether complications associated with lapa-
roscopic adjustable gastric banding are common in the first 1 to
2 years after surgery and then decrease, or whether the opposite
is true as the port continues to be used and the materials age.
Furthermore, it is difficult to weigh the tradeoffs between
complications. For example, a port leak that requires minor
reoperation is clearly less important than an anastomotic leak
that causes peritonitis and sepsis.
Patient Satisfaction
Only 1 comparative study reported data on patient satisfac-
tion.
36
Approximately 80% of the patients in the Roux-en-Y
gastric bypass group reported being very satisfied with the
procedure, and no patients in this group were unsatisfied or
regretted having had the procedure. In contrast, only 46% of
the patients in the laparoscopic adjustable gastric banding
Figure 1 Comparison of the resolution* of obesity-associated comorbidities after Roux-
en-Y gastric bypass or laparoscopic adjustable gastric banding. LAGB laparoscopic
adjustable gastric banding; RYGB Roux-en-Y gastric bypass. *Median value from com-
parative studies reporting resolution of comorbidity.
889Tice et al LapBand Versus Gastric Bypass
group reported being very satisfied with the procedure, and
19% of the patients in the laparoscopic adjustable gastric
banding group were unsatisfied or even regretted having
undergone the procedure (P .006 between the 2 groups).
Highest-quality Studies
The only randomized clinical trial that directly compared
laparoscopic adjustable gastric banding with Roux-en-Y
gastric bypass was the small Italian study by Angrisani et
al.
32
The excess body weight loss at 1 year was 51% for the
24 patients randomized to Roux-en-Y gastric bypass versus
35% for the 27 patients randomized to laparoscopic adjust-
able gastric banding. At 5 years, the excess body weight loss
was 67% and 47% (P .001), respectively; only 1 of 24
(4%) Roux-en-Y gastric bypass-treated patients failed to
lose weight, whereas 9 of 26 (35%, P .001) of the
laparoscopic adjustable gastric banding-treated patients ex-
hibited a failure to lose weight. Reoperation rates were 12%
for patients in the Roux-en-Y gastric bypass arm, compared
with 15% for patients in the laparoscopic adjustable gastric
banding arm. There were no deaths during follow-up.
The highest-quality observational study considered the out-
comes of 181 patients matched for age, sex, BMI, and date of
surgery.
37
The excess body weight loss at 1 year was 76% for
Roux-en-Y gastric bypass versus 48% (P .001) for laparo-
scopic adjustable gastric banding, and the results remained
stable at 3 years (P .001). Resolution of diabetes was
observed in 78% of the patients treated with Roux-en-Y gastric
bypass who had diabetes before surgery, compared with 50%
resolution in previously diabetic patients who then received
laparoscopic adjustable gastric banding. Reoperation rates
were 19% for patients in the Roux-en-Y gastric bypass arm,
compared with 24% for patients in the laparoscopic adjustable
gastric banding arm. No deaths were reported in the study.
DISCUSSION
Current data clearly demonstrate that weight loss at 1 year
is greater among patients treated with Roux-en-Y gastric
Table 3 Percentage of Patients with Short-term Complications (30 Days)
Study Arm N
Operation
time, min* LOS, d† Death Perforation Conversion VTE Bleed Infection Leak Total
Hell 2000 LAGB 30
RYGB 30
Biertho 2003‡ LAGB 805 3 0 0.1 3.0 0.2 1.2 1.2 0 1.7
RYGB 456 5 0.4 0 2.0 0.9 0.9 0.2 2.0 4.2‡
Weber 2004 LAGB 103 145 3 0 1.0 0 0 1.0 16 0 18
RYGB 103 190 8 0 1.0 1.0 1.0 1.0 7.8 1.9 21
Jan 2005 LAGB 154 76 1 0.6 1.9 0.6 0.6 1.3 1.3 0 3.9
RYGB 219 134 3 0.5 0.5 0.5 0 1.8 4.1 0.9 5.0
Mognol 2005 LAGB 179 70 2 0.6 0 0 1.7 0.0
RYGB 111 180 8 0.9 3.6 3.6 0.9 0.1
Parikh 2005 LAGB 197 60 1 0 0 0.5 0 0.5 1.0 0 4.7
RYGB 97 130 3 0 0 2.1 1.0 0 5.2 1.0 11
Bowne 2006 LAGB 60 75 2 0 0 1.7 1.7 1.7 0 18
RYGB 46 121 4 0 0 0 2.2 2.2 2.2 17
Cottam 2006 LAGB 181 0 0
RYGB 181 0 0
Galvani 2006 LAGB 470 66 1 0 0.2 0.2 0.2 0 0 0 3.6
RYGB 120 209 2 0.8 0 2.5 0 0.8 0.8 0.8 6.6
Kim 2006 LAGB 160 0 0 0 0 0 0.6 0 0.6
RYGB 232 0 0 0 0 0 2.6 0.9 5.2
Parikh 2006 LAGB 480 1 0 0 3.3
RYGB 235 3 0 0.9 9.4
Rosenthal 2006
§
LAGB 152 0 1.3 4.6§
RYGB 849 0 0 0.6 0.8 0.5 3.7 1.9 4.4
Angrisani 2007 LAGB 27 60 2 0 0 0 0 0 0 0
RYGB 24 220 4 0 4.2 4.2 0 0 0 4.2
Jan 2007 LAGB 406 68 1 0.2 0.5 0.5 0.5 2.5 0 7.9
RYGB 492 134 2 0.2 0.6 0.6 2.2 4.7 0.8 15
LAGB laparoscopic adjustable gastric banding; LOS length of stay; RYGB Roux-en-Y gastric bypass; VTE venous thromboembolism.
