Teens Get Lasting Weight Loss With Two of Three Bariatric Procedures

Kristin Jenkins

October 23, 2018

The largest retrospective US study to directly compare outcomes from the most common weight loss surgeries for severe obesity in adolescence shows that significant and sustained weight loss can be safely achieved with two out of three bariatric procedures.

Results from the National Patient-Centered Clinical Research Network (PCORnet) bariatric study, led by Thomas H. Inge, MD, PhD, of the University of Colorado, Denver, were recently published in Surgery for Obesity and Related Diseases.

The multisite analysis showed that both Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) procedures were superior to adjustable gastric banding (AGB) in 544 adolescents who underwent bariatric surgery between 2005 and 2015.

At 5 years, almost all of the teens who underwent RYGB maintained a reduction in mean body mass index (BMI) of approximately 24% and most treated with SG were able to maintain a mean BMI reduction of 21%, the study showed.

By comparison, half of teens who underwent AGB had a clinically meaningful decrease in body mass index (BMI) of 10% at 1 year. The small number of patients treated with AGB precluded analysis of longer-term outcomes, the researchers say.

There were no perioperative deaths and few patients experienced perioperative morbidity, so no procedural comparisons could be made, they note.

"These data will enable patients, families, and healthcare providers to better understand trends in the use of specific bariatric procedures and how they impact weight loss in adolescents," Inge and colleagues write. "Further long-term studies addressing how these bariatric procedures impact not only BMI but also nutrition, risk of adverse events, and obesity-related physical and mental health comorbidities are needed."

These results mirror earlier findings from the landmark Teen-Longitudinal Assessment of Bariatric Surgery Study (Teen-LABS) (N Engl J Med. 2016;374:113-123), which was also led by Inge and reported by Medscape Medical News.

Teen-LABS demonstrated a 3-year BMI reduction of 27% in adolescents undergoing either RYGB or SG, with significant improvements in weight, cardiometabolic health, and weight-related quality of life.

Sleeve Gastrectomy Now Preferred Method of Bariatric Surgery in Teens

The PCORnet study results also support a systematic review and meta-analysis of bariatric surgery outcomes in 1928 adolescent patients and confirm that the use of RYGB and AGB procedures has declined markedly (Surg Obes Relat Dis. 2018;14:413-422).

The US Food and Drug Administration (FDA) states that AGB is not indicated in patients younger than 18 years of age, the researchers say, adding that AGB "is unlikely to have a significant role in treatment of adolescent obesity in the future."

Based on these results, "sleeve gastrectomy is demonstrating the long-term durability for weight loss maintenance that we want to see," Inge told Medscape Medical News. Although a number of devices to treat obesity are currently in the research and development pipeline, "nothing on the immediate horizon appears to be superior to vertical sleeve gastrectomy for use in adolescence," he noted.

And early intervention is key, Inge stressed. "My feeling is that if we can treat severe obesity earlier in life we will have a greater opportunity to reverse these comorbid health conditions than if we wait until adulthood."

"Furthermore, I believe that by effectively treating severe obesity when it is diagnosed in adolescence, we will have a greater chance of preventing complications of obesity, such as type 2 diabetes, high blood pressure, and cardiovascular diseases, rather than waiting for them to develop."

And in a statement by the Children's Hospital of Colorado, in Aurora, where he is chief of pediatric surgery and director of the Bariatric Surgery Center, Inge added that there is "a dire need to identify effective strategies to combat the myriad of health problems associated with pediatric obesity."

It is estimated that 4% to 7% of youth in the United States are affected by severe obesity, defined as BMI ≥ 35 kg/m2 or BMI ≥ 120% of the 95th percentile for age and sex.

Last July, the Pediatric Committee of the American Society for Metabolic and Bariatric Surgery updated its evidence-based guidelines (Surg Obes Relat Dis. 2018;14:882-901) and concluded that metabolic bariatric surgery is safe and effective in adolescents.

"Given the higher risk of adult obesity that develops in childhood, metabolic bariatric surgery should not be withheld from adolescents when severe comorbidities, such as depressed health-related quality of life score, type 2 diabetes, obstructive sleep apnea, and nonalcoholic steatohepatitis exist," the committee wrote in its report. "Early intervention can reduce the risk of persistent obesity as well as end-organ damage from long-standing comorbidities."

