Journal of Pediatric Surgery 50 (2015) 115–122
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Laparoscopic vertical sleeve gastrectomy significantly improves short term weight loss as compared to laparoscopic adjustable gastric band placement in morbidly obese adolescent patients Felipe E. Pedroso a, Jeffery Gander a,b, Pilyung Stephen Oh a, Jeffrey L. Zitsman a,⁎ a b
New York Presbyterian Morgan Stanley Children’s Hospital, Columbia University Medical Center, Department of General Surgery, Division of Pediatric Surgery, Center for Adolescent Bariatric Surgery University of Virginia Health System, Department of Surgery, Division of Pediatric Surgery
a r t i c l e
i n f o
Article history: Received 1 October 2014 Accepted 6 October 2014 Key words: Bariatric Vertical sleeve gastrectomy Laparoscopic adjustable gastric band Adolescent
a b s t r a c t Background: Bariatric surgery has shown to be an effective weight loss treatment in morbidly obese adolescents. We compared outcomes of laparoscopic adjustable gastric band (LAGB) to laparoscopic vertical sleeve gastrectomy (VSG). Methods: A single institution, retrospective evaluation of a prospectively collected database of LAGB and VSG patients. Results: 174 morbidly obese patients underwent bariatric surgery at our institution between 2006 and 2013. 137 patients underwent LAGB and 37 underwent VSG. There were no significant differences between LAGB vs. VSG groups on day of surgery for age, gender, ethnicity, weight, and BMI. At 24-month follow up, patients who underwent VSG vs. LAGB displayed significantly greater percent excess weight loss (70.9 ± 20.7 vs. 35.5 ± 28.6, P = 0.004) and percent preoperative BMI loss (32.3 ± 11.0 vs. 16.4 ± 12.7, P = 0.004). Both VSG and LAGB significantly improved levels of HDL, HgA1c, and fasting glucose. LAGB patients had more complications than VSG patients. Conclusion: Bariatric surgery is an effective treatment strategy in morbidly obese adolescents who have failed medical management. VSG results in greater short term weight and BMI loss when compared to LAGB. Longer follow up with more patients will be required to confirm the long term safety and efficacy of VSG in adolescent patients. © 2015 Elsevier Inc. All rights reserved.
Obesity has become pandemic, and costs for the treatment of obesity related co-morbidities have dramatically increased worldwide. Coincidentally, the incidence of childhood obesity has risen, and with evidence demonstrating that many obese children ultimately become obese adults, effective weight loss strategies at an early age are essential [1,2]. The medical management of obesity has repeatedly been shown to be ineffective at reducing overall weight and sustaining weight loss in adults and children [3,4]. Bariatric surgery has been utilized as a treatment strategy in morbidly obese adults resulting in consistent and sustained weight loss and an overall reduction in obesity related comorbidities [5,6]. NIH guidelines recommend bariatric surgery for severely obese adult patients with BMI N 40 or BMI N 35 with coexisting co-morbidities [7]. The use of bariatric surgery in adolescents (12–18 years of age) remains controversial, however, recent results have shown bariatric surgery in combination with medical therapies to be a safe and effective tool for the treatment of adolescent obesity. NIH
⁎ Corresponding author at: Morgan Stanley Children’s Hospital/New York Presbyterian Hospital, CHN Room 212, 3959 Broadway, New York, NY, 100032. Tel.: +1 2123428585; fax: +1 2123059270. E-mail address: [email protected] (J.L. Zitsman). http://dx.doi.org/10.1016/j.jpedsurg.2014.10.014 0022-3468/© 2015 Elsevier Inc. All rights reserved.
guidelines for bariatric surgery have now been expanded to include adolescent patients [7]. Bariatric surgery performed in adolescent patients has shown promising short term results [8]. Laparoscopic adjustable gastric banding (LAGB), an accepted weight loss tool in adults, has been evaluated in adolescents. Our group and others have found LAGB to be an effective weight loss tool in adolescent patients [9–17]. Presently in the United States, LAGB remains an investigational device in adolescent patients thereby precluding its expanded use. Laparoscopic vertical sleeve gastrectomy (VSG) has been shown in adults to be more effective than LAGB at reducing postoperative weight, sustaining weight loss, and reducing the rates of obesity related co-morbidities [5,18,19]. VSG has now been instituted by our group and others for the treatment of severely obese adolescents. Moreover, several recent reports (mainly small case series) have shown VSG to be safe and successful at reducing weight, BMI, and the rates of obesity related co-morbidities in adolescents [20–25]. In an attempt to evaluate the safety and efficacy of VSG as compared to LAGB in adolescent patients, we have compared these two treatments strategies in adolescents for the first time. We hypothesized that VSG would not only be a safer procedure with lower complication rates, but also a more effective surgical tool in reducing overall weight, sustaining weight loss, and improving seromarkers associated with obese adolescent patients.
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1. Methods This study was approved by the Institutional Review Board of Columbia University Medical Center and the Morgan Stanley Children’s Hospital. All patients were treated at this one institution. The LAGB and VSG registries of the Center for Adolescent Bariatric Surgery have been prospectively developed since 2006, and all data were confirmed by a review of the medical records, clinic visits, and operative reports. All surgeries were performed by a single surgeon at the same tertiary institution. An investigational device exception from the FDA was obtained for the use of the adjustable gastric band in adolescent patients. All patients were screened by phone for height and weight prior to initial meeting with the pediatric surgeon. All patients completed a screening questionnaire (medical history, family history, psychological history, and history of any prior weight loss attempts) and were instructed to write a statement describing why they wished to undergo bariatric surgery. Preoperatively, patients were scheduled to visit with a pediatric endocrinologist, nutritionist, psychologist, and exercise specialist. Baseline laboratory panels were obtained (hematological, blood chemistries, liver function, lipid panels, fasting glucose, and C-reactive protein). Preoperatively, patients underwent monthly meetings with the nutritionist, the nurse practitioner, and the surgeon. Each patient was instructed to maintain an exercise log. Patient status was discussed at weekly team meetings and surgery was offered to patients with a documented failed weight loss despite compliance with recommended eating behavior and exercise changes for a minimum of 6 months. Preoperatively, informed consent was obtained from both patient and one parent. Between July 2010 and April 2011 patients were given a choice between LAGB and VSG, following April 2011 we recommended VSG, however we offered LAGB as another surgical option for patients 18 years and older. A protein-sparing liquid diet was started 2 weeks preoperatively. At surgery all patients received a preoperative antibiotic, and 5000 U of subcutaneous heparin. Sequential compression device stockings were placed on each lower extremity. Nathanson liver retractors were used in all cases. Laparoscopic adjustable gastric band was performed using the LapBand® Systems (Allergan Inc, Irvine, CA) via a 4 port method, which has been previously described by Ren and Fielding [26]. Laparoscopic vertical sleeve gastrectomy was also performed via a 4 port technique. A sleeve gastrectomy of the greater curvature of the stomach from 6 cm proximal from the pylorus to the angle of His was performed over a 40Fr bougie with a linear stapler and reinforced with Seamguard ® (W.L. Gore and Associates Inc.). Staple line bleeding was controlled with monopolar cautery or clips. Upper endoscopy was utilized for intragastric evaluation of the staple line and stomach was insufflated to evaluate for staple line leak. On postoperative day 1 the first 75 LAGB patients and all VSG patients underwent a gastrograffin contrast swallow study, and if negative for stricture or leak, patients were started on a bariatric clear liquid diet. Later LAGB patients had an upright abdominal radiograph to check for band and port positions. At the first postoperative appointment the diet was advanced to a bariatric pureed diet for two weeks, followed by foods as tolerated with continued nutritionist consultation throughout. All patients were seen postoperatively at 2 weeks, and then every month until 3 months, at 6 months, followed by every 6 months out to 2 years, then yearly. LAGB patients were encouraged to return for adjustments whenever necessary and all were performed by the surgeon. Weight in kilograms and height for both LAGB and VSG patients were measured at all visits. Analyses and comparisons were made at different time points including preoperatively, 6, 12, 18, and 24 months. Mean, standard deviation, median, and range weights (kg) and BMI (kg/m 2) were calculated for each time point for both groups. Preoperative body weight was measured at the visit 2 weeks prior to surgery before the protein-sparing diet was begun. Excess body weight was calculated by subtracting preoperative body weight by body weight for age, gender and height at the 85th percentile using CDC growth
charts [27]. Percent Excess Weight Loss (%EWL) was defined as [(preoperative weight − follow up weight)/(preoperative weight − weight corresponding to the 85th percentile for patients age, gender and height) × 100]. Percent preop BMI loss was defined as [(1 − (follow up BMI/preop BMI)) × 100]. Seromarkers associated with obesity including: total triglycerides, total cholesterol, High Density Lipoprotein (HDL), Low Density Lipoprotein (LDL), Hemoglobin gA1c (HgA1c), fasting glucose and C-Reactive Protein (CRP) were all measured preoperatively and at all time points. In order to evaluate the effect of gender on weight and BMI loss by operation (LAGB and VSG), patients were stratified by gender and comparisons of weight and BMI loss by LAGB vs. VSG were made. To evaluate for significant differences between weight and BMI loss in males and females for each procedure type, patients were stratified by type of procedure and comparisons of males and females were made. All analyses included percent excess weight loss and percent preoperative BMI. Linear regression analysis was performed evaluating the effect of LAGB and VSG in trends of seromarkers associated with obesity including: total triglycerides, total cholesterol, HDL, LDL, HgA1c, fasting glucose, and CRP. For each seromarker, slope, y-intercept at day 0 (representing preoperative levels), R square, and p-value for each slope were reported. Comparisons in trends between LABG and VSG were made for all seromarkers. Statistical analysis was performed with SPSS version 18.0 (PASW) released July 30, 2009 (IBM Corporation, Somers NY) and Graphpad Prism Version 5.0 was used for other statistical analysis and figures. Fisher’s exact T-test was used for categorical variables and analysis of variance was used for comparing weights at different time points between LAGB and VSG patients. Statistical significance was defined as P b 0.05.
