Efficacy and Safety of Laparoscopic Sleeve Gastrectomy in Adolescents

Abstract

Background:

Adolescent obesity is increasing worldwide, and the demand for bariatric surgery in this patient population is rising. This study assesses the safety and efficacy of laparoscopic sleeve gastrectomy (LSG) in the adolescent (≤21 years) population in two University hospitals in Lebanon.

Methods:

We retrospectively reviewed a cohort of 121 adolescent patients who underwent LSG at the American University of Beirut Medical Center and at Makassed General Hospital between January 2011 and September 2014.

Results:

The study included 119 patients with a median age of 18.6 ± 2.1 years (range 11–21). Most patients were female (71.4%). Mean preoperative weight and body mass index were 117.9 ± 24.3 kg and 41.9 ± 6.6 kg/m² (range 32.3–71.0 kg/m²), respectively. Follow-up was achieved in 90.6%, 65.9%, and 59.5% at 1, 2, and 3 years, respectively. Mean percentage of total weight loss was 31.5% ± 8.4%, 32.6% ± 10.4%, and 29.6% ± 13.7%, while mean percentage of excess weight loss was 90.1% ± 28.6%, 89.9% ± 32.0%, and 82.2% ± 38.6% at 1, 2, and 3 years, respectively. Diabetes, hypertension, and dyslipidemia resolved in 100%, 62.5%, and 83.3% of patients, respectively, at a mean follow-up of 13.8 ± 9.1 months. Gastroesophageal reflux disease was reported in 21% of patients followed up at 3 years. The most common long-term complication was symptomatic gallstones necessitating surgical intervention (10.1%).

Conclusion:

The study shows that LSG is an effective and safe weight loss procedure for morbidly obese adolescents, offering good medium-term weight loss outcomes and significant resolution of obesity-related comorbidities.

Introduction

Population studies in the last few decades have demonstrated a dramatic and progressive increase in the proportion of obese adolescents.¹ In 2012, the prevalence of obesity in the United States was 16.9% in adolescents and 34.9% in adults.² Obesity in adolescents is associated with hypertension, diabetes mellitus, dyslipidemia, osteoarticular disease, fatty liver disease, obstructive sleep apnea, and premature cardiovascular disease.^3–5

Obese children and adolescents have a 25% greater risk of progression to adult obesity³ and a twofold increase in the risk of mortality as early as the fourth decade of life.^1,6 Medical treatment of adolescent obesity, including dietary control, physical activity, and pharmacological management, has shown limited success.⁷

With the increasing popularity of bariatric surgery in the last two decades, the outcomes of these procedures in the adolescent population are gaining interest, but long-term data are still limited.⁸ Laparoscopic sleeve gastrectomy (LSG) has become the most popular bariatric operation worldwide and its application has been extended to treating children and adolescents with obesity.^9–11 Despite existing concerns of the effect of bariatric surgery on normal growth and sexual development in prepubertal children, a recent matched control study by Alqahtani et al. not only showed that LSG is safe and effective in this age group but also demonstrated that obese children undergoing LSG grew taller compared to their nonsurgical counterparts.¹¹

This study aims to assess the safety and efficacy of LSG in the adolescent obese population in two Lebanese hospitals.

Materials and Methods

This study is a retrospective observational study that uses data collected from January 2011 to September 2014. All adolescent patients who were less than (or equal) 21 years of age at the time of the operation and have undergone LSG at the American University of Beirut Medical Center and at Makassed General Hospital were included after respective institutional review board approval. Demographic data, anthropomorphic data (weight, height, body mass index [BMI]), baseline medical profile, and detailed postoperative history were obtained and analyzed using the Statistical Package for the Social Science (SPSS), version 22. Results are represented as mean ± standard deviation (SD). Paired sample t-test was used to compare continuous variables. Statistical significance was defined as p < 0.05. Weight loss was registered as change in BMI, percentage of total weight loss (%TWL), and percentage of excess weight loss (%EWL). BMI was calculated as weight divided by height.² %EWL was calculated using the formula \documentclass{aastex}\usepackage{amsbsy}\usepackage{amsfonts}\usepackage{amssymb}\usepackage{bm}\usepackage{mathrsfs}\usepackage{pifont}\usepackage{stmaryrd}\usepackage{textcomp}\usepackage{portland, xspace}\usepackage{amsmath, amsxtra}\pagestyle{empty}\DeclareMathSizes{10}{9}{7}{6}\begin{document} $$\frac { 100 \% \times ( initial_ {weight} - Follow - up_ { weight } )} {(Initial_ { weight } - IBW ) }$$ \end{document} , where ideal body weight (IBW) was defined as the weight corresponding to the 85th percentile of BMI for the patient's age, gender, and height.

