Results | Quality of Life Laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding: patient choice and early quality of life Maj Joshua B. Alley, MD, FACS; Maj Stephen J. Fenton, MD; Michael Angeletti, MS; LTC Michael C. Harnisch, MD; Maj Richard M. Peterson, MD, MPH, FACS Wilford Hall USAF Medical Center and Brooke Army Medical Center, San Antonio, Texas Background Results, cont. Results | Weight Loss Conclusion Laparoscopic vertical sleeve gastrectomy has gained popularity in recent years as a restrictive weight loss operation, although widespread adoption in the United States has been slow due to the reluctance of many insurance companies to offer coverage for the procedure. In our Department of Defense bariatric surgical practice, retirees, spouses, and dependents of active duty members are eligible for bariatric surgery, following the NIH 1991 consensus guidelines for operative candidacy. In this system, neither the patient nor the surgeon is influenced by cost or reimbursement. Care in the military healthcare system is not subject to insurance constraints, and the providers are salaried, active-duty military surgeons. This at least approaches a pure evidence-based practice, where patients are presented surgical options and, with the guidance of the surgeon, allowed to choose their operation. In this program, laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic adjustable gastric banding (LAGB) were the only options offered until October 2008, when laparoscopic vertical sleeve gastrectomy (LVSG) was introduced. Patient demand for LVSG soon outstripped that for LAGB; numbers of LRYGB remained steady. Our hypothesis is that, in the absence of cost or reimbursement constraints, a patient tends to choose his or her bariatric procedure based on real or perceived weight loss and quality of life outcome. The expected outcome may be communicated by other patients within the same program or other programs. Both LAGB and LVSG patients experienced significant excess weight loss and excess BMI loss when compared with baseline (p<0.0001 at 1, 3, 6, and 12 months). At 1, 3, 6, and 12 months of followup, the LVSG group demonstrated significantly more %EWL and %EBL than the LAGB group (Figure 2). An examination of the markedly different outcomes between LAGB and LVSG groups offers hints of why our patients have migrated toward LVSG in their choice of procedure. Both in weight loss and in early postoperative quality of life, the sleeve gastrectomy easily outperformed the adjustable gastric band in these core measures of well-being. An association between more weight loss and better quality of life has been noted before, and this may partly explain why the sleeve gastrectomy group showed better quality of life results. However, the trend towards more vomiting, heartburn, and nausea in the LAGB group was a surprise, since it has been suggested that one serious drawback of LVSG is a significant rate of postoperative reflux and regurgitation. Both laparoscopic vertical sleeve gastrectomy and adjustable gastric banding yield significant excess weight loss and excess BMI loss. Laparoscopic sleeve gastrectomy offers better early postoperative weight loss and quality of life when compared with laparoscopic adjustable gastric banding. The difference in excess weight loss and the more intangible quality of life benefits could explain the shift in patient preference for the sleeve gastrectomy in our practice. As more insurers offer coverage for LVSG, bariatric surgeons could see a significant shift in patients desiring this as their restrictive bariatric operation of choice. * * * Table 1. Baseline cohort comparison * Over time, the trend in procedure popularity is clearly evident in Figure 1, with LVSG rapidly assuming dominance over LAGB as the restrictive procedure of choice. Figure 2. Percent excess BMI loss (%EBL), band vs. sleeve; *p<0.0009 at all data points Results | Quality of Life Bariatric Quality of Life (BQL) composite scores and significant symptom subsets are shown in Figure 3 and Table 3. References 1. Weiner S, Sauerland S, Fein M, et al. The bariatric quality of life (BQL) index: a measure of well-being in obesity surgery patients. Obes Surg 2005;15: 538-545. 2. Lee CM, Cirangle PT, Jossart GH. Vertical gastrectomy for morbid obesity in 216 patients: report of two-year results. Surg Endosc 2007;21: 1810-1816. 3. Regan JP, Inabnet WB, Gagner M, et al. Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient. Obes Surg. 2003;13:861–4. 4. Almogy G, Crookes PF, Anthone GJ. Longitudinal gastrectomy as a treatment for the high-risk super-obese patient. Obes Surg 2004;14:492-497. 5. Han SM, Kim WW, Oh JH. Results of laparoscopic sleeve gastrectomy at 1 year in morbidly obese Korean patients. Obes Surg. 2005;15:1469–75. Materials and Methods Figure 1. Procedure choice by quarter, band vs. sleeve The study design is a retrospective cohort analysis. Institutional Review Board (IRB) approval was sought and granted. Patients in our bariatric program choose their procedure (LRYGB, LAGB, or LVSG) based on their preference and surgeon guidance. This study was designed to focus on restrictive procedures, since numbers of LRYGB remained stable throughout the study period. Early postoperative outcomes, including weight loss, lab values, and complications were recorded at baseline and at 1, 3, 6, and 12 months postoperatively. Additionally, the Bariatric Quality of Life (BQL) survey designed and reported by Weiner et al was administered to patients in a telephone survey at least 5 months postoperatively. Morbidity rates were equivalent between the two groups (Table 2). No mortalities, clinically apparent DVT/PE, or leaks were observed in either group. Figure 3. Bariatric Quality of Life (BQL) scores; *p=0.0002 In examination of the symptom subsets of the BQL survey, LAGB patients experienced significantly more vomiting and asthma symptoms, and a strong trend was seen toward more heartburn and nausea symptoms in the this group. All other symptom subsets did not approach statistical significance. Disclosures The authors have no disclosures to make. The opinions expressed in this presentation are solely those of the authors and do not represent and endorsement by or the views of the United States Air Force, the Department of Defense, or the United States Government. Results Between July 2008 and September 2009, 108 patients underwent restrictive procedures. LAGB comprised 39 patients (36.4%), and LVSG comprised 69 patients (63.6%). Baseline demographics and lab values are shown in Table 1. Only preoperative total cholesterol levels differed significantly between the two groups. Table 2. Postoperative morbidity, band vs. sleeve cohort Table 3. Bariatric Quality of Life (BQL) score subsets