2. Results 2.1. Patient and group demographics A total of 137 laparoscopic adjustable gastric bands (LAGBs) were placed from February 2006 to April 2011. Mean age for LAGB patients was 16.9 ± 1.2 and more females (94/137) underwent the procedure than males (43/137). Follow up data were available at 6, 12, 18, and 24 months for 137, 126, 111, 81, and 80 patients respectively in the LAGB group and in the VSG group follow up data were available at 6, 12, 18, and 24 months for 31, 21, 7, and 6 patients respectively. 37 laparoscopic vertical sleeve gastrectomies (VSGs) were performed from June 2010 to August 2013 with mean age of 17.3 ± 1.82 with more females (27/37) than males (10/37). No significant differences in age (P = 0.12), gender (P = 0.69), ethnicity (P = 0.07), or preoperative weight (kg) (136.1 ± 26.9, 138.2 ± 25.4, P = 0.68) were noted between LAGB and VSG patients (Table 1). Nine LAGB patients who had more than regained their preoperative weights (average weight gain of 14.9 kg), were converted to a VSG and included in the analysis. No significant difference between LAGB and VSG patients was observed in preoperative excess weight (kg) (65.1 ± 24.2, 66.7 ± 22.1, P = 0.73), or preoperative BMI (kg/m 2) (48.3 ± 8.3 vs. 50.1 ± 9.4, P = 0.26). Operative times were available for all 37 VSG patients and 113 LAGB patients and VSG patients had longer operative times than LAGB patients (144.1 ± 55.1 vs. 112.3. 25.7, P b 0.0001). However, when excluding the 9 reoperative patients who underwent conversions from LAGB to VSG, no significant difference in operative time between LAGB and VSG was observed (112.3 ± 25.7 vs. 114.8 ± 18.2, P = 0.60). No significant differences between LABG and VSG were present for all preoperative studied seromarkers associated with obesity (Total triglycerides, total cholesterol, HDL, LDL, Fasting glucose, HgA1c, and CRP, all P N 0.05), except that VSG patients exhibited a significantly greater fasting glucose (90 ± 13.8 vs. 85.9 ± 7.7, P = 0.02). (Table 1)
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Table 1 Patient characteristics.
# of Pts Age
Gender Ethnicity
Preop Weight (kg)
Preop Excess Body Weight (kg)
Preop BMI (kg/m2)
Operative Time (min)
Total Triglycerides
Total Cholesterol
High Density Lipoprotein
Low Density Lipoprotein
Hemoglobin A1c
Fasting Glucose
C-Reactive Protein
Mean ± S.D. Median Range Male Female Caucasian Hispanic African American Other Mean ± S.D. Median Range Mean ± S.D. Median Range Mean ± S.D. Median Range Mean ± S.D. Median Range Mean ± S.D. Median Range Mean ± S.D. Median Range Mean ± S.D. Median Range Mean ± S.D. Median Range Mean ± S.D. Median Range Mean ± S.D. Median Range Mean ± S.D. Median Range
2.2. Overall weight change following LAGB and VSG No significant difference in preoperative weight and BMI was observed between LAGB and VSG. Overall weight was significantly reduced in VSG patients compared to LAGB patients at 6 (123.4 ± 27.1 vs. 107.7 ± 24.5, P = 0.0004), 12 (118.7 ± 28.0 vs. 98.2 ± 18.1, P = 0.0016), and 18 months (118.6 ± 29.1 vs. 97.7 ± 39, P = 0.0046), with no difference at 24 months (115.1 ± 31.2 vs. 94.2 ± 20.1 P = 0.11). A significantly greater percent excess weight loss (%EWL) was observed in VSG patients as compared to LAGB patients at 6 (48.1 ± 17.9 vs. 21.5 ± 16.0, P b 0.0001), 12 (58.4 ± 22.5 vs. 28.7 ± 21.4, P b 0.0001), 18 (71.9 ± 19.5 vs. 31.5 ± 23.3, P b 0.0001), and 24 (70.9 ± 20.7 vs. 35.5 ± 28.6, P = 0.0039) months. No VSG patients had regained their preoperative weight (kg) at 6 and 12 months, while 10% (11/111) and 13.8% (11/80) of LAGB patients had regained their preoperative weight at 12 and 24 months respectively. The greatest reduction in %EWL was noted at 24 months for LABG (35.5 ± 28.6) and 18 months for VSG (71.9 ± 19.5). (Table 2, Fig. 1A) 2.3. Overall BMI change following LAGB and VSG Similarly, a significantly greater reduction in overall BMI was observed in VSG patients compared to LAGB patients at 6 (39.5 ± 9.4 vs. 43.8 ± 8.5, P = 0.016) and 12 months (35.7 ± 7.2 vs. 41.6 ± 8.4, P = 0.003), and reduced but not significant at 18 (37.0 ± 13.3 vs. 41.5 ±
LAGB
VSG
137 16.9 ± 1.22 17 14.3–19.6 43 94 58 51 22 6 136.1 ± 26.9 132.7 85.5–220 65.1 ± 24.2 61.5 21.6–144.4 48.3 ± 8.3 46.7 33.6–83.6 112.3 ± 25.7 113 65–167 122.6 ± 118 104 38–742 165.9 ± 35.4 165 78–274 42.5 ± 9.4 42 22–78 101 ± 29.6 100 29–207 5.6 ± 0.4 5.5 4.8–7.3 85.9 ± 7.7 86 65–106 9.1 ± 8.5 7.44 0.47–48.1
37 17.3 ± 1.82 17.09 12.7–21.4 10 27 11 21 2 3 138.2 ± 25.4 132.4 98.4–213.6 66.7 ± 22.1 62.5 34.6–142.8 50.1 ± 9.4 47.1 38–81.4 144.1 ± 55.1 124 77.0–303.0 111 ± 36.2 109 59–225 160.7 ± 24.2 162 105–214 40.8 ± 11.1 38 19–72 96.7 ± 23.2 96.5 57–148 5.5 ± 0.7 5.4 4.5–8.3 90 ± 13.8 87 72–146 10.1 ± 8.7 7.65 0.4–41
P-Value 0.12
0.69 0.07
0.68
0.73
0.26
b0.0001
0.67
0.13
0.25
0.20
0.28
0.02
0.69
8.9, P = 0.226) and 24 months (33.0 ± 6.2 vs. 40.5 ± 10.9, P = 0.099). Alternatively, percent preoperative BMI loss was greater in the VSG group as compared to the LAGB group at all time points: 6 (22.2 ± 6.7 vs. 9.3 ± 6.1, P b 0.0001), 12 (25.9 ± 9.9 vs. 12.6 ± 9.0 vs. P b 0.0001), 18 (31.1 ± 11.5 vs. 14.8 ± 10.2, P = 0.0001), and 24 months (32.3 ± 11.0 vs. 16.4 ± 12.7, P = 0.0038). No VSG patients had regained their preoperative BMI (kg/m 2) at 6 (0/21) and 12 months months (0/6). On the other hand 11.7% (13/111) of LAGB patients and 13.8% (11/80) had regained their starting BMI at 12 and 24 months respectively. The greatest reduction in percent preoperative BMI loss was at 24 months for both LAGB (16.4 ± 12.7) and VSG patients (32.3 ± 11.0). (Table 2, Fig. 1B) 2.4. Overall weight and BMI change by gender following LAGB and VSG Males and females were stratified into separate groups and comparisons were made for changes in weight, BMI, %EWL, and %Preoperative BMI. There was no significant difference in preoperative weight between LAGB and VSG for both males and females. Males had greater preoperative weight than females for both LABG (150.8 ± 27.1, vs. 129.4 ± 24.1, P b 0.0001) and VSG (151.7 ± 30.4 vs. 133.1 ± 21.9, P = 0.047). Irrespective of gender, VSG displayed significantly greater %EWL compared to LAGB at 6 (P b 0.0001), 12 (P b 0.001), and 24 months (P b 0.05). Also, irrespective of gender VSG displayed significantly greater percent preoperative BMI at 6 (P b 0.0001) and 12 months
b0.0001
0.0038
0.0001
P-Value
–
VSG
– – – – 31 (84) 22.2 ± 6.7 21.8 10.9–34.2 21 (57) 25.9 ± 9.9 24.1 11.8–47.4 7 (19) 31.1 ± 11.5 30.1 14.1–46.0 6 (16) 32.3 ± 11.0 37.2 12.0–41.4
LAGB
– – – – 126 (92) 9.3 ± 6.1 9 −10.9–29.8 111 (81) 12.6 ± 9.0 11.7 −12.4–37.7 81 (59) 14.8 ± 10.2 13.7 −10.9–38.7 80 (58) 16.4 ± 12.7 15.9 −12.6–51.9 0.099 0.0039
0.226 b0.0001
0.003 b0.0001
b0.0001
0.016
P-Value
0.26
VSG
37 (100) 50.1 ± 9.4 47.1 38–81.4 31 (84) 39.5 ± 9.4 37.4 26.2–64.8 21 (57) 35.7 ± 7.2 35.2 24.6–48.7 7 (19) 37.0 ± 13.3 35.3 24.7–63.8 6 (16) 33.0 ± 6.2 32.3 26.9–41.8
LAGB
137 (100) 48.3 ± 8.3 46.7 33.6–83.6 126 (92) 43.8 ± 8.5 43.2 27.8–79.9 111 (81) 41.6 ± 8.4 41.6 27.0–66.8 81 (59) 41.5 ± 8.9 41.7 26.3–67.0 80 (58) 40.5 ± 10.9 39.5 25.1–87.9
P-Value
0.11
0.0046
0.0016
0.0004
VSG
– – – – 31 (84) 48.1 ± 17.9 45 19.6–93.1 21 (57) 58.4 ± 22.5 56.6 25.1–96.0 7 (19) 71.9 ± 19.5 61.9 54.1–101.9 6 (16) 70.9 ± 20.7 77.6 32.5–91.8
LAGB
0.68
– – – – 126 (92) 21.5 ± 16.0 19.6 −24.2–86.9 111 (81) 28.7 ± 21.4 23.8 −15.6–83.0 81 (59) 31.5 ± 23.3 24.4 −24.4–89.8 80 (58) 35.5 ± 28.6 34.9 −41.4–101.5 24 Months
18 Months
12 Months
6 Months
VSG
37 (100) 138.2 ± 25.4 132.4 98.4–213.6 31 (84) 107.7 ± 24.5 101.4 71.4–182.8 21 (57) 98.2 ± 18.1 99.8 67.8–135.9 7 (19) 97.7 ± 39 89 68.4–182.2 6 (16) 94.2 ± 20.1 91 74.2 ± 129.6 137 (100) 136.1 ± 26.9 132.7 85.5–220 126 (92) 123.4 ± 27.1 119.5 71.8–201.3 111 (81) 118.7 ± 28.0 111.8 65.8–195.7 81 (59) 118.6 ± 29.1 113.8 63.2–200.5 80 (58) 115.1 ± 31.2 107.2 60.6–211.4 Count (%) Mean ± S.D. Median Range Count (%) Mean ± S.D. Median Range Count (%) Mean ± S.D. Median Range Count (%) Mean ± S.D. Median Range Count (%) Mean ± S.D. Median Range Preop
P-Value LAGB
–
Overall BMI (kg/m2) % Excess Weight Loss Overall Weight (kg)
Table 2 Postoperative weight (kg), percent preoperative weight and percent excess weight loss.
