Effectiveness of Gastric Banding vs Bypass
Northwest (KPNW), Kaiser Permanente Colorado (KPCO), and Kaiser Permanente Georgia (KPGA). We are indebted to the following SPAN investigators for the collaborations that made this study possible: KPCO (Matthew F. Daley, MD; Ella Lyons, MS; Marsha A. Raebel, PharmD; Lisa Pieper, MSHA, MBA), KPNC (Ameena T. Ahmed, MD, MPH), EIRH (Thomas E. Elliott, MD); GHS (Jove Graham, PhD; Christopher Still, DO; Craig Wood, MS), GHRI (Denise Boudreau, PhD, RPh); HPIER (Pamela Pawloski, PharmD); KPHI (Cynthia Nakasato, MD), DHHA (Art Davidson, MD); and KPNW (Lynn DeBar, PhD, MPH; Kristine Funk, MS, RD). All individuals listed received support from grant 1R01HS019912 from the Agency for Healthcare Research and Quality for this project. Michael Shainline, MS, provided technical and administrative assistance.
Original Investigation Research
14. Flum DR, Belle SH, King WC, et al; Longitudinal Assessment of Bariatric Surgery (LABS) Consortium. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med. 2009;361(5):445-454.
overweight and obesity in adults: the evidence report. Obes Res. 1998;6(suppl 2):51S-209S. 6. Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg. 2013;23(4): 427-436. 7. Tice JA, Karliner L, Walsh J, Petersen AJ, Feldman MD. Gastric banding or bypass? a systematic review comparing the two most popular bariatric procedures. Am J Med. 2008;121 (10):885-893. 8. O’Brien PE, MacDonald L, Anderson M, Brennan L, Brown WA. Long-term outcomes after bariatric surgery: fifteen-year follow-up of adjustable gastric banding and a systematic review of the bariatric surgical literature. Ann Surg. 2013;257(1):87-94.
REFERENCES
9. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292(14):1724-1737.
1. Sturm R. Increases in clinically severe obesity in the United States, 1986-2000. Arch Intern Med. 2003;163(18):2146-2148.
10. Maggard MA, Shugarman LR, Suttorp M, et al. Meta-analysis: surgical treatment of obesity. Ann Intern Med. 2005;142(7):547-559.
2. Sturm R. Increases in morbid obesity in the USA: 2000-2005. Public Health. 2007;121(7):492-496.
11. Cummings DE. Endocrine mechanisms mediating remission of diabetes after gastric bypass surgery. Int J Obes (Lond). 2009;33(suppl 1):S33-S40.
3. Finkelstein EA, Khavjou OA, Thompson H, et al. Obesity and severe obesity forecasts through 2030. Am J Prev Med. 2012;42(6):563-570. 4. Picot J, Jones J, Colquitt JL, et al. The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation. Health Technol Assess. 2009;13(41):1-190, 215-357, iii-iv. 5. National Institutes of Health. Clinical guidelines on the identification, evaluation, and treatment of
12. Chakravarty PD, McLaughlin E, Whittaker D, et al. Comparison of laparoscopic adjustable gastric banding (LAGB) with other bariatric procedures; a systematic review of the randomised controlled trials. Surgeon. 2012;10(3):172-182.
15. D’Agostino RB Jr. Propensity score methods for bias reduction in the comparison of a treatment to a non-randomized control group. Stat Med. 1998;17 (19):2265-2281. 16. Lin DY, Wei LJ, Ying Z. Checking the Cox model with cumulative sums of Martingale-based residuals. Biometrika. 1993;80(3):557-572. 17. Lin H, Scharfstein DO, Rosenheck RA. Analysis of longitudinal data with irregular, outcome-dependent follow-up. J R Stat Soc B. 2004;66:791-813. 18. Angrisani L, Lorenzo M, Borrelli V. Laparoscopic adjustable gastric banding versus Roux-en-Y gastric bypass: 5-year results of a prospective randomized trial. Surg Obes Relat Dis. 2007;3(2):127-132, discussion 132-133. 19. Nguyen NT, Slone JA, Nguyen XM, Hartman JS, Hoyt DB. A prospective randomized trial of laparoscopic gastric bypass versus laparoscopic adjustable gastric banding for the treatment of morbid obesity: outcomes, quality of life, and costs. Ann Surg. 2009;250(4):631-641.
