Laparoscopic adjustable gastric banding in adolescent:
safety and efficacy
Aayed R. Al-Qahtani*
Division of Pediatric Surgery, King Khalid University Hospital, Riyadh 11671, Saudi Arabia
Background: Obesity prevalence is rapidly increasing among children and adolescents worldwide. It is
considered one of the most alarming public health issues facing the world today. The adult experience
has demonstrated that surgery is the only effective means of achieving persistent weight loss in obese
patients. However, little is known about bariatric surgery in children and adolescents. The aim of this
study is to evaluate the safety and efficacy of laparoscopic adjustable gastric banding (LAGB) in this
group of patients.
Methods: A retrospective review included all children and adolescents who underwent LAGB from
January 2003 to December 2005.
Results: Fifty-one patients underwent LAGB. The mean age was 16.8 years (range, 9-19), and the mean
body mass index was 49.9 kg/m2(range, 38-63). Mean excess weight loss was 42% at 6 months and
60% at 1 year follow-up. The most prevalent comorbidities were obstructive sleep apnea, limited
physical activities, hypertension, and diabetes mellitus. Band adjustments were performed under
fluoroscopic guidance in 5 patients and direct access as a clinic procedure in the remaining. One
patient required port repositioning under fluoroscopic guidance. The mean follow-up was 16 months
(range, 3-34). There was no mortality or significant postoperative complications.
Conclusion: The absence of significant nutritional deficiency, the continued adjustability, and potential
reversibility of LAGB make it the safest, least invasive, and most effective bariatric surgery that can be
offered to the young and adolescent population.
D 2007 Elsevier Inc. All rights reserved.
Obesity prevalence is rapidly increasing among children
and adolescents worldwide. It is considered one of the most
alarming public health issues facing the world today [1-4].
Although believed in the past to be less frequently
associated with increased morbidity than in adults, obesity
in children is now recognized to be associated with insulin
resistance, hypertension, hyperlipemia, hepatic steatosis,
sleep apnea, and orthopedic complications [5-8]. The
physical and social effects of severe obesity in young
people are devastating . The greatest concern and
potential public health effects are that obesity during the
pediatric age is a strong predictor of obesity in adulthood
[10-13]. Studies show that 50% to 77% of children and
adolescents who are obese carry their obesity into adult-
hood, thus increasing their risks of developing serious and
often life-threatening conditions. The risk increases to 80%
if one of the parents is also obese [10,14].
0022-3468/$ – see front matter D 2007 Elsevier Inc. All rights reserved.
* Division of Pediatric Surgery, College of Medicine, PO Box 84147,
Riyadh 11671, Saudi Arabia. Tel.: +966 14671575.
E-mail address: firstname.lastname@example.org.
Journal of Pediatric Surgery (2007) 42, 894–897
The adult experience has demonstrated that surgery
is the only effective means of achieving persistent weight
loss in obese patients. However, little is known about
bariatric surgery in children and adolescents. The aim of
this study is to evaluate the safety and efficacy of lapa-
roscopic adjustable gastric banding (LAGB) in this group
1. Materials and methods
A retrospective review included all children and adoles-
cents who underwent LAGB in our institution from January
2003 to December 2005.Our criteria to consider patients for
surgery met adult criteria set by the National Institutes of
Health for surgical correction of morbid obesity , which
include body mass index (BMI) of 40 kg/m2with or without
comorbidities or 35 kg/m2with comorbidities, supportive
family environment, failure to obtain weight loss for at least
6 months with conservative medical treatment, and willing-
ness and motivation by the patients and their families to
undergo surgery and to follow postoperative instructions. All
patients were assessed by a multidisciplinary team consisting
ofa pediatrician,a dietician,a health educator,anda surgeon.
Preoperative laboratory screening includes a chemistry
profile, a lipid profile, a complete blood count, fasting blood
glucose, glucose tolerance tests, an insulin level, a urinalysis,
and a thyroid function test. The preliminary evaluation may
suggest the need for consultation by a cardiologist, a
pulmonologist, or an endocrinologist. Echocardiogram and
sleep studies or lung function tests were requested if
clinically indicated. Patients along with their families were
counseled in 3 consecutive weekly sessions regarding the
surgical technique, the benefits, and the risks of the
procedure in addition to their obligation toward postopera-
tive guidelines and lifestyle changes.
