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Figure.
Age and Sex Distribution of the Annual Cohort of Patients Receiving Gastric Banding in 2005-2006 (N = 6037)
Age and Sex Distribution of the Annual Cohort of Patients Receiving Gastric Banding in 2005-2006 (N = 6037)

The source for the data is Medicare Australia. Identification was based on utilization of Medicare Benefits Schedule item 30511 (gastric reduction or gastroplasty for morbid obesity, by any method), which is primarily used for laparoscopic adjustable gastric banding in Australia.3

Table.  
Data on Revisional Procedures
Data on Revisional Procedures
1.
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.
PubMedArticle
2.
Courcoulas  AP, Christian  NJ, Belle  SH,  et al; Longitudinal Assessment of Bariatric Surgery (LABS) Consortium.  Weight change and health outcomes at 3 years after bariatric surgery among individuals with severe obesity. JAMA. 2013;310(22):2416-2425.
PubMed
3.
Australian Government Department of Health and Ageing. Draft report for reviewing existing MBS items. Review name: items for the surgical treatment of obesity. http://www.health.gov.au/internet/main/publishing.nsf/Content/A878E2C4992E9AE8CA257BF0001F3E82/$File/DRAFT%20obesity%20report.pdf. Published May 24, 2011. Accessed November 19, 2013.
4.
Australian Government Department of Health. Medicare Benefits Schedule (MBS) Online. http://www.mbsonline.gov.au. Accessed November 19, 2013.
Research Letter
August 2014

Revisional Surgery After Laparoscopic Adjustable Gastric Banding in a National Australian Cohort

Author Affiliations
  • 1Deakin Health Economics, Deakin University, Melbourne Burwood Campus, Burwood, Victoria, Australia
JAMA Surg. 2014;149(8):874-875. doi:10.1001/jamasurg.2014.93

A recent systematic review reported wide-ranging long-term revision or reversal rates after laparoscopic adjustable gastric banding (LAGB) of between 8% and 60%.1 The marked variability is likely due to different definitions of revisional surgery, different follow-up durations, and the different “eras” of the surgical cohorts. The studies reviewed provided little detail regarding the types of revisional procedures performed.1 Two recent studies1,2 have significantly advanced evidence in this area. The Longitudinal Assessment of Bariatric Surgery2 in the United States reported that of 610 patients undergoing LAGB, the rate of revisional surgery was 17.5 events per 100 patients over 3 years, primarily for band removal, revision to another bariatric procedure, or port revision. O’Brien et al1 reported that of 1370 patients undergoing LAGB at an Australian bariatric center, the rate of revisional surgery was 15.3 events per 100 patients over 3 years, primarily for repositioning of the gastric band or port revisions. The present study reports revisional surgery rates for the national population of Australians undergoing LAGB between July 1, 2005, and June 30, 2006.

Methods

The population of Australians undergoing LAGB subsidized by Australia’s government tax-funded insurance program (known as Medicare) between July 1, 2005, and June 30, 2006, was identified (N = 6037). Identification was based on utilization of Medicare Benefits Schedule item (ie, billing code) 30511 (gastric reduction or gastroplasty for morbid obesity), which is primarily used for LAGB.3

Medical utilization data from the date of LAGB until 3.5 years after surgery was retrieved for each patient from an administrative database4 maintained by Medicare. Medicare funds approximately 3800 medical services.4 Selected predefined items directly related to bariatric surgery, as specified in the Table, were analyzed. For privacy reasons, de-identified, aggregate data on medical utilization were provided to the research team by Medicare. The earliest and latest dates for data capture were July 1, 2005, and December 30, 2009, respectively.

Observed frequencies over 3.5 years were converted to 3-year rates for each revisional surgery item. The Medicare item relating to LAGB reversal (item 30514) is used when the initial gastric banding procedure is repeated (item 30511) and when a conversion to another bariatric procedure is undertaken (items 30512 and 30518). Therefore, gastric banding reversals performed in association with other procedures were excluded from the data to remove the risk of double counting.

Results

The age and sex distribution of the LAGB population analyzed is provided in the Figure. During the 3 years after LAGB, the rate of revisional surgery was 18.9 events per 100 patients, comprising 11.4 intra-abdominal and 7.5 subcutaneous surgical procedures. The majority of revisional procedures were repeated or revisional LAGB procedures (8.3 events per 100 patients) and repairs or revisions of the LAGB reservoir (7.5 events per 100 patients). Conversions to another bariatric procedure (1.3 events per 100 patients) and LAGB reversals (1.9 events per 100 patients) were uncommon (Table).

Discussion

The present study found that almost 1 in 5 patients undergoing LAGB require some revisional surgery within 3 years. These results from our national cohort study are similar, albeit slightly higher, than the results from previous single-center (15.3% of patients)1 and multicenter cohort studies (17.5% of patients).2

There are 2 key strengths of our study. First, the data analyzed are observed health care utilization data maintained by the Australian government; therefore, the level of reliability is high, and the data set is complete (no loss to follow-up). Second, the entire population of Australians who received Medicare-subsidized LAGB was analyzed, thus providing results reflective of LAGB as delivered in a “real-world” setting.

Bariatric surgery is associated with dramatic weight loss and improvements in many clinical end points.2 The benefits of surgery must be compared with the risk of adverse events, the need for reoperations, and the associated costs for each patient.

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Article Information

Corresponding Author: Catherine L. Keating, MPH, Deakin Health Economics, Deakin University, Melbourne Burwood Campus, 221 Burwood Hwy, Burwood, Victoria, Australia 3125 (catherine.keating@deakin.edu.au).

Published Online: June 18, 2014. doi:10.1001/jamasurg.2014.93.

Author Contributions: Mss Keating and Ananthapavan had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: Keating.

Statistical analysis: Keating.

Obtained funding: Keating.

Conflict of Interest Disclosures: Ms Keating has previously received an independent research grant from Allergan Australia. No other disclosures are reported.

Funding/Support: This project was funded by Deakin University.

Role of the Sponsor: The funding agency had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank Medicare Australia for their assistance with the identification of the population analyzed in this study and for providing detailed medical data. We also thank Paul O’Brien, MD, FRACS, from the Centre for Obesity Research and Education, Monash University, Melbourne, Australia, for providing a critical review of the study from the perspective of a bariatric surgery expert. Dr O’Brien did not receive any compensation. Medicare Australia received an administrative fee to undertake the custom data extraction.

References
1.
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.
PubMedArticle
2.
Courcoulas  AP, Christian  NJ, Belle  SH,  et al; Longitudinal Assessment of Bariatric Surgery (LABS) Consortium.  Weight change and health outcomes at 3 years after bariatric surgery among individuals with severe obesity. JAMA. 2013;310(22):2416-2425.
PubMed
3.
Australian Government Department of Health and Ageing. Draft report for reviewing existing MBS items. Review name: items for the surgical treatment of obesity. http://www.health.gov.au/internet/main/publishing.nsf/Content/A878E2C4992E9AE8CA257BF0001F3E82/$File/DRAFT%20obesity%20report.pdf. Published May 24, 2011. Accessed November 19, 2013.
4.
Australian Government Department of Health. Medicare Benefits Schedule (MBS) Online. http://www.mbsonline.gov.au. Accessed November 19, 2013.
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