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Adolescent bariatric surgery

Teen-LABS shows CVD risk in adolescent patients

While the majority of study participants are female, researchers found an interesting link between gender and CVD

The short-term outcomes from the Teen Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study, have reported favourable short-term complication profile and supports the early postoperative safety of bariatric surgery in select adolescents. Nevertheless, they authors add that additional study from this surgical cohort is required to ascertain the long-term outcomes for adolescents undergoing bariatric surgery.

The paper, ‘Perioperative Outcomes of Adolescents Undergoing Bariatric Surgery: The Teen–Longitudinal Assessment of Bariatric Surgery (Teen-LABS) Study’,  published in JAMA Pediatrics, reports on the results from the Teen-LABS multi-centre clinical study funded by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) at the National Institutes of Health (NIH), which is examining the safety and health effects of surgical weight loss procedures.

The trial, conducted at five clinical centres in the US including Cincinnati Children's Hospital, Nationwide Children's Hospital, Texas Children's Hospital, the University of Alabama at Birmingham, and the University of Pittsburgh Medical Center, is headed by Dr Thomas H Inge from Cincinnati Children's Hospital Medical Center and Dr Marc P Michalsky, surgical director of the Center for Healthy Weight and Nutrition at Nationwide Children's, and the lead author paper, which focuses on cardiovascular risk factors within the study population.

"This NIH-funded study will add important knowledge to the field of severe obesity during adolescence and the effects of bariatric surgery," said Michalsky, also an Associate Professor of Clinical Surgery and Pediatrics at The Ohio State University College of Medicine. "Collaborating with colleagues around the country in a study of this magnitude to gather critical data defining cardiovascular disease (CVD) and other health risks, is both gratifying and hugely important. The results of this study will improve our understanding of the significant medical challenges faced by severely obese teens as well as document outcomes following surgical weight loss."

Marc P Michalsky

The researchers undertook the Teen-LABS research study, as while paediatric obesity is more common now than in previous decades, very little is known about the CVD risks in the most severely obese teens. The main goal of the current paper was to assess the baseline prevalence and predictors of CVD risks among severely obese adolescents before undergoing weight-loss surgery.

This prospective, multisite observational study enrolled patients from February  2007 to December 2011. Consecutive patients aged 19 years or younger who were approved to undergo surgery (n=277) were offered enrolment into the study; 13 declined participation and 22 did not undergo surgery after enrolment, thus the final analysis cohort consisted of 242 individuals.

The researchers examined preoperative anthropometrics, comorbid conditions, and major and minor complications occurring within 30 days of operation.

Although the final 242 final study participants were similar in terms of BMI, age, and race/ethnicity to the 35 who were not studied, compared with the 35 not studied, the final analysis cohort was more likely to be female (p=0.04). The 242 patients who underwent a primary WLS procedure had a mean age of 17.1 years at surgery, a median BMI of 50.5, and a median waist circumference of 145.9 cm at baseline. Twenty-one percent had a BMI greater than 60 at the time of study enrolment. The cohort was primarily non-Hispanic (93%), white (72%), and female (76%).

Approximately one-half of participants (49%) presented with three or fewer comorbid conditions, 39% presented with four or five, and 12% presented with six or more. The most commonly observed comorbidities were dyslipidaemia (74%), sleep apnoea (57%), back and joint pain (46%), hypertension (45%), and fatty liver disease (37%). The most common abnormal laboratory values (not adjusted for medication use) were elevated C-reactive protein (75%), hyperinsulinemia (71%), low high-density lipoprotein (64%), and hypertriglyceridemia (40%).

Microalbuminuria was detected in 17.7% of patients, while 13.4%, 2.7%, and 3.1% met criteria for chronic kidney disease stages 1, 2, and 3, respectively. No patient met criteria for chronic kidney disease stages 4 or 5.

The most common operative procedure performed was Roux-en-Y gastric bypass (RYGB) followed by vertical sleeve gastrectomy (VSG), and adjustable gastric banding (AGB). There was a shift in procedure use over time, with a relative increase in patients undergoing VSG and decrease in AGB.

Within 30 days of surgery, a total of 19 patients (7.9%) experienced 20 major complications and 36 (14.9%) experienced 47 minor complications. There were no deaths. Procedure-specific rates of patients with major complications were: RYGB = 9.3% (95% CI, 5.3-14.9); VSG = 4.5% (95% CI, 0.9-12.5); and AGB = 7.1% (95% CI, 0.2-33.9). Comparable rates for minor events were: RYGB = 16.8% (95% CI, 11.4-23.5); VSG = 11.9% (95% CI, 5.3-22.2); and AGB = 7.1% (95% CI, 0.2-33.9).

Twelve patients (5.0%) experienced 13 major perioperative complications including one intraoperative splenic injury requiring conversion to an open procedure for splenectomy; seven of these 12 underwent early reoperation for intestinal obstruction, bleeding, and confirmed or suspected gastrointestinal leak. Nineteen patients (7.9%) experienced 20 minor perioperative complications including four minor injuries to solid organs at operation and six urinary tract events (infections and complications of urethral catheterisation). All reoperations and 85% of readmissions were related to WLS.

The authors found that severely obese adolescents carry not only excess weight, but also have much higher risk for CVD than previously realised. Of the 242 participants in the Teen-LABS cohort, 95 percent had at least one CVD risk factor. Seventy-five percent had elevated blood pressure (including hypertension and pre-hypertension), 50 percent had unhealthy cholesterol levels, and nearly three-quarters of the group were insulin resistant. Importantly, the study also confirmed that increasing weight in teenagers is associated with increases in blood sugar and blood pressure.

While the majority of study participants are female, researchers found an interesting link between gender and CVD.

"We found that adolescent boys were at a markedly higher risk compared with adolescent girls for abnormal triglyceride levels," said Michalsky. "Among severely obese adolescents, recognition and treatment of CVD risk factors is important to help limit further progression of disease."

“These data demonstrated that 92% of the 242 severely obese adolescents who underwent weight loss surgery did so without major complications,” the authors note. “This safety profile, including a 5% rate of major inpatient morbidity, was demonstrated despite the presence of significant comorbidities and severity of obesity that exceeded that of most published adult and adolescent bariatric studies.”

“The findings highlight the presence of both overt comorbidities and less-obvious indicators of organ dysfunction at baseline, and they indicate that WLS procedure selection has evolved over time,” they conclude. “The fact that major, life-threatening complications were infrequently observed documents the short-term safety of these procedures in this patient population…Longitudinal data from this cohort will inform us about the effects of surgery on comorbidities, physical/metabolic health and health-related quality-of-life changes, nutritional effects, and durability of weight loss.”

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