Bariatric Surgery for the Severely Obese Adolescent Madelyn H. Fernstrom, PhD, CNS; and Anita P. Courcoulas, MD, MPH In recent years, a growing number of severely obese adolescents and their families have sought out surgical treatment because behavioral or medical therapies were not successful. A number of reports have suggested that bariatric surgery for this patient group is safe and can provide durable weight loss. However, most of these reports have been retrospective studies with short-term outcomes, and more long-term, prospective studies are needed to optimize care for these patients. Evaluation of the severely obese patient for surgery involves multiple factors, including the overall maturity of the patient; joint discussions with the patient and his or her family; a complete medical evaluation; evaluation by a child psychologist or psychiatrist; and a minimum of 6 months of private, interdisciplinary, multifaceted lifestyle preparation. Surgical options are restricted to severely overweight adolescents without endocrine disorders who have achieved puberty and have failed more conservative therapies. The Roux-en-Y gastric bypass is the most commonly performed procedure in adolescents, but the laparoscopic adjustable gastric band procedure is growing in popularity. Postoperatively, patients are evaluated 2 weeks after surgery and then every 1 to 2 months for the first postoperative year; every 2 months to 6 months in the second year, depending on the individual case; and then annually for life. A careful diet plan backed by continuing family support is essential. Short- and longterm complications are similar to those seen in adults, and include bowel obstruction, bleeding, blood clots, nausea, gallstones, hernia, and vitamin and iron deficiencies. (Aesthetic Surg J 2008;28:331–334.)
GUEST EDITOR’S NOTE ariatric surgery has had a major impact on obesity in the United States, and the number of procedures performed annually has risen dramatically. Many plastic surgeons will encounter bariatric surgery patients in their practice, and a thorough understanding of surgical weight loss procedures will enable them to provide better care for this unique population. This is the third article in a series of papers that will review important aspects of weight loss surgery involving a number of medical specialties, including current techniques, patient selection, nutritional deficiencies, psychological factors, and treatment of adolescents. The series will conclude with an update on post-bariatric plastic surgery. The individual authors have been selected for their expertise on the topic presented. We are pleased to have Dr. Madelyn H. Fernstrom, Founding Director of the UPMC Weight Management Center at the University of Pittsburgh School of Medicine, as the senior author for this review of the issues involved in bariatric surgery for the severely obese adolescent, including evaluation, preparation for surgery, and postoperative follow-up. J. Peter Rubin, MD Chair, ASPS-ASAPS Post-Bariatric Task Force
Drs. Fernstrom and Courcoulas are from the UPMC Weight Management Center and the Departments of Surgery and Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA. Aesthetic Surgery Journal
hile there is significant debate about the risks and benefits of bariatric surgery in the adolescent population, there are an increasing number of studies demonstrating the success of this option for the appropriate patient. It has become apparent that a comprehensive assessment of the teenage patient must be carried out, in a systematic and sequential manner. This should begin with an initial patient and family interview, followed by a complete medical and psychological assessment. A minimum of a 6-month multidisciplinary, one-on-one lifestyle program (featuring nutritional, behavioral, and exercise components) is key to preparing the adolescent patient for the rigorous and sustained lifestyle changes needed for long-term success following weight loss surgery. The decision about the procedure (laparoscopic adjustable banding or gastric bypass) requires an in-depth discussion between patient and surgeon to assess the best option for the individual. A successful outcome in the adolescent patient is predicated on a detailed presurgical evaluation and close postoperative follow-up. This review will first provide an overview of this developing field as well as short- and long-term issues facing this select population. We then present our treatment pathways for adolescents at the University of Pittsburgh Medical Center, which are based on nearly a
Volume 28 • Number 3 • May/June 2008 • 331
decade of experience in assessing and treating this population. In addition, our center is part of a National Institutes of Health–National Institute of Diabetes and Kidney Diseases (NIH-NIDDK) funded national study called Teen Longitudinal Assessment of Bariatric Surgery (Teen-LABS), which is an observational, prospective cohort study with the goal of collecting coordinated clinical, epidemiologic, and behavioral data in teenage bariatric surgical patients. Such a study will permit a realistic and evidence-based estimate of the risks and benefits of bariatric surgery in adolescent years and will lead to a better understanding of the associated obesityrelated conditions.