b0.0001
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% Preop BMI Loss
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(P b 0.001). At 24 months significant differences between LAGB and VSG, in percent preoperative BMI, were observed in females (32.1 ± 13.6 vs. 17.2 ± 12.7, P = 0.027). Comparisons at 18 months were excluded due to insufficient number of patients at this time point (Tables 3a and 3b). 2.4.1. Complications Our study showed an overall complication rate in LAGB patients at 5 years of 23.4% (32/137) which included: port displacement (8%), band displacement (8%), port leakage (0.7%), bowel obstruction (1.5%), esophagitis (3.6%), gastric prolapse (0.7%) and bleeding (0.7%). Limited by long term follow up data in our VSG patients, only one complication in 37 patients was observed. One VSG patient presented to the emergency room on postoperative day 12 with a chief complaint of abdominal pain with workup discovering that she had developed a massive mesenteric venous thrombosis resulting in septic shock, multiorgan system failure, and ultimately death. 2.5. Linear regression analysis for seromarkers associated with obesity following LAGB and VSG Both LAGB and VSG resulted in significantly reduced levels of HDL, Hemoglobin A1c, fasting glucose, and C-reactive protein, while VSG alone resulted in significantly reduced levels of total triglycerides. When comparing trends between VSG and LABG, a significantly greater negative trend was observed in VSG for fasting glucose levels (P = 0.003). (Table 4) 3. Discussion The rate of childhood obesity worldwide is dramatically increasing and if not curtailed will cause a rise in the number of adults with obesity related co-morbidities, resulting in a dramatic increase in future health care costs [2]. Surgery has repeatedly shown to be an effective weight loss strategy in morbidly obese adults resulting in dramatic short term and sustained long term weight loss with significant reductions in obesity related co-morbidities. Weight loss surgery is now considered the most effective treatment for morbidly obese adults [28]. Studies on the efficacy of bariatric surgery in adolescent patients have shown promising results with profound short term and sustained long term weight loss [9,10,13,15,17,20,21,24,25,29–38]. Laparoscopic adjustable gastric banding (LAGB) in adults has been effectively used for many years with %EWL ranging from 33% to 50% at 3 years [5,39–41]. LAGB in adolescents has shown to result in similar weight loss as adults with reported %EWL loss at 3 years of 42%–70% [30,32,42]. We recently showed, in a group of 100 adolescent patients who underwent LAGB, a mean %EWL of 31.9% at 12 months [16], which was similar to other reports of 44% [32] and 52% [30]. This current study expands our analysis to include more patients with longer follow up showing %EWL at 2 years of 35.5% ± 28.6% in 80 patients (Table 2) and at 3 years in 61 patients of 41.8% ± 35.7% (Data not shown). Similarly, in a cohort of 24 adolescent patients Dillard et al. found a 42% EWL at 3 years and Holterman et al. found an EWL of 34%. Similar to adults, successful weight loss following LAGB in adolescents results in a significant reduction in obesity related co-morbidities (HTN, HLD, DM) of 55%–69% at 1 year [10,13,37], with one study reporting a complete resolution of measured obesity related co-morbidities at 2 years [9]. We have similarly shown significant reductions in some seromarkers associated with obesity including HDL, HgA1c, fasting glucose, and CRP following LAGB (Table 4). Furthermore, psychological benefits, including improvements in depressive symptoms and quality of life have also previously been shown by our group [43]. Vertical sleeve gastrectomy (VSG) is gaining acceptance due to improved short term and sustained long term weight loss compared to LAGB [5,18,19]. In a systematic review of the literature evaluating the efficacy of VSG which included 123 studies and 12,129 patients, Fischer
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Fig. 1. Laparoscopic vertical sleeve gastrectomy (VSG) results in (A) greater short term percent excess body weight loss (%EWL) and (B) percent preoperative BMI loss compared to laparoscopic adjustable gastric band (LAGB). **** = P b 0.0001 *** = P b 0.001.
et al. found an average %EWL at 1 and 2 years of 59% and 64.5% [44]. The first report from the American College of Surgeons Bariatric Surgery Center Network evaluating the efficacy of VSG compared to LAGB and Roux en Y found an overall greater reduction in BMI for VSG compared to LAGB (11.87 kg/m 2 vs. 7.05 kg/m 2) [45]. Few studies have evaluated the efficacy of VSG in adolescent obese patients; however similarities in efficacy and safety between adults and adolescents have been shown [46]. McGuire at al. recently showed a %EWL of 38.6% at 6 months in 59 adolescent obese patients who underwent VSG, similar to our results of 48.1% ± 17.9% [24]. The largest study evaluating the efficacy of VSG in adolescent patients is by Algahtani et al., in which 108 patients showed a 65.8% and 64.9 %EWL at 1 and 2 years respectively with additional resolution of obstructive sleep apnea (90.9%), diabetes (93.8%), dyslipidemia (70%), and hypertension (75%) [25]. Algahtani et al.’s findings were similar to our %EWL at 1 (58.4 ± 22.4) and 2 years (70.9 ± 20.7) and we too observed a reduction in total triglycerides, increased levels of HDL, and significant reductions in seromarkers associated with diabetes: HgA1c, and fasting glucose. C-reactive protein, a marker of inflammation in obese patients, was also significantly reduced following VSG. Several adult studies have shown superiority of VSG over LAGB in short term and sustained long term weight and BMI loss [5,18]. In one prospective randomized study involving 80 adult patients comparing
LAGB to VSG, a significant reduction in %EWL at 1 (41.4% vs. 57.7%) and 3 years (48% vs. 66%) was noted [18]. Our study compares the efficacy of LAGB to VSG at achieving weight loss and improving seromarkers associated with obesity in adolescent obese patients. In this study VSG patients achieved superior reductions compared to LAGB in %EWL at 6 (48.1 ± 17.9 vs. 21.5 ± 16.0, P b 0.0001), 12 (58.4 ± 22.5 vs. 28.7 ± 21.4, P b 0.0001), 18 (71.9 ± 19.5 vs. 31.5 ± 23.3, P b 0.0001), and 24 months (70.9 ± 19.5 vs. 35.5 ± 28.6, P = 0.004) and percent preoperative BMI loss at 6 (22.2 ± 6.7 vs. 9.3 ± 6.1, P b 0.0001), 12 (25.9 ± 9.9 vs. 12.6 ± 9.0), 18 (31.1 ± 11.5 vs. 14.8 ± 10.2, P = 0.0001) and 24 months (32.3 ± 11.0 vs. 16.4 ± 12.7, P = 0.004) (Table 2, Fig. 1A, B). Moreover, we have shown that the significantly greater %EWL and percent preoperative BMI loss observed following VSG when compared to LAGB were independent of gender (Tables 3a and 3b). VSG results in a significantly greater weight loss compared to LAGB, however, the mechanisms producing this effect are not fully understood. Both surgeries limit the quantity for food into the stomach. LAGB restricts food entry into the otherwise normal fundus and patients express a feeling of being unable to eat more but can remain hungry. VSG allows the stomach to fill with a reduced volume and stimulates earlier satiety. The impact of early satiety on weight loss in VSG patients does not explain the observed greater weight loss compared to LAGB.
Table 3a Comparisons of percent excess weight loss (%EWL) by gender. Male
Preoperative Weight (kg)
6 Months %EWL
12 Months %EWL
18 Months %EWL
24 Months %EWL
Count (%) Mean ± S.D. Median Range Count (%) Mean ± S.D. Median Range Count (%) Mean ± S.D. Median Range Count (%) Mean ± S.D. Median Range Count (%) Mean ± S.D. Median Range
P-Value
Female
P-Value
P-Value
P-Value
LAGB
VSG
LAGB vs. VSG
LAGB
VSG
LAGB vs. VSG
LAGB (Male Vs. Female)
VSG (Male Vs. Female)
43 (100) 150.8 ± 27.1 150.9 96.1–220.0 39 (91) 18.4 ± 11.1 17.4 −3.1–49.4 37 (86) 24.2 ± 18.1 21.9 −15.6–67.6 28 (65) 26.9 ± 21.6 22.2 −15.6–83.1 24 (56) 30.7 ± 31.5 23.8 −41.4–85.1
10 (100) 151.7 ± 30.4 139.6 117.8–213.6 8 (80) 50.8 ± 21.5 47.3 26.3–93.1 4 (40) 71.5 ± 28.1 80.7 30.4–94.0 1 181.5 – – 2 (20) 79.4 ± 2.2 79.4 77.9–81.0
NS
94 129.4 ± 24.1 127.2 85.5–205.2 87 (93) 22.6 ± 17.7 20.5 −24.2–86.9 74 (79) 30.9 ± 22.7 26.5 −15.2–83 53 (56) 33.9 ± 24.0 27.8 −24.4–89.8 56 (60) 37.6 ± 27.4 36.7 −17.1–101.5
27 133.1 ± 21.9 130 98.4–208.4 23 (85) 47.1 ± 16.9 44.8 19.6–85.4 17 (63) 55.3 ± 20.8 53.8 25.1–96.0 6 (22) 71.9 ± 19.5 61.9 54.1–101.9 4 (15) 66.7 ± 25.2 71.2 32.5–91.8
NS
b0.00001
0.047
b0.0001
NS
NS
0.0001
NS
NS
0.0005
NS
–
0.043
NS
NS
b0.0001
b0.0001
–
0.042
120
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Table 3b Comparisons of percent preoperative BMI (kg/m2) by gender. Male
Preoperative BMI (kg/m2)
6 Months %Preop-BMI
12 Months %Preop-BMI
18 Months %Preop-BMI
24 Months %Preop-BMI
Count (%) Mean ± S.D. Median Range Count (%) Mean ± S.D. Median Range Count (%) Mean ± S.D. Median Range Count (%) Mean ± S.D. Median Range Count (%) Mean ± S.D. Median Range
P-Value
Female
P-Value
P-Value
P-Value
LAGB
VSG
LAGB vs. VSG
LAGB
VSG
LAGB vs. VSG
LAGB (Male Vs. Female)
VSG (Male Vs. Female)
43 (100) 49.7 ± 6.8 49.3 36–64.9 39 (91) 9.0 ± 5.0 8.63 −1.61–18.4 37 (86) 11.7 ± 7.6 11.8 −4.0–27.1 28 (65) 13.8 ± 9.7 12.8 −4.0–36.9 24 (56) 14.5 ± 13.0 14.5 −12.6–32.3
10 (100) 51.8 ± 11.2 47.3–39.5 39.5–74.3 8 (80) 23.5 ± 7.7 22.3 13.4–34.2 4 (40) 29.6 ± 14.6 29.61 11.8–47.4 – – – – 2 (20) 32.7 ± 7.5 32.7 27.4–38.0
NS
94 (100) 47.7 ± 8.8 46.6 33.6–83.6 87 (93) 9.4 ± 6.5 9.3 −10.9–29.8 74 (79) 13.1 ± 9.6 11.6 −12.4–37.7 53 (56) 15.3 ± 10.4 14.8 −10.9–38.2 56 (60) 17.2 ± 12.7 16.9 −6.6–51.9
27 (100) 49.4 ± 8.7 47.1 38–81.4 23 (85) 21.8 ± 6.4 21.8 10.9–33.4 17 (63) 25.0 ± 8.9 23.8 12.7–43.1 6 (22) 33.9 ± 9.6 31.9 22.2–46.0 4 (15) 32.1 ± 13.6 37.4 12.0–41.4
NS
NS
NS
b0.0001
NS
NS
b0.0001
NS
NS
0.0001
NS
–
0.027
NS
NS
b0.0001
0.0002
–
0.065
NS, not significant (P N 0.05).
