Laparoscopic Banding Procedure Helps Overweight Adolescents Lose Weight and Improve Health

NEW ORLEANS, Oct. 9 (medianowonline)- As the number of
overweight children in the United States approaches epidemic proportions,
one group of surgeons is taking an active role in researching new ways to
reduce obesity rates in children. Evan Nadler, MD, and colleagues at the
New York University School of Medicine have been researching the
effectiveness of surgical intervention to help morbidly obese children lose
weight: they studied the effect of laparoscopic banding procedures on
weight loss in a group of 14- to 17-year-olds who were extremely
overweight. They reported their findings at the 2007 Clinical Congress of
the American College of Surgeons.

To be eligible for the study, teenage patients had to meet National
Institutes of Health (NIH) guidelines for weight loss surgery, having
either a BMI (body mass index) of 35 with at least one cormorbidity
(weight-related illness) or a BMI of 40 without. According to Dr. Nadler,
"Generally, participants had to be about 100 pounds or more overweight."
Participants also had to have been obese for five or more years and had to
have failed medically supervised attempts at weight loss for six months or
more, Dr. Nadler explained.

Being overweight places people at risk for other illnesses (or
comorbidities), including type 2 diabetes (high blood sugar), hypertension
(high blood pressure), heart disease, stroke, sleep apnea, gallbladder
disease, liver disease, some types of cancer, and irregular menstrual
periods. Dr. Nadler also notes, "These individuals typically have back pain
or joint pain. They can have depression -- actually, the mental health side
of this is vastly underappreciated in my opinion. Obesity is devastating to
these children's social development."

Currently, two major operations for weight loss in adults are performed
in the United States: the gastric bypass procedure and the laparoscopic
adjustable gastric band procedure. Dr. Nadler's group studied the use of
the laparoscopic adjustable gastric band on adolescents. He was
particularly interested in studying this procedure because "Gastric bypass
has a mortality rate of about one percent in the adult population; the lap
band mortality rate is about 20 times less. Therefore, in my estimation,
it's a better operation for teenagers because it's safer," Dr. Nadler
explains. "Gastric bypass probably is a little bit more effective in terms
of absolute weight loss than gastric banding, but the amount of weight you
need to lose to have your obesity-related illnesses get better is about 20
percent of your excess weight." With the gastric band, the weight loss was
found to be "about 50 percent of your excess weight while the bypass may be
closer to 60 percent." As for the difference in the rates of weight loss,
Dr. Nadler notes "As long as the obesity-related illnesses get better, I
don't really care if you're a size 8 as opposed to a size 10. Getting the
extra pounds of weight loss is not worth a 20-fold increase in the
likelihood of dying," he explained.

The gastric banding procedure itself is minimally invasive and is
performed laparoscopically. This procedure involves putting a camera
through a small abdominal incision and using special, long instruments that
allow the surgeons to do the procedure without making a real cut in the
abdomen. Dr. Nadler describes the procedure this way: "Surgeons make five
small holes in the abdomen and place the band around the top of the
stomach. The band itself has a balloon on the inside of it which is
connected to a port. We access the port periodically to inflate the balloon
to tighten it, and as the band gets tighter, the patient experiences a
sense of fullness and then they're not hungry any more, and thus they don't
eat very much." As a conservative measure, the children were kept in the
hospital overnight; in adults, however, the operation can be done on an
outpatient basis and takes about an hour to an hour and a half to complete.

Dr. Nadler and colleagues used a scanning technique called DEXA
(dual-energy x-ray absorptiometry) to assess body composition. "The reason
body composition is important, is that there are a multitude of studies
that show that fat loss centrally is much more important than fat loss
peripherally. So men who carry their fat in the bellies are at higher risk
for bad comorbidities than some women who carry their fat on their hips and
thighs." These are commonly called the "apple" and "pear" shapes,
respectively. While previously published studies had shown that
laparoscopic adjustable banding was effective in producing weight loss, "We
wanted to know whether the weight loss was central or peripheral (ie.,
apple or pear) and then whether we were able to reverse the comorbidities
in our patients significantly," Dr. Nadler said.

In the study presented at the ACS Clinical Congress, the researchers
reported on a one-year follow-up data on 14 of the adolescent participants.
They found fat mass, lean mass, and android (male-pattern visceral) fat
were all significantly decreased. Prior to the operation, there were a
total of 43 comorbidities in all 14 participants, back pain, dyslipidemia
(a lipoprotein metabolism disorder) depression, osteoarthritis, and sleep
disorders. At one-year follow-up, 34 of these factors were reassessed and
the vast majority had improved. Twenty-five comorbidities were completely
resolved and five were improved, for a total improvement rate of 70 percent
in obesity-related illnesses, Dr. Nadler reported.

In terms of how this surgical procedure impacts lifestyle, Dr. Nadler
says, "We think of it as a behavior modification tool. It really changes
the way you eat. It forces you to. There's no choice." While some patients
may have to endure a second operation if the band slips out of position,
this is relatively uncommon, occurring in less than 10 percent of cases.
More importantly, Dr. Nadler says, "This particular study shows that the
weight loss associated with laparoscopic adjustable gastric banding in
adolescents is the important weight loss: it's the weight loss of central
fat which directly relates to the comorbid conditions associated with
obesity. So this particular dataset shows that you lose central fat, and
that for a large majority of our patients, their comorbidities are resolved
and/or improved."

According to Dr. Nadler, "Childhood obesity is a very controversial
topic and probably the most pressing health care issue facing children
today. What to do about it is certainly discussed among many experts, and I
think everyone agrees that prevention is the ideal strategy. But then the
question is, what do you do with all these children who are already 100
pounds overweight and are now getting sick from being that overweight?"

"It has been estimated that there are a million children in the US who
would qualify for obesity surgery based on their current weight and medical
illnesses related to their weight. We have been looking at children ages 14
to 17 for now, because that's the age group just younger than adults.
Whether or not the evaluation will expand to younger patients in the future
is unclear. But certainly there even are 12-year-olds these days who are so
overweight that they have severe medical problems based on their weight. I
think most of us would agree that if someone is really debilitated by their
weight, if they're 12 or 13, they might be a candidate for a lap-band
procedure, despite the fact they may not have reached their full adult
height," he observed. Dr. Nadler's study of the effect of gastric banding
on overweight adolescents is ongoing. Future studies will examine larger
numbers of adolescents.

In addition to Dr. Nadler, the research team included Valerie Peck, MD;
Christine Ren, MD, FACS; George Fielding, MD; and Shivani Reddy, MD.

SOURCE American College of Surgeons