longest follow-up to date. Over a 21-year period, mean BMI measured preoperatively and at 1, 5, 10, and 14 years after surgery was 52, 36, 33, 34, and 38 kg/m2, respectively. Five patients (15%) regained all or most of their lost weight 5 to 10 years postsurgery. Because the long-term outcomes are still not well known in teens, more clinically based, prospective studies are needed to optimize care for this age group. Part of what Teen-LABS will do is to assess the short- and long-term safety and efficacy of weight loss surgery in the teen population.10,11
STATE OF THE FIELD: BARIATRIC SURGERY IN ADOLESCENTS
Preoperative Assessment and Evaluation
The growing obesity epidemic in the United States now extends to both adolescents and adults.1 More adolescents and their families are seeking surgical treatment for severe obesity because many are not responsive to behavioral or medical treatments. Between 1996 and 2003, an estimated 3000 bariatric procedures were performed on adolescents. While this is only a fraction of a number of procedures performed on adults, during this time frame there was a 5-fold increase in the number of adolescent bariatric surgeries performed.2 The Roux-en-Y gastric bypass (RYGB) is the most commonly performed procedure in adolescents as well as in adults in the United States, while the laparoscopic adjustable gastric band is growing in popularity in this country. Adults achieve significant and durable weight loss and associated health benefits with bariatric surgery, and these procedures are considered to be safe, with low mortality rates.3,4 There are studies specific to the adolescent population, and there are some data which indicate that bariatric surgery is safe and provides durable weight loss in younger patients. Most of these reports are retrospective studies with limited follow-up and short-term outcomes. Long-term weight loss outcomes for band surgery and results of comorbidity change are still lacking. Fielding5 reported a 30% weight reduction after 3 years, and Yitzhak6 reported that at least 80% of teens had sustained weight loss 5 years after adjustable band surgery. Lawson’s study7 from Cincinnati Children’s Hospital was a cohort controlled, multicenter study in which laparoscopic RYGB was compared to outcomes of extremely obese adolescents who participated for 1 year in a pediatric behavioral treatment program. Laparoscopic RYGB resulted in a change in mean body mass index (BMI) from 56.5 to 35.8 kg/m2, as compared to no significant change in BMI in the comparison group with behavioral intervention. Strauss et al8 evaluated the results of gastric bypass in 10 adolescents and reported that mean preoperative BMI was 52.4 and maximal weight loss was achieved at 12 to 15 months postoperatively. Sugerman et al9 have provided the largest retrospective study of adolescent bariatric surgery with the 332 • Volume 28 • Number 3 • May/June 2008
UPMC ADOLESCENT PATHWAY
A comprehensive approach is key to evaluating the adolescent surgical candidate. The morbidly obese adolescent seeking surgery is often is conflicted about many issues relating to his or her weight, and the first step is to understand the views of the patient, and how these are often separate from their parents. There are multiple key points to assess early on in the evaluation process: (1) Overall maturity level of the patient. This first step is done in a private 45-minute assessment, discussing, with the patient alone, weight history and desire for surgery. (2) A discussion with the family and patient together. Once it is established that the patient independently desires a surgical intervention, the discussion continues with the family. It is key to assess the level of parental commitment and support, as well as the recognition that this is a life change that the patient must be prepared for and undertake. The family can only support, not replace, the effort of the adolescent. (3) A complete medical evaluation of the patient. This is needed to identify and correct any metabolic barriers to previous weight loss attempts or to future success after bariatric surgery. An evaluation that includes thyroid and adrenal function, reproductive hormone panel, and fasting insulin and glucose (including an oral glucose tolerance test), establishes the absence or resolution of existing illness, including polycystic ovarian syndrome and sleep apnea. The medical clearance at this point is a major step. (4) Evaluation by a child psychologist or psychiatrist is essential. Standardized assessments of behavioral/psychological functioning in addition to an in-depth interview identify if there are behavioral barriers that must be better managed to optimize the surgical outcome. The behavioral clearance at this point allows the patient to continue forward in the pathway. (5) A minimum of 6 months of a private, interdisciplinary, multifaceted lifestyle preparation. This includes nutritional, medical, behavioral, and exercise components. The patient must understand and implement a lifestyle plan compatible with the postoperative lifestyle. This is also an indication of future compliance, and ability to maintain the same daily routine of focus and discipline needed to succeed with long-term weight loss and Aesthetic Surgery Journal
maintenance. This program can continue beyond 6 months, and until the date of surgery, if appropriate. A separate, bariatric surgery diet consult is also scheduled within 2 months before surgery. By the time the patient visits the surgeon for the surgical evaluation, all of the above steps should be completed or be close to completion. The goal of the surgical visit is to further educate the patient about the surgical options available and to establish any further medical testing needed to prepare for surgery. After the surgical consult, when the specific procedure is discussed (either band or bypass), the patient should receive a private bariatric surgery diet and nutrition consult for the appropriate surgery. We have developed separate diet plans for band and bypass patients. If sufficient understanding is not present, then some additional supportive consults are scheduled before clearing the patient as ready for surgery. When the 6 months of lifestyle, medical, psychological, and nutritional evaluations are complete and approved, the patient is now fully prepared for surgery and in the hands of the surgical team.