Presence of Type II diabetes mellitus (T2DM) was defined as a glycosylated hemoglobin (HBA1C) level ≥6.5% or fasting blood glucose ≥126 mg/dL. Remission was defined as an HBA1C < 6% or FBG <100 mg/dL in the absence of antidiabetic medications. Diagnosis of hypertension included both stage 1 (blood pressure [BP]: 120–159/90–99 mmHg) and stage 2 (>160/>100). A normal BP (<120/80) when off antihypertensive medication as reported by the patient was considered as remission of hypertension. Initial diagnosis of dyslipidemia was based on high levels of LDL (>130 mg/dL), total cholesterol (>200 mg/dL), or triglycerides (>150 mg/dL). Normalization of lipid profile laboratory values when off treatment was considered as a resolution of dyslipidemia. As for gastroesophageal reflux disease (GERD), asthma, osteoarticular disease, and obstructive sleep apnea, diagnosis and resolution were subjective and based on symptom severity, frequency, or on medication use. For GERD, resolution meant absence of symptoms and no medication use. Similarly, for asthma, osteoarticular disease, and obstructive sleep apnea, remission was based on subjective reporting by the patient.

Surgical procedure

The procedure was performed under general anesthesia in the supine position. The number of laparoscopic ports ranged from three to five with a Nathanson liver blade to retract the left lateral segment of the liver. The vessels along the greater curvature were sealed and divided with the LigaSure all the way to the angle of Hiss, and to 3–5 cm proximal to the pylorus. All the retrogastric adhesions were released so that the stomach was quite floppy. A 36 French orogastric tube was placed and oriented toward the antrum, and starting around 4 cm proximal to the pylorus, the stomach was stapled and divided along the 36 French orogastric tube with an endoscopic stapler. The staple line was then sutured with 2-0 PDS sutures serosa to serosa, and then the orogastric tube was removed. The ports were then removed under direct vision, and the stomach was retrieved through the umbilical incision. The fascia at the umbilicus was closed with PDS, and the skin was closed with absorbable sutures.

Results

One hundred twenty-one adolescent patients aged 11–21 years old underwent LSG between 2011 and 2014. Two patients (1.7%) were lost to follow-up shortly after the operation and were excluded from the study. Hence, 119 patients (98.3%) constituted the study cohort.

Most patients were female (71.4%). The median age of the study group was 18.6 years ±2.1 (range 11–21 years), and the mean preoperative weight and BMI were 117.9 ± 24.3 kg and 41.9 ± 6.6 kg/m² (range 32.3–71.0 kg/m²), respectively (Table 1). All operations were completed laparoscopically by one of two surgeons (BYS, HF). Mean %TWL was 24.8% ± 6.9% at 6 months and 32.6 ± 10.4 at 1 year. At 3 years post-LSG, mean %TWL was 29.6 ± 13.7 (Table 2, Fig. 1A). In contrast, mean %EWL was 71.2% ± 25.2%, 90.1% ± 28.6%, 89.9% ± 32.0%, and 82.2% ± 38.6% at 6 months and 1, 2, and 3 years, respectively. No significant difference in weight loss was found at 1, 2, and 3 years postoperatively (p = 0.64) (Fig. 1B).

FIG. 1.

(A) Most weight loss occurs during the first postoperative year. After year 1, weight loss decreases with time. (B) After the first postoperative year, no difference in excess weight loss is noted (p > 0.05). BMI, body mass index; %TWL, percentage of total weight loss; %EWL, percentage of excess weight loss.

Table 1.

