Perioperative Course, Weight Loss and Resolution of Comorbidities After Primary Sleeve Gastrectomy for Morbid Obesity: Are There Differences Between Adolescents and Adults?

A Population-Based Cohort Study on Efficacy and Safety of Bariatric Surgery in Young Adults Versus Adults

PURPOSE

Bariatric surgery is the most effective treatment for severe obesity in adults and has shown promising results in young adults. Lack of insight regarding efficacy and safety outcomes might result in delayed bariatric surgery utilization in young adults. Therefore, this study aimed to assess the efficacy and safety of bariatric surgery in young adults compared to adults.

METHODS

This is a nationwide population-based cohort study utilizing data from the Dutch Audit Treatment of Obesity (DATO). Young adults (aged 18-25 years) and adults (aged 35-55 years) who underwent primary Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) were included. Primary outcome was percentage total weight loss (%TWL) until five years postoperatively.

RESULTS

A total of 2,822 (10.3%) young adults and 24,497 (89.7%) adults were included. The follow-up rates of the young adults were lower up to five years postoperatively (46.2% versus 56.7% three years postoperatively; p < 0.001). Young adults who underwent RYGB showed superior %TWL compared to adults until four years postoperatively (33.0 ± 9.4 versus 31.2 ± 8.7 three years after surgery; p < 0.001). Young adults who underwent SG showed superior %TWL until five years postoperatively (29.9 ± 10.9 versus 26.2 ± 9.7 three years after surgery; p < 0.001). Postoperative complications ≤ 30 days were more prevalent among adults, 5.3% versus 3.5% (p < 0.001). No differences were found in the long term complications. Young adults revealed more improvement of hypertension (93.6% versus 78.9%), dyslipidemia (84.7% versus 69.2%) and musculoskeletal pain (84.6% versus 72.3%).

CONCLUSION

Bariatric surgery appears to be at least as safe and effective in young adults as in adults. Based on these findings the reluctance towards bariatric surgery in the younger age group seems unfounded.

Laparoscopic sleeve gastrectomy for obesity treatment in adolescents and young adults: a systematic review and meta-analysis

BACKGROUND

The incidence of obesity has been increasing in younger population, posing a significant impact on adolescents' life and health care system worldwide.

METHODS

We critically analyzed the existing literature on the use of laparoscopic sleeve gastrectomy (LSG) for the treatment of obesity. We performed an in-depth evaluation of 37 studies and analyzed the effect of LSG in 2300 patients, aged ≤ 22 years.

RESULTS

Mean body mass index (BMI) loss after LSG was 17.81 kg/m2. Gastroesophageal reflux was the most common complication. Most of the patients showed remission of comorbidities including hypertension, diabetes, and obstructive sleep apnea after LSG.

CONCLUSIONS

These findings suggest that surgical intervention is highly beneficial for reducing BMI in appropriately selected adolescents and young adults suffering from obesity and comorbidities such as life-threatening obstructive sleep apnea.

Surgery for the treatment of obesity in children and adolescents

BACKGROUND

Child and adolescent overweight and obesity have increased globally and are associated with significant short- and long-term health consequences.

OBJECTIVES

To assess the effects of surgery for treating obesity in childhood and adolescence.

SEARCH METHODS

For this update, we searched Cochrane Central Register of Controlled Trials, MEDLINE, Latin American and Caribbean Health Science Information database (LILACS), World Health Organization International Clinical Trials Registry Platform (ICTRP)and ClinicalTrials.gov on 20 August 2021 (date of the last search for all databases). We did not apply language restrictions. We checked references of identified studies and systematic reviews.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) of surgical interventions for treating obesity in children and adolescents (age < 18 years) with a minimum of six months of follow-up. We excluded interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or which included participants with a secondary or syndromic cause of obesity, or who were pregnant.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently extracted data and assessed the risk of bias using the Cochrane Risk of Bias 2.0 tool. Where necessary, we contacted authors for additional information.