Both endocrine disorders and genetic syndromes should be considered and excluded in the differential diagnosis.14 Medical treatment of associated co-morbid conditions, such as diabetes, hypertension, and sleep apnea, should be optimized. The preoperative education program should be multidisciplinary, well structured, and geared to both the patient and the patient’s family. Family-based behavioral intervention following surgery is a necessary adjunct to the treatment of obesity with surgery. In this educational process, the application of the principles of adolescent growth, development, and compliance is essential to avoid adverse outcomes following surgery.15 Bariatric surgery should be part of a multidisciplinary approach for the care of the adolescent patient that includes a nutritionist, anesthesiologist, psychologist or psychiatrist, internist or pediatrician, and surgeon, all of whom are dedicated to the care of young patients in a specialized and experienced program setting. The decision about specific procedure type is made among patient, family, and surgeon, because many factors impact this decision, including eating habits, age, and insurance issues.
Preparation for Surgery
Surgical options are restricted to severely overweight adolescents who, in the absence of endocrine disorders, have achieved puberty and growth landmarks and who have failed more conservative therapy. The rationale for considering surgical options for adolescents rests on the success of such therapy in adults with excellent longterm weight loss results, reversal of medical complications, low morbidity and mortality, and improved quality of life.12 Patient selection for bariatric surgery is critical to the success of the procedure and the long-term outcome. This selection becomes even more important in the adolescent population, because an operation will dramatically and permanently change the gastrointestinal anatomy and lifestyle habits at an early age. Behavior modification, dietary changes, lifestyle modifications, and supplement compliance are necessary for long-term safety and weight loss success with this “tool” for weight management. For these reasons and some others, the presurgical evaluation and education for bariatric surgery in children must be extensive. This includes a detailed assessment of height, weight, dietary history, physical activity, and family interactions. Surgically-related psychological assessments are aimed at diagnosing and treating underlying depression and other psychiatric and psychosocial symptoms, such as low self-esteem. A thorough evaluation for eating disorders, including binge eating and purging, should be obtained, along with an assessment of readiness for change. Psychological readiness may predict better short- and long-term outcomes, while binge eating may be associated with poorer long-term weight loss and other outcomes.13 At the present time, there are no other well characterized or definitive screening criteria to identify prospective “ideal” younger candidates for surgery.
Our program has a close lifestyle follow-up paired with postoperative follow-up. While compliance requires constant vigilance, we find that the preoperative preparation provides the most helpful foundation for future lifestyle commitment, because the patient is well prepared for the lifestyle transition after surgery. The multidisciplinary team approach remains for the postoperative adolescent patient. Medical follow-up is maintained and coupled with nutritional, exercise, and behavioral consults to address present issues and help address future concerns. All weight loss surgery patients are followed closely in the surgeon’s office postoperatively for life. In the short term, patients are evaluated at 2 weeks after surgery and then every 1 to 2 months for the first year. In the second postoperative year, patients are seen as frequently as every 2 months, if band adjustments are needed, or as infrequently as twice a year for bypass patients that are doing well. In the third postoperative year, band patients continue with follow-up as needed for adjustments, and bypass patients are evaluated annually and if problems occur. The complications of the surgical treatment of obesity in children include the same short- and long-term problems seen in adults. Early complications include bowel obstruction, bleeding, blood clots, and persistent nausea. Band patients may experience device-related problems, such as slippage, infection, and port or tube problems. Late problems can be experienced, such as gallstones, hernias, vitamin and iron deficiencies, and weight loss failures. To date, in the Strauss8 series, there have not been any unanticipated side effects following surgery that are specific to adolescents. For the banding patients, continued assessment of the connection between volume of food and fullness must
Bariatric Surgery for Adolescents
Volume 28 • Number 3 • May/June 2008 • 333
be reinforced. Helping the patient identify the sense of contentment, with ability to eat more—but choosing to stop—is key. The adolescent is often learning, for the first time, the signals of physical hunger and how to manage with appropriate portion size. Learning when a fill is in order is another challenge. In the early months, rigorous attention to meal size and balance is crucial, and the rate of weight loss is an excellent indicator of compliance. After about 6 months, the rate of weight loss can slow significantly, and motivation to sustain the lifestyle effort is important. Family support is important for the adolescent patient, who most often is living at home and eating meals prepared by others. Encouragement to accompany the family shopper to the grocery store engages the patient in the day-to-day choices which must be made. For the bypass patients, a smooth transition through the 4 phases of the diet plan is important. Family support often helps with compliance. Our regimen has four phases: phase 1 (clear liquids; week 1), phase 2 (liquids/soft foods; weeks 2–3), phase 3 (soft/semi-solid foods; weeks 3–4), and phase 4 (regular foods; weeks 4–5). Most patients are ready for phase 4, the adaptive phase, lasting from 4 to 16 weeks, during which time more solid foods are introduced, and tolerance is learned for a variety of foods. Continuing support is essential. Most adolescents do not prefer to attend adult support group meetings, and many resist the option of a teen support group. We have found that private follow-up is optimal, with many patients offering to be a resource to new adolescents in the process. This “buddy approach” has been successful in providing discreet, but continuing support, compatible with the adolescent’s desire for privacy.
