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Cost, need for reoperation raise questions about gastric band effectiveness
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The high cost and frequent need for reoperation after laparoscopic gastric band surgery raise concerns about the procedure’s safety and efficacy, according to findings published in JAMA Surgery.
“The laparoscopic gastric band was approved by the FDA in 2001 and widely adopted for the surgical treatment of morbid obesity,” Andrew M. Ibrahim, MD, MSc, Robert Wood Johnson Clinical Scholar, Institute for Healthcare Policy and Innovation at the University of Michigan in Ann Arbor, told Endocrine Today. “Reported rates of reoperation to revise or remove the device ranged from 4% to 60% in small scale studies, but no population estimates in the United States existed. In a review of Medicare Claims data between 2006 and 2013, we observed that reoperation was common with 18% of patients requiring at least one reoperation. Moreover, we found that, on average, patients who did need a reoperation underwent an average of 3.8 additional procedures. Taken together, nearly half (47%) of the $470 million paid by Medicare for device-related procedures was for reoperation.”
Ibrahim and colleagues evaluated data from 25,042 Medicare beneficiaries who underwent gastric band placement between 2006 and 2013 to determine the rate of device-related reoperations and associated payments.
Rates of hypertension (P < .001) and diabetes (P < .001) were lower among participants who underwent reoperation compared with those who did not. Participants who underwent reoperation were more likely to have had their index operation at a nonprofit center (68.6% vs. 56.7%; P < .01) or a teaching hospital (61.7% vs. 54.4%; P < .01) compared with participants who did not undergo reoperation.
During a mean 4.5-year follow-up, 18.5% of participants underwent 17,539 reoperations, for an average 3.8 procedures per patient; 19% of participants who underwent reoperation had a different subsequent bariatric procedure.
Medicare paid $470 million for laparoscopic gastric band-associated procedures; 47.6% of that total was for reoperations during the study period. Reoperations increased from 16.4% of total Medicare spending related to the gastric band device in 2006 to 77.3% in 2013. Reoperations were more expensive compared with the index operation for total amounts, index hospitalization, readmission, physician services and postdischarge ancillary care.
“Device-related reoperation after gastric band surgery is common and costly, which should be taken into account by patients, providers and payers when choosing an appropriate treatment for morbid obesity,” Ibrahim said. “As we now are rapidly adopting the sleeve gastrectomy for treatment of morbid obesity, we will need to follow its long-term outcomes (including reoperations) and expenditures at a population level.”
In an accompanying editorial, Jon C. Gould, MD, of the department of surgery at the Medical College of Wisconsin in Milwaukee, wrote that he disagrees with the findings, and that the device still has a role because many patients do well for a long period.
“A committed surgeon and program, and the ideal patients with a similar level of commitment, are needed to achieve these best outcomes,” Gould wrote. “Now that patients and surgeons are better informed of the drawbacks to the device, use has decreased without external regulations or policies to drive this change. No single bariatric procedure is appropriate for all patients. Patients need options, and we need better to help guide their decisions.” – by Amber Cox
Disclosure: Gould and Ibrahim report no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures.
Perspective
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The roughly 20% risk of reoperation over 5 years is not surprising, nor is the observation that reoperation was more likely in for-profit centers.
These data will be taken by many to mean that we should stop offering the gastric band to obese patients. However, in my view, the band still has a place because it is far safer than sleeve gastrectomy or gastric bypass and is reversible. Many patients value these attributes and derive satisfactory long-term weight loss of 15% to 20% over a decade or more.
This study also makes the important point that we need to start collating prospective cost data for all types of bariatric surgery. There was no attempt to compare the costs of gastric banding to those of other bariatric operations in this paper, which is a shame. Anastomotic leaks, particularly after sleeve gastrectomy, can lead to prolonged ICU stays. It would be interesting to know what the population cost of these other operations is in the United States.
A final comment concerns the health benefits of bariatric surgery. There are data from nonrandomized cohort studies to suggest substantial sustained weight loss slightly reduces the risk for vascular events and death. However, the major benefit of bariatric surgery is better quality of life and reduced medication burden. Similar benefits were achieved with intensive lifestyle intervention in the Look AHEAD study. Prospective trials that use economic measures for the primary outcome are needed to tell us how best to spend our money on an ever-growing number of obese patients.
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