Bariatric surgery in adolescents

Childhood obesity has emerged as one of the most important public health problems in the United States. Almost one-fifth of adolescents in the United States are obese and approximately 7 percent have severe obesity — defined as a body mass index (BMI) either ≥ 120 percent of the 95th percentile or ≥ 35 kg/m2.

Seema Kumar, M.D., a pediatric endocrinology consultant at Mayo Clinic in Rochester, Minnesota, says: "Children and adolescents with severe obesity are at risk of important comorbidities, including obstructive sleep apnea, diabetes, hypertension, cardiac hypertrophy and nonalcoholic steatohepatitis, as well as depression and impaired quality of life. Children with severe obesity almost always remain in the obese range as adults, and 65 percent will have class III obesity as adults (BMI ≥ 40 kg/m2).

"Additionally, children with obesity during childhood have been shown to have more health complications and higher mortality as compared with those who developed obesity during adulthood. Therefore, treatment that is targeted at achieving weight loss during childhood and adolescence may treat or prevent these problems and improve long-term health outcomes."

Medical options consisting of lifestyle modifications to support changes in diet and physical activity, with goals of reducing caloric intake and increasing energy expenditure are the first line treatment for children and adolescents with obesity.

Dr. Kumar comments: "Unfortunately, dietary and behavioral interventions alone have not been demonstrated to result in significant long-term success for children and adolescents with severe obesity. Pharmacotherapy options in adolescents with obesity are very limited, and currently orlistat is the only medication that is approved in the United States for the indication of weight loss in adolescents. This medication has been shown to have low efficacy in obese adolescents."

Due to the mounting evidence of the adverse long-term consequences of severe adolescent obesity coupled with poor efficacy of nonsurgical options for weight loss, and a demonstrated safety and efficacy record of bariatric procedures in adults, there has been increasing interest in bariatric surgery for adolescents with severe obesity.

Experts in pediatric obesity and bariatric surgery recommend that adolescents with a BMI ≥ 35 kg/m2 and a severe comorbidity that has significant short-term effects on health — such as moderate to severe obstructive sleep apnea, type 2 diabetes mellitus, pseudotumor cerebri, or severe and progressive steatohepatitis — or BMI ≥ 40 kg/m2 with more minor comorbidities be considered as candidates for bariatric surgery.

Todd A. Kellogg, M.D., a bariatric surgeon at Mayo Clinic in Rochester, Minnesota, says: "Other important criteria for patient selection include physical maturity, lack of medically correctable causes of obesity, and adequate emotional maturity and stability to ensure competent decision-making and good adherence to medical follow-up. Most experts also agree that the patient should have failed organized and sustained attempts to lose weight through lifestyle intervention.

"Contraindications to bariatric surgery include an ongoing substance abuse problem (within the preceding year) and medical, psychiatric, psychosocial or cognitive conditions that prevent adherence to postoperative dietary and medication regimens or impair decisional capacity.

"Weight-loss surgery for adolescents should be performed in the context of a multidisciplinary program with specific expertise in pediatric obesity, bariatric surgery, nutrition and psychology. The evaluation for weight-loss procedures includes evaluation for the presence and severity of coexisting diseases as well as assessment of the patient's and family's understanding and readiness for a life-changing and often permanent procedure. The risks and benefits of weight-loss surgery for individuals with syndromic obesity (such as Prader-Willi syndrome) have not been adequately explored."

Currently, the most widely performed procedures in adolescents and adults are the Roux-en-Y gastric bypass (RYGB), the sleeve gastrectomy (SG) and the adjustable gastric band (AGB).

Dr. Kellogg explains: "The AGB is not approved by the Food and Drug Administration for patients less than 18 years of age. Accumulating adolescent data suggest that SG may prove to be a safe alternative to RYGB, probably with fewer nutritional risks. As compared with AGB, SG has the advantage of avoiding a foreign body and potential associated complications.

"Malabsorptive procedures such as biliopancreatic diversion are not recommended for adolescents due to lack of safety data in this age group and concerns about long-term nutritional complications."

Dr. Kumar highlights: "Existing data demonstrate that bariatric surgery in adolescents leads to clinically important decreases in weight and BMI in the majority of patients. Obesity-related diseases such as diabetes, obstructive sleep apnea, as well as depression and quality of life also have been demonstrated to improve or resolve after surgically induced weight loss in adolescents. Information about long-term outcomes (more than two years) is limited, but the weight loss appears to be sustained in most cases, as it is in adult cohorts.

"There is insufficient information at this time to directly compare the long-term weight-loss outcomes of RYGB with those for SG or AGB in adolescents. Lifelong supplementation with vitamins and minerals is recommended for all adolescents undergoing any bariatric procedure to avoid development of nutritional complications secondary to reduced intake, mild malabsorption or both. Adolescents who have undergone bariatric surgery should be followed on a regular basis by a multidisciplinary team consisting of a dietitian, an expert in obesity and a psychologist."