Posters of Distinction (BOMSS 2012)

Posters of Distinction (BOMSS 2012)

Comparing Gastric Bypass to Adjustable Gastric Banding: A Systematic Review
Julien Al Shakarchi
Russells Hall Hospital, Dudley, UK

Although bariatric surgery has become widely popular, there is currently little strong evidence to support one bariatric procedure over another. The two more popular surgical procedures are gastric bypass and gastric banding. We aimed to evaluate which of those treatment is more efficient.

We searched the Cochrane Database of Systematic Reviews and Pubmed for meta-analyses comparing the gastric bypass and gastric banding in the treatment of obesity between 2000 and 2010. Strict inclusion criteria and thorough appraisal of the reviews was required to ensure comparability of the included papers.

Our dataset comprised of individual data on 6796 patients from 15 different studies that compared gastric bypass with adjustable gastric banding. The median difference in excess body weight loss across the thirteen studies which reported weight loss was a significant difference of 24.8% (range 16-24). However the mortality rate at 1 year favoured gastric banding (0.12% vs 0.34%) as well as short term complications.

From the data we have gathered it may be reasonable to conclude that gastric bypass is a more efficacious procedure than adjustable gastric banding in terms of excess body weight loss. However it is important to be aware that it does carry with it more significant short term morbidity and mortality.


A comparison of utilization of health services, by obese patients, before and after bariatric surgery
Muhammad Ali Karim, Jamil Ahmed, Clare Arneil, Haris Iqbal, Pamela Lindsey, Kevin McMahon, Abdulmajid Ali
Ayr University Hospital, Ayr, UK

Background:  Morbid obesity is a worldwide health problem and has tremendous implications on both, the individual health and the health economics. Bariatric surgery has become a recognized intervention to deal with this problem.  It is a cost effective method to improve metabolic disorders, long term weight loss and quality of life.
The aim of this study was to compare the utility of various health services, used by the morbidly obese patients, before and after bariatric surgery.

Methods:  A retrospective review of 73 consecutive patients, undergoing elective bariatric surgery, between May 2008 and December 2010 was performed. All patients had laparoscopic procedure. 58 patients were female whilst 15 were male. Median age was 45 (IQR 26-65) years. Data of utilization of various health services before and after surgical procedure was collected.   The preoperative period ranged from 42 to 72 months (mean=60months), while postoperative period ranged from 12 to 42 months (mean=24months).  Health services analyzed included; number of visits to accident and emergency and outpatient departments, admission to hospital, length of stay in hospital and change in regular medication before and after surgery.

Results: Outpatient clinic visits were reduced by 13.8% per year in post procedure period (P=0.04). Main reduction was noted in medicine and surgical clinics. However there was no change in use of accident and emergency services in both periods. Number of hospital admissions per year was decreased by 40.2 % (P=0.01) while total length of stay in hospital was reduced by 50.28 % per year (P=0.04) as compared to the pre operative period. The number of regular medications was reduced by 26% (P=0.003) in post operative period .This was mainly due to reduced analgesic requirement and better glycemic control

Conclusion: The utilization of various health services was decreased soon after bariatric surgery.  This was mainly due to reduction in body weight and improvement in the chronic metabolic disorders. This can further improve the efficiency of health care provision and will also translate into cost-effectiveness.


A survey of GP’s knowledge and attitudes towards bariatric surgery in Scotland
James Kynaston1, Andrew Mitchell1, Duff Bruce2
1Aberdeen Royal Infirmary, Aberdeen, UK, 2Aberdeen Surgical, Aberdeen, UK

Background:  25% of Scotland’s population are obese. The benefits of bariatric surgery are established however General Practitioners (GP’s) influence equality of access to this treatment. This study examines GP’s knowledge and attitudes to bariatric surgery in Scotland.