MAIN RESULTS

With this update, we did not find any new RCTs. Therefore, this updated review still includes a single RCT (a total of 50 participants, 25 in both the intervention and comparator groups). The intervention focused on laparoscopic adjustable gastric banding surgery, which was compared to a control group receiving a multi-component lifestyle programme. The participating population consisted of Australian adolescents (a higher proportion of girls than boys) aged 14 to 18 years, with a mean age of 16.5 and 16.6 years in the gastric banding and lifestyle groups, respectively. The trial was conducted in a private hospital, receiving funding from the gastric banding manufacturer. For most of the outcomes, we identified a high risk of bias, mainly due to bias due to missing outcome data. Laparoscopic gastric banding surgery may reduce BMI by a mean difference (MD) of -11.40 kg/m2 (95% CI -13.22 to -9.58) and weight by -31.60 kg (95% CI -36.66 to -26.54) compared to a multi-component lifestyle programme at two years follow-up. The evidence is very uncertain due to serious imprecision and a high risk of bias. Adverse events were reported in 12/25 (48%) participants in the intervention group compared to 11/25 (44%) in the control group. A total of 28% of the adolescents undergoing gastric banding required revisional surgery. The evidence is very uncertain due to serious imprecision and a high risk of bias. At two years of follow-up, laparoscopic gastric banding surgery may increase health-related quality of life in the physical functioning scores by an MD of 16.30 (95% CI 4.90 to 27.70) and change in health scores by an MD of 0.82 (95% CI 0.18 to 1.46) compared to the lifestyle group. The evidence is very uncertain due to serious imprecision and a high risk of bias. No data were reported for all-cause mortality, behaviour change, participants' views of the intervention and socioeconomic effects. Finally, we have identified three ongoing RCTs that are evaluating the efficacy and safety of metabolic and bariatric surgery in children and adolescents.

AUTHORS' CONCLUSIONS

Laparoscopic gastric banding led to greater body weight loss compared to a multi-component lifestyle program in one small study with 50 participants. These results have very limited application, primarily due to more recent recommendations derived from observation studies to avoid the use of banding in youth due to long-term reoperation rates. This systematic review update still highlights the lack of RCTs in this field. The authors are concerned that there may be ethical barriers to RTCs in this field, despite the lack of other effective therapies for severe obesity in children and adolescents and the significant morbidity and premature mortality caused by childhood obesity. Nevertheless, future studies, whether pre-registered and planned non-randomised or pragmatic randomised trials, should assess the impact of the surgical procedure and post-operative care to minimise adverse events, including the need for post-operative adjustments and revisional surgery. Long-term follow-up is also critical to comprehensively assess the impact of surgery as participants enter adulthood.

Primary Sleeve Gastrectomy and Leaks: The Impact of Fundus-Wall Thickness and Staple Heights on Leakage-An Observational Study of 500 Patients

Introduction: The most feared complication of laparoscopic sleeve gastrectomy (LSG) is staple-line leakage. Staple height and fundus-wall thickness might influence such leakage, and this study examined their possible impact on leak incidence. Factors including gender, age, comorbidities, and reinforcement of the staple line were also investigated.

Methods: A total of 500 patients between 17 and 71 years of age who were scheduled for LSG were selected to participate in the study. For technical reasons, 53 were excluded. The fundus-wall thickness of 447 patients after LSG was investigated. The impact of staple height, fundus-wall thickness, demographic and medical factors on leak incidence were investigated. Most of our patients (309) were female (69%), while 138 were male (31%).

Results: The mean thickness of the proximal fundus wall was 2,904 μm, 3,172 μm in men and 2,784 μm in women. The leak rate was 4.9%. Age, fundus-wall thickness, and BMI showed a strong influence on leak risk, but this effect was significant only for age (p = 0.01). Patient gender and staple size showed no significant influence on the correlation between fundus-wall thickness and leak risk. Gender displayed a small effect of influence on this correlation, with η2 = 0.05.

