Adolescent Bariatric Surgery: Acknowledging a Knowledge Gap while Providing Needed Healthcare

by Marc P. Michalsky, MD, and Thomas H. Inge, MD

Dr. Michalsky is Associate Professor of Clinical Surgery and Surgical Director, Center for Healthy Weight and Nutrition, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Department of Pediatric Surgery, Columbus, Ohio. Dr. Inge is from Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio.

Funding: There was no funding for the preparation of this article.

Disclosures: Drs. Michalsky and Inge report no conflicts of interest relevant to the content of this article.

Bariatric Times. 2011;8(12):12–13

Reprinted with permission from: MP Michalsky, TH Inge. Adolescent bariatric surgery: Acknowledging a knowledge gap while providing needed healthcare. American Academy of Pediatrics—The Section on Endocrinology Newsletter. 2011;(21): 6–8.

INTRODUCTION
Recent data indicate that four percent of children and adolescents suffer from extreme obesity [body mass index (BMI)>99th percentile], greater than those affected by childhood cancer, cystic fibrosis, human immunodeficiency virus (HIV), and diabetes combined.[1] Children with a BMI above the 99th percentile have a high probability of having obesity in adulthood (BMI≥30kg/m2),[2] and the weight loss success of behavioral and pharmacological intervention is modest at best.[3] The consequences of obesity-related disease burden are quite striking when one considers recent data demonstrating that nearly two-thirds of the affected pediatric population have two or more cardiovascular risk factors as well as a spectrum of metabolic comorbidities that were previously thought to only be associated with severe obesity in the adult population.

Not surprisingly, the cumulative physiological and metabolic effects of related comorbid diseases that are established during childhood contribute to a broad sense of urgency when considering effective treatment of juvenile-onset obesity compared to those who develop obesity later in life.
Current national evidence shows that bariatric cases performed in the pediatric population tripled from the late 1990s, with an estimated 2,000 procedures performed in 2004.[4]

In addition, analysis of data from California indicates that rates of laparoscopic adjustable gastric banding increased 6.9-fold from 2005 to 2007 (1.5 per 100,000 population in 2007).[5]

As the overall number of surgical procedures being performed is increasing, understanding the risks and multiple factors that predict longitudinal success is becoming correspondingly more important.

EFFECTIVENESS OF ADOLESCENT BARIATRIC SURGERY
In contrast to the lack of long-term effectiveness of nonsurgical treatment approaches, accumulating evidence shows that that the use of weight loss surgery in adolescents with severe obesity results in significant reduction in body weight.[4] Indeed, depending on type of procedure, operations for weight loss have typically resulted in 20- to 35-percent mean reduction in BMI for adolescent cohorts. In addition, multiple investigators have now reported improvements and/or complete reversal for multiple comorbid diseases states, including type 2 diabetes, insulin resistance, dyslipidemia,[6,7] obstructive sleep apnea,[8] hypertension, cardiac hypertrophy,[9] and quality of life.[10]

SAFETY
Most would agree that bariatric surgery, as applied to adults with morbid obesity, has been established as a safe and effective treatment with well-described outcomes that include low associated risks. However, most would also agree that little peer-reviewed, quality information is available about the safety of bariatric surgery in children of various ages.[4,11] The unique metabolic, developmental, and physiological aspects of younger age groups certainly deserve careful attention. Indeed, thus far, there are dozens of papers reporting retrospective, uncontrolled experience with use of surgery in pediatric age groups but only one randomized, controlled trial comparing bariatric surgery with a lifestyle intervention in adolescents.[12] This trial demonstrated that bariatric surgery was effective and generally associated with few severe surgical complications but an unexpectedly high (33%) elective reoperation rate during the two-year trial. Collectively, it seems that most practicing pediatricians are legitimately concerned about acute surgical risks, timing of intervention, whether adolescent patients and families are adequately prepared for surgery, how to determine the optimal procedure to recommend to adolescents, adherence with follow up and micronutrient intake, consent issues, risk-taking behaviors, and durability of treatment effects (weight and comorbidity change) following significant weight loss. Unfortunately, answers to these questions are not yet available and, for the present time, much data have to be adapted from what is known about the surgical treatment of obesity in older (i.e. adult) populations.

That said, some statements can be made about risks of surgery in adolescents based on two systematic reviews of the published literature.[4,11]

Risks of adolescent gastric bypass include dehydration, ulceration or stricture near the gastrojejunostomy, intestinal leakage, wound infection, nutritional deficiencies, beriberi, acute gallstone pancreatitis, cholelithiasis, iron deficiency anemia, bowel obstruction, dumping syndrome, and weight regain.

After adjustable gastric banding, a range of complications have also been described, including poor initial weight loss, band slippage, dilation of esophagus and/or gastric pouch above the band, band removal due to psychological intolerance, repeated vomiting, band readjustment, and weight regain.

