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Adolescent bariatric surgery

Study favours LAGB vs lifestyle changes for obese adolescents

Study reports associated benefits to health and quality of life

According to the results of an Australian study that examined laparoscopic adjustable gastric banding (LAGB) and optimal lifestyle programme in obese adolescents, the bariatric surgical group were reported to have lost more total body weight and excess weight. 

The study was a prospective, randomised controlled trial of 50 adolescents between 14 and 18 years with a BMI>35, recruited at the Centre for Obesity Research and Education at Monash University, Melbourne, Australia. The patients were assigned either to a supervised lifestyle intervention or to undergo LAGB and followed up for two years.

"This study demonstrates that lifestyle interventions can be effective for some teens and should remain the first option”
the paper's authors

At the time of recruitment all of the patients had obesity-related medical complications, including hypertension, metabolic syndrome, asthma, back pain, as well as physical limitations (performing activities of daily living). In addition, as adolescents they had also reported psychosocial problems including isolation, low self-esteem and bullying. 


The study was performed between May 2005 and September 2008. The main outcome measure was loss of at least 50% of excess weight, with secondary outcomes including change in metabolic syndrome, insulin resistance, quality of life and adverse outcomes. 


The optimal lifestyle programme focused on reduced energy intake (800–2,000 kcal per day, depending on age and weight); increased physical activity (more than 10,000 steps/day as measured by pedometer), which included structured exercise for at least 30 minutes per day; and behaviour modification. Patients were advised to spend more performing physical activities (bike rides, hiking trips, sports), as well as been advised against watching television and playing computer games. In addition, recruits received six weeks of instruction from a personal trainer and met with a physician, a dietician or an exercise consultant every six weeks. 


Outcomes


A total of 24 of the 25 patients in the LAGB group (96%) completed the full two years of follow-up, compared with 18 of the 25 in the lifestyle group (72%). A total of 21 patient in the LAGB group (84%) but only three subjects in the lifestyle group (12%) achieved the primary outcome measure of a loss of at least 50% of excess weight. 


The results revealed that LAGB patients had lost a mean of 35kg, which represents a mean loss of 28% of total body weight. In comparison, subjects in the lifestyle group lost a mean of 3kg, which represents a mean loss of 3% of total body weight.


Overall, the mean changes in the gastric banding group were a weight loss of 34.6 kg (95% CI, 30.2–39.0), representing an excess weight loss of 78.8% (95% CI, 66.6%–91.0%), 12.7 BMI units (95% CI, 11.3–14.2), and a BMI z score change from 2.39 (95% CI, 2.05–2.73) to 1.32 (95% CI, 0.98-1.66). The mean losses in the lifestyle group were 3.0 kg (95% CI, 2.1-8.1), representing excess weight loss of 13.2% (95% CI, 2.6%–21.0%), 1.3 BMI units (95% CI, 0.4–2.9), and a BMI z score change from 2.41 (95% CI, 2.21–2.66) to 2.26 (95% CI, 1.91–2.43). 


At the start of the study, nine participants (36%) in the LAGB group and ten (40%) in the lifestyle group had the metabolic syndrome. At two years follow-up, none of the LAGB group had the metabolic syndrome (p=0.008; McNemar X2) compared with four of the 18 patients (22%) in the lifestyle group (p=0.13). 


In addition, insulin resistance was abnormally high in more than half of the subjects at baseline. The problem resolved in all subjects in the surgery group but persisted in three subjects in the lifestyle group. Those who underwent gastric banding also showed significant improvements in quality of life in the domains of physical functioning, general health, self-esteem, and family activities, whereas those who participated in the nonsurgical intervention did not.


The gastric banding group experienced improved quality of life with no perioperative adverse events. However, eight operations (33%) were required in seven patients for revisional procedures either for proximal pouch dilatation or tubing injury during follow-up. On this point the researchers noted, “The need for revisional procedures for enlargement of the stomach above the band or injury to the tubing is intrinsic to the gastric banding procedure.”


Conclusions  


The authors concluded that the use of LAGB compared with lifestyle intervention resulted in a greater percentage achieving a loss of 50% of excess weight, corrected for age, among obese adolescents. There were associated benefits to health and quality of life. 


However, they also noted that adolescents may have more difficulty understanding and complying with instructions to eat only small meals and to eat very slowly in order to avoid the need for revisional procedures, compared to adults. Therefore, additional education and supervision of eating may be helpful for this age group, they added. 


“Bariatric surgery is now extensively used for adults and is being evaluated for adolescents. Laparoscopic adjustable gastric banding has the potential to provide a safe and effective treatment,” they conclude. “The gastric banding approach to weight loss is not a quick fix. For optimal effectiveness it requires long-term supportive follow-up by trained health professionals. This study demonstrates that lifestyle interventions can be effective for some teens and should remain the first option.”


In an accompanying editorial, Dr Edward H Livingston of the University of Texas Southwestern Medical Center, Dallas, said that the quality of the current evidence in support of bariatric surgery is ‘poor’ and welcomed the study as a further randomised controlled trial that favourably compares bariatric surgery with non-surgical treatments. 


He commented the 28% rate of revisional procedures in LAGB group study is important as O’Brien et. al are among the most experienced group in the world with these operations, suggesting that revisional procedures will probably be higher in real world practice.


The study was funded by a grant from the Australian National Health and Medical Research Council. The laparoscopic adjustable gastric bands used in the study were provided by the manufacturer, Allergan.

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