Discussion: Because older age had a significant effect on increasing the risk of staple-line leakage, there is a need for a more specific focus on these patients. Thinner fundus wall and female gender might predispose patients to staple-line leaks, but a significant value could not be reached. Therefore, staple size should remain the surgeon's choice based on clinical experience.

Comparison of the one-year outcomes of bariatric surgery in adolescents and young adults: a matched case-control study, Tehran Obesity Treatment Study (TOTS)

PURPOSES

The increasing use of bariatric surgery in adolescents has raised some concerns regarding the postoperative outcomes and the optimal time of surgery at young ages. However, no study has yet compared the weight loss and comorbidity resolution following bariatric surgery between adolescents and young adults.

METHODS

This study was conducted on a case group of adolescents (aged 11-18) and a control group of young adults (aged 19-29) undergoing bariatric surgery (sleeve gastrectomy or gastric bypass). The two groups were matched in terms of gender, body mass index (BMI), and surgery type and were assessed regarding the surgical outcomes at 1 year after surgery.

RESULTS

The baseline characteristics of the adolescents (n = 118, mean age: 17.0 ± 1.6 years) and young adults (n = 236, mean age: 25.2 ± 3.2 years) were similar, as well as surgery-associated complications. The mean loss of BMI (- 15.4 ± 3.6 vs. -15.8 ± 4.6 kg/m²) and 12-month percentage of excess weight loss (80.4 ± 20.1 vs. 80.2 ± 20.1%) were similar in the two groups. Both groups showed parallel reductions in the cardiovascular risk factors. The remission of hypertension, diabetes mellitus, and dyslipidemia was similar between the groups. The increase in the hemoglobin level and copper deficiency was greater in young adults, whereas the increase in ferritin deficiency was greater in adolescents.

CONCLUSION

Similar to young adults, bariatric surgery is an effective and safe method to achieve weight loss, resolve obesity-related comorbidities, and improve cardiovascular risk factors in the adolescents.

Outcomes of Bariatric Surgery in Older Versus Younger Adolescents

OBJECTIVES

In this report, we compare weight loss, comorbidity resolution, nutritional abnormalities, and quality of life between younger and older adolescents after metabolic and bariatric surgery.

METHODS

From March 2007 to December 2011, 242 adolescents (≤19 years of age) who underwent bariatric surgery at 5 clinical centers in the United States were enrolled in the prospective, multicenter, long-term outcome study Teen-Longitudinal Assessment of Bariatric Surgery. Outcome data from younger (13-15 years; n = 66) and older (16-19 years; n = 162) study participants were compared. Outcomes included percent BMI change, comorbidity outcomes (hypertension, dyslipidemia, and type 2 diabetes mellitus), nutritional abnormalities, and quality of life over 5 years post surgery.

RESULTS

Baseline characteristics, except for age, between the 2 cohorts were similar. No significant differences in frequency of remission of hypertension (P = .84) or dyslipidemia (P = .74) were observed between age groups. Remission of type 2 diabetes mellitus was high in both groups, although statistically higher in older adolescents (relative risk 0.86; P = .046). Weight loss and quality of life were similar in the 2 age groups. Younger adolescents were less likely to develop elevated transferrin (prevalence ratio 0.52; P = .048) and low vitamin D levels (prevalence ratio 0.8; P = .034).

CONCLUSIONS

The differences in outcome of metabolic and bariatric surgery between younger and older adolescents were few. These data suggest that younger adolescents with severe obesity should not be denied consideration for surgical therapy on the basis of age alone and that providers should consider adolescents of all ages for surgical therapy for obesity when clinically indicated.

