The Role of Bariatric Surgery in Adolescent Morbid Obesity

| August 23, 2010

by Daniel DeUgarte, MD; Wendy Slusser, MD; and Amir Mehran, MD

Dr. DeUgarte is Surgical Director, UCLA Fit for Healthy Weight Program and Assistant Professor, Department of Surgery, Division of Pediatric Surgery for the David Geffen School of Medicine at UCLA, Los Angeles, California. Dr. Slusser is Medical Director, UCLA Fit for Healthy Weight Program and Assistant Professor, Department of Pediatrics for the David Geffen School of Medicine at UCLA, Los Angeles, California. Dr. Mehran is Surgical Director, UCLA Metabolic and Bariatric Surgery Center and Associate Professor, Departments of Surgery, Division of General Surgery for the David Geffen School of Medicine at UCLA, Los Angeles, California.

Bariatric Times. 2010;7(8):15–17

Abstract
Childhood obesity is a major public health problem. Increasingly, adolescents with morbid obesity are being evaluated for weight loss surgery. We review the rationale, recommended guidelines, and surgical options for adolescent bariatric surgery.

Introduction
Nearly one-third of children in the United States are obese or overweight.[1] Previously, type 2 diabetes was considered “adult-onset,” and now it accounts for an estimated one-third of diabetes cases seen in adolescence.[2] Increasingly, metabolic syndrome is being recognized in youngsters with severe obesity.[3] Childhood obesity is also associated with cardiovascular disease,[4] liver disease,[5] impaired quality of life,6 and premature death.[7] While preventative measures are essential in addressing this public health problem, the medical community must care for a rising number of adolescents with morbid obesity. Many of these patients have a compromised quality of life and are stigmatized by society. The purpose of this article is to review the rationale, recommended guidelines, and surgical options for adolescent bariatric surgery.

Why not wait until adolescents are older to intervene?
There are several benefits to early intervention including the following: 1) earlier resolution of comorbid conditions, 2) lower achievable weight, and 3) earlier improvements in quality of life. Similar to adults, adolescents have been found to have a resolution or marked improvement in comorbid conditions following bariatric surgery.[8,9] The improvements seen in cardiovascular disease, diabetes, and risks of cancer following bariatric surgery have been demonstrated to improve life expectancy.[10,11] Comorbidities are less advanced and more likely to be reversible in younger patients with less advanced disease.[12,13] In fact, waiting too long for conditions like diabetes may result in beta-islet cell ‘burn out’.[12] Adolescent patients may be at lower operative risk as their comorbidities are less advanced. Not surprisingly, adolescent bariatric deaths have not been observed in recent studies evaluating outcomes in large inpatient national databases.[14,15]

One of the compelling reasons to intervene earlier is to halt progression of disease. In fact, surgical outcomes have been influenced by the severity of disease at the time of treatment.[12,13] Nadir body mass index (BMI) is directly influenced by preoperative BMI.[16] Thus, delaying surgery may result in ongoing weight gain and ultimately impact the “best” weight a patient can hope to achieve.

Perhaps the most compelling rationale for early intervention is the profound improvement in quality of life that can result.[17,18] Many adolescents with morbid obesity are unable to attend school because of their health, the social stigma of their weight, and/or the inability of school seats to accommodate them.

Recommended guidelines for adolescent bariatric surgery
Adolescents with morbid obesity should undergo extensive evaluation prior to consideration for bariatric surgery. As with adults, bariatric surgery is only a tool to aid patients achieve better health. Patients must demonstrate a commitment to lifestyle changes, including diet and physical activity. In general, patients must undergo a physician-supervised behavioral therapy program for a minimum of six months. BMI criteria recommended for adolescents are similar to those for adults (BMI >35 with serious comorbidities or BMI >40 with other comorbidities).[8,9] Physical and skeletal maturity is advised especially if intestinal bypass is considered. In general, the minimum recommended age is 13 for adolescent girls and 15 for adolescent boys. Patients must be evaluated by a psychologist or psychiatrist ideally with expertise in both adolescent and bariatric psychology. As bariatric surgery requires strict adherence to post-operative dietary regimens and follow up, patients and their families are expected to be have excellent attendance at preoperative clinic visits as this may be predictive of postoperative adherence. Female patients must commit to avoiding pregnancy for the first two years after surgery. Finally, both patient assent and parental consent must be obtained prior to bariatric surgery.

Ideally, adolescent bariatric surgery candidates should be evaluated by a multidisciplinary team consisting of a bariatrician, dietitian, psychologist, surgeon, and other specialists when indicated. Some have proposed the ideal setting for adolescent bariatric surgery centers to be a children’s hospital within an adult hospital.[14] This setting provides the pediatric specialty support with the backbone of a large-volume adult bariatric practice. In addition, this environment facilitates transition of care from adolescence to adulthood. Regardless of the environment, there must be a commitment from the bariatric team to address the potential long-term consequences of bariatric surgery in an adolescent patient.