One predominate physiologic hypothesis involves the role of ghrelin, a powerful hormonal appetite stimulant in humans. It has been shown that chronic ghrelin intake results in increased hunger, facilitating overall weight gain. Conversely pharmacologic ghrelin blockage results in significantly reduced food intake and overall weight [47]. Since ghrelin production predominantly occurs in the fundus of the stomach which is removed in VSG, it has been suggested that reduced overall ghrelin production may be responsible for the greater weight loss with VSG [48,49]. Langer et al. compared pre- and postoperative ghrelin levels in 10 LAGB and 10 VSG patients, finding significant reductions in postoperative ghrelin levels in the VSG group at 1 and 6 months, but no difference in the LAGB patients at either time point [48]. Furthermore, in a diet induced obese mouse model, Wang et al. found significant reductions in VSG treated mice (0.4 fold) compared to LAGB treated mice (2 fold) [49]. We have also previously shown no significant difference in pre- and postoperative fasting ghrelin levels at 1 year following LAGB [43]. The reasons for weight loss following LAGB and VSG continue to be incompletely understood, however, we believe them to be multifactorial, related to the effects of mechanical restriction, changes in postoperative physiologic and hormone release, and most importantly, from changes in eating behavior. Complications following bariatric surgery are well known and therefore must be taken into account when counseling adolescent patients who are planning to undergo bariatric surgery. In a large cohort of adult patients Carlin et al. found a significantly lower overall complication rate among patients who underwent VSG compared to RYGB (6.3% vs. 10.0%, P b 0001), and a reduced overall complication rate in LAGB vs. VSG patients (2.4% vs. 6.3%, P b 0.0001). Our study showed an overall complication rate at 5 years of 23.4% (32/137), and details related to complications in VSG patients are limited due to a shorter follow up period. However our one complication of a postoperative VSG patient who developed massive mesenteric venous thrombosis 12 days after surgery resulting in septic shock, multi-organ system failure, and ultimately death is a significant consideration when consenting patients for VSG. A higher incidence of venous thrombosis has been observed in adult VSG patients [50]. However, reports in adolescent patients are limited. Given the risks associated with either procedure, our patients preoperatively are extensively counseled, understanding our limited long term follow up, on the benefits, limitations, and most importantly the risks associated with either procedure.
There remain several limitations to this study. The reduced number of VSG patients as compared to LAGB patients limited our analysis on overall weight loss, efficacy of sustaining weight loss and especially in long term complications. Indeed, missed follow up appointments have occurred in both populations, further limiting our data collection. Postoperative medical management differed slightly insofar as LAGB patients required additional visits for band adjustments and practical issues such as timing and transportation may have contributed to less compliance with follow up visits in LAGB patients. Our analysis on trends of seromarkers associated with obesity has several limitations including follow up time (1 year), the lack of direct comparisons at separate times and limiting our analysis to linear regression due to some patients not having labs at all time points. However, significant trends in improved seromarkers associated with obesity were observed in both VSG and LAGB. Regardless of the limitations associated with this study, we believe that this study enhances our understanding of the efficacy of LAGB and VSG in adolescent obese patients. Successful short term and sustained long term weight loss with low complication rates in morbidly obese adults has led bariatric surgery to become widely accepted. As a treatment option for adolescent obesity, bariatric surgery has shown promising results in effective weight reduction and improvements in co-morbidities associated with obesity. The long term impact of bariatric surgery in adolescents remains unknown. Additional studies with longer follow up will offer a better understanding of the risks and benefits of this treatment strategy. In conclusion, the complex task of helping obese patients develop healthy eating behaviors mandates a multidisciplinary approach to the obese adolescent. Bariatric surgery in adolescent obese patients is an effective treatment tool to help reduce overall weight and sustain weight loss. Our results show VSG to be significantly more effective than LAGB in obese adolescents at reducing weight and BMI short term (6, 12, 18, and 24 months) independent of gender. Nonetheless, the long term risks associated with both procedures and their efficacy in long term sustained weight loss still need to be elucidated with studies having longer follow up and greater number of patients.
Appendix A. Discussion Laparoscopic vertical sleeve gastrectomy significantly improves short-term weight loss as compared to laparoscopic adjustable gastric
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Table 4 Linear regression analysis: seromarkers associated with obesity.
Total Triglycerides Total Cholesterol High Density Lipoprotein Low Density Lipoprotein Hemoglobin A1c Fasting Glucose C-Reactive Protein
LAGB VSG LAGB VSG LAGB VSG LAGB VSG LAGB VSG LAGB VSG LAGB VSG
Y-Intercept ± S.D.
Slope
(Day 0)
95%CI
117.9 108.1 164.0 154.7 42.3 40.9 99.7 92.1 5.5 5.5 85.5 89.9 9.0 9.9
± ± ± ± ± ± ± ± ± ± ± ± ± ±
6.3 4.9 2.5 3.9 0.7 1.4 2.1 3.4 0.03 0.09 0.6 1.9 0.6 1.1
R Square
−0.0365 −0.0718 0.0060 0.0043 0.0091 0.0140 −0.0005 0.0048 −0.0004 −0.0009 −0.0065 −0.0262 −0.0089 −0.0182
band placement in morbidly obese pediatric patients: presented by Felipe Pedroso, New York, NY.
Thomas Inge (Cincinnati, OH) Thank you for a wonderful report. The question that always comes to my mind is in the U.S. data the band does not seem to have the same effect as we’ve seen in international studies, for instance, the randomized controlled trial from Australia. I’m just wondering, in your experience or in your population, do you have any hypotheses about why the results may be poorer here? Your slides went by pretty fast but it seemed to me like your percent weight loss may have been in the 10% to 15% range whereas in Australia it’s nearer to 30% weight loss at two years. Can you hypothesize about the differences?
Felipe Pedroso Actually you may have missed it but in looking at our slides – thank you for your question – but in looking at our slides, we have in excess body weight loss of 30% which is found out to two years and that has stayed out to 36 months and 48 months. However, with sleeve gastrectomy we’re seeing significant increases with doubling of that weight loss. In regards to the Australian study versus our findings, I can only hypothesize as to why we are seeing less weight loss as compared to them. It may be lifestyle and our Western civilization, how we eat, McDonald’s …
Thomas Inge They have McDonald’s there too. It’s interesting. Thank you.
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± ± ± ± ± ± ± ± ± ± ± ± ± ±
0.0284 0.0229 0.0111 0.0184 0.0032 0.0066 0.0093 0.0162 0.0001 0.0004 0.0025 0.0089 0.0025 0.0053
0.0052 0.1013 0.0009 0.0006 0.0257 0.0498 0.00001 0.0009 0.0314 0.065 0.022 0.0919 0.0401 0.1256
Slope
(Slope LAGB vs. VSG)
P-Value
P-Value
0.199 0.002 0.588 0.815 0.004 0.036 0.96 0.769 0.002 0.016 0.009 0.004 b0.001 b0.001
0.532 0.942 0.483 0.791 0.095 0.003 0.096
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[32] Fielding GA, Duncombe JE. Laparoscopic adjustable gastric banding in severely obese adolescents. Surg Obes Relat Dis 2005;1:399–405 [discussion 405–397]. [33] Gothberg G, Gronowitz E, Flodmark CE, et al. Laparoscopic Roux-en-Y gastric bypass in adolescents with morbid obesity—surgical aspects and clinical outcome. Semin Pediatr Surg 2014;23:11–6. [34] Horgan S, Holterman MJ, Jacobsen GR, et al. Laparoscopic adjustable gastric banding for the treatment of adolescent morbid obesity in the United States: a safe alternative to gastric bypass. J Pediatr Surg 2005;40:86–90 [discussion 90–81]. [35] Lee DY, Guend H, Park K, et al. Outcomes of laparoscopic Roux-en-Y gastric bypass versus laparoscopic adjustable gastric banding in adolescents. Obes Surg 2012;22:1859–64. [36] Lennerz BS, Wabitsch M, Lippert H, et al. Bariatric surgery in adolescents and young adults-safety and effectiveness in a cohort of 345 patients. Int J Obes (Lond) 2014; 38:334–40. [37] Nadler EP, Reddy S, Isenalumhe A, et al. Laparoscopic adjustable gastric banding for morbidly obese adolescents affects android fat loss, resolution of comorbidities, and improved metabolic status. J Am Coll Surg 2009;209:638–44. [38] Yitzhak A, Mizrahi S, Avinoach E. Laparoscopic gastric banding in adolescents. Obes Surg 2006;16:1318–22. [39] O'Brien PE, MacDonald L, Anderson M, et al. Long-term outcomes after bariatric surgery: fifteen-year follow-up of adjustable gastric banding and a systematic review of the bariatric surgical literature. Ann Surg 2013;257:87–94. [40] Alhamdani A, Wilson M, Jones T, et al. Laparoscopic adjustable gastric banding: a 10year single-centre experience of 575 cases with weight loss following surgery. Obes Surg 2012;22:1029–38.