Baseline Characteristics of the Study Population

Variable	Mean ± SD	N (%)
Age (years)	18.6 ± 2.1
Gender
Male		34 (28.6)
Female		85 (71.4)
Weight (kg)	117.9 ± 24.3
Height (cm)	167.4 ± 8.9
BMI (kg/m²)	41.9 ± 6.6
Comorbidities
Diabetes		15 (12.6)
Hypertension		8 (6.7)
Dyslipidemia		12 (10.1)
Asthma		15 (12.6)
Obstructive sleep apnea		5 (4.2)
Osteoarticular disease		16 (13.4)

BMI, body mass index; SD, standard deviation.

Table 2.

Changes of Weight, BMI, and Percentage of Weight Loss over Time

Characteristics	Initial	6 Months	1 Year	2 Years	3 Years
Patients followed/eligible	119	116/119	106/117	56/85	25/42
% Follow-up		97.5	90.6	65.9	59.5
Weight (kg) ± SD	117.9 ± 24.3	88.2 ± 17.7	80.3 ± 14.5	81.8 ± 14.3	84.3 ± 16.5
Range	75–220	54–158	57–132	56–120	58–112
BMI (kg/m²) ± SD	41.9 ± 6.6	31.4 ± 5.0	28.4 ± 4.4	28.5 ± 4.6	29.2 ± 5.5
Range	32.3–71.0	23.7–49.9	20.7–41.7	21.3–39.8	21.3–41.6
%TWL ± SD		24.8 ± 6.9	31.5 ± 8.4	32.6 ± 10.4	29.6 ± 13.7
Range		7.0–46.9	7.0–47.3	4.7–51.8	2.6–52.3
%EWL		71.2 ± 25.2	90.1 ± 28.6	89.9 ± 32.0	82.2 ± 38.6
Range		24.7–136.6	31.7–169.5	25.5–171.3	6.6–163.8

%EWL, percentage excess weight loss; %TWL, percentage of total weight loss.

Comorbidities

Of the 119 patients included in the study cohort, 34 (28.6%) had abnormal HbA1C levels. Of those, 15 patients (12.6%) were diagnosed with diabetes on initial assessment, and thus, an additional 19 patients (16.0%) were considered prediabetic due to elevated HbA1C. Eight patients (6.7%) had hypertension, 12 (10.1%) had dyslipidemia, 15 (12.6%) had asthma, and 5 (4.2%) had obstructive sleep apnea. Sixteen patients (13.4%) reported symptoms of osteoarticular disease, including joint and back pain.

After 1 year, diabetes resolved in all 15 patients (100%), while hypertension resolved in 5 out of 8 patients (62.5%). Resolution of dyslipidemia started at 6 months (33.3%) reaching 83.3% at 2 and 3 years postoperatively. 86.6% of asthmatics had no asthma at 1 year postoperatively. In contrast, 80% had resolution of their obstructive sleep apnea after 6 months. Joint and/or back pain improved in 81.2% at 6 months and up to 3 years (Table 3).

Table 3.

Resolution Rates of Several Obesity-Related Comorbidities at Different Follow-Up Periods

Comorbidity	6 Months	1 Year	2 Years	3 Years
Diabetes (n = 15)	11 (73.3%)	15 (100%)	15 (100%)	15 (100%)
Hypertension (n = 8)	4 (50%)	5 (62.5%)	5 (62.5%)	5 (62.5%)
Dyslipidemia (n = 12)	4 (33.3%)	7 (58.3%)	10 (83.3%)	10 (83.3%)
Asthma (n = 15)	8 (53.3%)	13 (86.6%)	13 (86.6%)	13 (86.6%)
Obstructive sleep apnea (n = 5)	4 (80.0%)	4 (80.0%)	4 (80.0%)	4 (80.0%)
Osteoarticular disease (n = 16)	13 (81.2%)	13 (81.2%)	13 (81.2%)	13 (81.2%)

Gastroesophageal reflux disease

Eleven patients (9.8%) reported intermittent gastroesophageal reflux symptoms initially. Out of 94 patients who were followed up at 1 year, 26 (27.7%) had GERD symptoms. At 3 years after the surgery, 21% of patients reported persistent symptoms of GERD.

Postoperative morbidity

No staple line leaks, stenosis/strictures, or bleeding was observed in the study cohort. There was no operative mortality. Short-term complications (≤30 days) included one case (0.8%) of wound infection treated with antibiotics, one case (0.8%) of portal vein/splenic vein thrombosis treated with anticoagulation, as well as one case of dehydration (0.8%) necessitating IV hydration. The patient who had portal vein/splenic vein thrombosis also had concomitant splenectomy at the time of LSG for idiopathic thrombocytopenia purpura.