13. Toh S, Platt R, Steiner JF, Brown JS. Comparative-effectiveness research in distributed health data networks. Clin Pharmacol Ther. 2011;90 (6):883-887.
Invited Commentary
The Beginning of the End for Laparoscopic Banding Justin B. Dimick, MD, MPH; Jonathan F. Finks, MD
For many years, laparoscopic gastric bypass and adjustable gastric banding were the only 2 bariatric procedures performed by most bariatric surgeons. The trade-offs for the 2 procedures were seemingly straightforward: gastric bypass had higher risks but more weight loss; the laparoscopic band was safer but had lower Related article page 1279 weight loss. However, emerging evidence from single-center studies challenge this understanding, suggesting that adjustable gastric banding may not be as safe as we thought, especially when considering longterm outcomes. Many centers report that adjustable gastric banding is associated with high subsequent operation rates, and even laparoscopic band removal, for weight loss failure, slippage, erosion, and obstructive symptoms.1 This concerning trend in long-term safety and effectiveness, coupled with the emergence of sleeve gastrectomy, may be the beginning of the end of adjustable gastric banding. The study by Arterburn et al2 in this issue of JAMA Surgery adds another important perspective to our understanding of the outcomes of bariatric surgery procedures. This study confirms what we know about the perioperative safety: that
bypass is higher risk than laparoscopic band placement. However, both procedures have extraordinarily low perioperative event rates (3.0% for bypass and 1.3% for adjustable gastric banding), especially when compared with other abdominal operations of similar complexity. The results of this study also confirm what we know about weight loss, namely, that gastric bypass is about twice as effective in the intermediate term (2-4 years) as the adjustable gastric band. Most important, despite having a median follow-up of only 1.5 years, this study also confirms the trend of high long-term complications of adjustable gastric banding seen in singlecenter studies. Even at 1.5 years, the subsequent intervention rate was 5.3% for the laparoscopic band patients, although the rate of laparoscopic band removal was only 1.7%. It will be important to reexamine these data when longer-term follow-up is available (eg, 5 and 10 years). Perhaps the most important contribution of this study lies in the methods and data sources for 2 important reasons. First, the data used in this study give us a picture of what is happening in the real world—a range of hospitals and practice settings—by linking hospital-billing data to electronic health care records. This perspective is an impor-
jamasurgery.com
JAMA Surgery December 2014 Volume 149, Number 12
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Purdue University User on 05/21/2015
1287
Research Original Investigation
Effectiveness of Gastric Banding vs Bypass
tant complement to the data from highly contrived randomized clinical trials and prospective cohort studies. The latter often overestimate the benefits and underestimate the risks of interventions when applied more broadly. Second, this study demonstrates the feasibility of using these large, readily available data sets for meaningful comparative ARTICLE INFORMATION Author Affiliations: Department of Surgery, University of Michigan, Ann Arbor. Corresponding Author: Justin B. Dimick, MD, MPH, Department of Surgery, University of Michigan, 2800 Plymouth Rd, Bldg 16, Office 137E, Ann Arbor, MI 48109 ([email protected]). Published Online: October 29, 2014. doi:10.1001/jamasurg.2014.1717.
1288
effectiveness research. These methods will no doubt be important for the ongoing assessment of these emerging long-term safety concerns with laparoscopic adjustable gastric banding but will also be essential for assessing the comparative effectiveness of numerous other surgical interventions.
Conflict of Interest Disclosures: Dr Dimick reported having received grants from the National Institutes of Health, the Agency for Healthcare Research and Quality (AHRQ), and Blue Cross Blue Shield of Michigan Foundation, and having cofounded ArborMetrix. REFERENCES
laparoscopic adjustable gastric banding. Arch Surg. 2011;146(7):802-807. 2. Arterburn D, Powers JD, Toh S, et al. Comparative effectiveness of laparoscopic adjustable gastric banding vs laparoscopic gastric bypass [published online October 29, 2014]. JAMA Surg. doi:10.1001/jamasurg.2014.1674.
