Context and Policy Issues
Laparoscopic adjustable gastric banding (LAGB) is a surgical option for obese patients. Other surgery options include the Roux-en-Y gastric bypass (RYGB) and vertical banded gastroplasty (VBG). Both these options can be performed laparoscopically or as open surgery.
Bariatric surgery is typically recommended for obese adults with a body mass index (BMI) of ≥35 kg/m2 and risk factors, or a BMI ≥40 kg/m2. Bariatric surgery induces weight loss. All bariatric surgery candidates have failed to achieve significant and sustainable weight loss through lifestyle modification.
Weight loss in obese patients can reduce obesity-related comorbidities such as hypertension, type 2 diabetes, and heart disease, and produce improvements in quality of life outcomes such as self-reported depression symptoms.
LAGB is becoming more common, especially in parts of Europe and Australia, where it is a publicly funded medical service. This procedure is being considered as an option in Canada. As a result, the question whether it should be publicly funded is arising. To help answer this question, recent published clinical and cost information must be synthesized.
This report investigates evidence on the clinical effectiveness and cost-effectiveness of LAGB as compared to RYGB (open and laparoscopic), VBG (open and laparoscopic), lifestyle modification, or control groups.
What is the evidence for the clinical effectiveness and cost-effectiveness of LAGB in obese patients when it is compared to VBG or RYGB?
Published literature was obtained by cross-searching PubMed, BIOSIS Previews, EMBASE, MEDLINE, and PreMEDLINE. Regular alerts were established on PubMed, BIOSIS Previews, EMBASE, MEDLINE, and PreMEDLINE. The information retrieved via alerts is current to April 9, 2007. A parallel search was performed on the Cochrane Library (Issue 1, 2007) database. Publication language limits were not applied. Filters were applied to limit the retrieval to systematic reviews, health technology assessments, trials (including primary research), and economic studies. Retrieval was limited from 2004 to 2007 for the primary clinical and economic studies, and from 2005 to 2007 for the systematic reviews and health technology assessments.
The web sites of regulatory agencies, and health technology assessment and related agencies, were searched, as were specialized databases, such as those of the University of York Centre for Reviews and Dissemination. The Google™ search engine was used to search for information on the Internet. Efforts were made to find international funding information on the LAGB procedure. These searches were supplemented by hand searches of the bibliographies of selected papers.
Two external reviewers provided comments on this report.
Clinical Effectiveness of LAGB
Patients who undergo LAGB lose a lot of excess weight. This is generally not as much weight as is lost by patients who undergo RYGB (open or laparoscopic) or VBG (open or laparoscopic) procedures. The excess weight that is lost in all surgical groups is enough to reduce obesity-related comorbidities. In general, very low mortality rates are associated with all bariatric surgeries. LAGB consistently produced fewer short-term complications than RYGB or VBG. Re-operation or conversion to a different bariatric technique may be needed to correct lap band issues (e.g., band erosion).
Limitations of the evidence on LAGB include the lack of long-term studies, the lack of randomized controlled trials, and the poor or not reported follow-up participation rates.
Cost-effectiveness of LAGB
The economic research, while limited, suggests that investment in LAGB may lower total future health care costs by lowering the severity and incidence of obesity-related comorbidities and the associated costs. The initial set-up costs, long-term costs, and costs of surgeons’ learning curves must be considered in these calculations.
LAGB has been shown to produce a significant loss of excess weight while maintaining low rates of short-term complications and reducing obesity-related comorbidities. LAGB may not result in the most weight loss but it may be an option for bariatric patients who prefer or who are better suited to undergo less invasive and reversible surgery with lower perioperative complication rates.
One caution with LAGB is the uncertainty about whether the low complication rate extends past three years, given a possibility of increased band-related complications (e.g., erosion, slippage) requiring re-operation.