Gastric Band: A Viable Interim Option for Obese Adolescents

Pam Harrison

January 30, 2017

Laparoscopic-adjustable gastric banding (LAGB) is a reasonable interim approach for the treatment of morbid obesity in adolescents, because it promotes weight loss in the short term and is a reversible procedure.

That said, the band must be removed within a reasonable timeframe before the risk of complications sets in, according to new data from the longest-ever follow-up of LAGB-treated adolescents in Australia.

Should the patient then require another procedure to induce further weight loss, they will at least be more suitable candidates for sleeve gastrectomy or the gold-standard Roux-en-Y gastric bypass (RYGB), which, although perhaps more effective than LAGB, is associated with more serious complications, the Australian authors of this latest study argue.

"The reason why we chose to publish this study now, when people could argue that the lap band is 'yesterday's story,' is to say that perhaps the lap band's role has not been played out in the manner that it should have been," Sanjeev Khurana, MD, senior lecturer, University of Adelaide, Australia, told Medscape Medical News.

"If you go in considering that the lap band will be only temporary, then you have a different paradigm because you know that you will need a second operation to remove it, but at least you will kick start the weight-loss process, in that adolescents do achieve significant weight loss with the lap band. That's what our numbers show," he added.

The study was published online January 12 in Obesity Surgery.

Skepticism About Gastric Band Safety in Teens

When the researchers initiated their study back in 2009, major concerns at the time included whether weight loss was even desirable in young adolescents, and if it was, should it be achieved by aggressive lifestyle intervention alone, or was surgery a viable option?

However, studies have since largely confirmed that aggressive lifestyle intervention promotes at best a 3-unit drop in body mass index (BMI), while medications associated with weight loss (eg, metformin) can produce only about a 1-unit drop in BMI. Used together, people attempting to lose weight can, at best, expect a 4- to 5-unit drop in BMI, which is not enough to make much of a difference in the morbidly obese, everyone agrees.

"At that time, the lap band was the main procedure for weight loss that was being talked about, and my concern was, how could you place a foreign body indefinitely inside a young person and not expect an increasing rate of complications down the track?" Dr Khurana explained.

Thus, he and his colleagues commenced their study with a great deal of skepticism about the long-term safety and efficacy of the lap-band procedure in morbidly obese adolescents.

They recruited 21 adolescents between the ages of 14 and 18 years with a BMI of 40 kg/m2 or higher, or a BMI of 35 kg/m2 or higher in the presence of obesity-related comorbidities.

"All procedures were performed laparoscopically by a single pediatric surgeon mentored by two experienced bariatric surgeons," the investigators report. The Swedish Adjustable Gastric Band (SAGB-VC, Ethicon) was used in all patients.

The median age of the group was 17.3 years and median baseline BMI was 47.1 kg/m2; 16 out of the 21 patients had a BMI in excess of 40 kg/m2. Baseline comorbidities included prediabetes, elevated liver enzymes, an abnormal lipid profile, and hypertension.

After a median follow-up of 45.5 months, the group's median BMI was 39.2 kg/m2 at last follow-up.

Following the procedure, BMI at all follow-up visits — 3, 6, 12, 24, 36, and 48 months — significantly improved compared with preprocedural BMI levels (P < .001, all comparisons).

As the researchers note, slightly over half of the cohort who had at least one comorbidity at baseline, improved after LAGB, and overall quality of life scores also significantly improved after the procedure, as reported by both the adolescents and their parents.

For example, at 6 months post-LABG adolescent quality-of-life scores improved to 60 from approximately 75 at baseline on the Pediatric Quality of Life Inventory (P = .03).

Parental scores improved to approximately 53 post-LAGB compared with 74 at baseline on the Parent Proxy Report (P = .02).

BMI Over Time Following LAGB

Measure 12 mo 24 mo 36 mo 48 mo
BMI (kg/m2) 39 40 36 35
BMI loss (kg/m2) 7 7 8 6
Body weight loss (%) 19 16 16 16
BMI loss (%) 18 16 19 15

 Gastric Band Helped Adolescents Reach Weight-Loss Benchmark

"There were four early, minor and 12 late band- or weight-loss–related complications," Dr Khurana and colleagues report. Specifically, seven patients had to have their band removed after 3.5 years — two because of lack of weight loss and five because of weight regain.

Two additional patients also developed obstructive symptoms combined with weight regain, yielding a reoperation rate of 42%.

However, as Dr Khurana explained, "Our threshold for removing the band was actually very low and, in other hands, the bands would not have been removed."

Furthermore, despite the high rate of band removal, he emphasized they do not consider their study a failure for a number of reasons.

A recent meta-analysis exploring relative weight loss achieved with LAGB, RYGB, or sleeve gastrectomy in obese adolescents showed that BMI loss was 11.6 kg/m2 after LAGB compared with 16.6 kg/m2 after RYGB, and was 14.1 kg/m2 after sleeve gastrectomy (Obes Surg. 2015;25:860–878).

"At 48 months, our BMI loss with the lap band was about 10 kg/m2, so we certainly met the benchmark in that regard," Dr Khurana noted.

Furthermore, only a few patients in their cohort did not show a decrease in BMI of 4 to 5 units, the maximum possible achievable with a combination of aggressive lifestyle intervention and weight-loss medication.

"We have shown that the use of LAGB in severely obese adolescents reduced BMI by 10 kg/m2 over 45 months," he and his colleagues observe.

"And adolescents had improvement in quality of life and comorbidities without significant morbidity with LAGB," they add.

As previously reported by Medscape Medical News, two separate recent studies in which obese adolescents underwent RYGB found that they maintained an average weight loss of approximately 30% in both studies.

That said, at the end of 8 years 63% of participants in one study were still severely obese (BMI ≥ 35 kg/m2) despite receiving the gold-standard RYGB procedure, although this needs to be viewed in the context that mean baseline BMI before the procedure was 58.5 kg/m2. And at the end of 5 years in the other study, 72% of adolescents undergoing the same procedure achieved a BMI of 35 kg/m2 or lower.

Lap Band Must Be Removed Within 5 Years

As a bariatric procedure, LAGB has fallen out of favor over the past few years because surgeons have increasingly recognized that it is not without complications, and the risk of complications increases the longer the band is left in place.

Dr Khurana told Medscape Medical News, "There is a big difference in the dogma regarding the lap-band procedure now, so that it's no longer, 'the lap band can be removed if need be,' but rather, 'the lap band must be removed because the longer you leave it in, the more likely it will cause problems that may not be truly reversible.' "

So the approach should be that the band is being put in for a "limited timeframe," he noted, and "you also know that you'll be taking it out within a definite timeframe, and that's the big difference in our approach compared with others elsewhere."

He said the current study can't answer exactly how long a lap band should be left in place if complications don't arise, but he suggests that a maximum of 5 years would be reasonable.

The authors have reported no relevant financial relationships.

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Obese Surg. Published online January 12, 2017. Abstract

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