Method:  An electronic questionnaire-based study was emailed to all 902 GP’s within the NHS Highland, Grampian and Tayside health board regions in Scotland. The questionnaire was piloted with a convenience sample of GP’s. Respondents were asked their age, sex and eight questions examining their knowledge, experience and opinions regarding bariatric surgery.

Results:  230 GP’s completed the survey (25.4% response), a further 11 incomplete submissions were not analysed. 60%(n=139) of respondents were female. 93% of GPs acknowledge they often encounter weight management issues. 62%(n=142) of GPs acknowledge bariatric surgery has an important role in weight management and 69%(n=159) acknowledge it’s importance in the management of the obesity related co-morbidities. 30%(n=68) of GPs are not aware of NICE/SIGN guidelines and 57%(n = 132) are not aware of their local referral criteria. 40% (n=103) of GPs have never referred. Of those that have, 34%(n=43) of referrals were to the private sector. 76%(n=174) of GPs are not comfortable managing patients who have undergone bariatric surgery. 8%(n=17) of GPs believe the primary role of bariatric surgery is cosmetic. Of these, 47%(n=9) are aged 25-40 years.

Discussion:  Weight management issues are common in primary care and most GP’s support bariatric surgery. However a third of GP’s are unaware of national guidelines and half do not know how to refer to their local service in Northern Scotland. Most GP’s are not comfortable providing long-term care after bariatric surgery. These findings suggest GP’s require education and support to allow their patients access to bariatric surgery.


Weight loss following laparoscopic band replacement/repositioning for failed primary laparoscopic adjustable gastric band procedure
Somasekhara Menakuru, Javed Ahmed, Michael Larvin, Paul Leeder
Centre for Bariatric Surgery, Royal Derby Hospital, Derby, UK

Introduction: With the increasing popularity of laparoscopic adjustable gastric banding (LAGB), reoperations to treat non-port related band complications are now reported in 4.5% to 32% of patients.  A significant number of the reoperations are for symmetrical pouch dilatation or band slippage.  Laparoscopic band replacement/repositioning is one option to treat these patients.  Very few studies have documented the results of these revisional procedures and there are conflicting views as to their usefulness in achieving long term, sustained weight loss. 

Method: A review of the institution’s prospective bariatric database was performed.  All patients who underwent laparoscopic band replacement/ repositioning from 2005 to 2011 with a minimum follow up of six months were included.  Data on their initial body-mass index (BMI), and progress after primary surgery as well as after revision operation in terms of BMI and excess weight loss was retrieved and analysed. 

Results: Out of a total of 860 patients on the database who had primary LAGB during the study period, 38 patients (4.4%) underwent revision.  21 patients had band replacement and 17 underwent repositioning for band slippage.  The commonest presenting symptom which led to discovery of the complication was reflux (40%) followed by vomiting (22%).  The mean interval between the initial operation and reoperation was 31.97 months (+/- 13.1m).  The operative mortality rate for revision surgery was nil.  The mean initial BMI was 46.26 (+/- 6.2) and the BMI at revision was 38.7(+/-6.89).  Mean excess weight loss (EWL) following initial surgery was 21.5% (+/-11.64%) at 6 months and 35.62% (+/-14.68%) at one-year.  Prior to revisional surgery, mean EWL was 36.34 %(+/- 24.53%).  EWL fell to 25.79% (+/-22.02%) at 6 months and 23.13% (+/-20.43%) at one-year after revisional surgery, representing a mean weight regain at 6 months of 6.4kg (+/-9.2kg) and 10.9kg (+/-10.3kg) at one-year. 

Conclusion:  Although limited by the duration of follow up, the current study has identified that although revisional gastric band surgery by replacement or reposition was safe, weight loss outcomes were poor.  If further follow up and more studies confirm these findings, these patients may be better served by alternative revisional procedures to achieve their weight loss goals.