Other procedures, including the malabsorptive biliopancreatic diversion, have also been used in adolescents. Reported complications include nutritional deficiencies, anemia, electrolyte imbalance, early and late protein calorie malnutrition, infections, ulcers, intestinal leakage, and acute necrotizing pancreatitis. Whether the odds of developing one or more of these complications is greater, the same, or less than that expected for adults is yet unknown, but initial data comparing early complications in adolescents and adults are actually quite reassuring.[5]

THE DILEMMA
The essential dilemma is easily deduced from the information presented previously. Adolescents are developing unprecedented levels of severe obesity aggravated by comorbid conditions that will shorten both quality and quantity of life. Developing comorbidities of obesity early in life seems to translate into greater “compounded” adverse effects on health. Effective, nonsurgical weight loss interventions have been elusive, and while surgery is effective, there are still significant questions to be anwered. Adding to the dilemma faced by those on the front lines battling the obesity epidemic is an intriguing observation about the timing of surgery. In an analysis of a series of adolescent patients (n=61) who underwent Roux-en-Y gastric bypass, the authors noted that there may be a fixed “ceiling” effect of surgical weight loss.[13] The authors determined that the average BMI decrease at one year after surgery was 37 percent, irrespective of the baseline BMI value.[13] For these adolescents, who arguably were referred for surgery very late in the progression of their severe obesity, only 17 percent achieved a postoperative nonobese BMI. Those patients who achieved nonobese status postoperatively were from the lowest BMI range (typically BMI values in the 40s). Thus, we infer from this preliminary data that those who ascend into the highest levels of BMI (e.g., BMI values in the 60s or greater) will have little chance of becoming nonobese, even after use of aggressive surgical therapy. If these data are replicated, and it is found that a critical BMI threshold exists beyond which a nonobese postoperative BMI value is unlikely to be achieved, then this finding will have important implications for timing of referral. Indeed, the goal would be to intervene before an individual’s obesity “deteriorates” beyond the effectively treatable stage.

IS TIMING IS EVERYTHING?
While the data and inferences presented previously are motivating in a sense, other practical healthcare delivery factors clearly have to be taken into account when considering how best to provide complex bariatric care to teens. Surgical programs that understand both adolescent/developmental issues and who are adept and expert at modern bariatric surgical care are still few and far between. Programs and institutions aspiring to care for teens with morbid obesity should be able to devote the multidisciplinary resources needed to prepare a teen and his or her family for a bariatric intervention. These institutions will likely be best positioned to provide the best and safest care postoperatively as well.

CONCLUSION
Although guidelines for the implementation of an effective adolescent bariatric program are not yet fully defined, a national dialogue is beginning to emerge that will help to shape the development of such programs.[14] In addition, our research institutions will need to devote considerable resources to filling our knowledge gaps around safety and effectiveness of modern bariatric care applicable to teens. As the epidemic of pediatric severe obesity continues to progress essentially unchecked, healthcare systems will need to increasingly build or modify existing programs to meet the needs of these deserving patients in an evidence-based manner.

References
1.     Inge TH, Xanthakos SA, Zeller MH. Bariatric surgery for pediatric extreme obesity: now or later? International Journal of Obesity. 2005;2007;31(1):1–14.
2.     Freedman DS, Mei Z, Srinivasan SR, et al. Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the Bogalusa Heart Study. J Pediatr. 2007;150(1):12–17 e12.
3.     Oude Luttikhuis, H et al. Interventions for treating obesity in children. Cochrane Database Syst Rev. 2009;(1):CD001872.
4.    Treadwell JR, Sun F, Schoelles K. Systematic review and meta-analysis of bariatric surgery for pediatric obesity. Ann Surg. 2008;248(5):763–776.
5.    Jen HC, Rickard DG, Shew SB, et al. Trends and outcomes of adolescent bariatric surgery in California, 2005–2007. Pediatrics. 2010;126(4):e746–753.
6.    Inge TH, Miyano G, Bean J, et al. Reversal of type 2 diabetes mellitus and improvements in cardiovascularrisk factors after surgical weight loss in adolescents. Pediatrics. 2009;123:214–222.
7.     Brandt M, Harmon C, Helmrath M, et al. Morbid obesity in pediatric diabetes mellitus: surgical options and outcomes. Nat Rev Endocrinol. 2010;6(11):637–245.
8.    Kalra M, Inge T, Garcia V, et al. Obstructive sleep apnea in extremely overweight adolescnets undergoing bariatric surgery. Obes Res. 2005;13:1175–1179.
9.    Ippish HM, Inge TH, Daniels SR, et al Reversability of cardiac abnormalities in morbidly obese adolescents with severe obesity. Obes Surg. 2008;18:675–679.
10.     Zeller MH, Modi AC, Noll JG, et al. Psychological functioning improves following adolescent bariatric surgery. Obesity. 2009;17(5):985–990.
11.    Aikenhead A, Knai C, Lobstein T. Effectiveness and cost-effectiveness of paediatric bariatric surgery: a systematic review. Clinical Obesity. 2011:1–14.
12.    O’Brien PE, Sawyer SM, Laurie C, et al. Laparoscopic adjustable gastric banding in severely obese adolescents: A randomized trial. JAMA. 2010;303(6):519–536.
13.    Inge TH, Jenkins TM, Zeller M, et al. Baseline BMI is a strong predictor of nadir BMI after adolescent gastric bypass. J Pediatr. 2010;156(1):103–108 e101.
14.     Michalsky M, Kramer R, Fullmer M, et al. Developing criteria for pediatric/adolescent bariatric surgery programs. Pediatrics. 2011;128 Suppl 2:S65–70.

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