(1) Upper Gastrointestinal Surgical Unit, The Alfred Hospital (2) Monash University Centre for Obesity Research and Education (CORE)

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1 Yazmin Johari (1,2), Geri Ooi (1,2), Paul Burton (1,2), Shourye Dwivedi (2), Cheryl Laurie (2), Kalai Shaw (1), Richard Chen (1,2), Wendy Brown (1,2), Peter Nottle (1) (1) Upper Gastrointestinal Surgical Unit, The Alfred Hospital (2) Monash University Centre for Obesity Research and Education (CORE)

2 Re-operation rate 8-60% Complication rate <15% (staple line leak 0 5.5%)

3 Safety Efficacy Follow up Patient's outcome Healthcare resource utilization

4 Aims To compare the outcomes of primary LAGB and sleeve gastrectomy Clinical outcomes Weight loss Peri-operative outcome and complications reoperations Hospital resource use relating to procedure Length of hospital stay Follow-up Patient reported outcome Symptoms QOL satisfaction Ultimately, aimed at discerning differences in a range of clinical measures to better inform patient counselling and decision making and use of scarce health care resources.

5 Methods Primary sleeve gastrectomy (SG) or laparoscopic adjustable gastric banding (LAGB) Patients recruited with 5 year follow up 1:1 Matched cohort (age, weight, BMI, gender, timeframe)

6 Prospectively maintained MS Access and online bariatric EMR (LAP-BASE TM ) Clinical outcome Weight loss Complications Re-operations Hospital resource use Length of hospital stays Re-admission Follow up Questionnaire Patient reported outcome measures Adverse symptoms Quality of life

7 Results

8 Patient population (n = 526) LAGB (n=263) Sleeve gastrectomy (n=263) p-value Age ± ± Male gender 85 (32.3%) 80 (30.2%) 0.64 Baseline weight (kg) 131.2± ± Baseline BMI (kg/m 2) 46.7± ± Average length of follow up (years) = 4.8 years

9 Clinical outcomes

10 Percentage TBWL (%) Weight loss over 5 years Baseline 3m 6m 9m 12m 18m 2y 3y 4y 5y Time from operation Sleeves Bands

11 Specific procedural complications Early complication sleeve 1.1% 4.2% 0.8% 0.3% Total 6.4% Early complication LAGB 0.3% 8% 1.1% 1.1% 5.3% 5.3% Total 21.1% Bleeding Infection Pouch dilatation Prolapse Erosion/infected band Port/tubing leak Port position Leak Portal vein thrombosis Stenosis

12 Re-operation Revisional Surgery 35 Port revision/ removal 526 patients 263 LAGB 20 Revision of LAGB 22 Removal of LAGB 1 Gastric plication 5 Re-insertion 9 Sleeve gastrectomy 91 operations 263 Sleeve gastrectomy 1 Sleeve gastrectomy revision 10 Roux-en-Y 13 operations 1 Biliopancreatic division

13 The use of hospital resources

14 Days Mean Length Of Stay Of Primary Operation Median Standard error LAGB Sleeve P < 0.001

15 NUMBER OF ADMISSIONS Total number of additional admissions (excluding primary operation) LAGB 16 SLEEVE Unplanned Planned

16 Days Total hospital days relating to the bariatric procedure LAGB Leak = 516 days (11 patients) sleeve

17 Clinical follow-up Active clinical followup 230 LAGB (88.5%) 198 Sleeve (76.4%) 100% 80% 60% Active F/U Called back LTFU % 89.9% 40% Contacted to return for follow-up: 18 LAGB 35 Sleeve 20% 0% LAGB Sleeve

18 Number of clinic visits Frequency of post-operative clinic visits over 5 year-follow up LAGB sleeve

19 Patient reported outcomes

20

21 Adverse symptoms: Heartburn

22 Adverse symptoms: Dysphagia

23 Patient reported satisfaction

24 Bands Sleeves Quality of life (SF-36) p=0.357 MCS Physical Function p=0.88 Role Physical p= p=0.002 PCS Bodily pain p< Mental Health p=0.019 General Health p=0.036 Role Emotional p=0.014 Social Function p=0.004 Vitality p<0.001

25 SUMMARY Clinical outcome Sustained and substantial weight loss, Sleeve > LAGB Complication rate Sleeve < LAGB Use of hospital resources Total hospital days Sleeve > LAGB Post-op hospital stay Sleeve > LAGB Readmission and reoperation Sleeve < LAGB Post op visit required Sleeve > LAGB High compliance with follow up, Sleeve < LAGB Patient reported outcomes Regurgitation Sleeve < LAGB Reflux Sleeve > LAGB Satisfaction with surgery Sleeve > LAGB QOL Sleeve > LAGB

26 CONCLUSION Comprehensive comparison of sleeve and gastric banding Significant differences in patient reported outcomes and hospital resource use Can be used to objectively counsel patients pre-operatively Significant hospital resource use following gastric sleeve complications and LAGB re-operations Future directions - comprehensive analysis of total health care resource use, comparison of other procedures across a similar range of outcome measures