1. Himpens J, Cadière GB, Bazi M, Vouche M, Cadière B, Dapri G. Long-term outcomes of
JAMA Surgery December 2014 Volume 149, Number 12
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Purdue University User on 05/21/2015
jamasurgery.com
Northwest (KPNW), Kaiser Permanente Colorado (KPCO), and Kaiser Permanente Georgia (KPGA). We are indebted to the following SPAN investigators for the collaborations that made this study possible: KPCO (Matthew F. Daley, MD; Ella Lyons, MS; Marsha A. Raebel, PharmD; Lisa Pieper, MSHA, MBA), KPNC (Ameena T. Ahmed, MD, MPH), EIRH (Thomas E. Elliott, MD); GHS (Jove Graham, PhD; Christopher Still, DO; Craig Wood, MS), GHRI (Denise Boudreau, PhD, RPh); HPIER (Pamela Pawloski, PharmD); KPHI (Cynthia Nakasato, MD), DHHA (Art Davidson, MD); and KPNW (Lynn DeBar, PhD, MPH; Kristine Funk, MS, RD). All individuals listed received support from grant 1R01HS019912 from the Agency for Healthcare Research and Quality for this project. Michael Shainline, MS, provided technical and administrative assistance.
Original Investigation Research
14. Flum DR, Belle SH, King WC, et al; Longitudinal Assessment of Bariatric Surgery (LABS) Consortium. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med. 2009;361(5):445-454.
overweight and obesity in adults: the evidence report. Obes Res. 1998;6(suppl 2):51S-209S. 6. Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg. 2013;23(4): 427-436. 7. Tice JA, Karliner L, Walsh J, Petersen AJ, Feldman MD. Gastric banding or bypass? a systematic review comparing the two most popular bariatric procedures. Am J Med. 2008;121 (10):885-893. 8. O’Brien PE, MacDonald L, Anderson M, Brennan L, Brown WA. Long-term outcomes after bariatric surgery: fifteen-year follow-up of adjustable gastric banding and a systematic review of the bariatric surgical literature. Ann Surg. 2013;257(1):87-94.
REFERENCES
9. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292(14):1724-1737.
1. Sturm R. Increases in clinically severe obesity in the United States, 1986-2000. Arch Intern Med. 2003;163(18):2146-2148.
10. Maggard MA, Shugarman LR, Suttorp M, et al. Meta-analysis: surgical treatment of obesity. Ann Intern Med. 2005;142(7):547-559.
2. Sturm R. Increases in morbid obesity in the USA: 2000-2005. Public Health. 2007;121(7):492-496.
11. Cummings DE. Endocrine mechanisms mediating remission of diabetes after gastric bypass surgery. Int J Obes (Lond). 2009;33(suppl 1):S33-S40.
3. Finkelstein EA, Khavjou OA, Thompson H, et al. Obesity and severe obesity forecasts through 2030. Am J Prev Med. 2012;42(6):563-570. 4. Picot J, Jones J, Colquitt JL, et al. The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation. Health Technol Assess. 2009;13(41):1-190, 215-357, iii-iv. 5. National Institutes of Health. Clinical guidelines on the identification, evaluation, and treatment of
12. Chakravarty PD, McLaughlin E, Whittaker D, et al. Comparison of laparoscopic adjustable gastric banding (LAGB) with other bariatric procedures; a systematic review of the randomised controlled trials. Surgeon. 2012;10(3):172-182.
15. D’Agostino RB Jr. Propensity score methods for bias reduction in the comparison of a treatment to a non-randomized control group. Stat Med. 1998;17 (19):2265-2281. 16. Lin DY, Wei LJ, Ying Z. Checking the Cox model with cumulative sums of Martingale-based residuals. Biometrika. 1993;80(3):557-572. 17. Lin H, Scharfstein DO, Rosenheck RA. Analysis of longitudinal data with irregular, outcome-dependent follow-up. J R Stat Soc B. 2004;66:791-813. 18. Angrisani L, Lorenzo M, Borrelli V. Laparoscopic adjustable gastric banding versus Roux-en-Y gastric bypass: 5-year results of a prospective randomized trial. Surg Obes Relat Dis. 2007;3(2):127-132, discussion 132-133. 19. Nguyen NT, Slone JA, Nguyen XM, Hartman JS, Hoyt DB. A prospective randomized trial of laparoscopic gastric bypass versus laparoscopic adjustable gastric banding for the treatment of morbid obesity: outcomes, quality of life, and costs. Ann Surg. 2009;250(4):631-641.