A 10- or 11-cm Lap-Band (Bioenterics, USA) was placed
laparoscopically to create a 15-mL proximal pouch using
the pars flaccida technique in all patients. Postoperatively,
patients were observed for 24 hours before discharge after a
dietician visit. Those patients with sleep apnea were
admitted to the intensive care unit for overnight observation.
Preoperatively, subcutaneous heparin and intravenous cefur-
oxime were prescribed.
All patients were discharged home on a liquid diet that
was advanced to solid food during the ensuing 4- to 6-week
period. The first follow-up visit was 2 weeks after discharge.
The first Lap-Band adjustment was performed at least
6 weeks postoperatively, when the patient had ceased losing
weight. All adjustments, except in 5 patients, were done in
the clinic without fluoroscopic guidance. The patients were
given water to drink using straws while adjusting to assess
the adequacy of the adjustment. Adjustments were per-
formed as often as necessary based on patient weight loss
and symptoms. The injected volume during the first
adjustment was 1 to 2 mL. Any further adjustment was
performed as required based on weight loss with maximum
of 0.5 mL normal saline each time.
Fifty-one patients underwent LAGB (27 females and
24 males). Mean age was 16.8 years (range, 9-19), and mean
preoperative BMI was 49.9 kg/m2(range, 38-63). The most
prevalent comorbidities were metabolic syndromes (obesity,
dyslipidemia, hypertension, insulin resistance) in 15 patients,
obstructive sleep apnea in 10 patients, significant limitation
in daily physical activities in 37 patients, arthropathies in
7 patients, hypertension in 6 patients, and type 2 diabetes
mellitus in 7 patients. The average operative time was
70 minutes (range, 40-110). All patients were fully ambu-
lating the night of surgery and were discharged the next day.
Mean excess weight loss (EWL) was 42% (range, 15-63) at
6 months, 60% (range, 27-80) at 1 year, and 67% (range,
26-100) with more than 18 months of follow-up. Band
adjustments were performed under fluoroscopic guidance in
5 patients and direct access as a clinic procedure in the
remaining. One patient required port repositioning under
fluoroscopic guidance, and one patient required readmission
and rehydration because of an overly tight adjustment. Nine
patients complained of repeated attacks of vomiting espe-
cially when eating fast or eating foods that are supposed to be
avoided during the early postoperative period. The mean
follow-up was 16 months (range, 3-34). There was no
mortality or other postoperative complications. Late compli-
cations of band erosion, band prolapse, pouch dilatation, or
significant port problems were not seen. Patients with
diabetes and hypertension were cured of their disease, and
other comorbidities improved or resolved with discontinua-
tion of their therapy. All the adolescents reported an
improvement in overall well-being and were happier with
past 2 decades has been the emergence of a new chronic
disease: obesity in childhood and adolescence. The preva-
lence of obesity and excessive weight among children and
adolescents has tripled since the 1960s [2,16-18]. Twenty to
thirty percent of all children aged 2to19 are overweight .
Obesity is associated with significant health problems in
the pediatric age group and is an important early risk factor
for adult morbidity and mortality [7-11]. A dose-response
relationship between BMI during young adulthood and the
risk of death has been demonstrated, with extreme obesity
resulting in a reduction of 20, 13, 5, and 8 years of life
expectancy for black men, white men, white women, and
black women, respectively . Importantly, the loss of 5%
to 10% of body weight results in a significant improvement
in risk and comorbidity .
Laparoscopic adjustable gastric banding in adolescent895
The medical community is struggling to develop
effective strategies for the treatment of this epidemic.
Effective treatment is essential to aid both weight reduction
and to reduce the impact of comorbid health and psycho-
social problems. It has been shown that the conservative
treatment of obesity is ineffective and associated with high
attrition rates. Indeed, up to 90% of people will return to
their original weight within 2 years of stopping treatment
[21,22]. Resorting to surgery to change the metabolism of a
growing child is a profoundly new concept, but adolescents
with morbid obesity who have life-threatening comorbid-
ities may warrant such radical therapy.
When considering weight loss surgery in adolescents, the
indications, the type of procedure, and the age at which it can
be performed are controversial. The indications for bariatric
surgery in adults were derived by a National Institutes of
Health consensus panel in 1991 . In general, adults with
a BMI of 40 with or without comorbidities and a BMI of 35
with comorbidities are considered candidates for bariatric
surgery. This panel specifically avoided making a recom-
mendation for the treatment of patients younger than 18
years. A task force convened by the American Pediatric
Surgical Association addressed this issue. The indications for
surgery described by this task force are much more
conservative than those for adults . Evidence suggests
that early surgical intervention in extreme obesity provides
the best chance to reverse comorbidities [24-26]. Indeed, it is
necessary to be more aggressive in the treatment of
adolescent obesity by using established adult criteria.
