Long Term Outcomes of Laparoscopic Adjustable Gastric Banding for Treatment of Morbid Obesity in Adolescents

Chrestiana Dewi1; Suc; y Iswanto

doi:10.4172/2165-7904.1000175

ISSN: 2165-7904

Journal of Obesity & Weight Loss Therapy

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Long Term Outcomes of Laparoscopic Adjustable Gastric Banding for Treatment of Morbid Obesity in Adolescents

*Chrestiana Dewi^1 and Sucandy Iswanto²**
¹Abington Memorial Hospital, Department of Surgery, Abington, PA, USA
²Airlangga University School of Medicine, Surabaya, Indonesia
Corresponding Author :	Dewi Chrestiana, M.D Department of Surgery Abington Memorial Hospital Abington, 117 N Easton Road Glenside PA 19038, USA Tel: 215-429-6400 E-mail: dewichrestiana@yahoo.com
Received April 29, 2013; Accepted May 10, 2013; Published May 13, 2013
Citation: Dewi C, Iswanto S (2013) Long Term Outcomes of Laparoscopic Adjustable Gastric Banding for Treatment of Morbid Obesity in Adolescents. J Obes Weight Loss Ther 3:175. doi:10.4172/2165-7904.1000175
Copyright: © 2013 Dewi C, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Childhood obesity becomes a concern to parents and health providers. Children with body mass index (BMI) >99^th percentile tends to become obese adults with more health complications and higher mortality rate than those who become obese in adulthood. Nonoperative management through a well supervised diet, psychological counseling, and physical activity program have been shown to result in poor long-term sustainability and low success rate in significant percentage of adolescents [1,2]. A minimally invasive procedure without alteration in the anatomy of the gastrointestinal tract is considered more appropriate and less risky. Laparoscopic adjustable gastric banding (LAGB), therefore, has rapidly become the preferred bariatric operation for adolescents. Despite promising short-term results, little is known about its long term outcomes. We designed a study to review long term outcomes of LAGB in morbidly obese adolescents to understand the procedure benefits and to delineate its role in the treatment of childhood obesity.

Using PubMed, MEDLINE, and CHINAHL databases, metaanalytic review of 13 articles from 2005 to 2012 was performed (Table 1). Keywords used were adolescent, children, and laparoscopic gastric banding. The primary endpoint was long-term weight loss outcomes of LAGB for treatment of morbid obesity in adolescents.

Five hundred ninety one morbidly obese adolescents were included with equal gender distribution. The average preoperative BMI was 46.5 kg/m². Preoperative obesity-related co morbidities included steatohepatitis (80.8 ± 14.3%), dyslipidemia (55.1 ± 29.4%), diabetes mellitus (DM) (51.0 ± 44.1%), hypertension (HTN) (38.9 ± 24.7%), polycystic ovary syndrome (PCOS) (34.4 ± 11.9%), obstructive sleep apnea (OSA) (30.7 ± 15.8%), depression (26.9 ± 4.2%), osteoarthritis (OA) (22.5 ± 19.5%), and gastroesophageal reflux disease (GERD) (12.2 ± 15.5%). The mean operative time was 62.7 minutes and the length of hospital stay was 32.9 hours. At 6, 12, 18, 24, 36, 48, and 60 months after the LAGB, the average excess weight loss were 29.1%, 44%, 57.8%, 51%, 60.8%, 63%, and 66.2%, respectively (Table 2). All of the comorbidities were improved or resolved postoperatively. Postoperative complications were reported in 76 patients (12.3%), which included band slippage ± pouch dilation 30 (39.47%), vitamin or mineral deficiency 11 (14.5%), subcutaneous port complications requiring revision 8 (10.5%), severe gastro esophageal reflux 5 (6.6%), dehydration 4 (5.3%), band leakage 3 (3.9%), and others.

Morbidly obese adolescents with multiple obesity-related co morbidities are at risk for suboptimal performance and development during their adulthood. Childhood obesity is associated with steatosis, dyslipidemia, type 2 diabetes, hypertension, polycystic ovary, obstructive sleep apnea, depression, nonalcoholic fatty liver, orthopedic problems, gastroesophageal reflux disease, coronary artery disease, fatty liver disease, and premature mortality in adulthood. Obesity causes vessels rigidity especially carotid artery, which subsequently causes hypertension and cardiovascular disease. Consequence of obstructive sleep apnea presents as learning difficulties, hyperactivity, and cardiovascular abnormalities. Depression brings a concern where it is accompanied by potentially dangerous behaviors such as feelings of guilt, anxiety, panic, paranoia, alcohol use, tobacco use, illicit drug use, suicidal ideation, suicidal attempts, and deliberate self-harm [3].

Surgical weight loss method has been known to be the most effective and durable treatment for morbid obesity. O’Brien et al. reported in their study of randomized controlled trial comparing gastric banding procedure versus a lifestyle weight loss program [1]. The extent of weight loss, resolution of metabolic syndrome and insulin resistance were substantially greater in the gastric banding group. The variability in the rate of weight loss between time periods was observed and it is thought to be related to uncontrolled diet, lack of exercise or psychological support [1,4-6], and loss of follow-up [7,8]. A combination of surgical procedure, exercise program and lifestyle modification produce the most optimal outcomes. Lack of social supports, failure to change eating habits, and failure to incorporate recommended exercise are the most common causes of suboptimal weight loss following LAGB. Overall complication after LAGB was 12.3% (Figure 1). Band slippage with or without pouch dilation was the most common complication after LAGB. Yitzhak et al. and Fielding et al. proposed the solution for this problem by utilizing pars-flaccida approach to the esophagogastric angle. This method reduced the incidence of band slippage from 28% to <3% [2] and from 12% to 1-2% [9], respectively. Of the total patients, only eleven (1.8%) experienced vitamin or mineral deficiency. Appropriate supplementation before symptoms development effectively prevents this complication. Gastroesophageal reflux and inability to tolerate oral diet resulting in dehydration can be managed by adjusting the gastric banding during follow-up visits. Lack of experience in managing early port-related complications is associated with increased need for reoperation. Other reported minor complications include tube crack, port site bleeding or hematoma, superficial soft tissue infection, cholelithiasis and nephrolithiasis.

Morbidly obese adolescent who failed multiple attempts of nonoperative weight loss programs, potentially benefit from laparoscopic adjustable gastric banding. This procedure is safe, effective, and durable in achieving weight loss outcome, with acceptable rates of postoperative complications. Postoperative exercise program, lifestyle modification, and psychological support continue to play a major role in the ultimate success of the operation.