The overall popularity of LAGB has been declining. Australia, UK, Israel, Canada and Belgium are the few countries with a reasonable market share for LAGB amongst the bariatric procedures. This study is thus unique since it aims to present data to a sceptical bariatric society.
Operative mortality in this cohort was zero and there were no in-hospital returns to theatre, confirming that the LAGB is an extremely safe procedure. The study has the advantage of a large cohort, but the obvious disadvantage that – despite strenuous efforts to contact patients - the follow-up rates could have been better.
The observed weight loss in our study is consistent with many previous reports and the pattern of weight loss was typical of the LAGB – a gradual rise followed by a stable plateau at around 50% excess BMI loss [17, 18]. This contrasts with procedures such as SG and RYGB, where the pattern tends to be one of substantial initial weight loss, followed by gradual weight regain [16, 19]. In fact, a number of studies have shown that the initial advantages of procedures such as SG and RYGB are attenuated at ≥5 years and that beyond this, there is little difference in outcomes .
Age and BMI as predictors of weight loss outcomes after bariatric procedures has been reported in several studies. In general, older patients (> 50 years) seem to do as well as younger age-groups and this observation has been confirmed in the present study16,21. Our finding that weight loss in the first 12-months was greater in those with a pre-operative BMI < 50 kg/m2 than those in the BMI ≥50 kg/m2 group, but that there was no difference for years 2-,3- and 4, is precisely the same observation made by Dixon and O’Brien . Others have also found no significant difference in weight loss between the obese and the super-obese .
Complications of LAGB are widely reported in the literature. LAGB slippage has a highly variable incidence of anywhere between 1 and 22% [23,24,25,26,27]. O’Brien and Dixon reported a LAGB slip rate of less than 5% and a recently reported review of LAGBs from a UK-based facility, reported a rate of 3.1% in a single-centre cohort of 719 patients [28, 29]. In a five-year follow up of 2815 LAGB patients, Coburn et al. reported a slippage rate of 4.2% . Thus, our overall slippage rate of 1.4% in the present study is at the very lowest end of the range. It is important to note that all our LAGBs were implanted using a pars flaccida approach, which is known to be associated with lower rates of complications than the perigastric technique. For example, Ponce et al. reported a 20.5% slippage rate with the perigastric approach, which decreased to 1.4% after adopting the pars flaccida technique and O’Brien et al. have shown the risk of anterior slippage to be almost four times higher for the perigastric approach compared with the pars flaccida [30, 31].
Erosion (migration) is another important, though uncommon, complication of the LAGB. The reported incidence varies between 0.5–3.3% and requires removal of the device, which can usually be achieved endoscopically [2, 4, 32]. In the current study erosion was a rare complication of LAGB, with an incidence of just 0.1%.
Port and tubing complications, including leakages and infections, were observed in 76 (3.4%) patients. Once again, there is a wide variation in the literature with rates varying between 1.2–24%, often depending on the length of follow-up [4, 33]. Most complications of this kind are eminently correctable, usually by replacing or re-positioning the access port or, occasionally, replacing the entire LAGB.
A key factor in the decline in LAGB has been the high revision and early removal rates of up to 60% in some publications [5,6,7,8,9,10]. However, very much lower revision rates have also been reported. For example, Coburn et al., in a 5-year follow-up of 2815 LAGB patients reported complications in 8.5% with an explantation rate of just 1.2% . In a 12-year follow-up of 1791 patients, Favretti et al. report a re-operation rate of 5.9% and LAGB removal in 3.7% . Similarly, in a 5-year follow-up of 442 patients, Ray and Ray reported % EWL of 60% at 5-years, with a slippage and erosion rate of 2% and 0.4% respectively and an explantation rate of 1.8% . In the present study, we found a total 105 (4.6%) of patients requiring re-operation for LAGB complications, necessitating removal in 35 (1.5%). However, these results need to be tempered with an 80.48% follow up of those eligible at 2 years. We also need to acknowledge that most patients were not in a paid follow up programme after 2 years and only presented to us if they wanted to manage their complications in the private sector.
Thus, our results lend strong support to the currently unfashionable view that, when correctly applied and managed, the LAGB is a safe, effective and durable short-stay procedure which can be safely revised and is well tolerated by patients37. We of course concede that the outcomes of LAGB are variable both in terms of revision and explanation rates. An appraisal of the multicentre Realize study  and the French study by Lazzati et al  which involved almost 53,000 patients confirmed that outcomes were highly dependent on the experience of the teams. Moreover, band salvage was more likely if the patient had presented to the original implanting hospital.
Based on these findings, we believe that sub-optimal outcomes for the LAGB are primarily a function of low volume surgeons or facilities and an inadequate LAGB aftercare programme. The issue of sub-optimal follow-up is of relevance in the National Health Service (NHS) because of chronic funding problems. The LAGB is perceived to be a resource-intensive intervention which, because of the requirement for regular adjustments and clinic visits, places an undue burden on an already limited healthcare funding. The fact is that LAGB requires a long-term commitment to the patient and whilst this is obviously true for all bariatric patients, it is an indispensable requirement for success with the LAGB. In circumstances where they cannot provide the requisite level of support, many NHS surgeons will feel that this is a commitment they simply cannot make and will opt for alternative procedures.