Long-term complications (>30 days) included 12 cases (10.1%) of symptomatic gallstones necessitating surgical intervention at a mean follow-up of 11.9 ± 3.6 months. Two patients were admitted for worsening depression (1.7%) and two other patients necessitated IV hydration. One patient developed thiamine deficiency 2 months after the operation and was treated promptly without any sequelae (Table 4).

Table 4.

Major Complications Related to Laparoscopic Sleeve Gastrectomy

Complication	Patients (%)
≤30 Days
Wound infection	1 (0.8)
Splenic/portal vein thrombosis	1 (0.8)
Fluid/electrolyte imbalance with IV hydration	1 (0.8)
>30 Days
Thiamine deficiency	1 (0.8)
Cholecystectomy	12 (10.1)
Depression	2 (1.7)
Fluid/electrolyte imbalance with IV hydration	2 (1.7)

LSG, laparoscopic sleeve gastrectomy.

Discussion

Morbid obesity is increasing in adolescents and is associated with much comorbidity, including cardiovascular disease, Type 2 diabetes mellitus, obstructive sleep apnea, polycystic ovarian syndrome, and many musculoskeletal problems.¹² However, data are limited regarding long-term outcomes of bariatric surgery in young patients, which increases concerns of the use of bariatric surgery in this vulnerable population. LSG has become a popular and preferred primary bariatric intervention, whose applicability in the adolescent age group is becoming more established.^11–17

Postoperative weight loss and complications in young patients are similar to those reported for adults. A retrospective review by Alqahtani et al. of 108 pediatric patients aged 21 years or younger and 114 adult patients older than 21 years who underwent LSG showed similar safety and effectiveness in the pediatric group compared with the adult group. However, pediatric patients had fewer major complications and were more compliant with follow-up than adults.¹⁷

The average %EWL achieved by our patients at 6, 12, 24, and 36 months was 71.2, 90.1, 89.9, and 82.2%, respectively (Table 2). Our results are in line with those reported in the literature (Table 5). Looking at results of individual patients, successful weight loss results according to Reinhold's criteria (%EWL ≥50%) were documented in 92.3%, 91.1%, and 76% of those followed up at 1, 2, and 3 years, respectively.²³ Only two patients had poor outcomes (%EWL <25%) at 3 years with respective %EWL of 24.3% and 6.6%, respectively.

Table 5.

%EWL After Sleeve Gastrectomy in Different Adolescent Studies

Study	Population	Mean age (years)	Mean BMI (kg/m ² )	6 Months	1 Year	2 Years	3 Years
Alqahtani and Elahmedi¹²	Saudi Arabia (N = 291)	14.4	48.3	NA	56.6	69.8	75.1
Park et al.¹³	Korea (N = 14)	19	40.1	52.6%	74.2%	82.7%	75.6%
Raziel et al.¹⁴	Israel (N = 32)	16.75	43.23	62.6%	81.7%	71%	75.9%
Nocca et al.¹⁶	France (N = 61)	19.5	46.7	48%	66.7%	78.4%	NA^a
Boza et al.¹⁸	Chile (N = 51)	18	38.5 ± 3.7	94.6%	96.2%	92.9%	NA
Pedroso et al.¹⁹	USA (N = 37)	17.3	50.1	48.1%	58.4%	70.9%	NA
Nadler et al.²⁰	USA (N = 23)	17.3	52 ± 9	38%	40%	NA	NA
Pourcher et al.^{21, b}	France (N = 16)	17.8^c	45.3	NA	70.61%	NA	NA
Al-Sabah et al.²²	Kuwait (N = 135)	19^c	48.5	NA	NA	84% (males),77% (females)	NA
This study—2015	Lebanon (N = 119)	19.4	41.9	71.2	90.1	89.9	82.2

Not applicable/available.

Single port SG.

Median values.