[41] Angrisani L, Cutolo PP, Formisano G, et al. Long-term outcomes of laparoscopic adjustable silicone gastric banding (LAGB) in moderately obese patients with and without co-morbidities. Obes Surg 2013;23:897–902. [42] Zitsman JL, Digiorgi MF, Marr JR, et al. Comparative outcomes of laparoscopic adjustable gastric banding in adolescents and adults. Surg Obes Relat Dis 2011;7:720–6. [43] Sysko R, Devlin MJ, Hildebrandt TB, et al. Psychological outcomes and predictors of initial weight loss outcomes among severely obese adolescents receiving laparoscopic adjustable gastric banding. J Clin Psychiatry 2012;73:1351–7. [44] Fischer L, Hildebrandt C, Bruckner T, et al. Excessive weight loss after sleeve gastrectomy: a systematic review. Obes Surg 2012;22:721–31. [45] Hutter MM, Schirmer BD, Jones DB, et al. First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg 2011;254:410–20 [discussion 420–412]. [46] Alqahtani A, Alamri H, Elahmedi M, et al. Laparoscopic sleeve gastrectomy in adult and pediatric obese patients: a comparative study. Surg Endosc 2012;26:3094–100. [47] Cummings DE. Ghrelin and the short- and long-term regulation of appetite and body weight. Physiol Behav 2006;89:71–84. [48] Langer FB, Reza Hoda MA, Bohdjalian A, et al. Sleeve gastrectomy and gastric banding: effects on plasma ghrelin levels. Obes Surg 2005;15:1024–9. [49] Wang Y, Liu J. Plasma ghrelin modulation in gastric band operation and sleeve gastrectomy. Obes Surg 2009;19:357–62. [50] Salinas J, Barros D, Salgado N, et al. Portomesenteric vein thrombosis after laparoscopic sleeve gastrectomy. Surg Endosc 2014;28:1083–9.
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Laparoscopic vertical sleeve gastrectomy significantly improves short term weight loss as compared to laparoscopic adjustable gastric band placement in morbidly obese adolescent patients Felipe E. Pedroso a, Jeffery Gander a,b, Pilyung Stephen Oh a, Jeffrey L. Zitsman a,⁎ a b
New York Presbyterian Morgan Stanley Children’s Hospital, Columbia University Medical Center, Department of General Surgery, Division of Pediatric Surgery, Center for Adolescent Bariatric Surgery University of Virginia Health System, Department of Surgery, Division of Pediatric Surgery
a r t i c l e
i n f o
Article history: Received 1 October 2014 Accepted 6 October 2014 Key words: Bariatric Vertical sleeve gastrectomy Laparoscopic adjustable gastric band Adolescent
a b s t r a c t Background: Bariatric surgery has shown to be an effective weight loss treatment in morbidly obese adolescents. We compared outcomes of laparoscopic adjustable gastric band (LAGB) to laparoscopic vertical sleeve gastrectomy (VSG). Methods: A single institution, retrospective evaluation of a prospectively collected database of LAGB and VSG patients. Results: 174 morbidly obese patients underwent bariatric surgery at our institution between 2006 and 2013. 137 patients underwent LAGB and 37 underwent VSG. There were no significant differences between LAGB vs. VSG groups on day of surgery for age, gender, ethnicity, weight, and BMI. At 24-month follow up, patients who underwent VSG vs. LAGB displayed significantly greater percent excess weight loss (70.9 ± 20.7 vs. 35.5 ± 28.6, P = 0.004) and percent preoperative BMI loss (32.3 ± 11.0 vs. 16.4 ± 12.7, P = 0.004). Both VSG and LAGB significantly improved levels of HDL, HgA1c, and fasting glucose. LAGB patients had more complications than VSG patients. Conclusion: Bariatric surgery is an effective treatment strategy in morbidly obese adolescents who have failed medical management. VSG results in greater short term weight and BMI loss when compared to LAGB. Longer follow up with more patients will be required to confirm the long term safety and efficacy of VSG in adolescent patients. © 2015 Elsevier Inc. All rights reserved.
Obesity has become pandemic, and costs for the treatment of obesity related co-morbidities have dramatically increased worldwide. Coincidentally, the incidence of childhood obesity has risen, and with evidence demonstrating that many obese children ultimately become obese adults, effective weight loss strategies at an early age are essential [1,2]. The medical management of obesity has repeatedly been shown to be ineffective at reducing overall weight and sustaining weight loss in adults and children [3,4]. Bariatric surgery has been utilized as a treatment strategy in morbidly obese adults resulting in consistent and sustained weight loss and an overall reduction in obesity related comorbidities [5,6]. NIH guidelines recommend bariatric surgery for severely obese adult patients with BMI N 40 or BMI N 35 with coexisting co-morbidities [7]. The use of bariatric surgery in adolescents (12–18 years of age) remains controversial, however, recent results have shown bariatric surgery in combination with medical therapies to be a safe and effective tool for the treatment of adolescent obesity. NIH
⁎ Corresponding author at: Morgan Stanley Children’s Hospital/New York Presbyterian Hospital, CHN Room 212, 3959 Broadway, New York, NY, 100032. Tel.: +1 2123428585; fax: +1 2123059270. E-mail address: [email protected] (J.L. Zitsman). http://dx.doi.org/10.1016/j.jpedsurg.2014.10.014 0022-3468/© 2015 Elsevier Inc. All rights reserved.
guidelines for bariatric surgery have now been expanded to include adolescent patients [7]. Bariatric surgery performed in adolescent patients has shown promising short term results [8]. Laparoscopic adjustable gastric banding (LAGB), an accepted weight loss tool in adults, has been evaluated in adolescents. Our group and others have found LAGB to be an effective weight loss tool in adolescent patients [9–17]. Presently in the United States, LAGB remains an investigational device in adolescent patients thereby precluding its expanded use. Laparoscopic vertical sleeve gastrectomy (VSG) has been shown in adults to be more effective than LAGB at reducing postoperative weight, sustaining weight loss, and reducing the rates of obesity related co-morbidities [5,18,19]. VSG has now been instituted by our group and others for the treatment of severely obese adolescents. Moreover, several recent reports (mainly small case series) have shown VSG to be safe and successful at reducing weight, BMI, and the rates of obesity related co-morbidities in adolescents [20–25]. In an attempt to evaluate the safety and efficacy of VSG as compared to LAGB in adolescent patients, we have compared these two treatments strategies in adolescents for the first time. We hypothesized that VSG would not only be a safer procedure with lower complication rates, but also a more effective surgical tool in reducing overall weight, sustaining weight loss, and improving seromarkers associated with obese adolescent patients.
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1. Methods This study was approved by the Institutional Review Board of Columbia University Medical Center and the Morgan Stanley Children’s Hospital. All patients were treated at this one institution. The LAGB and VSG registries of the Center for Adolescent Bariatric Surgery have been prospectively developed since 2006, and all data were confirmed by a review of the medical records, clinic visits, and operative reports. All surgeries were performed by a single surgeon at the same tertiary institution. An investigational device exception from the FDA was obtained for the use of the adjustable gastric band in adolescent patients. All patients were screened by phone for height and weight prior to initial meeting with the pediatric surgeon. All patients completed a screening questionnaire (medical history, family history, psychological history, and history of any prior weight loss attempts) and were instructed to write a statement describing why they wished to undergo bariatric surgery. Preoperatively, patients were scheduled to visit with a pediatric endocrinologist, nutritionist, psychologist, and exercise specialist. Baseline laboratory panels were obtained (hematological, blood chemistries, liver function, lipid panels, fasting glucose, and C-reactive protein). Preoperatively, patients underwent monthly meetings with the nutritionist, the nurse practitioner, and the surgeon. Each patient was instructed to maintain an exercise log. Patient status was discussed at weekly team meetings and surgery was offered to patients with a documented failed weight loss despite compliance with recommended eating behavior and exercise changes for a minimum of 6 months. Preoperatively, informed consent was obtained from both patient and one parent. Between July 2010 and April 2011 patients were given a choice between LAGB and VSG, following April 2011 we recommended VSG, however we offered LAGB as another surgical option for patients 18 years and older. A protein-sparing liquid diet was started 2 weeks preoperatively. At surgery all patients received a preoperative antibiotic, and 5000 U of subcutaneous heparin. Sequential compression device stockings were placed on each lower extremity. Nathanson liver retractors were used in all cases. Laparoscopic adjustable gastric band was performed using the LapBand® Systems (Allergan Inc, Irvine, CA) via a 4 port method, which has been previously described by Ren and Fielding [26]. Laparoscopic vertical sleeve gastrectomy was also performed via a 4 port technique. A sleeve gastrectomy of the greater curvature of the stomach from 6 cm proximal from the pylorus to the angle of His was performed over a 40Fr bougie with a linear stapler and reinforced with Seamguard ® (W.L. Gore and Associates Inc.). Staple line bleeding was controlled with monopolar cautery or clips. Upper endoscopy was utilized for intragastric evaluation of the staple line and stomach was insufflated to evaluate for staple line leak. On postoperative day 1 the first 75 LAGB patients and all VSG patients underwent a gastrograffin contrast swallow study, and if negative for stricture or leak, patients were started on a bariatric clear liquid diet. Later LAGB patients had an upright abdominal radiograph to check for band and port positions. At the first postoperative appointment the diet was advanced to a bariatric pureed diet for two weeks, followed by foods as tolerated with continued nutritionist consultation throughout. All patients were seen postoperatively at 2 weeks, and then every month until 3 months, at 6 months, followed by every 6 months out to 2 years, then yearly. LAGB patients were encouraged to return for adjustments whenever necessary and all were performed by the surgeon. Weight in kilograms and height for both LAGB and VSG patients were measured at all visits. Analyses and comparisons were made at different time points including preoperatively, 6, 12, 18, and 24 months. Mean, standard deviation, median, and range weights (kg) and BMI (kg/m 2) were calculated for each time point for both groups. Preoperative body weight was measured at the visit 2 weeks prior to surgery before the protein-sparing diet was begun. Excess body weight was calculated by subtracting preoperative body weight by body weight for age, gender and height at the 85th percentile using CDC growth
charts [27]. Percent Excess Weight Loss (%EWL) was defined as [(preoperative weight − follow up weight)/(preoperative weight − weight corresponding to the 85th percentile for patients age, gender and height) × 100]. Percent preop BMI loss was defined as [(1 − (follow up BMI/preop BMI)) × 100]. Seromarkers associated with obesity including: total triglycerides, total cholesterol, High Density Lipoprotein (HDL), Low Density Lipoprotein (LDL), Hemoglobin gA1c (HgA1c), fasting glucose and C-Reactive Protein (CRP) were all measured preoperatively and at all time points. In order to evaluate the effect of gender on weight and BMI loss by operation (LAGB and VSG), patients were stratified by gender and comparisons of weight and BMI loss by LAGB vs. VSG were made. To evaluate for significant differences between weight and BMI loss in males and females for each procedure type, patients were stratified by type of procedure and comparisons of males and females were made. All analyses included percent excess weight loss and percent preoperative BMI. Linear regression analysis was performed evaluating the effect of LAGB and VSG in trends of seromarkers associated with obesity including: total triglycerides, total cholesterol, HDL, LDL, HgA1c, fasting glucose, and CRP. For each seromarker, slope, y-intercept at day 0 (representing preoperative levels), R square, and p-value for each slope were reported. Comparisons in trends between LABG and VSG were made for all seromarkers. Statistical analysis was performed with SPSS version 18.0 (PASW) released July 30, 2009 (IBM Corporation, Somers NY) and Graphpad Prism Version 5.0 was used for other statistical analysis and figures. Fisher’s exact T-test was used for categorical variables and analysis of variance was used for comparing weights at different time points between LAGB and VSG patients. Statistical significance was defined as P b 0.05.
