Surgery for the treatment of obesity in children and adolescents

Review question

How effective is bariatric surgery in safely reducing weight in obese children and adolescents?

Background

Across the world more children and adolescents are becoming overweight and obese. As overweight and obese children are more likely to suffer from health problems, more information is needed about how best to treat this problem.

Study characteristics

We found one randomised controlled trial with a total of 50 participants (25 in both the intervention and comparator group) and a follow-up of two years. The surgery used was 'laparoscopic adjustable gastric banding' (gastric band placed around the entrance of the stomach by means of keyhole surgery). The control group received a program consisting of reduced energy intake (individualised diet plans ranging between 800 and 2000 kcal per day, depending on age and weight), increased activity (target of 10,000 steps per day) with a structured exercise schedule of at least 30 minutes a day and behavioural modification.

Key results

Australian adolescents (higher proportion of girls than boys) with an average age of 16.5 and 16.6 years in the gastric banding and 'lifestyle' group participated. The study authors reported an average reduction in weight of 34.6 kg at two years, representing a change in body mass index units (kg/m²) of 12.7 for the gastric banding group; and an average reduction in weight of 3.0 kg representing a change in body mass index units of 1.3 for the lifestyle intervention. Side effects were reported in 12 of 25 (48%) participants in the intervention group and in 11 of 25 (44%) in the control group. A total of 28% of the adolescents undergoing gastric banding required a 'revisional procedure' (surgery because of complications from the gastric banding surgery). No data were reported for all-cause mortality, behaviour change, participants views of the intervention and socioeconomic effects. At two years, the gastric banding participants performed better than the lifestyle participants in two of eight health-related quality of life concepts as measured by the Child Health Questionnaire (physical functioning score (94 versus 78, community norm 95) and change in health score (4.4 versus 3.6, community norm 3.5).

Quality of the evidence

Our results are limited to two years of follow‐up and are based on just one small Australian study with some risk of bias which was conducted in a private hospital, receiving funding from the gastric banding manufacturer. There is currently insufficient evidence to make an informed judgement about surgery for the treatment of obesity in children and adolescents.

Currentness of evidence

This evidence is up to date as of March 2015.

Authors' conclusions: 

Laparoscopic gastric banding led to greater body weight loss compared to a multi component lifestyle program in one small study with 50 patients. These results do not provide enough data to assess efficacy across populations from different countries, socioeconomic and ethnic backgrounds, who may respond differently. This systematic review highlights the lack of RCTs in this field. Future studies should assess the impact of the surgical procedure and post operative care to minimise adverse events, including the need for post operative adjustments and revisional surgery. Long-term follow-up is also critical to comprehensively assess the impact of surgery as participants enter adulthood.

Read the full abstract...
Background: 

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

Objectives: 

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

Search strategy: 

We searched the Cochrane Library, MEDLINE, PubMed, EMBASE as well as LILACS, ICTRP Search Portal and ClinicalTrials.gov (all from database inception to March 2015). References of identified studies and systematic reviews were checked. No language restrictions were applied.

Selection criteria: 

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

Data collection and analysis: 

Two review authors independently assessed risk of bias and extracted data. Where necessary authors were contacted for additional information.

Main results: 

We included one RCT (a total of 50 participants, 25 in both the intervention and comparator group). The intervention focused on laparoscopic adjustable gastric banding surgery, which was compared to a control group receiving a multi component lifestyle programme. The participating population consisted of Australian adolescents (a higher proportion of girls than boys) aged 14 to 18 years, with a mean age of 16.5 and 16.6 years in the gastric banding and lifestyle group, respectively which was conducted in a private hospital, receiving funding from the gastric banding manufacturer. The study authors were unable to blind participants, personnel and outcome assessors which may have resulted in a high risk of performance and detection bias. Attrition bias was noted as well. The study authors reported a mean reduction in weight of 34.6 kg (95% confidence interval (CI) 30.2 to 39.0) at two years, representing a change in body mass index (BMI) of 12.7 (95% CI 11.3 to 14.2) for the surgery intervention; and a mean reduction in weight of 3.0 kg (95% CI 2.1 to 8.1) representing a change in BMI of 1.3 (95% CI 0.4 to 2.9) for the lifestyle intervention. The differences between groups were statistically significant for all weight measures at 24 months (P < 0.001). The overall quality of the evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) was low. Adverse events were reported in 12/25 (48%) participants in the intervention group compared to 11/25 (44%) in the control group (low quality evidence). A total of 28% of the adolescents undergoing gastric banding required revisional surgery. No data were reported for all-cause mortality, behaviour change, participants views of the intervention and socioeconomic effects. At two years, the gastric banding group performed better than the lifestyle group in two of eight health-related quality of life concepts (very low quality evidence) as measured by the Child Health Questionnaire (physical functioning score (94 versus 78, community norm 95) and change in health score (4.4 versus 3.6, community norm 3.5)).

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