Surgical options for adolescent bariatric surgery
Gastric bypass remains the gold standard weight loss surgery for both adolescent and adult patients.[8] Adjustable gastric banding has become increasingly popular in adults because it is heavily marketed, considered less invasive and reversible, and requires a shorter hospitalization than other bariatric procedures.[20] Utilization of the gastric band for adolescents has been somewhat limited as bands have not yet received United States Food and Drug Administration (FDA) approval for patients under age 18 in the United States. The sleeve gastrectomy is increasingly being used as a single-stage procedure in adults. Each of these procedures has potential advantages and disadvantages, which require additional discussion and investigation.

Gastric bypass has been demonstrated to have similar results in adolescents as in adults.[8,9] Gastric bypass in adolescents has also been demonstrated to be more effective than gastric banding in weight loss and resolution of comorbidities.[9] The mean excess body weight loss for adolescents patients undergoing gastric bypass is greater than 60 percent. The majority of patients with preoperative type 2 diabetes can expect to be off medications with normal hemoglobin A1C levels within one year of the surgery.[21] Dramatic improvements in quality of life have also been demonstrated.[17,18] The disadvantage of gastric bypass is the malabsorption caused by intestinal bypass and the life-long need for nutritional supplementation.[22] Furthermore, intestinal bypass can impair medication absorption and impair the ability to perform endoscopic surveillance of the bypassed foregut. Finally, the operation is associated with a higher in-hospital complication rate than less invasive alternatives.[8,9]

Adjustable gastric banding has become increasingly popular in the United States despite poor long-term results in Europe. A recent randomized, controlled trial comparing gastric banding with lifestyle-modification in adolescents with morbid obesity was published in the Journal of the American Medical Association by the Monash group in Australia.[23] They reported a two-year excess body weight loss of 79 percent in the band group and 13 percent in the control group. While these results were encouraging, the authors also noted a 33-percent reoperation rate, which is higher than the reoperation rate seen in their adult population. Furthermore, the weight loss results are not reproducible across the globe as other centers report far inferior excess body weight loss.[8,9,24] Finally, the band is an implanted foreign body, which is destined to require removal or replacement during a patient’s lifetime. Historically, removal of a gastric band results in recurrent weight gain in the majority of patients.[25] In adolescents with a lifetime ahead of them, this is a particularly sobering notion. In European studies with long-term follow up, gastric banding results have been worse in younger patients.[26,27] Furthermore, despite its marketed “reversibility,” the gastric band may cause scar tissue in the proximal stomach. This may lead to higher complication rate in patients who ultimately require band removal and revisional surgery in the future.[28]
Sleeve gastrectomy has proven promising as a single-stage procedure in adults,[29] but there is limited data in adolescents.[30]

In addition to causing satiety by decreasing the stomach capacity, sleeve gastrectomy is associated with decreased levels of ghrelin (an orexigenic hormone)[31] and accelerated gastric emptying.[32] Most mid- and long-term results with sleeve gastrectomy in adults demonstrate results that are nearly equivalent to gastric bypass and superior to adjustable gastric banding.[29] The procedure also appears to be better tolerated by patients.33 Sleeve gastrectomy (like gastric bypass) appears to result in immediate improvement in insulin resistance unlike the gastric band, which is more dependent on weight loss for its improvements in insulin resistance.[34,35,36] The main concern with the sleeve gastrectomy is its irreversibility and the potential development of a staple-line leak. Sleeve gastrectomy has the advantage of avoiding intestinal bypass and is less likely to cause malabsorption than gastric bypass. It also does not require a foreign body or adjustment as with the band.
The long-term results of gastric bypass, gastric banding, and sleeve gastrectomy in adolescents are not well known and hampered by problems with patient follow up. We await the results of an ongoing National Institute of Health study to evaluate patients undergoing adolescent gastric bypass (Teen Longitudinal Assessment of Bariatric Surgery [(Teen-LABS)] and a multicenter, company-sponsored gastric banding trial. It is advised that adolescent patients undergoing sleeve gastrectomy be evaluated prospectively.

Conclusion
Childhood obesity remains a major public health problem. Adolescents with morbid obesity require a multidisciplinary approach to their care involving at minimum a physician, dietitian, and psychologist. Patients who meet criteria and demonstrate a commitment to follow up can be considered for bariatric surgery. The gold standard operation is the gastric bypass, which requires long-term nutritional supplementation. Enthusiasm for adjustable gastric banding should be tempered by an apparent higher complication rate in adolescents and the long-term potential for weight regain when the implant eventually fails and requires removal and replacement or revision. Sleeve gastrectomy, while promising, requires ongoing prospective evaluation.

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