Long-Term Follow-Up of Bariatric Surgery Essential for Teens

In an editorial accompanying the PCORnet study, Oliver A. Varban, MD, from the University of Michigan Health System in Ann Arbor, pointed out that whether bariatric surgery has a lasting impact on physiology "before, during, or after maturity" remains to be determined.

For this reason, long-term follow-up is important in all patients undergoing bariatric surgery, especially those who are adolescents and still growing, he emphasizes.

"Lack of insight, knowledge, or understanding of various bariatric procedures can lead to life-threatening complications, which can occur well into adulthood," Varban cautions.

"For example, adolescents who choose to smoke again or take nonsteroidal anti-inflammatory medications at any time of their life after gastric bypass may be prone to marginal ulceration, which can stricture, bleed, or perforate."

The risk of esophageal reflux can also be increased after SG, which remains the only procedure that is completely irreversible, Varban pointed out. "Hence, the collection of long-term follow-up data is imperative for clinicians and patients to understand what role bariatric surgery plays in the course of treatment for obesity over a lifetime."

PCORnet Study Results

For the study, Inge and colleagues analyzed data from de-identified electronic health records for 544 adolescents retrieved from 56 healthcare systems across the United States. Most of the patients were white (66%), female (79%), and between the ages of 16 and 19 years.

Over the 10-year study period, a total of 177 underwent RYGB, 306 had SG, and 61 received AGB. The mean BMI at baseline was 49.8 kg/m2 with follow-up BMI measures taken at years 1, 3, and 5.

Comorbid health conditions included obstructive sleep apnea in 36% of patients, dyslipidemia (35%), hypertension (32%), depression (28%), gastroesophageal reflux disease (25%), polycystic ovary syndrome (22%), nonalcoholic fatty liver disease (19%), and type 2 diabetes (16%).

Rates of perioperative morbidity within 30 days of surgery were low and included percutaneous, endoscopic, or subsequent operative procedures in 3.3% of patients, venous thromboembolic events in 0.4%, and failure to discharge from hospital within 30 days in 0.7% of patients.

This finding also mirrored results from Teen-LABS. As previously reported by Medscape Medical News, 90% of teenagers in the Teen-LABS cohort did not have major surgical complications following bariatric surgery.

In the current study, teens treated with RYGB or SG experienced the greatest reductions in BMI at each time point during follow-up. At 1 year, RYGB was associated with a mean BMI loss of 31%, SG with a mean BMI loss of 28%, and AGB with a mean BMI loss of 10%.

At 3 years, a mean BMI loss of 29% and 25% was seen in RYGB and SG patients, respectively. A mean BMI reduction of over 30% was also seen in 49% of RYGB patients and 37% of SG patients.

In patients who underwent AGB, there were insufficient observations to make meaningful comparisons with other procedures, the researchers say. However, trend analysis suggested there were no further reductions in BMI after 1 year in these patients.

After 3 years, BMI reduction stabilized in patients who underwent RYGB or SG, confirming results from earlier studies, they explain.

Lifestyle Changes Needed After Surgery, Insurance Coverage Improving

Inge emphasized that maintaining weight loss over the long-term requires a commitment to lifestyle modification.

"Irrespective of the type of operation performed, I believe patients need to make serious changes in the way they approach food, as well as physical activity," he told Medscape Medical News.

Before surgery, "a very deliberate series of discussions" should take place with adolescent patients and their families about what will be required for optimal outcomes following surgery, he suggested.

Like other surgeries involving a minor, written consent from a parent or authorized adult is accompanied by verbal consent from the patient.

Although the cost of bariatric surgery is covered by insurance, Inge noted that attempts are often made to exclude adolescents on the basis of "lack of outcome data for this age group."

After assembling "a great deal of evidence" supporting the use of bariatric surgery in adolescents, however, his group has successfully appealed cases in which an adolescent patient was denied benefits or reimbursement available to an adult member in the same family.

"It is simply wrong to discriminate against teens in this manner and to put them off until they have developed a health problem due to obesity," Inge said. He noted that Medicaid has made coverage determination in favor of bariatric surgery in adolescents in some states but not all.

The study authors and editorialist have reported no financial disclosures.

Surg Obes Relat Dis. 2018;14:1372-1373, 1374-1386.

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