Comparison of Short and Long-Term Outcomes of Metabolic and Bariatric Surgery in Adolescents and Adults

Objective: We sought to compare the short and long-term outcomes of MBS in adolescents vs. adults who have undergone a Roux-en-Y gastric bypass (RYGB) or Sleeve gastrectomy (SG). Design: Retrospective cohort study. Setting: Single tertiary care academic referral center. Participants: One hundred fifty adolescent (≤ 21-years) and adult (>21-years) subjects with severe obesity between 15 and 70 years of age who underwent RYGB or SG. Outcomes: Metabolic parameters, weight and height measures were obtained pre-and post-surgery (at 3 and 6 months, and then annually for 4 years). Results: Median pre-surgical body mass index (BMI) was higher in adolescents (n = 76) vs. adults (n = 74): 50 (45-57) vs. 44 (40-51) kg/m2 (p < 0.0001). However, obesity related complications were greater in adults vs. adolescents: 66 vs. 21% had hypertension, 68 vs. 28% had dyslipidemia, and 42 vs. 21% had type 2 diabetes mellitus (all p < 0.010). % BMI reduction and % weight loss (WL) were greater in adolescents vs. adults at all time points (p < 0.050). %WL was higher in adolescents who underwent SG at each time point (p < 0.050), and trended higher among adolescents who underwent RYGB (p = 0.060), compared to adults with the respective procedure. Follow-up data showed greater resolution of type 2 diabetes and hypertension in adolescents than adults (87.5 vs. 54.8%; p = 0.04, and 68.7 vs. 35.4%; p = 0.040). Conclusion: Adolescents compared to adults had greater reductions in BMI and weight, even at 4 years, and greater resolution of type 2 diabetes and hypertension. Earlier intervention in the treatment of severe obesity with MBS may lead to better outcomes.

Complications of bariatric surgery in adolescents

Over the past decade, outcomes data have demonstrated the benefit of bariatric surgery in achieving both sustained weight loss and reversal of co-morbidities. Comparing these data to contemporary known risks of adolescent bariatric surgery informs the patients and providers considering bariatric procedures and provides insight into potential ways to reduce and manage complications. The goal of this article is to review the common surgical and postoperative complications following bariatric procedures and discuss approaches to improve their safety. A systematic review identifying bariatric surgery complications in adolescents was conducted. The review focused on the data relevant to adolescent bariatric surgery. However, when necessary, adult studies were used to address the gaps in available pediatric information. The data pertaining to the intraoperative, short term, and long term surgically related and nutritional related complications show that complication are declining with increasing experience. Specific recommendations and strategies to avoid major complications of bariatric surgery in adolescents are offered.

Endoscopic Sleeve Gastroplasty in 109 Consecutive Children and Adolescents With Obesity: Two-Year Outcomes of a New Modality

OBJECTIVES

Endoscopic sleeve gastroplasty (ESG) uses full-thickness sutures that restrict the stomach to a sleeve-like configuration. There is no published evidence on endoscopic tissue apposition techniques in pediatric patients. In this article, we report our ESG experience with the first 109 pediatric patients with obesity who underwent ESG under our care.

METHODS

ESG was offered as a day-case procedure under a standardized protocol and clinical pathway that included surgical, medical, and endoscopic modalities for the treatment of pediatric and adult obesity. ClinicalTrials.gov Identifier: NCT03778697.

RESULTS

The 109 patients in this study had a baseline body mass index and age of 33.0 ± 4.7 and 17.6 ± 2.2 (range: 10-21) years, respectively. Ninety-nine (90.8%) were females. The mean procedure time was 61 ± 19 minutes. The mean % total weight loss at 6, 12, 18, and 24 months was 14.4% ± 6.5%, 16.2% ± 8.3%, 15.4% ± 9.2%, and 13.7% ± 8.0%, respectively. Fourteen adolescents visited the ambulatory clinic for analgesia. One patient (aged 19.8 years) requested removal of endoscopic stitches due to abdominal pain, and another underwent Redo-ESG for insufficient weight loss. There were no blood transfusions, emergency admissions, mortality, or significant morbidity.