*Mean.
†Median.
‡Major complications in the first postoperative week rather than 30 days.
§Major complications for Roux-en-Y gastric bypass and complications that required surgical correction for the laparoscopic adjustable gastric banding group.
890 The American Journal of Medicine, Vol 121, No 10, October 2008
bypass than among those treated with laparoscopic adjustable
gastric banding. The best studies show that this difference in
weight loss is preserved for at least 5 years. The data regarding
measures other than weight loss are less robust, but the findings
suggest that more patients would be cured of their diabetes,
obstructive sleep apnea, hypertension, and other obesity-asso-
ciated comorbidities if treated with Roux-en-Y gastric bypass
rather than laparoscopic adjustable gastric banding. When
asked, patients who underwent Roux-en-Y gastric bypass gen-
erally appeared more satisfied than those who underwent lapa-
roscopic adjustable gastric banding. However, early complica-
tions (reflected in longer initial hospitalizations and greater
early reoperation rates) were observed more commonly in the
Roux-en-Y gastric bypass groups; long-term complication
rates were more common in the laparoscopic adjustable gastric
banding group. It remains difficult to precisely assess the rel-
ative risks and benefits of the 2 procedures, because the quality
of the studies is generally low and the sample sizes in higher-
quality studies are small.
Between 1998 and 2004, the number of bariatric surger-
ies performed in the United States increased from approx-
imately 13,000 annually to 121,000.
26
During the same
period, inpatient mortality associated with bariatric surgery
decreased from 0.89% to 0.19%, and the average length of
stay decreased from 5 to 3.1 days.
26
The majority of these
procedures were Roux-en-Y gastric bypasses. The improve-
ments in outcomes over a relatively short time illustrate why
contemporary rather than historical controls must be used
when comparing surgical treatments for obesity.
Compared with Roux-en-Y gastric bypass, laparoscopic
adjustable gastric banding is a technically less-demand-
ing procedure with shorter operating time, shorter length
of hospital stay, and fewer initial complications. There-
fore, laparoscopic adjustable gastric banding has great
appeal for surgeons, who could treat more patients with
laparoscopic adjustable gastric banding than with Roux-
en-Y gastric bypass over the same time period. There is
a risk that commercial sponsorship of laparoscopic ad-
justable gastric banding may promote the use of these
devices over Roux-en-Y gastric bypass, which has no
commercial sponsor. The complex mixture of early and
late complications and benefits after both procedures, as
well as the impact of patient characteristics on outcomes,
requires randomized trials to carefully compare the rela-
tive merits of Roux-en-Y gastric bypass and laparoscopic
adjustable gastric banding. Given the rapid increase in
the number of patients interested in bariatric surgery,
such clinical trials are feasible. The publication of such
studies will enable patients and surgeons to determine
whether the possible lower rates of early complications
with laparoscopic adjustable gastric banding outweigh
the benefits of greater weight loss and fewer long-term
complications with Roux-en-Y gastric bypass.
CONCLUSIONS
Current evidence, although predominantly observational,
consistently demonstrates greater weight loss and improve-
ments in obesity-related conditions with Roux-en-Y gastric
bypass compared with laparoscopic adjustable gastric band-
ing. Both procedures have acceptable morbidity and mor-
tality when performed in appropriate patients at experienced
centers. Randomized, controlled comparative trials with
larger sample sizes are needed to determine whether there
are subgroups of patients who may benefit from the lower
short-term complication rates of laparoscopic adjustable
Figure 2 Comparison of the short- and long-term serious complication rates* after Roux-
en-Y gastric bypass or laparoscopic adjustable gastric banding. LAGB laparoscopic adjust-
able gastric banding; RYGB Roux-en-Y gastric bypass. *Median value from comparative
studies reporting complication rates.
