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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.
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
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| Less Serious Comorbidities | |
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