2. Results 2.1. Patient and group demographics A total of 137 laparoscopic adjustable gastric bands (LAGBs) were placed from February 2006 to April 2011. Mean age for LAGB patients was 16.9 ± 1.2 and more females (94/137) underwent the procedure than males (43/137). Follow up data were available at 6, 12, 18, and 24 months for 137, 126, 111, 81, and 80 patients respectively in the LAGB group and in the VSG group follow up data were available at 6, 12, 18, and 24 months for 31, 21, 7, and 6 patients respectively. 37 laparoscopic vertical sleeve gastrectomies (VSGs) were performed from June 2010 to August 2013 with mean age of 17.3 ± 1.82 with more females (27/37) than males (10/37). No significant differences in age (P = 0.12), gender (P = 0.69), ethnicity (P = 0.07), or preoperative weight (kg) (136.1 ± 26.9, 138.2 ± 25.4, P = 0.68) were noted between LAGB and VSG patients (Table 1). Nine LAGB patients who had more than regained their preoperative weights (average weight gain of 14.9 kg), were converted to a VSG and included in the analysis. No significant difference between LAGB and VSG patients was observed in preoperative excess weight (kg) (65.1 ± 24.2, 66.7 ± 22.1, P = 0.73), or preoperative BMI (kg/m 2) (48.3 ± 8.3 vs. 50.1 ± 9.4, P = 0.26). Operative times were available for all 37 VSG patients and 113 LAGB patients and VSG patients had longer operative times than LAGB patients (144.1 ± 55.1 vs. 112.3. 25.7, P b 0.0001). However, when excluding the 9 reoperative patients who underwent conversions from LAGB to VSG, no significant difference in operative time between LAGB and VSG was observed (112.3 ± 25.7 vs. 114.8 ± 18.2, P = 0.60). No significant differences between LABG and VSG were present for all preoperative studied seromarkers associated with obesity (Total triglycerides, total cholesterol, HDL, LDL, Fasting glucose, HgA1c, and CRP, all P N 0.05), except that VSG patients exhibited a significantly greater fasting glucose (90 ± 13.8 vs. 85.9 ± 7.7, P = 0.02). (Table 1)
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Table 1 Patient characteristics.
# of Pts Age
Gender Ethnicity
Preop Weight (kg)
Preop Excess Body Weight (kg)
Preop BMI (kg/m2)
Operative Time (min)
Total Triglycerides
Total Cholesterol
High Density Lipoprotein
Low Density Lipoprotein
Hemoglobin A1c
Fasting Glucose
C-Reactive Protein
Mean ± S.D. Median Range Male Female Caucasian Hispanic African American Other Mean ± S.D. Median Range Mean ± S.D. Median Range Mean ± S.D. Median Range Mean ± S.D. Median Range Mean ± S.D. Median Range Mean ± S.D. Median Range Mean ± S.D. Median Range Mean ± S.D. Median Range Mean ± S.D. Median Range Mean ± S.D. Median Range Mean ± S.D. Median Range
2.2. Overall weight change following LAGB and VSG No significant difference in preoperative weight and BMI was observed between LAGB and VSG. Overall weight was significantly reduced in VSG patients compared to LAGB patients at 6 (123.4 ± 27.1 vs. 107.7 ± 24.5, P = 0.0004), 12 (118.7 ± 28.0 vs. 98.2 ± 18.1, P = 0.0016), and 18 months (118.6 ± 29.1 vs. 97.7 ± 39, P = 0.0046), with no difference at 24 months (115.1 ± 31.2 vs. 94.2 ± 20.1 P = 0.11). A significantly greater percent excess weight loss (%EWL) was observed in VSG patients as compared to LAGB patients at 6 (48.1 ± 17.9 vs. 21.5 ± 16.0, P b 0.0001), 12 (58.4 ± 22.5 vs. 28.7 ± 21.4, P b 0.0001), 18 (71.9 ± 19.5 vs. 31.5 ± 23.3, P b 0.0001), and 24 (70.9 ± 20.7 vs. 35.5 ± 28.6, P = 0.0039) months. No VSG patients had regained their preoperative weight (kg) at 6 and 12 months, while 10% (11/111) and 13.8% (11/80) of LAGB patients had regained their preoperative weight at 12 and 24 months respectively. The greatest reduction in %EWL was noted at 24 months for LABG (35.5 ± 28.6) and 18 months for VSG (71.9 ± 19.5). (Table 2, Fig. 1A) 2.3. Overall BMI change following LAGB and VSG Similarly, a significantly greater reduction in overall BMI was observed in VSG patients compared to LAGB patients at 6 (39.5 ± 9.4 vs. 43.8 ± 8.5, P = 0.016) and 12 months (35.7 ± 7.2 vs. 41.6 ± 8.4, P = 0.003), and reduced but not significant at 18 (37.0 ± 13.3 vs. 41.5 ±
LAGB
VSG
137 16.9 ± 1.22 17 14.3–19.6 43 94 58 51 22 6 136.1 ± 26.9 132.7 85.5–220 65.1 ± 24.2 61.5 21.6–144.4 48.3 ± 8.3 46.7 33.6–83.6 112.3 ± 25.7 113 65–167 122.6 ± 118 104 38–742 165.9 ± 35.4 165 78–274 42.5 ± 9.4 42 22–78 101 ± 29.6 100 29–207 5.6 ± 0.4 5.5 4.8–7.3 85.9 ± 7.7 86 65–106 9.1 ± 8.5 7.44 0.47–48.1
37 17.3 ± 1.82 17.09 12.7–21.4 10 27 11 21 2 3 138.2 ± 25.4 132.4 98.4–213.6 66.7 ± 22.1 62.5 34.6–142.8 50.1 ± 9.4 47.1 38–81.4 144.1 ± 55.1 124 77.0–303.0 111 ± 36.2 109 59–225 160.7 ± 24.2 162 105–214 40.8 ± 11.1 38 19–72 96.7 ± 23.2 96.5 57–148 5.5 ± 0.7 5.4 4.5–8.3 90 ± 13.8 87 72–146 10.1 ± 8.7 7.65 0.4–41
P-Value 0.12
0.69 0.07
0.68
0.73
0.26
b0.0001
0.67
0.13
0.25
0.20
0.28
0.02
0.69
8.9, P = 0.226) and 24 months (33.0 ± 6.2 vs. 40.5 ± 10.9, P = 0.099). Alternatively, percent preoperative BMI loss was greater in the VSG group as compared to the LAGB group at all time points: 6 (22.2 ± 6.7 vs. 9.3 ± 6.1, P b 0.0001), 12 (25.9 ± 9.9 vs. 12.6 ± 9.0 vs. P b 0.0001), 18 (31.1 ± 11.5 vs. 14.8 ± 10.2, P = 0.0001), and 24 months (32.3 ± 11.0 vs. 16.4 ± 12.7, P = 0.0038). No VSG patients had regained their preoperative BMI (kg/m 2) at 6 (0/21) and 12 months months (0/6). On the other hand 11.7% (13/111) of LAGB patients and 13.8% (11/80) had regained their starting BMI at 12 and 24 months respectively. The greatest reduction in percent preoperative BMI loss was at 24 months for both LAGB (16.4 ± 12.7) and VSG patients (32.3 ± 11.0). (Table 2, Fig. 1B) 2.4. Overall weight and BMI change by gender following LAGB and VSG Males and females were stratified into separate groups and comparisons were made for changes in weight, BMI, %EWL, and %Preoperative BMI. There was no significant difference in preoperative weight between LAGB and VSG for both males and females. Males had greater preoperative weight than females for both LABG (150.8 ± 27.1, vs. 129.4 ± 24.1, P b 0.0001) and VSG (151.7 ± 30.4 vs. 133.1 ± 21.9, P = 0.047). Irrespective of gender, VSG displayed significantly greater %EWL compared to LAGB at 6 (P b 0.0001), 12 (P b 0.001), and 24 months (P b 0.05). Also, irrespective of gender VSG displayed significantly greater percent preoperative BMI at 6 (P b 0.0001) and 12 months
b0.0001
0.0038
0.0001
P-Value
–
VSG
– – – – 31 (84) 22.2 ± 6.7 21.8 10.9–34.2 21 (57) 25.9 ± 9.9 24.1 11.8–47.4 7 (19) 31.1 ± 11.5 30.1 14.1–46.0 6 (16) 32.3 ± 11.0 37.2 12.0–41.4
LAGB
– – – – 126 (92) 9.3 ± 6.1 9 −10.9–29.8 111 (81) 12.6 ± 9.0 11.7 −12.4–37.7 81 (59) 14.8 ± 10.2 13.7 −10.9–38.7 80 (58) 16.4 ± 12.7 15.9 −12.6–51.9 0.099 0.0039
0.226 b0.0001
0.003 b0.0001
b0.0001
0.016
P-Value
0.26
VSG
37 (100) 50.1 ± 9.4 47.1 38–81.4 31 (84) 39.5 ± 9.4 37.4 26.2–64.8 21 (57) 35.7 ± 7.2 35.2 24.6–48.7 7 (19) 37.0 ± 13.3 35.3 24.7–63.8 6 (16) 33.0 ± 6.2 32.3 26.9–41.8
LAGB
137 (100) 48.3 ± 8.3 46.7 33.6–83.6 126 (92) 43.8 ± 8.5 43.2 27.8–79.9 111 (81) 41.6 ± 8.4 41.6 27.0–66.8 81 (59) 41.5 ± 8.9 41.7 26.3–67.0 80 (58) 40.5 ± 10.9 39.5 25.1–87.9
P-Value
0.11
0.0046
0.0016
0.0004
VSG
– – – – 31 (84) 48.1 ± 17.9 45 19.6–93.1 21 (57) 58.4 ± 22.5 56.6 25.1–96.0 7 (19) 71.9 ± 19.5 61.9 54.1–101.9 6 (16) 70.9 ± 20.7 77.6 32.5–91.8
LAGB
0.68
– – – – 126 (92) 21.5 ± 16.0 19.6 −24.2–86.9 111 (81) 28.7 ± 21.4 23.8 −15.6–83.0 81 (59) 31.5 ± 23.3 24.4 −24.4–89.8 80 (58) 35.5 ± 28.6 34.9 −41.4–101.5 24 Months
18 Months
12 Months
6 Months
VSG
37 (100) 138.2 ± 25.4 132.4 98.4–213.6 31 (84) 107.7 ± 24.5 101.4 71.4–182.8 21 (57) 98.2 ± 18.1 99.8 67.8–135.9 7 (19) 97.7 ± 39 89 68.4–182.2 6 (16) 94.2 ± 20.1 91 74.2 ± 129.6 137 (100) 136.1 ± 26.9 132.7 85.5–220 126 (92) 123.4 ± 27.1 119.5 71.8–201.3 111 (81) 118.7 ± 28.0 111.8 65.8–195.7 81 (59) 118.6 ± 29.1 113.8 63.2–200.5 80 (58) 115.1 ± 31.2 107.2 60.6–211.4 Count (%) Mean ± S.D. Median Range Count (%) Mean ± S.D. Median Range Count (%) Mean ± S.D. Median Range Count (%) Mean ± S.D. Median Range Count (%) Mean ± S.D. Median Range Preop
P-Value LAGB
–
Overall BMI (kg/m2) % Excess Weight Loss Overall Weight (kg)
Table 2 Postoperative weight (kg), percent preoperative weight and percent excess weight loss.