Band slippage and erosion after laparoscopic gastric banding: a meta-analysis
Rishi Singhal1, Catherine Bryant1, Mark Kitchen1, Khalid Khan2, Jon Deeks2, Boliang Guo2, Paul Super1
1Heart of England NHS Foundation Trust, Birmingham, UK, 2University of Birmingham, Birmingham, UK

Background: Laparoscopic adjustable gastric banding has the lowest morbidity and mortality amongst the common bariatric procedures. Troublesome complications associated with this procedure include band slippage and erosion often requiring revisionary surgery. In our experience, units with a low slippage rate also have low erosion rates and vice versa. Thus a systematic review was undertaken to investigate this relationship.

Methods: Electronic databases were searched up to 31st Dec 2008. Publications focusing solely on LAGB with at least 500 patients and a minimum of two year follow up were included. Publications in languages other than English, and those that failed to mention erosion and slippage rates were excluded. Multivariate meta analyses were conducted separately for pars flaccida group, perigastric group and the combined overall group to pool the average rates of both erosion and slippage for each paper included. The correlation between occurrence rates of both erosion and slippage was then examined.

Results: 19 studies satisfied the inclusion criteria. The mean rates of erosion and slippage were 1.03 and 4.93 respectively. Results demonstrated a statistically significant overall correlation between erosion and slippage rates (r=0.48; p=0.032). There was a very strong correlation between erosion and slippage if the perigastric technique of insertion was used (r=0.99; p<0.001). However this correlation was not statistically significant where the pars flaccida technique of insertion was utilised (r=0.34; p=0.38).

Conclusions: The high correlation rate between erosion and slippage for the perigastric group strongly suggests that these complications share a common pathophysiology. This correlation is reduced with the pars flaccida technique suggesting that perhaps a different aetiology is associated with erosion in these studies. Surgical techniques which help eliminate lap band slippage should also reduce rates of erosion.


STOP-BANG Questionnaire as a Screening Tool for Obstructive Sleep Apnoea in Bariatric Surgery
Pratik Sufi, Howard Branley, Louise Restrick, Sara Lock, Dugal Heath, Rizwan Kaiser
NLOSS, Whittington Health, London, UK

Background:  Epworth Sleepiness Score (ESS) is unreliable in predicting the risk of Obstructive Sleep Apnoea (OSA) in bariatric surgery patients – hence, they often undergo Polysomnography (PSG). A STOP-BANG score of ≥3 is generally regarded to indicate need for PSG in these patients. We aimed to define the prevalence of OSA and validate the STOP-BANG questionnaire as a screening tool in our patients.

Methods:  We prospectively collected clinical data and sleep study results from 61 bariatric patients who underwent sleep studies between January and March 2011 at NLOSS. STOP-BANG scores were retrospectively calculated and correlated with PSG results. Apnoea-Hypopnea Index (AHI) of >15 was defined as significant OSA which may require treatment with preoperative Continuous Positive Airway Pressure (CPAP).

Results:  There were 61 patients (87.3% female) with a mean age of 45 years – the mean BMI was 46.2 kg/m2. The mean ESS was 6.5 (0-20) – 55.7% had STOP-BANG score of ≥ 4, 44.3% had score of ≤ 3. On PSG, 68.9% had AHI < 15, 18% had AHI 15-30 and 13.1% had AHI >30. Patients with AHI>15  had mean BMI 47.2 kg/m2, mean neck circumference 41.4cm and mean ESS 8.5 – 66.6% had ESS <11 and 89.4% were loud snorers. A STOP-BANG score of ≥ 4 had 94.7% sensitivity, 61% specificity, 52.9% positive predictive value (PPV) and 96.2% negative predictive value (NPV) to screen for OSA with AHI >15.

Conclusions:  Only 31% of our patients had significant OSA and ESS was poorly predictive of risk. STOP-BANG score of < 4 had a high NPV of 96.2% for AHI >15 – a score of ≥4 had a high sensitivity but poor specificity. Therefore STOP-BANG questionnaire using a cut-off risk score of 4 may be used as a screening tool to rule out significant OSA and avoid PSG in a significant proportion of bariatric surgery patients.