891Tice et al LapBand Versus Gastric Bypass
gastric banding. Essential outcomes to evaluate in future trials
would be surgical and long-term mortality, surgical complica-
tions, weight loss, change in comorbidities, quality of life, and
long-term complications. Until trials demonstrate the advan-
tages of laparoscopic adjustable gastric banding in clearly
defined subgroups of patients, Roux-en-Y gastric bypass
should remain the bariatric procedure of choice in the United
States.
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Table 4 Percentage of Patients with Long-term Complications (30 Days Postprocedure)
Study Arm N Total Death Reoperation
Obstruction
(Stricture)
Marginal
Ulcer
Incisional
Hernia Gallbladder
LAGB-specific
Complications
Slippage/
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RYGB 456 8.1 0 1.3 3.3 0 0.2 0
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RYGB 103 14 0 11 11 2.9 1.0 0 1.0 1.9 0
Jan 2005 LAGB 154 1.9 0 20 0 0 1.9 0 16 0 6.5
RYGB 219 2.3 0.2 9.6 4.6 1.4 3.2 0
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RYGB 1 0 1.8 1.8 3.6 0.9 0
Parikh 2005 LAGB 197
RYGB 97
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Cottam 2006 LAGB 181 0 24 0 0 0 0 7.2 0 9.4
RYGB 181 0 19 1.7 0 0 0
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RYGB 849 7.7 0 0 1.4 1.4 0.2 0
Angrisani 2007 LAGB 27 0 15.2 0 0 0 0 7.6 0 0
RYGB 24 0 12.5 4.2 0 0 0
Jan 2007 LAGB 406 19 0.2 17 0.7 0 0.2 1.7 8.1 0.7 4.9
RYGB 492 23 0.6 17 1.6 2.4 2.2 2.0
LAGB laparoscopic adjustable gastric banding; RYGB Roux-en-Y gastric banding.
*Major complications in the first postoperative week rather than 30 days.
†Major complications for Roux-en-Y gastric bypass and complications that required surgical correction for the laparoscopic adjustable gastric banding group.
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893Tice et al LapBand Versus Gastric Bypass
    • "Das adaptierbare Magenband zeigt bei der initialen Anlage eine geringe perioperative Morbidität [25] . Im Langzeitverlauf treten jedoch erhöhte Komplikationsraten auf, wie die Magenperforation, die Magenbanddislokation, die Magenbandmigration , die gastroösophageale Refluxkrankheit oder die endoluminale Magenbanderosion [26][27][28]. "
    [Show abstract] [Hide abstract] ABSTRACT: Der Roux-en-Y-Magenbypass (RYGB) ist der Goldstandard zur chirurgischen Behandlung der morbiden Adipositas. Unter den Patienten, welche mittels Schlauchmagen oder Magenband behandelt werden, gibt es hingegen vermehrt Therapieversager. In diesen Fällen werden die Adipositas-assoziierten Morbiditäten und das Körpergewicht nicht ausreichend reduziert. Außerdem kann eine medikamentös-therapierefraktäre gastroösophageale Refluxkrankheit auftreten. Unter bestimmten Voraussetzungen kann daher ein Konversionseingriff mit der Anlage eines RYGB indiziert sein.
    Article · Aug 2016
    • "These options must be explained to the patients before or at their arrival, founded in a selective and meticulous analysis of the patient physical condition, kind of surgery, as well as of the surgical time.Obesity surgery has been modified in the past 5 years when placement of a gastric band was the most common procedure, and its results have favored the growth of procedures such as the gastric sleeve and gastroyeyunal bypass, both laparoscopic procedures [23,24]. In plastic surgery the most common procedures are liposuction with or without fat transfer of the sucked fat tissue, breast implants, facial rejuvenation surgery and body contour procedures for people who have lost weight242526. Ambulatory and short stay patients. These patients are usually ASA 1 or 2, with minimal invasive surgery, with short or medium time duration (1-4 hours). "
    Article · Dec 2015 · Der Chirurg
    • "These options must be explained to the patients before or at their arrival, founded in a selective and meticulous analysis of the patient physical condition, kind of surgery, as well as of the surgical time.Obesity surgery has been modified in the past 5 years when placement of a gastric band was the most common procedure, and its results have favored the growth of procedures such as the gastric sleeve and gastroyeyunal bypass, both laparoscopic procedures [23,24]. In plastic surgery the most common procedures are liposuction with or without fat transfer of the sucked fat tissue, breast implants, facial rejuvenation surgery and body contour procedures for people who have lost weight242526. Ambulatory and short stay patients. These patients are usually ASA 1 or 2, with minimal invasive surgery, with short or medium time duration (1-4 hours). "
    Full-text · Article · Dec 2015 · Der Chirurg
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