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Gastric Band Is First Step Surgery for Morbidly Obese Teens


Lisa Nainggolan

SOFIA, Bulgaria — Among severely obese adolescents, laparoscopic adjustable gastric-band surgery is a reasonable option for weight loss after all other avenues have failed, say experts.
Reporting some of the longest-term results to date, out to 3 years, on a cohort of teenagers who underwent the procedure, pediatrician Myriam Dabbas, MD, of Necker-Enfants Malades Hospital, Paris, France, told the 2014 European Congress on Obesity here that, on the whole, the operation is a success.
"Patients improve their eating behavior rapidly in the first month, and we see the majority of weight loss within the first 2 years," she explained.
Her team also found amelioration of metabolic syndrome among the teenagers who underwent gastric-band surgery and an improvement in cardiovascular-risk profiles. "Losing weight as soon as possible is essential to the future well-being of obese young people," she observed, noting that the teens lost, on average, 40 kg.
However, she stressed that it is very important to have adequate professional support — her team found a correlation between the amount of weight lost and the number of follow-up visits.
Asked to comment, session chair Francois Pattou, MD, a bariatric surgeon from Lille University Hospital, France, said he too performs gastric banding in morbidly obese adolescents and believes it is the best surgical option in this age group due to the low risk associated with it and the reversibility, among other things.
"I think there is a strong, sound clinical rationale [for this procedure] because there is nothing else. These patients are suffering incredibly, and there is no other option," he told Medscape Medical News.
Banding Is a "One-Step-at-a-Time" Approach for Teens
Dr. Dabbas explained that surgery is considered in her center only in patients with a body mass index (BMI) of 40 or greater who are at least 14 years of age and in whom all other approaches have failed, including at least 1 to 2 years of on-site multidisciplinary programs such as group-based and behavioral/lifestyle interventions.
Although some centers perform sleeve gastrectomy and/or gastric bypass on adolescents, and gastric banding is to an extent falling out of favor as an adult bariatric procedure  — because of complications such as band slippage — both Drs. Dabbas and Pattou said they felt banding is the best option in this age group for a number of reasons.
First, weight loss in teenagers needs to be progressive to prevent nutritional deficiencies, and the band allows gradual weight loss, as it can be adjusted, Dr. Dabbas noted.
"It's one step at a time with adolescents," she said, noting that patients can always go on to have further procedures such as sleeve gastrectomy or gastric bypass when they are older.
The reversibility of the band is also a big draw compared with other bariatric procedures, Dr. Pattou added.
"This is important because we are faced with patients who are not deciding [all by] themselves, so in 5 years they might be in terrible dispute with their parents."
And despite sleeve gastrectomy being "a la mode," there are signs that complications are starting to be seen with this procedure too, both doctors told Medscape Medical News.
"Sleeve gastrectomy has advantages: it's quicker, with greater weight loss, but no one knows about the long term," said Dr. Pattou. "In our experience with adults, the 5-year results with the sleeve are not better than with the band. And this is 5 years only, and we are speaking about lifelong maintenance."
Also, it's higher risk, he noted. "The risk of death with sleeve gastrectomy is 0.3%, meaning 3 adolescents will die in 1000. I think this is a toll that is not acceptable" when banding is safe, he observed.
Good Results but Longer-term Follow-up Will Be Key
Dr. Dabbas said her center has been performing gastric banding since 2008, and so far they have operated on 37 teens, of whom 26% were male, with a mean age of 16 (range, 14 to 18 years) who weighed 130 kg, on average, and had a mean BMI of 45. Before surgery, careful psychological evaluation is performed to ensure the patients are suitable candidates, she noted.
Prior to surgery, 60% of the patients had insulin resistance and 75% of them had metabolic syndrome, but no one had developed type 2 diabetes. Almost half of all the females had menstrual disorders.
Three years after surgery, median weight loss was 42 kg, corresponding to 69% excess weight loss.
Most of this was evident the first year after surgery, and weight tended to stabilize after the second year (mean BMI at 2 years was 34 compared with 33.7 at 3 years, a nonsignificant difference), Dr. Dabbas explained. All metabolic parameters were also normal at 3 years, she added, and cardiovascular risk factors, such as dyslipidemia, improved.
She stressed that the extensive follow-up was important in gaining the good results, with the patients having an average of 12 visits in the first year after the operation and 9 in the second year.
Nevertheless, even longer-term follow-up will yield key information, she said, noting that even now, "after 3 years we are beginning to have difficulties, complications, slippage of banding, and patients being lost to follow-up."
And there was a subset of 5 patients in whom the procedure was not particularly successful, who suffered complications such as regurgitation, heartburn, dysphagia, and reflux, she said, noting that her team had been unable to determine why this was — there were no obvious predictors of failure.
Which Surgeons Should Perform the Operation?
Unfortunately, there was also 1 death among the series of 35 patients, the result of an abdominal hemorrhage in a patient who presented to the emergency room some time after surgery.
Dr. Dabbas said all operations were suspended for 6 months following this fatality, but they were unable to determine whether it was related to the surgery.
She explained that the pediatric surgeons in her institution performed the gastric banding, but Dr. Pattou told Medscape Medical News he believes that bariatric surgeons should conduct these operations.
"Very unfortunately, this team had a death, but this is very unexpected and very rare," he noted, acknowledging that it has not been demonstrated that the surgery was a contributory factor in the fatality.
Nevertheless, "this operation should be done with a pediatrician team for follow-up but with a bariatric team for surgery," he stressed. "I think it's a mistake to have a pediatric-surgery team who does only a few of these operations, because these are young anatomical adults."
Dr. Dabbas and Dr. Pattou reported no relevant financial relationships.
2014 European Congress on Obesity. Abstract T5:S1.1, presented May 29, 2014.