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Bariatric surgery in adolescents.

The Problem

A 17-year-old male with a history of extreme obesity (body mass index 61.6 kg/ m2) and asthma presents to you with a 3-day history of back pain and radicular symptoms. He recalls discomfort after lifting several heavy items during a move to a new apartment. He denies bowel or bladder symptoms, fevers, history of cancer, or weakness. On exam, the patient has a positive straight leg raise. You start a proton-pump inhibitor, NSAIDs, and gabapentin. He returns 6 weeks later because of ongoing pain and inability to work. MRI shows a right paracentral disk protrusion at the L3-L4 level, which narrows the lateral recess and displaces the transiting nerve roots posteriorly with degenerative joint disease of the facet joints. The neurosurgeon declines to operate on the patient because of his obesity. The patient's pain gradually improves, but he gained additional weight because of inactivity. He read about gastric banding on the Internet and inquires about it.

The Question

In adolescents with obesity, is gastric banding safe and more effective than lifestyle modifications in producing long-term weight loss?

The Search

You go to PubMed (www.pubmed.gov) and search "obesity AND adolescents AND bariatric." You limit the search to randomized, controlled trials. You find a relevant study. (See box at right.)

Our Critique

The major weakness of this study is that no sham gastric banding procedure was performed. Although the article presents comparable adverse event rates between the two groups (48% vs. 44%), we suggest that the adverse event rate was appreciably higher in the gastric banding group. The authors adjudicated loss to follow-up as an adverse event; in our opinion, loss to follow-up is perhaps more of an adverse event for the investigators than it is for the subjects. If loss to follow-up is not counted as an adverse event, then the adverse event rate was 44% in the gastric banding group and 16% in the lifestyle group. Overall, the results of the trial are not surprising, showing superior weight loss with gastric banding. Despite additional costs associated with adverse events, we hypothesize that economic models would likely show an overall cost savings with gastric banding, assuming that the weight loss is durable, given the tremendous health care costs associated with obesity.

Clinical Decision

After a discussion with the patient, you refer him to educational classes in your area on bariatric procedures.

The Evidence

O'Brien RE., et al. Laparoscopic adjustable gastric banding in severely obese adolescents. JAMA 2010; 303:519-26.

* Design and setting: Randomized clinical trial done in Melbourne, Australia.

* Patients: Potential subjects were eligible for enrollment if they were 14-18 years of age; had a BMI over 3 5; had medical complications such as hypertension, metabolic syndrome, asthma, or back pain; had physical limitations such as an inability to play sports or difficulties with activities of daily living; had psychosocial difficulties such as isolation or low self-esteem; and had attempted to lose weight by lifestyle means for more than 3 years. Potential subjects were excluded if they had an intellectual disability or Prader-Willi syndrome.

* Intervention: After completing baseline food diaries, pedometer activity recordings, and a 2-month course involving recommendations for physical activity subjects were ran domized to receiving a LAP-BAND adjustable gastric banding system or to a lifestyle program. Adjustments to band fluid volume were based upon weight loss, satiety, and eating pattern and symptoms. The lifestyle program focused on reducing energy intake and increasing activity with a structured exercise schedule of at least 30 minutes a day and behavioral modification. The gastric banding group also received instructions on nutrition and exercise. Every 6 weeks, participants had consultations with a physician and a dietitian or exercise consultant, the study coordinator, and a sports medicine physician. Family members were engaged as much as possible in the process.

* Outcomes: The primary end point was loss of 50% excess weight. Excess weight was de fined as weight above the 85th percentile of BMI for age and sex. Presence of the metabolic syndrome and quality of life were also noted.

* Results: A total of 163 adolescents were screened, of whom 50 were randomized (25 in each group). One subject in the gastric banding group withdrew from the study, compared with seven in the lifestyle group. Mean BMI was 42.3 in the gastric banding group and 40.4 in the lifestyle group. At 2 years, the gastric banding group had lost a mean of 34.6 kg (95% confidence interval, 30.2-39.0), representing an overall mean loss of 28.3% total body weight (95% CI, 24.9%-31.7%), 78.8% excess weight loss (95% CI, 66.6%-91.0%), and 12.7 BMI units (95% CI, 11.3-14.2). The lifestyle group lost a mean of 3.0 kg (95% CI, 2.1-8.1), representing a mean 3.1% total weight loss (95% CI, 0.7%6.8%), 13.2% excess weight loss (95% CI, 2.6%21.0%), and 1.3 BMI units (95% CI, 0.4-2.9). At study entry 9 participants (36%) in the gastric banding group and 10 in the lifestyle group (40%) had metabolic syndrome. At 24 months, none of the 24 completers in the gastric banding group had metabolic syndrome and 4 of the 18 completers in the lifestyle group had metabolic syndrome. In the gastric banding group, 12 participants (48%) experienced a total of 13 adverse events, and 7 required eight revisional procedures. Both groups experienced significant improvements in general health.

Dr. Ebbbrt and Dr. Tangalos are with the Mayo Clinic in Rochester, Minn. They report having no conflicts of interest. To respond to this column or suggest topics for consideration, write to Dr. Ebbert and Dr. Tangalos at our editorial offices or e-mail them at imnews@elsevier.com.

BY JON O. EBBERT, M.D., AND ERIC G. TANGALOS, M.D.
COPYRIGHT 2010 International Medical News Group
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Article Details
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Title Annotation:MINDFUL PRACTICE
Author:Ebbert, Jon O.; Tangalos, Eric G.
Publication:Internal Medicine News
Article Type:Column
Date:May 15, 2010
Words:970
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