CONCLUSION Bariatric surgery remains a reasonable option in the continuity of care approach to the treatment of obesity, extending to the well screened adolescent patient. For a selected number of severely obese adolescents for whom other comprehensive, family-based dietary and behavioral approaches to weight loss have been unsuccessful, surgery can be a useful adjunct to make the lifestyle effort more manageable and successful over the long term. Future directions indicate the need for long-term, prospective outcome analyses of bariatric surgery in younger patients, such as those being done by TeenLABS. The importance of family support as an adjunct to surgery in the context of a family-based behavioral weight control program should not be underestimated. As with the adult population, the surgical program should be a part of a multidisciplinary approach to the care of the adolescent patient. Lifelong medical and nutritional surveillance after surgery are required; especially during later pregnancy. Obesity surgery should not be undertaken without a long-term commitment on the part of the patients, parents, and physicians. ◗
334 • Volume 28 • Number 3 • May/June 2008
DISCLOSURES The authors have no financial interest in and received no compensation from manufacturers of products mentioned in this article.
REFERENCES 1. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999–2004. JAMA 2006;295:1549–1555. 2. Tsai WS, Inge TH, Burd RS. Bariatric surgery in adolescents: Recent national trends in use and in-hospital outcome. Arch Pediatr Adolesc Med 2007;161:217–221. 3. Adams TD, Gress RE, Smith SC, Halverson RC, Simper SC, Rosamond WD, et al. Long-term mortality after gastric bypass surgery. N Engl J Med 2007;357:753–761. 4. Sjöström L, Narbro K, Sjöström CD, Karason K, Larsson B, Wedel H, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 2007;357:741–752. 5. Fielding GA, Duncombe JE. Laparoscopic adjustable gastric banding in severely obese adolescents. Surg Obes Relat Dis 2005;1:399–405. 6. Yitzhak A, Mizrahi S, Avinoach E. Laparoscopic gastric banding in adolescents. Obes Surg 2006;16:1318–1322. 7. Lawson ML, Kirk S, Mitchell T, Chen MK, Loux TJ, Daniels SR, et al. 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;41:137–143. 8. Strauss RS, Bradley LJ, Brolin RE. Gastric bypass surgery in adolescents with morbid obesity. J Pediatr 2001;138:499–504. 9. Sugerman HJ, Sugerman EL, DeMaria EJ, Kellum JM, Kennedy C, Mowery Y, et al. Bariatric surgery for severely obese adolescents. J Gastrointest Surg 2003;7:102–107. 10. Cincinnati Children’s Hospital Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) Web site. Available at: http://www.cincinnatichildrens.org/research/project/teen-labs/ default.htm. Accessed February 18, 2008. 11. Inge TH, Zeller M, Harmon C, Helmrath M, Bean J, Modi A, et al. Teen-Longitudinal Assessment of Bariatric Surgery: Methodological features of the first prospective multicenter study of adolescent bariatric surgery. J Pediatr Surg 2007;42:1969–1971. 12. Higa KD, Ho T, Boone KB. Laparoscopic Roux-en-Y gastric bypass: Technique and 3-year follow-up. J Laparoendosc Adv Surg Tech A 2001;11:377–382. 13. Kalarchian MA, Marcus MD. Management of the bariatric surgery patient: Is there a role for the cognitive behavior therapist? Cog Behav Pract 2003;10:112–119. 14. Yanovski JA. Pediatric obesity. Rev Endocr Metab Disord 2001;2:371–383. 15. Garcia VF, Langford L, Inge TH. Application of laparoscopy for bariatric surgery in adolescents. Curr Opin Pediatr 2003;15:248–255. Accepted for publication March 24, 2008. Reprint requests: Madelyn H. Fernstrom, PhD, CNS, 3811 O’Hara St, Ste 1617, Pittsburgh, PA 15213. E-mail: [email protected]
. Copyright ©2008 by The American Society for Aesthetic Plastic Surgery, Inc. 1090/820X/$34.00 doi:10.1016/j.asj.2008.03.010
Aesthetic Surgery Journal