Gastric banding results in significant weight loss for obese adolescents

Article Outline

• Question
• Design
• Setting
• Participants
• Intervention
• Outcomes
• Main Results
• Conclusions
• Commentary
• Copyright

O'Brien P, Sawyer S, Laurie C, Brown W, Skinner S, Veit F, et al. Laparoscopic adjustable gastric banding in severely obese adolescents: a randomized trial. JAMA 2010;303:519-26.

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Question 

Among obese adolescents, is gastric banding more effective at reducing weight compared with an optimal lifestyle program?

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Design 

Prospective, randomized, controlled trial.

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Setting 

Melbourne, Australia, community.

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Participants 

Fifty adolescents, between 14 and 18 years, with a body mass index (BMI) higher than 35.

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Intervention 

Supervised lifestyle intervention or gastric banding. Subjects were followed up for 2 years.

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Outcomes 

The primary outcome was weight loss. Secondary outcomes included change in metabolic syndrome, insulin resistance, quality of life, and adverse outcomes.

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Main Results 

Twenty-four of 25 patients in the gastric banding group and 18 of 25 in lifestyle group completed the study. Twenty-one (84%) in the gastric banding and 3 (12%) in the lifestyle groups lost more than 50% of excess weight, corrected for age (number needed to treat = 2). Overall, the mean changes in the gastric banding group were a weight loss of 34.6 kg (95% CI, 30.2 to 39.0), representing an excess weight loss of 78.8% (95% CI, 66.6% to 91.0%), 12.7 BMI units (95% CI, 11.3 to 14.2), and a BMI z score change from 2.39 (95% CI, 2.05 to 2.73) to 1.32 (95% CI, 0.98 to 1.66). The mean losses in the lifestyle group were 3.0 kg (95% CI, 2.1 to 8.1), representing excess weight loss of 13.2% (95% CI, 2.6% to 21.0%), 1.3 BMI units (95% CI, 0.4 to 2.9), and a BMI z score change from 2.41 (95% CI, 2.21 to 2.66) to 2.26 (95% CI, 1.91 to 2.43). At entry, 9 participants (36%) in the gastric banding group and 10 (40%) in the lifestyle group had the metabolic syndrome. At 24 months, none of the gastric banding group had the metabolic syndrome (P = .008; McNemar χ²) compared with 4 of the 18 completers (22%) in the lifestyle group (P = .13). The gastric banding group had 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.

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Conclusions 

Among obese adolescent participants, use of gastric banding compared with lifestyle intervention resulted in a greater percentage achieving a loss of 50% of excess weight, corrected for age. There were associated benefits to health and quality of life.

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Commentary 

In this randomized, controlled trial investigating the impact of laparoscopic banding procedures on adolescents, those receiving laparoscopic banding procedures had impressive amounts of weight loss and substantial improvement in medical comorbidities. What was most interesting, however, was that the group receiving intensive medical therapy also demonstrated substantial improvement in medical comorbid diseases, although there was very little weight loss. This trial was not a clear victory for surgery because a quarter of the laparoscopic banding patients required revisional operations. This revision rate was much higher than in adults and might reflect compliance problems typical of teenagers undergoing bariatric surgery. Although surgery was effective, it came at a high price and required a great deal of extra intervention. O'Brien's study clearly demonstrated that intensive medical treatment for adolescent obesity is worthwhile. It also showed that one needs to exert caution before advising bariatric surgery for children. Children do not have the emotional maturity required to comply with post–bariatric surgery dietary needs. Because good results can be obtained with laparoscopic banding procedures, it is inadvisable to pursue operations that permanently alter anatomy and physiology such as gastric bypass and other more aggressive approaches in children. Obese children who are relatively healthy can have the laparoscopic banding approach while they are young; they can have a gastric bypass performed when they are older and more emotionally prepared to comply with the operation's requirements and can make their decision to permanently change their gastric anatomy when they are legally allowed.