13. Toh S, Platt R, Steiner JF, Brown JS. Comparative-effectiveness research in distributed health data networks. Clin Pharmacol Ther. 2011;90 (6):883-887.
Invited Commentary
The Beginning of the End for Laparoscopic Banding Justin B. Dimick, MD, MPH; Jonathan F. Finks, MD
For many years, laparoscopic gastric bypass and adjustable gastric banding were the only 2 bariatric procedures performed by most bariatric surgeons. The trade-offs for the 2 procedures were seemingly straightforward: gastric bypass had higher risks but more weight loss; the laparoscopic band was safer but had lower Related article page 1279 weight loss. However, emerging evidence from single-center studies challenge this understanding, suggesting that adjustable gastric banding may not be as safe as we thought, especially when considering longterm outcomes. Many centers report that adjustable gastric banding is associated with high subsequent operation rates, and even laparoscopic band removal, for weight loss failure, slippage, erosion, and obstructive symptoms.1 This concerning trend in long-term safety and effectiveness, coupled with the emergence of sleeve gastrectomy, may be the beginning of the end of adjustable gastric banding. The study by Arterburn et al2 in this issue of JAMA Surgery adds another important perspective to our understanding of the outcomes of bariatric surgery procedures. This study confirms what we know about the perioperative safety: that
bypass is higher risk than laparoscopic band placement. However, both procedures have extraordinarily low perioperative event rates (3.0% for bypass and 1.3% for adjustable gastric banding), especially when compared with other abdominal operations of similar complexity. The results of this study also confirm what we know about weight loss, namely, that gastric bypass is about twice as effective in the intermediate term (2-4 years) as the adjustable gastric band. Most important, despite having a median follow-up of only 1.5 years, this study also confirms the trend of high long-term complications of adjustable gastric banding seen in singlecenter studies. Even at 1.5 years, the subsequent intervention rate was 5.3% for the laparoscopic band patients, although the rate of laparoscopic band removal was only 1.7%. It will be important to reexamine these data when longer-term follow-up is available (eg, 5 and 10 years). Perhaps the most important contribution of this study lies in the methods and data sources for 2 important reasons. First, the data used in this study give us a picture of what is happening in the real world—a range of hospitals and practice settings—by linking hospital-billing data to electronic health care records. This perspective is an impor-
jamasurgery.com
JAMA Surgery December 2014 Volume 149, Number 12
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Purdue University User on 05/21/2015
1287
Research Original Investigation
Effectiveness of Gastric Banding vs Bypass
tant complement to the data from highly contrived randomized clinical trials and prospective cohort studies. The latter often overestimate the benefits and underestimate the risks of interventions when applied more broadly. Second, this study demonstrates the feasibility of using these large, readily available data sets for meaningful comparative ARTICLE INFORMATION Author Affiliations: Department of Surgery, University of Michigan, Ann Arbor. Corresponding Author: Justin B. Dimick, MD, MPH, Department of Surgery, University of Michigan, 2800 Plymouth Rd, Bldg 16, Office 137E, Ann Arbor, MI 48109 ([email protected]). Published Online: October 29, 2014. doi:10.1001/jamasurg.2014.1717.
1288
effectiveness research. These methods will no doubt be important for the ongoing assessment of these emerging long-term safety concerns with laparoscopic adjustable gastric banding but will also be essential for assessing the comparative effectiveness of numerous other surgical interventions.
Conflict of Interest Disclosures: Dr Dimick reported having received grants from the National Institutes of Health, the Agency for Healthcare Research and Quality (AHRQ), and Blue Cross Blue Shield of Michigan Foundation, and having cofounded ArborMetrix. REFERENCES
laparoscopic adjustable gastric banding. Arch Surg. 2011;146(7):802-807. 2. Arterburn D, Powers JD, Toh S, et al. Comparative effectiveness of laparoscopic adjustable gastric banding vs laparoscopic gastric bypass [published online October 29, 2014]. JAMA Surg. doi:10.1001/jamasurg.2014.1674.
1. Himpens J, Cadière GB, Bazi M, Vouche M, Cadière B, Dapri G. Long-term outcomes of
JAMA Surgery December 2014 Volume 149, Number 12
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Purdue University User on 05/21/2015
jamasurgery.com