DISCUSSION

In this first study to date on ESG in pediatric patients, we observed that the procedure is safe and effective in children and adolescents with obesity. Significant weight loss occurs during the first 2 years without mortality or significant morbidity, and this weight loss seems to be maintained.

Five-year Outcomes of Laparoscopic Sleeve Gastrectomy: a Comparison Between Adults and Adolescents

BACKGROUND

Bariatric surgery in adolescents is still under debate. Literature about the long-term impact of laparoscopic sleeve gastrectomy (LSG) on adolescents' obesity and associated morbidities is scarce. It is unknown if LSG shows better long-term results in the adolescent or adult group.

AIM

To compare the long-term effectiveness of LSG on obesity and associated comorbidities between adolescents and adults.

METHODS

This retrospective study analyzed all patients with morbid obesity who underwent LSG in (2011-2012) and were followed for up to 5 years. Patients were divided into two groups: adolescents and adults. Data were compared between the two groups.

RESULTS

LSG was performed in 139 adults and 91 adolescents. The mean ages of the adults and adolescents were 37.4 ± 11.4 and 17 ± 1.5 years, respectively. The preoperative body mass index values of the adults and adolescents were 48.4 ± 8.7 and 47.6 ± 7.5 kg/m2, respectively (P = 0.95). At 5 years, percentage of total weight loss increased in adolescents (to 35.8 ± 11.5%), while it remained almost the same in adults (26.3 ± 10%). At 1 year, about 68.2% of adults and 62.5% of adolescents were cured from diabetes though, 13% of diabetic adults had relapse at 5 years and none of the adolescents relapsed. Postoperative complications occurred in both groups.

CONCLUSION

LSG showed comparable weight loss results in adults and adolescents, with better results in adolescents. LSG is more effective in preventing and treating diabetes/prediabetes in the adolescent group.

Recent trends of bariatric surgery in adolescent population in the state of New York

BACKGROUND

In the United States the percentage of adolescents with obesity has reached an alarming level of 21%. Bariatric surgery has emerged as a successful intervention in the weight loss for adolescents.

OBJECTIVE

To compare bariatric procedures performed in adolescent and adult populations.

SETTING

University Hospital, United States.

METHODS

Using the Statewide Planning and Research Cooperative System (SPARCS) database, records from the adolescent (age 12-21years) and adult populations undergoing bariatric surgery during 2005-2014 were examined. Patients' demographics, surgery type (Roux-en-Y gastric bypass (RYGB), Sleeve Gastrectomy (SG), Laparoscopic Adjustable Gastric Banding (LAGB), length of stay (LOS), complications and comorbidities were analyzed.

RESULTS

The annual adolescent bariatric cases increased from 150 in 2005 to 406 in 2014. In the adolescent population, increasing utilization trends were noted in the Hispanic population (RR=1.08, p-value<0.0001), use of Public (Medicaid or Medicare) insurance (RR=1.10, p-value=0.0003) and SG procedures (RR= 1.56, p-value <0.0001). Decreasing trends were noted in the Caucasian population (RR=0.95, p-value<0.0001), RYGB (RR=0.92, p-value<0.0001) and LAGB (RR= 0.84, p-value=0.0001). Adolescents undergoing bariatric surgery had fewer comorbidities (55.4% vs 81.1%, p-value<0.0001), experienced fewer complications (3.3% vs 4.9%, p-value<0.0001) and 30-day readmissions (3.8% vs 5.0%, p-value=0.0029). Length of stay was also found to be significantly shorter for the adolescent population (1.73 vs 2.00 days, p-value<0.0001). After adjusting for other confounding factors, adolescent patients still had significantly lower complication risk (p-value=0.01) and shorter length of stay (p-value=0.0005) than adults.

CONCLUSION

Bariatric surgery procedure rates have increased in the adolescent population with increasing trend of using LSG. The data from our study supports that bariatric surgery is safe in adolescents with significantly lower complication risk and shorter length of stay as compared to the adult population.