Should age > 60 years be considered a contraindication to bariatric surgery?
Salim Tayeh, Samuel Adegbola, Sanjay Agrawal
Homerton University Hospital, London, UK

Background:  The prevalence of obesity is increasing and so is its incidence in the elderly. There have been a few reports on the safety and effectiveness of bariatric surgery in the elderly. The aim of this study was to review the published literature on bariatric surgery in patients over the age of 60 years with the mortality rate being the primary outcome.

Method:  Systematic search in Medline and Embase using the medical subject headings terms “bariatric surgery” and “elderly” was done on 31st July, 2011 with further free text search and cross references. Studies which reported the results for laparoscopic or open Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB) in patients over the age of 60 years were included in this review.

Results:  10 studies evaluated 657 patients who had RYGB. Patients’ age ranged from 60-77 years with the majority being females. The mean pre-operative body mass index (BMI) ranged from 33 to 78.3kg/m2. 7 studies reported mean percentage of excess weight loss (%EWL) of 51 – 74.8%. 30-day mortality rate was 0.30%.
7 studies evaluated 462 patients who had LAGB. Patients’ age ranged from 60-83 years with the majority being females. The average BMI was 44.6kg/m2. 5 studies reported %EWL of 32-54%. 30-day mortality rate was 0.22%.
5 studies compared the outcome of patients >60 years (n=250) with those of <60 years (n=3799) following RYGB surgery. There was no significant difference (p=0.3, fisher exact test) in the 30-day mortality in patients >60 years (0.8%) as compared to <60 years old (0.24%).

Conclusion:  Our review showed that elderly patients can safely undergo RYGB or LAGB without a significantly higher mortality. Age as a single factor should not be considered a contraindication to bariatric surgery.


Goldie-Khera-ASiTCouncil Prize Winner:
Does social deprivation impact on access to a NHS Bariatric Service?
Goldie Khera, James Brown, Kunjan Patel, Stephen Attwood, Sean Woodcock, Keith Seymour
Northumbria Healthcare NHS Foundation Trust, Tyne and Wear, UK

Introduction:  Our Bariatric Service has been established for five years. Local audit data indicates that a minority of patients referred for bariatric services end up having surgery. The importance of socioeconomic position (SEP) in bariatric care is unknown. We wished to be sure that the selection criteria we used for surgery allowed all groups the equitable opportunity to progress. This study examined patient progress along our Bariatric pathway according to SEP.

Methods:  Patients invited to attend bariatric seminars between 01/09/2008 and 31/07/2009 were included in the study. The Index of Multiple Deprivation score 2004 (IMD) was used to calculate SEP. The score was collapsed into thirds representing a graduated deprivation profile from IMD1 (most deprived) to IMD3 (least deprived).

Results:  353 patients met the inclusion criteria. Most patients were female M=77 (21.8%) F=276 (78.2%) and under the age of 60yrs (89.2%). Almost 50% of patients were in IMD1. Neither age (p=0.4) nor gender (p=0.31) mix varied by IMD group. Non attendance at the seminar did not vary by IMD. A trend towards completion of the weight management programme and SEP was seen; IMD1 (49.7%) IMD2 (51.3%) IMD3 (61.9%) but was not significant (p=0.24).  Assessment by the bariatric nurse specialist, discussion at the MDT and consultation with the surgeon did not vary by IMD. Overall 103 patients underwent a bariatric procedure and the trend across all three pooled IMD groups on a regression analysis was significant (p=0.04). The more socially deprived were less likely to have an intervention. Comparing categorical IMD groups to each other revealed no significant differences.

Conclusion:  As with other health care related outcomes deprivation is a barrier to bariatric surgical care. Some evidence of variation by SEP exists and further work to understand these differences are needed.