Post Publication Peer Review of Published Literature

By Mr. Kamal K Mahawar
Corresponding Author Mr. Kamal K Mahawar
Department of General Surgery, Sunderland Royal Hospital, Kayll Road, - United Kingdom SR4 7TP
Submitting Author Mr. Kamal K Mahawar

Bariatric Surgery, Adolescent, Obesity, Laparoscopic gastric banding

Mahawar KK. Review of JAMA article "Laparoscopic Adjustable Gastric Banding in Severely Obese Adolescents" by O'Brien et al. WebmedCentral BARIATRIC AND METABOLIC SURGERY 2012;3(4):WMC003255
doi: 10.9754/journal.wmc.2012.003255

This is an open-access article distributed under the terms of the Creative Commons Attribution License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submitted on: 13 Apr 2012 11:41:11 PM GMT
Published on: 13 Apr 2012 11:43:48 PM GMT

Citation of the Article Reviewed

O'Brien PE, Sawyer SM, Laurie C, Brown WA, Skinner S, Veit F, Paul E, Burton PR, McGrice M, Anderson M, Dixon JB. Laparoscopic adjustable gastric banding in severely obese adolescents: a randomized trial. JAMA 2010; 303(6):519-26.


Obesity surgery is the only solution for some obese adolescents for them to have a fair chance at what lies ahead in life. Though there are many retrospective studies reporting safe and effective use of gastric bypasses, banding and even sleeve gastrectomies in this patient group, this study is the only available randomised controlled trial examining the role of surgery in obese adolescents. That makes this article very interesting and also provides for an opportunity to do a risk vs benefit analysis of bariatric surgery in this subgroup of patients.

Even though one does not think twice before doing an emergency laparotomy on an adolescent, thought of bariatric surgery in adolescents seems rather drastic. That is probably because the benefits of an emergency surgery are visible rapidly, but that of surgery for a chronic disease will only become obvious in due course. Moreover carrying out surgery for a disease caused predominantly by lifestyle factors generally evokes negative sentiments in a publicly funded healthcare system. This is despite the fact that this particular group of patients may not have had any choice in deciding their lifestyle. We treat lifestyle related medical conditions all the time, but rather surprisingly the response of some healthcare professionals to other life style related medical conditions (related to smoking, alcohol abuse, promiscuous sexual behaviour, sports injury etc.) is less negative.

However, complexity of the issues involving bariatric surgery in obese adolescents cannot be underestimated. Surgical procedure(s) must be safe and effective in the long term. It must be easy for patient to work with must not affect physiological growth. Emotional maturity to cope with the aftermath of surgery in a supportive social environment as well as provision of care in a truly multidisciplinary team comprising of surgeons, paediatricians, psychologists, dietitians, and social support workers must be a basic minimum requirement for the teams offering this service.


This is a landmark article for anybody examining the role of bariatric surgery for obese adolescents and establishes safety and efficacy of laparoscopic gastric banding in this subgroup of patients over a 2 year follow up. Adolescents between 14-18 years old with BMI >35 were included in this study. Excess weight was defined as the weight above the 85th percentile of BMI for age and sex.

Participants were recruited through newspaper advertisements. I would be interested to know what the advertisements said and what incentives were patients offered? Patients did not pay any medical costs and study was partly funded by Allergan.

The primary end point of this study was to see if significantly more adolescents in gastric banding group would lose >50% excess weight compared to the lifestyle group. Authors showed a mean weight loss of 34.6 Kgs in the gastric banding group as opposed to 3.0 Kgs in the lifestyle group at 2 years.. This translated into an excess body weight loss of 78.8% for gastric banding group at 2 years compared to 13.2% for the lifestyle group. Results seem better than what would be expected with gastric band. This could partly be due to the rigorous follow up in this study and strong emphasis on exercise post surgery. Gastric band group had a mean of 20.4 visits (range 10-31) visits during the 2 year follow up and had 9.5 adjustments made. Authors need to be congratulated on their close and diligent follow up. Gastric banding group also experienced complete resolution of metabolic syndrome, and improvement in insulin resistance and quality of life.

Twelve participants (48%) experienced a total of 14 adverse events in the gastric banding group and 8 of these in 7 patients (28%) required a revisional procedure during the 2 year period. It is noteworthy that 6 (24%) patients developed pouch in a relatively short follow up of 2 years. One does wonder if this was because bands were kept a bit “too tight”. I would be interested to see the outcome of these bands in the longer term. Duration of follow up is an obvious drawback of this study, which authors themselves acknowledge too. 28% patients requiring revisional surgery in a relatively short follow up is obviously a cause for concern. Whether this would rise in longer term over a 5/10/20 year follow up would be interesting to know. I do hope authors come back with longer follow up in future.

There was no mortality in the banding group but one must bear in mind a widely accepted 30 day mortality of 1:1000 with laparoscopic adjustable gastric banding. One patient in banding group, who had depression and trichotillomania, required hospital admission for depression at 8 months of follow up. In this case, the social support network also broke down (parental divorce) within a few months of surgery. It is not clear if the outcome in this specific patient was less than rewarding. Many units would be hesitant about carrying out bariatric surgery on such patients. It would seem appropriate to ensure preoperatively that the adolescent in question does not have any active psychological issues and has strong social support.

Authors report two pregnancies in the banding group and suggest that sexual counselling should be a part of the overall management of these patients.

Overall, this is a very significant and well carried out study. One just hopes authors publish longer term results in due course. Following up this cohort for another few years would not be an easy task though!


Source(s) of Funding


Competing Interests

Author is a shareholder, director, and CEO of Webmed Limited, UK (the company that owns this portal WebmedCentral)


This article has been downloaded from WebmedCentral. With our unique author driven post publication peer review, contents posted on this web portal do not undergo any prepublication peer or editorial review. It is completely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscript but also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions before submitting any information that requires obtaining a consent or approval from a third party. Authors should also ensure not to submit any information which they do not have the copyright of or of which they have transferred the copyrights to a third party.
Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater to the needs of an individual patient. The web portal or any content(s) therein is neither designed to support, nor replace, the relationship that exists between a patient/site visitor and his/her physician. Your use of the WebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harm that you may suffer or inflict on a third person by following the contents of this website.

0 reviews posted so far

0 comments posted so far

Please use this functionality to flag objectionable, inappropriate, inaccurate, and offensive content to WebmedCentral Team and the authors.


Author Comments
0 comments posted so far


What is article Popularity?

Article popularity is calculated by considering the scores: age of the article
Popularity = (P - 1) / (T + 2)^1.5
P : points is the sum of individual scores, which includes article Views, Downloads, Reviews, Comments and their weightage

Scores   Weightage
Views Points X 1
Download Points X 2
Comment Points X 5
Review Points X 10
Points= sum(Views Points + Download Points + Comment Points + Review Points)
T : time since submission in hours.
P is subtracted by 1 to negate submitter's vote.
Age factor is (time since submission in hours plus two) to the power of 1.5.factor.

How Article Quality Works?

For each article Authors/Readers, Reviewers and WMC Editors can review/rate the articles. These ratings are used to determine Feedback Scores.

In most cases, article receive ratings in the range of 0 to 10. We calculate average of all the ratings and consider it as article quality.

Quality=Average(Authors/Readers Ratings + Reviewers Ratings + WMC Editor Ratings)