Bariatric surgery in adolescents: questions remain

A multidisciplinary adolescent bariatric team should conduct a thorough preoperative evaluation and selection prior to surgery.

Issue: September 2008

ByMartin I. Montenovo, MD

ByBrant K. Oelschlager, MD

In the past 30 years, the prevalence of obesity among pediatric age groups in the United States has almost tripled. Current estimates indicate that 15.5% of children and adolescents are obese (BMI >95th percentile for age).

Many comorbidities associated with adult obesity are commonly seen in obese adolescents and include hypertension, dyslipidemia, type 2 diabetes, asthma, sleep apnea, as well as problems unique to children, such as developmental problems and orthopedic injuries.

Studies show that 50% to 77% of pediatric patients who are obese carry their obesity into adulthood. Combining pharmacologic with behavioral therapy occasionally provides moderately effective short term weight loss, but is fraught with adverse effects from medications and problems of rebound weight gain upon discontinuation of therapy. For severely overweight adolescents who have not lost weight and/or not maintained weight loss through conventional non-operative approaches and who have serious or life-threatening conditions, bariatric surgery may be the only practical alternative for achieving a healthy weight .

Martin I. Montenovo

Brant K. Oelschlager

In 2004, experts in the field of obesity treatment in the pediatric population developed a guideline that addressed several important points regarding patient evaluation/selection and surgical options.

This guideline emphasizes multidisciplinary weight management teams experienced in meeting the distinct physical and psychological needs of adolescents. These teams should include specialists with expertise in adolescent obesity evaluation and management, psychology, nutrition, physical activity instruction and bariatric surgery.

Due to the lack of data supporting the long-term efficacy and safety of bariatric surgery among adolescents, patient selection for surgical treatment requires consideration of a number of factors and clinical judgment from the treating team.Based on the current pediatric guideline, bariatric surgery should be considered:

in adolescents with a BMI > 40 and a serious comorbid condition,
in adolescents with a BMI > 50 and a less serious comorbid condition.

There are medical conditions that are relative contraindications for bariatric surgery in this population. These conditions include a medically correctable cause of obesity; a substance abuse problem; a medical, psychiatric or cognitive condition that would significantly impair the patient’s ability to adhere to postoperative dietary or medication regimens; current lactation, pregnancy, or planned pregnancy within two years after surgery; and inability or unwillingness of either the patient or the parents to fully comprehend the surgical procedure and its medical consequences.

The timing of surgical treatment among adolescents is another controversial issue and often depends on the severity of obesity-related comorbidities. The rapid somatic growth observed in early adolescence requires adequate nutrition; therefore, bariatric procedures performed before the growth spurt could potentially compromise linear growth.

No data are available comparing the efficacy and safety of bariatric procedures among adolescents. Nonetheless, both Roux-en-Y gastric bypass and adjustable gastric banding have been shown to be effective in adolescent patients. From 1997 to 2003, the estimated number of adolescent bariatric procedures performed nationally increased fivefold. Roux-en-Y comprised a growing majority of procedures, increasing from 74% to 91% in the same period.

In Roux-en-Y, a small gastric pouch is connected to a segment of the Roux limb. Food passes from the gastric pouch through the Roux limb into the remainder of the small bowel. The gastric bypass achieves weight loss through both restrictive and malabsorptive mechanisms.

The first study reported included 33 adolescents between 1981 and 2001. Significant weight lost was observed overall (from 52 kg/m2 to 31 kg/m2 at 14 years after surgery). Five patients regained most or all of their body weight five to 10 years after the operation; however, significant weight loss was maintained in the remaining patients for up to 14 years after surgery. Most comorbid conditions resolved at one year with the exception of hypertension in two patients, gastroesophageal reflux in two, and degenerative joint disease in seven. Two late deaths were reported between 15 months and six years after the operation, which were thought to be unrelated to the procedure. Based on these results, the researchers stated that bariatric surgery in adolescents is safe and is associated with significant weight loss, correction of obesity comorbidity, and improved self-image.

In 2006, the Pediatric Bariatric Study Group reported outcomes with Roux-en-Y in 36 adolescents after one year of follow-up. The primary outcome was weight change and secondary outcomes were metabolic variables and complications; mean BMI dropped 37% after the operation (from 56.5 preoperatively to 35.8 kg/m2). There was a significant improvement in triglycerides (-65 mg/dL), total cholesterol (-28 mg/dL), fasting blood glucose (-12 mg/dL), and fasting insulin (-21 µM/mL). Thirty-nine percent of the patients developed some complication: 13 minor/moderate complications (wound infection, anastomotic stricture, electrolyte disturbances, iron deficiency, peripheral neuropathy, internal hernia) and two severe medical complication (including beriberi and death). The researchers concluded that the risks are offset by health benefits.

Adjustable gastric banding consists of laparoscopic placement of a silicone band that encircles the most proximal stomach. The band is adjustable with injection of saline into a peripherally placed reservoir. Major advantages include the ease and safety placement, adjustability, and potential reduction of nutritional consequences. However, adjustable gastric banding is not FDA approved for use among patients aged younger than 18 years. In 2005 the first U.S. experience with adjustable gastric banding in four morbidly obese adolescents was published. Results showed no operative morbidity, short operative time/hospital stay, and a weight loss pattern that mirrored the adult experience with this technique.

Results of adult studies suggested that adjustable gastric banding may not provide the same degree of durable, long-term weight loss as that expected after gastric bypass. Thereby, until an appropriate trial determines which procedure is optimal for adolescents, it is unclear which procedure is the most appropriate surgical option for most adolescents candidates for bariatric surgery.

Although we need to gather more data on patient selection and preferable operation, it appears that bariatric procedures will play an ever greater role in treatment for morbidly obese adolescents after a thorough preoperative evaluation is done by a multidisciplinary adolescent bariatric team. Until more information is acquired, physicians should consider doing these procedures within the confines of a prospective trial.

Martin I. Montenovo, MD, is a Senior Fellow in the Swallowing Center at the University of Washington Medical Center.

Brant K. Oelschlager, MD, is an Associate Professor and Director of the Center for Videoendoscopic Surgery, Director of the Swallowing Center and Director of Bariatric Surgery in the Department of Surgery at the University of Washington.

For more information:

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Horgan S, Holterman MJ, Jacobsen GR, et al. Laparoscopic adjustable gastric banding for the treatment of adolescent morbid obesity in the United States: a safe alternative to gastric bypass. J Ped Surg. 2005;40:86-91.

Inge TH, Krebs NF, Garcia VF, et al. Bariatric surgery for severely overweight adolescents: concerns and recommendations. Pediatrics. 2004;114:217-223.

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