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Adolescent bariatric surgery

First submitted by:
Danielle Walsh
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Introduction:

Adolescent bariatric surgery has emerged secondary to the growing epidemic of childhood obesity. With over one third of American children and adolescents being considered overweight or obese, the incidence of this disease has nearly tripled since 1960. [1, 2] Approximately 4% of adolescents are considered extremely obese, defined as weights at or above the 99th percentile. [3] There is a great deal of discordance as to why teens are experiencing such a steep rise in obesity. When medical treatment fails to provide durable weight reduction, bariatric surgery should be considered. There are a number of different procedures being performed, both restrictive and malabsorptive, with varying levels of efficacy. In an important prospective randomized trial, Adjustable Gastric Banding (AGB) was shown to have a 26.9% reduction in BMI at 1 year. [4] The Roux-en-Y Gastric Bypass (RYGB) came to the forefront for treatment of adolescent obesity after its widespread success in the adult population with durable weight loss, amelioration of comorbidities and a 37.5% reduction in BMI in one recent report. [5] The Laparoscopic Sleeve Gastrectomy (LSG) appears to be emerging as a good option for successful weight loss in adolescents with a 36.1% reduction in BMI and significant comorbidity resolution. [6, 7] The long-term impact of morbid obesity in adolescents is not fully understood, but it has been documented that these patients develop the same comorbidities as seen in the obese adult population. [7, 8] One of the more prevalent comorbid conditions, Type 2 Diabetes Mellitus (T2DM), is a growing epidemic that responds favorably to bariatric surgery. The adolescent population has a higher rate of amelioration of T2DM after RYGB (90.9%) than reported in adults (83.7%). [5, 7, 8, 9] Furthermore, the improvement in lipid profiles and reduction in blood pressure in adolescents is of great significance since cardiovascular risks are decreased before permanent damage is incurred. [9, 10] Preliminary data suggests the LSG has similar efficacy to RYGB in reversal of comorbidities including a 93.8% resolution of T2DM. [6, 7]

Diagnosis and Evaluation:

The American Society for Metabolic and Bariatric Surgery (ASMBS) Pediatric Committee recently released guidelines for the surgical treatment of morbid obesity in adolescents. The selection criteria for adolescents being considered for a bariatric procedure should include a BMI of 35 kg/m2 with major co-morbidities such as T2DM, moderate to severe sleep apnea (apnea-hypopnea index > 5), pseudotumor cerebri, or severe Non-Alcoholic Steatohepatitis (NASH). Additionally, adolescents with a BMI of 40 kg/m2 and minor co-morbidities such as hypertension, insulin resistance, glucose intolerance, substantially impaired quality of life or activities of daily living, dyslipidemia, sleep apnea (apnea-hypopnea index < 5) should also be considered for this procedure. [11] Adolescent patients should undergo early surgical intervention because patients experience similar percentage weight loss regardless of their starting BMI. Therefore, starting treatment at a lower BMI will result in the patient being closer to a healthy weight range after maximal weight loss. [12] The evaluation of these obese adolescents requires a team approach and must consider the potential long-term health risks of untreated or inadequately treated obesity for each candidate. [11] Most centers use a multidisciplinary review board that includes specialists in adolescent medicine, endocrinology, pulmonology, gastroenterology, cardiology, orthopedics, ethics, psychology, and surgery to analyze and screen candidates. In addition to medical considerations, patients undergo extensive psychological and family counseling to identify and cope with potential factors that could undermine the strenuous post-operative lifestyle changes.

Operative Management:

Adolescent bariatric surgical patients are by definition high risk operative candidates and should only be managed in centers with a multidisciplinary team capable of treating adolescents with complications of severe obesity. RYGB and LGB have been the most commonly performed procedures and have the most data available. However, LSG has recently been shown to provide operative safety and good short term outcomes when analyzing weight loss, amelioration of comorbidities, and post-operative complications. [7] All procedures are performed using the same techniques as in the operation for the adult patient.