b0.0001
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% Preop BMI Loss
118
(P b 0.001). At 24 months significant differences between LAGB and VSG, in percent preoperative BMI, were observed in females (32.1 ± 13.6 vs. 17.2 ± 12.7, P = 0.027). Comparisons at 18 months were excluded due to insufficient number of patients at this time point (Tables 3a and 3b). 2.4.1. Complications Our study showed an overall complication rate in LAGB patients at 5 years of 23.4% (32/137) which included: port displacement (8%), band displacement (8%), port leakage (0.7%), bowel obstruction (1.5%), esophagitis (3.6%), gastric prolapse (0.7%) and bleeding (0.7%). Limited by long term follow up data in our VSG patients, only one complication in 37 patients was observed. One VSG patient presented to the emergency room on postoperative day 12 with a chief complaint of abdominal pain with workup discovering that she had developed a massive mesenteric venous thrombosis resulting in septic shock, multiorgan system failure, and ultimately death. 2.5. Linear regression analysis for seromarkers associated with obesity following LAGB and VSG Both LAGB and VSG resulted in significantly reduced levels of HDL, Hemoglobin A1c, fasting glucose, and C-reactive protein, while VSG alone resulted in significantly reduced levels of total triglycerides. When comparing trends between VSG and LABG, a significantly greater negative trend was observed in VSG for fasting glucose levels (P = 0.003). (Table 4) 3. Discussion The rate of childhood obesity worldwide is dramatically increasing and if not curtailed will cause a rise in the number of adults with obesity related co-morbidities, resulting in a dramatic increase in future health care costs [2]. Surgery has repeatedly shown to be an effective weight loss strategy in morbidly obese adults resulting in dramatic short term and sustained long term weight loss with significant reductions in obesity related co-morbidities. Weight loss surgery is now considered the most effective treatment for morbidly obese adults [28]. Studies on the efficacy of bariatric surgery in adolescent patients have shown promising results with profound short term and sustained long term weight loss [9,10,13,15,17,20,21,24,25,29–38]. Laparoscopic adjustable gastric banding (LAGB) in adults has been effectively used for many years with %EWL ranging from 33% to 50% at 3 years [5,39–41]. LAGB in adolescents has shown to result in similar weight loss as adults with reported %EWL loss at 3 years of 42%–70% [30,32,42]. We recently showed, in a group of 100 adolescent patients who underwent LAGB, a mean %EWL of 31.9% at 12 months [16], which was similar to other reports of 44% [32] and 52% [30]. This current study expands our analysis to include more patients with longer follow up showing %EWL at 2 years of 35.5% ± 28.6% in 80 patients (Table 2) and at 3 years in 61 patients of 41.8% ± 35.7% (Data not shown). Similarly, in a cohort of 24 adolescent patients Dillard et al. found a 42% EWL at 3 years and Holterman et al. found an EWL of 34%. Similar to adults, successful weight loss following LAGB in adolescents results in a significant reduction in obesity related co-morbidities (HTN, HLD, DM) of 55%–69% at 1 year [10,13,37], with one study reporting a complete resolution of measured obesity related co-morbidities at 2 years [9]. We have similarly shown significant reductions in some seromarkers associated with obesity including HDL, HgA1c, fasting glucose, and CRP following LAGB (Table 4). Furthermore, psychological benefits, including improvements in depressive symptoms and quality of life have also previously been shown by our group [43]. Vertical sleeve gastrectomy (VSG) is gaining acceptance due to improved short term and sustained long term weight loss compared to LAGB [5,18,19]. In a systematic review of the literature evaluating the efficacy of VSG which included 123 studies and 12,129 patients, Fischer
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Fig. 1. Laparoscopic vertical sleeve gastrectomy (VSG) results in (A) greater short term percent excess body weight loss (%EWL) and (B) percent preoperative BMI loss compared to laparoscopic adjustable gastric band (LAGB). **** = P b 0.0001 *** = P b 0.001.
et al. found an average %EWL at 1 and 2 years of 59% and 64.5% [44]. The first report from the American College of Surgeons Bariatric Surgery Center Network evaluating the efficacy of VSG compared to LAGB and Roux en Y found an overall greater reduction in BMI for VSG compared to LAGB (11.87 kg/m 2 vs. 7.05 kg/m 2) [45]. Few studies have evaluated the efficacy of VSG in adolescent obese patients; however similarities in efficacy and safety between adults and adolescents have been shown [46]. McGuire at al. recently showed a %EWL of 38.6% at 6 months in 59 adolescent obese patients who underwent VSG, similar to our results of 48.1% ± 17.9% [24]. The largest study evaluating the efficacy of VSG in adolescent patients is by Algahtani et al., in which 108 patients showed a 65.8% and 64.9 %EWL at 1 and 2 years respectively with additional resolution of obstructive sleep apnea (90.9%), diabetes (93.8%), dyslipidemia (70%), and hypertension (75%) [25]. Algahtani et al.’s findings were similar to our %EWL at 1 (58.4 ± 22.4) and 2 years (70.9 ± 20.7) and we too observed a reduction in total triglycerides, increased levels of HDL, and significant reductions in seromarkers associated with diabetes: HgA1c, and fasting glucose. C-reactive protein, a marker of inflammation in obese patients, was also significantly reduced following VSG. Several adult studies have shown superiority of VSG over LAGB in short term and sustained long term weight and BMI loss [5,18]. In one prospective randomized study involving 80 adult patients comparing
LAGB to VSG, a significant reduction in %EWL at 1 (41.4% vs. 57.7%) and 3 years (48% vs. 66%) was noted [18]. Our study compares the efficacy of LAGB to VSG at achieving weight loss and improving seromarkers associated with obesity in adolescent obese patients. In this study VSG patients achieved superior reductions compared to LAGB in %EWL at 6 (48.1 ± 17.9 vs. 21.5 ± 16.0, P b 0.0001), 12 (58.4 ± 22.5 vs. 28.7 ± 21.4, P b 0.0001), 18 (71.9 ± 19.5 vs. 31.5 ± 23.3, P b 0.0001), and 24 months (70.9 ± 19.5 vs. 35.5 ± 28.6, P = 0.004) and percent preoperative BMI loss at 6 (22.2 ± 6.7 vs. 9.3 ± 6.1, P b 0.0001), 12 (25.9 ± 9.9 vs. 12.6 ± 9.0), 18 (31.1 ± 11.5 vs. 14.8 ± 10.2, P = 0.0001) and 24 months (32.3 ± 11.0 vs. 16.4 ± 12.7, P = 0.004) (Table 2, Fig. 1A, B). Moreover, we have shown that the significantly greater %EWL and percent preoperative BMI loss observed following VSG when compared to LAGB were independent of gender (Tables 3a and 3b). VSG results in a significantly greater weight loss compared to LAGB, however, the mechanisms producing this effect are not fully understood. Both surgeries limit the quantity for food into the stomach. LAGB restricts food entry into the otherwise normal fundus and patients express a feeling of being unable to eat more but can remain hungry. VSG allows the stomach to fill with a reduced volume and stimulates earlier satiety. The impact of early satiety on weight loss in VSG patients does not explain the observed greater weight loss compared to LAGB.
