What are the positives and negatives of bariatric surgery in adolescents?

An irreversible decision is made at a young age.

The main positive for adolescents undergoing bariatric surgery is that they can avoid the long-term deleterious effects of obesity and its related conditions by having these conditions resolved, or cured, early in the disease process, or completely avoid them by losing the weight before being afflicted by these weight-related conditions.

The main negative is that these adolescents are undergoing a complex procedure, accepting not insignificant risk, which will permanently alter them at a young age. If they become unhappy with that choice in the future, they still have to live with that choice. Adolescents aren’t always able to make lifelong choices well.

David S. Tichansky

The risks of any of the surgical complications associated with bariatric surgery in adults, including leakage of the intestinal connections and possibly death, exist for adolescent patients as well. In addition, possible long-term effects on growth and development are not well known or described. The actual surgical procedures don’t differ significantly from those being performed on adults. However, patient selection needs to be much more stringent and should be done only through a bariatric program specifically designed for adolescent patients and their families.

The ethical dilemmas apply more to the younger patients, who in many cases don’t shop for themselves or prepare their own meals. In these cases, this has to be a family effort, as the child’s obesity is as much a result of the environment they have grown up in as anything else. Unlike in the adult population, postoperative behavior modification has to be for the child’s caretaker, as well as the patient. The legal issue comes into play if the child patient turned adult resents the decisions made on his behalf and lashes out legally. Also, if it turns out retrospectively that deficiencies in growth or development do occur, legal repercussions would be likely. Lastly, mortality does occur sometimes after bariatric surgery. The catastrophe of this complication is only magnified when the patient is a child.

David S. Tichansky, MD, is Associate Professor of Surgery and Director of Minimally Invasive and Bariatric Surgery at Thomas Jefferson University, Philadelphia.

Younger patients have more physiologic reserve.

The benefits are the same as we see in adults, which are significant comorbidity reduction, massive weight loss and improved quality of life.

The risks for a given procedure are the same in children and adults. The difference is the length of time the younger patients are exposed to the risks such as long-term vitamin and mineral deficits, in the case of the bypass, or mechanical problems with the band, for example, a slipped band. The same procedures currently done on adults are also offered to carefully selected adolescents and include the LAGB, laparoscopic gastric bypass and laparoscopic sleeve gastrectomy.

Stacy Brethauer

The challenge is in determining the best procedure for each individual patient based on their surgical risk, comorbidities and expectations. And this must be done on an individual basis with the patient and their family.

There are currently limited long-term outcome data in the adolescent group, but it is not surprising that the younger patient will do very well in terms of their postoperative recovery and comorbidity reduction.

Unlike older patients who often have end-stage diabetes and CV disease related to their obesity, younger patients are earlier in the spectrum of their comorbid conditions and therefore may have more physiologic reserve to handle the stress of surgery and achieve improvement in their medical conditions before end-organ damage has occurred.

There are many ethical issues that have been raised regarding bariatric surgery in children and adolescents. Fortunately, those surgeons who perform these procedures have taken a cautious, conservative approach to this population that has helped to alleviate many of the safety concerns.

We do expect a general increase in studies, given the severe obesity problem in the adolescent population and the increasing acceptance of bariatric surgery for this group.

Stacy Brethauer, MD, is Associate Staff Physician in the Section of Laparoscopic and Bariatric Surgery at Cleveland Clinic.