Post-Operative Care:

In addition to the standard surgical complications, post-operative adolescent bariatric patients should be closely monitored for gastrointestinal bleeding, marginal ulceration, anastomotic stenosis and malnutrition. It is crucial to have a bariatric dietitian familiar with the progressive high protein diet plan that begins with at least .5 g/kg of protein broken into 5-6 small meals. [8] Dumping syndrome can occur after RYGB, especially with a high carbohydrate meal. Other common nutritional complications include deficiencies in B12, folate, calcium, and thiamine. [8, 12] Menstruating teenagers may require iron supplementation and reliable birth control to prevent a potentially high risk pregnancy during the dramatic weight loss in the first year. Most patients reach a weight loss plateau after the first year by which time a sustainable diet plan should be implemented. [10] Lifelong medical management is imperative and patients should ideally follow-up yearly with their multidisciplinary bariatric team. Routine blood work should include blood counts and chemistry profiles to detect derangements in physiology secondary to bariatric anatomy. Psychological counseling is also encouraged to help patients cope with the psychosocial issues and post-operative lifestyle changes, especially in the teenage population. As we gain more knowledge about the effects of bariatric surgery in a young, reproductively active population, it is crucial to have long-term follow-up to assess how these procedures affect our patients later in life.

References:

  1. US Department of Health and Human Services. National Institutes of Health. Overweight and obesity statistics. WIN Weight-control information network 2010. Accessible at: https://win.niddk.nih.gov/statistics/index.htm. Accessed 23 May 2012.
  2. Center for Health Statistics. Prevalence of overweight, obesity and extreme obesity among adults: United States, trends 1960–1962 through 2005–2006. Health E-Stats 2008; Dec. https://www.cdc.gov/nchs/data/hestat/overweight/overweight_adult.htm. Accessed 23 May 2012.
  3. Freedman DS, et al. Relation of body mass index and waist-to height ratio to cardiovascular disease risk factors in children and adolescents: the Bogalusa Heart Study. American Journal of Clinical Nutrition. 2007; 86(1):33–40.Centers for Disease Control and Prevention. National
  4. O’Brien PE, Dixon JB; Laparoscopic Adjustable Gastric Banding in Severely Obese Adolescents A Randomized Trial; JAMA. Feb 2010;303(6):519-526.
  5. Lawson ML, Kirk S, Mitchell T, Chen MK, Loux TJ, Daniels SR, Harmon CM, Clements RH, Garcia VF, Inge TH. One-year outcomes of Roux-en-Y gastric bypass for morbidly obese adolescents: a multicenter study from the Pediatric Bariatric Study Group. J Pediatr Surg. 2006 Jan; 41(1):137-43; discussion 137-43.
  6. Brandt ML, Harmon CM, Helmrath MA, Inge TH, McKay SV, Michalsky MP; Morbid obesity in pediatric diabetes mellitus: surgical options and outcomes: Nature Reviews Endocrinology. 6.11 (Nov. 2010): p637.
  7. Nadler EP, Barefoot LC, Qureshi FG. Early results after laparoscopic sleeve gastrectomy in adolescents with morbid obesity. Surgery. 2012 Aug; 152(2):212-7.
  8. Pories WJ, Mehaffey JH, Staton KS; Surgical Treatment of Diabetes Mellitus; Surgical Clinics of North America; 2011 Aug; 91(4):821-36, viii
  9. Inge TH, Miyano G, Bean J, Helmrath M, Courcoulas A, Harmon CM, Chen MK, Wilson K, Daniels SR, Garcia VF, Brandt ML, Dolan LM. Reversal of type 2 diabetes mellitus and improvements in cardiovascular risk factors after surgical weight loss in adolescents. Pediatrics. 2009 Jan; 123(1):214-22.
  10. Inge TH, et al.; Bariatric Surgery for Severely Overweight Adolescents: Concerns and Recommendations; Pediatrics 2004; 114;217
  11. Michalsky M, Reichard K, Inge TH; ASMBS pediatric committee best practice guidelines; Surgery for Obesity and Related Diseases, Volume 8, Issue 1, Jan 2012, Pages 1–7
  12. Towbin A, Inge TH, Garcia VF, Roehrig HR, Clements RH, Harmon CM, Daniels SR. Beriberi after gastric bypass surgery in adolescence. J Pediatr. 2004 Aug;145(2):263-7.
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