Bariatric Surgical Procedures in Adolescence


Childhood obesity is a prevalent and progressive disease with few successful treatment options. Not only have increasing numbers of children and adolescents been affected over the years, but the average weight achieved by obese individuals has soared as well. Pediatric specialists are increasingly considering effective and sustainable measures to combat the serious and immediate health complications of this chronic disease. Evidence from clinical trials shows that behavioral weight management of obesity is seldom successful in children. Pharmacologic treatment options for obese adolescents are limited, and efficacy is also generally modest. Conventional treatment approaches are even less effective for those with severe obesity, leading many to consider weight loss surgical options as the initial treatment for select adolescents. Surgical weight loss results in significant improvement, if not resolution, of most obesity-related comorbidity in adults. Increasingly, quality outcomes research is demonstrating that this also is true for adolescents.

Definitions

Obesity specifically refers to the condition of having excess body fat. Measurement of body mass index (BMI) is a reasonably accurate method for predicting adiposity, is reproducible in the clinical setting, and is often used as a screening tool. In children and adolescents, physiologic increases in adiposity, height, and weight are expected during growth. Growth charts that are typically used to define obesity are age and gender specific.

The terms overweight (BMI for age and gender ≥85th percentile), obese (BMI for age and gender ≥95th percentile), and severely obese (BMI for age and gender >120% of the 95th percentile) have been used to refer to increasing grades of excess weight in children. Whereas more than 32% of adults in the United States are obese, 18% of children and adolescents are obese—a prevalence that has more than tripled in the last two decades. Currently, approximately 9% of adolescents meet the definition of severe obesity, which is problematic particularly because metabolic and health risks mount with increasing severity of obesity. In addition, longitudinal analysis of data from our study data shows that essentially all adolescents and most children with a BMI in the severely obese range will continue to be obese as adults. In addition, in a recent study, it was found that surgical treatment was associated with a 50% reduction in obesity-related mortality risk. Thus, bariatric surgery is considered a reasonable option for weight control and long-term health improvement in severely obese adolescents.

Consequences of Adolescent Obesity

Associated with the remarkable increase in prevalence of pediatric obesity is a parallel increase in the severity of obesity-related chronic diseases. These diseases have an onset at a younger age and carry an increased risk for adult morbidity and mortality. In addition, childhood obesity has adverse social and economic consequences. Important comorbid health conditions, which are used to justify the use of weight loss operations, are cited in Box 76.1 .

Box 76.1
Selected Comorbidities of Adolescent Obesity

Complication of Pediatric Obesity
Psychosocial Poor self-esteem
Depression
Eating disorders
Discrimination and prejudice
Quality of life
Sexual abuse
Neurologic Pseudotumor cerebri
Pulmonary Sleep apnea, asthma, and exercise intolerance
Cardiovascular Dyslipidemia
Hypertension
Coagulopathy
Chronic inflammation
Endothelial dysfunction
Gastrointestinal Gallstones
Nonalcoholic fatty liver disease
Renal Glomerulosclerosis
Endocrine Type 2 diabetes mellitus
Insulin resistance
Polycystic ovary syndrome
Musculoskeletal Slipped capital femoral epiphysis
Blount’s disease
Forearm fractures
Flat feet

Guidelines for Performing Bariatric Surgical Procedures in Adolescents

Patient Selection Criteria

National Institutes of Health (NIH) guidelines suggest that it is reasonable to consider weight loss surgery for adults with a BMI of 35 kg/m 2 or greater in the presence of severe obesity related comorbidities or 40 kg/m 2 or greater with or without comorbidities. Similarly, in adolescents with a BMI ≥35 kg/m 2 and major comorbid conditions such as type 2 diabetes mellitus (DM), obstructive sleep apnea (OSA), severe nonalcoholic steatohepatitis, or symptomatic pseudotumor cerebri, surgery may be an appropriate initial treatment option. Surgery is also considered a reasonable first treatment option for those adolescents with a BMI of 40 kg/m 2 or greater with other weight related comorbidities or risk factors that are responsive to weight loss (e.g., hypertension, mild OSA, glucose intolerance, obesity-related renal dysfunction, or dyslipidemia), functional impairment, or quality of life (QOL) impairment. Figure 76.1 outlines a suggested algorithm for management.

Fig. 76.1, Algorithm for management of the severely obese adolescent. BMI, Body mass index.

Bariatric Programs for Adolescents

For highly motivated adolescents who meet patient selection criteria ( Box 76.2 ) following unsuccessful prior attempts at weight loss, bariatric surgery should be considered a treatment option. Youth being considered for bariatric surgical procedures should be referred to a specialized center with a multidisciplinary bariatric team with pediatric expertise. Such a team is equipped to manage the sometimes difficult patient selection decisions and can provide appropriate follow-up and management of the unique challenges posed by the severely obese adolescent. Guidelines have been established by the American College of Surgeons that define such multidisciplinary bariatric teams, which include expertise in obesity evaluation and management, psychology, nutrition, physical activity, and bariatric surgical treatment. Depending on the individual needs of the adolescent, additional expertise in developmental pediatrics, adolescent medicine, endocrinology, pulmonology, gastroenterology, cardiology, orthopedics, social work, and ethics should be readily available. In programs dedicated to adolescent bariatric care, the patient review process is similar to that used in the multidisciplinary oncology and transplant programs. This review by a panel of experts from various disciplines results in specific treatment recommendations for individual patients, including appropriateness and timing of possible operative intervention based on patient understanding, compliance, family dynamics, and psychosocial support.

Box 76.2
Clinical Indications for Adolescent Bariatric Surgery

Documented Outcome After Adolescent Bariatric Surgery (references)
Serious Comorbidities

  • Type 2 diabetes mellitus

  • (12, 96, 98)

  • Obstructive sleep apnea

  • (47, 99–101)

  • Pseudotumor cerebri

  • (88, 102)

  • Severe nonalcoholic steatohepatitis (with NASH [nonalcoholic steatohepatitis] activity score [NAS] ≥4 or with presence of fibrosis)

  • (103, 104)

Less Serious Comorbidities
  • Pre-diabetes (HbA1c 5.7–6.4%)

  • (12, 47, 105)

  • Hypertension

  • (12, 13, 96)

  • Dyslipidemias

  • (12, 47)

  • Fatty liver disease (any)

  • (104)

  • Significant impairment in activities of daily living

  • Stress urinary incontinence

  • (106)

  • Gastroesophageal reflux disease

  • Weight-related arthropathies that impair physical activity

  • (107)

  • Weight-related quality-of life-impairment

  • (108–110)

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