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PCORnet study

Bypass and sleeve beat AGB for adolescents undergoing surgery

The study is the largest retrospective US study directly comparing outcomes of the most common weight loss procedures among adolescents

Adolescents undergoing Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) have a greater decline in BMI, compared to those who had laparoscopic adjustable gastric banding (AGB), according to researchers reporting outcomes from the PCORnet Bariatric Study (PBS).  In addition, the authors also reported that the majority of patients maintained weight loss over the five-year follow-up time period, while patients undergoing AGB lost the least weight.

The paper, ‘Comparative Effectiveness of Bariatric Procedures among Adolescents: The PCORnet Bariatric Study’, published in SOARD by authors writing on behalf of the PCORnet Bariatric Study Collaborative, sought to compare effectiveness of bariatric procedures in adolescents. The researchers analysed data from the National Patient Centered Clinical Research Network (PCORnet) including 11 Clinical Data Research Networks representing up to 56 participating health care systems.

The primary outcome of the study was percentage change in BMI from baseline among the patients at one, three and five years after surgery, and regression models were used (and further adjusted) for covariates (including age, sex, baseline BMI, race, ethnicity, year and site) and for propensity score deciles to ascertain RYGB vs. SG and RYGB vs. AGB comparisons.

Outcomes

In total, 544 (306 SG, 177 RYGB, 61 AGB) patients were included in the study - 79% were females (79%), mean age prior to surgery was 17.3 (±1.6) years and the mean BMI at baseline was 49.8 (±7.8).  Comorbidities included obstructive sleep apnoea (36%), dyslipidaemia (35%), hypertension (32%), depression (28%), gastro-oesophageal reflux disease (GERD; 25%), polycystic ovary syndrome (PCOS; 22%), NAFLD (19%) and type 2 diabetes (16%). The number of individuals with sufficient follow-up weight data for inclusion in one, three and five years analyses were 524, 174, and 47, respectively, represents 82%, 50%, and 39% of patients, respectively.

The authors reported that patients undergoing RYGB and SG experienced the greatest reduction in BMI at each time point during follow-up. At year one for those undergoing RYGB, SG and AGB - RYGB was associated with BMI loss of 31.4%, SG was associated with BMI loss of 28% and AGB was associated with BMI loss of 10%.

At three years, RYGB patients experienced five percentage point greater BMI loss (p=0.051), compared to those undergoing SG. The authors point out that at five years there were insufficient numbers available for statistical comparison, although RYGB maintained an average (unadjusted) loss of 24% of their baseline BMI, compared to SG patients who maintained a loss of 21%. There were also insufficient observations beyond one year to make “meaningful comparisons between AGB and other procedures”, the authors noted however, “trends suggested no further reduction in BMI among those who underwent AGB.”

"Understanding how these procedures impact long term weight loss helps patients, families, and healthcare providers have more informed conversations about the potential benefits of surgical treatment of severe obesity in adolescents."

There were no perioperative death reported and only a minority of patients had perioperative morbidity - the numbers were so small that no procedural comparisons were possible. Percutaneous, endoscopic or subsequent operative procedures were seen in only 3.3% of patients. VTEs were observed in only 0.4% and failure to discharge in 30 days was reported in 0.7% of patients.

Interestingly, the authors noted that the decline of AGB procedures in adults as well as additional studies that have shown less weight loss among patients who used AGB compared to SG and RYGB, could indicate that AGB is “unlikely to have a significant role in treatment of adolescent obesity in the future” - at least in the US - where AGB is currently not indicated for individuals under 18 years of age according to the FDA.

“Understanding how these procedures impact long term weight loss helps patients, families, and healthcare providers have more informed conversations about the potential benefits of surgical treatment of severe obesity in adolescents,” the authors conclude. “Further long-term studies addressing how these bariatric procedures impact not only BMI but also nutrition, risk of adverse events, and obesity-related physical and mental health comorbidities are needed.”

The PCORnet Study is funded by the Patient-Centered Outcomes Research Institute (PCORI). To access this paper, please click here

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