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!
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