Studies of LSG in the adult population show significant improvement and resolution in several obesity-related comorbidities ranging from 40% to 80.9%.²⁴ In our study, resolution rates ranged from 62.5% to 100% at 2 and 3 years postoperatively. This in line with other published results on LSG in the adolescent population (Table 6). GERD was the only comorbidity that worsened after LSG with many patients reporting persisting symptoms at 2 and 3 years postoperatively. A study on comorbidity resolution in morbidly obese children and adolescents undergoing sleeve gastrectomy showed remission or improvement of 90.3% of comorbidities, 64.9% of which were within the first 3 months postoperatively.²⁵

Table 6.

Resolution Rates (%) of Different Comorbidities After LSG in Different Adolescent Studies

Study	Diabetes (%)	Hypertension (%)	Dyslipidemia (%)	OAD (%)	Asthma (%)	OSA (%)	Complications (%)
Alqahtani et al.^12,25	95	80	63			∼98	4.1
Park et al.¹³	100	50	53.8	NA	NA	100	Mostly GERD
Raziel at al.¹⁴	100	71.4	75	100	60	100	6.25^a
Yang et al.¹⁵	66.67	50	50	NA	NA	80	NA
Nocca et al.¹⁶	100	85.7	NA	NA	NA	70	6.56
Pourcher et al.²¹	100	NA	83.3	NA	NA	NA	NA
Al-Sabah et al.²²	100	75	NA	NA	NA	NA	NA
Our study	100	62.5	83.3	81	86.6	80.0	6.7^b

Early staple line leak & late acute cholecystitis.

Not including cholecystectomy.

GERD, gastroesophageal reflux disease; NA, not available; OAD, osteoarticular disease; OSA, obstructive sleep apnea.

Data from The Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) Study showed that 92% of 242 severely obese adolescents underwent weight loss surgery without major complications.²⁶ In contrast, data from 409 adolescents who underwent RYGB in California showed the rates of inpatient morbidity, reoperation, and readmission to be 5.9%, 2.9%, and 11.5%, respectively.²⁷ The types of complications observed in our adolescents were similar to those that would be expected for morbidly obese adults undergoing bariatric surgery; however, no hiatal or incisional hernias were seen. One patient (0.8%) had a wound infection that was successfully treated with antibiotics. Another patient had portal vein/splenic vein thrombosis and was treated with anticoagulation for 1 year and a half postoperatively with frequent follow-up imaging. Two patients (1.7%) were admitted for worsening depression, one of whom had suicidal ideation, which increases concern regarding the long-term psychological well-being of those patients after bariatric surgery. A systematic review and meta-analysis on the impact of bariatric surgery on the quality of life in general indicated a significantly greater positive influence on physical quality of life compared to mental quality of life and called for a greater focus on the psychological well-being of patients undergoing bariatric surgery.²⁸ Studies on the effect of bariatric surgery in adolescents in specific are limited. A matched case–control study from Saudi Arabia among 32 adolescents with extreme obesity showed significant improvement in self-esteem and quality of life 1 year after LSG, with weight loss being a significant predictor for this improvement.²⁹ However, larger studies with longer follow-up are needed. Other complications in our cohort were that IV hydration was needed for three patients (2.5%). In addition, one patient was diagnosed with thiamine deficiency after presenting with lower extremity numbness and was treated promptly. Symptomatic gallstones necessitating cholecystectomies were seen in 12 (10.7%) patients.

Study Limitations

Due to the study's retrospective nature, we were unable to precisely assess the improvement in many obesity-related comorbidities, especially the data regarding laboratory tests and medication usage were limited. Moreover, the quality of life and psychological well-being of patients following bariatric surgery were not assessed, which precludes definitive conclusions being made for the efficacy and safety of sleeve gastrectomy in this special population. Finally, one height measurement was used in the study, whereas BMI considers that height increases at every follow-up. Since the majority of our patients were above 18 years old, changes of height were considered negligible. Despite those limitations, our study gives important insight on the efficacy and safety of LSG in this region's adolescent population.

Conclusions

Our study shows that LSG is an effective and safe weight loss procedure for morbidly obese adolescents offering good weight loss outcomes and significant resolution of many obesity-related comorbidities. However, it necessitates appropriate and cautious patient selection, management, and follow-up. Moving forward, prospective studies that assess the quality of life of these patients on long-term follow-up are recommended, especially that data on the psychological impact of bariatric surgery in adolescents are scarce.

Ethical Approval

This article was approved by the Institutional Review Board at the American University of Beirut and Makassed General Hospital. For this type of study, formal consent is not required.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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