However, we should look for the ideal procedure. The
LAGB may be the ideal operation for the adolescent
population precisely because the gastric banding is easily
and completely reversible as well as providing great
flexibility in a population that has dynamic changes in their
physical and dietary needs.
Since LAGB was first performed in 1993 by Belachew
et al , 130,000 procedures have been performed
worldwide . It is one of the most commonly performed
operations for the treatment of morbid obesity outside of the
United States. Roux-en-Y gastric bypass, however, is still
the most frequently performed bariatric operation in the
United States . Several studies have demonstrated that
morbidly obese patients can achieve superior weight loss
using LAGB [30,31].
Several authors have reviewed their experience using
varied open bariatric surgical techniques in adolescent
obesity with varied results [32-37].
Recently, surgical experiences with severely obese
adolescents treated via laparoscopic approaches have been
reported in the international literature [38-44].
Stanford et al performed laparoscopic gastric bypass on
4 obese children and achieved an EWL of 87% at 18 months.
Dolan et al  published their initial experience with
LAGB in 17 morbidly obese adolescents. At a median
follow-up of 25 months, the EWL was 60%. A slipped band
and a leaking port after 2 years of follow-up were reported.
Similarly, Abu-Abeid et al  reported on LAGB in
11 children with a reduction of the mean preoperative BMI
from 46 to 32 after a mean follow-up of 23 months and no
complications. Fielding and Duncombe  present their
experience with 41 adolescents who underwent the LAGB
procedure. They maintained a mean EWL of 70% at 5 years,
and the 2 patients with diabetes were cured. Angrisani et al
 (the Italian Collaborative Study Group for Lap-Band)
reported on 58 patients less than 19 years of age undergoing
LAGB. The overall postoperative complication rate was
10.3%. Band slippage was observed in 1 patient, gastric
pouch dilatation in 2, and intragastric migration in 3 patients.
The band was removed in 2 patients for psychologic
intolerance, and 1 patient was converted 2 years later to
open gastric bypass. The overall band removal rate was
10.3%. Conversion was necessary in 1 patient with gastric
perforation, and delayed biliopancreatic diversion was
performed in 2 patients.
The current report of LAGB in adolescents is one of the
largest in the literature. It showed a comparable EWL with
previous reports [38-43]; however, the complication rate and
the necessity to convert to open or other bariatric procedures
were not seen in our series. The recent modification  in
LAGB technique, which we applied in all cases, might have
contributed to these different results. These modifications
include the pars flaccida technique, a very small (15 mL)
initial pouch with a proper anterior fixation of the band
avoiding fixing the stomach to the crura of the diaphragm
and leaving the band empty at surgery with the first
adjustment 6 weeks later. This study also demonstrated that
we can minimize the radiation exposure by avoiding
fluoroscopic guidance during adjustment without jeopardiz-
ing the port or the stoma.
One of the most important advantages of LAGB in
adolescents is the absence of significant nutritional defi-
ciencies that are seen commonly with gastric bypass. None
of our patients received routine nutritional supplements, and
none were found to have any clinical or biochemical
evidence of malnutrition. Similar results have been reported
in other studies [38,41,43,44].
Another common concern in performing bariatric surgery
in adolescents is related to compliance with postoperative
dietary protocols. All patients in our group were compliant
with the follow-up program. This could have been because
of our flexible follow-up schedule. All patients have open
access to the clinic and direct contact with the treating
physician through his personal contact numbers. In addition,
all patients who do not come to their appointment are
contacted and rescheduled. In each visit, we reinforce, to the
patients and their families, the importance of adhering to the
postoperative instructions, including diet and exercise,
regardless of the weight loss during the previous weeks.
In conclusion, LAGB provides an effective surgical
solution for morbidly obese children and adolescents and
avoids the risk of metabolic problems associated with
bypass procedures. The LAGB procedure is unique in
leaving completely intact the physiologic and anatomic
function of the digestive system. Furthermore, the gastric
band may be easily manipulated or reversed as necessary.
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Laparoscopic adjustable gastric banding in adolescent897