Table 3a Comparisons of percent excess weight loss (%EWL) by gender. Male
Preoperative Weight (kg)
6 Months %EWL
12 Months %EWL
18 Months %EWL
24 Months %EWL
Count (%) Mean ± S.D. Median Range Count (%) Mean ± S.D. Median Range Count (%) Mean ± S.D. Median Range Count (%) Mean ± S.D. Median Range Count (%) Mean ± S.D. Median Range
P-Value
Female
P-Value
P-Value
P-Value
LAGB
VSG
LAGB vs. VSG
LAGB
VSG
LAGB vs. VSG
LAGB (Male Vs. Female)
VSG (Male Vs. Female)
43 (100) 150.8 ± 27.1 150.9 96.1–220.0 39 (91) 18.4 ± 11.1 17.4 −3.1–49.4 37 (86) 24.2 ± 18.1 21.9 −15.6–67.6 28 (65) 26.9 ± 21.6 22.2 −15.6–83.1 24 (56) 30.7 ± 31.5 23.8 −41.4–85.1
10 (100) 151.7 ± 30.4 139.6 117.8–213.6 8 (80) 50.8 ± 21.5 47.3 26.3–93.1 4 (40) 71.5 ± 28.1 80.7 30.4–94.0 1 181.5 – – 2 (20) 79.4 ± 2.2 79.4 77.9–81.0
NS
94 129.4 ± 24.1 127.2 85.5–205.2 87 (93) 22.6 ± 17.7 20.5 −24.2–86.9 74 (79) 30.9 ± 22.7 26.5 −15.2–83 53 (56) 33.9 ± 24.0 27.8 −24.4–89.8 56 (60) 37.6 ± 27.4 36.7 −17.1–101.5
27 133.1 ± 21.9 130 98.4–208.4 23 (85) 47.1 ± 16.9 44.8 19.6–85.4 17 (63) 55.3 ± 20.8 53.8 25.1–96.0 6 (22) 71.9 ± 19.5 61.9 54.1–101.9 4 (15) 66.7 ± 25.2 71.2 32.5–91.8
NS
b0.00001
0.047
b0.0001
NS
NS
0.0001
NS
NS
0.0005
NS
–
0.043
NS
NS
b0.0001
b0.0001
–
0.042
120
F.E. Pedroso et al. / Journal of Pediatric Surgery 50 (2015) 115–122
Table 3b Comparisons of percent preoperative BMI (kg/m2) by gender. Male
Preoperative BMI (kg/m2)
6 Months %Preop-BMI
12 Months %Preop-BMI
18 Months %Preop-BMI
24 Months %Preop-BMI
Count (%) Mean ± S.D. Median Range Count (%) Mean ± S.D. Median Range Count (%) Mean ± S.D. Median Range Count (%) Mean ± S.D. Median Range Count (%) Mean ± S.D. Median Range
P-Value
Female
P-Value
P-Value
P-Value
LAGB
VSG
LAGB vs. VSG
LAGB
VSG
LAGB vs. VSG
LAGB (Male Vs. Female)
VSG (Male Vs. Female)
43 (100) 49.7 ± 6.8 49.3 36–64.9 39 (91) 9.0 ± 5.0 8.63 −1.61–18.4 37 (86) 11.7 ± 7.6 11.8 −4.0–27.1 28 (65) 13.8 ± 9.7 12.8 −4.0–36.9 24 (56) 14.5 ± 13.0 14.5 −12.6–32.3
10 (100) 51.8 ± 11.2 47.3–39.5 39.5–74.3 8 (80) 23.5 ± 7.7 22.3 13.4–34.2 4 (40) 29.6 ± 14.6 29.61 11.8–47.4 – – – – 2 (20) 32.7 ± 7.5 32.7 27.4–38.0
NS
94 (100) 47.7 ± 8.8 46.6 33.6–83.6 87 (93) 9.4 ± 6.5 9.3 −10.9–29.8 74 (79) 13.1 ± 9.6 11.6 −12.4–37.7 53 (56) 15.3 ± 10.4 14.8 −10.9–38.2 56 (60) 17.2 ± 12.7 16.9 −6.6–51.9
27 (100) 49.4 ± 8.7 47.1 38–81.4 23 (85) 21.8 ± 6.4 21.8 10.9–33.4 17 (63) 25.0 ± 8.9 23.8 12.7–43.1 6 (22) 33.9 ± 9.6 31.9 22.2–46.0 4 (15) 32.1 ± 13.6 37.4 12.0–41.4
NS
NS
NS
b0.0001
NS
NS
b0.0001
NS
NS
0.0001
NS
–
0.027
NS
NS
b0.0001
0.0002
–
0.065
NS, not significant (P N 0.05).
One predominate physiologic hypothesis involves the role of ghrelin, a powerful hormonal appetite stimulant in humans. It has been shown that chronic ghrelin intake results in increased hunger, facilitating overall weight gain. Conversely pharmacologic ghrelin blockage results in significantly reduced food intake and overall weight [47]. Since ghrelin production predominantly occurs in the fundus of the stomach which is removed in VSG, it has been suggested that reduced overall ghrelin production may be responsible for the greater weight loss with VSG [48,49]. Langer et al. compared pre- and postoperative ghrelin levels in 10 LAGB and 10 VSG patients, finding significant reductions in postoperative ghrelin levels in the VSG group at 1 and 6 months, but no difference in the LAGB patients at either time point [48]. Furthermore, in a diet induced obese mouse model, Wang et al. found significant reductions in VSG treated mice (0.4 fold) compared to LAGB treated mice (2 fold) [49]. We have also previously shown no significant difference in pre- and postoperative fasting ghrelin levels at 1 year following LAGB [43]. The reasons for weight loss following LAGB and VSG continue to be incompletely understood, however, we believe them to be multifactorial, related to the effects of mechanical restriction, changes in postoperative physiologic and hormone release, and most importantly, from changes in eating behavior. Complications following bariatric surgery are well known and therefore must be taken into account when counseling adolescent patients who are planning to undergo bariatric surgery. In a large cohort of adult patients Carlin et al. found a significantly lower overall complication rate among patients who underwent VSG compared to RYGB (6.3% vs. 10.0%, P b 0001), and a reduced overall complication rate in LAGB vs. VSG patients (2.4% vs. 6.3%, P b 0.0001). Our study showed an overall complication rate at 5 years of 23.4% (32/137), and details related to complications in VSG patients are limited due to a shorter follow up period. However our one complication of a postoperative VSG patient who developed massive mesenteric venous thrombosis 12 days after surgery resulting in septic shock, multi-organ system failure, and ultimately death is a significant consideration when consenting patients for VSG. A higher incidence of venous thrombosis has been observed in adult VSG patients [50]. However, reports in adolescent patients are limited. Given the risks associated with either procedure, our patients preoperatively are extensively counseled, understanding our limited long term follow up, on the benefits, limitations, and most importantly the risks associated with either procedure.
There remain several limitations to this study. The reduced number of VSG patients as compared to LAGB patients limited our analysis on overall weight loss, efficacy of sustaining weight loss and especially in long term complications. Indeed, missed follow up appointments have occurred in both populations, further limiting our data collection. Postoperative medical management differed slightly insofar as LAGB patients required additional visits for band adjustments and practical issues such as timing and transportation may have contributed to less compliance with follow up visits in LAGB patients. Our analysis on trends of seromarkers associated with obesity has several limitations including follow up time (1 year), the lack of direct comparisons at separate times and limiting our analysis to linear regression due to some patients not having labs at all time points. However, significant trends in improved seromarkers associated with obesity were observed in both VSG and LAGB. Regardless of the limitations associated with this study, we believe that this study enhances our understanding of the efficacy of LAGB and VSG in adolescent obese patients. Successful short term and sustained long term weight loss with low complication rates in morbidly obese adults has led bariatric surgery to become widely accepted. As a treatment option for adolescent obesity, bariatric surgery has shown promising results in effective weight reduction and improvements in co-morbidities associated with obesity. The long term impact of bariatric surgery in adolescents remains unknown. Additional studies with longer follow up will offer a better understanding of the risks and benefits of this treatment strategy. In conclusion, the complex task of helping obese patients develop healthy eating behaviors mandates a multidisciplinary approach to the obese adolescent. Bariatric surgery in adolescent obese patients is an effective treatment tool to help reduce overall weight and sustain weight loss. Our results show VSG to be significantly more effective than LAGB in obese adolescents at reducing weight and BMI short term (6, 12, 18, and 24 months) independent of gender. Nonetheless, the long term risks associated with both procedures and their efficacy in long term sustained weight loss still need to be elucidated with studies having longer follow up and greater number of patients.
Appendix A. Discussion Laparoscopic vertical sleeve gastrectomy significantly improves short-term weight loss as compared to laparoscopic adjustable gastric
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Table 4 Linear regression analysis: seromarkers associated with obesity.
Total Triglycerides Total Cholesterol High Density Lipoprotein Low Density Lipoprotein Hemoglobin A1c Fasting Glucose C-Reactive Protein
LAGB VSG LAGB VSG LAGB VSG LAGB VSG LAGB VSG LAGB VSG LAGB VSG
Y-Intercept ± S.D.
Slope
(Day 0)
95%CI
117.9 108.1 164.0 154.7 42.3 40.9 99.7 92.1 5.5 5.5 85.5 89.9 9.0 9.9
± ± ± ± ± ± ± ± ± ± ± ± ± ±
6.3 4.9 2.5 3.9 0.7 1.4 2.1 3.4 0.03 0.09 0.6 1.9 0.6 1.1
R Square
−0.0365 −0.0718 0.0060 0.0043 0.0091 0.0140 −0.0005 0.0048 −0.0004 −0.0009 −0.0065 −0.0262 −0.0089 −0.0182
band placement in morbidly obese pediatric patients: presented by Felipe Pedroso, New York, NY.
Thomas Inge (Cincinnati, OH) Thank you for a wonderful report. The question that always comes to my mind is in the U.S. data the band does not seem to have the same effect as we’ve seen in international studies, for instance, the randomized controlled trial from Australia. I’m just wondering, in your experience or in your population, do you have any hypotheses about why the results may be poorer here? Your slides went by pretty fast but it seemed to me like your percent weight loss may have been in the 10% to 15% range whereas in Australia it’s nearer to 30% weight loss at two years. Can you hypothesize about the differences?
Felipe Pedroso Actually you may have missed it but in looking at our slides – thank you for your question – but in looking at our slides, we have in excess body weight loss of 30% which is found out to two years and that has stayed out to 36 months and 48 months. However, with sleeve gastrectomy we’re seeing significant increases with doubling of that weight loss. In regards to the Australian study versus our findings, I can only hypothesize as to why we are seeing less weight loss as compared to them. It may be lifestyle and our Western civilization, how we eat, McDonald’s …
Thomas Inge They have McDonald’s there too. It’s interesting. Thank you.
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± ± ± ± ± ± ± ± ± ± ± ± ± ±
0.0284 0.0229 0.0111 0.0184 0.0032 0.0066 0.0093 0.0162 0.0001 0.0004 0.0025 0.0089 0.0025 0.0053
0.0052 0.1013 0.0009 0.0006 0.0257 0.0498 0.00001 0.0009 0.0314 0.065 0.022 0.0919 0.0401 0.1256
Slope
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P-Value
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0.199 0.002 0.588 0.815 0.004 0.036 0.96 0.769 0.002 0.016 0.009 0.004 b0.001 b0.001
0.532 0.942 0.483 0.791 0.095 0.003 0.096
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