- Email: [email protected]
Bariatric Surgery in Youth
Bariatric Surgery in Youth Tamar L. Mirensky,
MD
KEYWORDS Bariatric surgery Obesity Adolescent obesity Childhood obesity Gastric bypass Sleeve gastrectomy KEY POINTS Pediatric obesity is at epidemic proportions and has been associated with numerous medical conditions that increase morbidity and mortality. Bariatric surgery is found to be the most clinically effective and cost-effective means of achieving sustained weight reduction and management of obesity-related comorbidities. Similar to adult patients, laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy are the favored approaches to managing obesity in youth undergoing weight reduction procedures.
DEFINITION
Obesity is defined as an excessive accumulation and storage of fat in the body relative to lean body mass that may greatly impair health or present a risk to an individual’s health.1 Classification of overweight and obesity is typically based on body mass index (BMI), which is calculated by dividing an individual’s weight in kilograms by the height in meters squared. Overweight is characterized by a BMI between 25 to 30 and obese by a BMI exceeding 30 in an adult.2 Although BMI does not directly measure body fat, it is correlated with such measurements.2 The dynamics of obesity, however, are more complicated in a growing child; therefore, pediatric classification depends not only on the BMI but also on the child’s gender, age, and growth curve percentiles. A normal-weight child has a BMI between the fifth and 85th percentile for age; overweight is characterized by a BMI between the 85th and 95th percentile and obese by a BMI greater than the 95th percentile for age.2 EPIDEMIOLOGY
Rates of obesity worldwide have continued to increase to epidemic proportions with more than 42 million children younger than 5 years considered overweight or obese in 2013.3 Although in the United States, the prevalence of obesity has recently declined among preschool-age children between 2 and 5 years,4 childhood obesity
Disclosure Statement: The author has nothing to disclose. Division of Pediatric General and Thoracic Surgery, Department of Surgery, The Mount Sinai Hospital, 5 East 98th Street, 10th Floor, Box 1259, New York, NY 10029-6574, USA E-mail address: [email protected] Endocrinol Metab Clin N Am - (2016) -–http://dx.doi.org/10.1016/j.ecl.2016.02.003 0889-8529/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
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remains among the most serious health concerns of this generation. Currently, in the United States, a reported 17% (12.7 million) of children and adolescents between the ages of 2 and 19 years are characterized as obese, with extreme obesity outnumbering those US children afflicted by childhood cancer, cystic fibrosis, human immunodeficiency virus, and juvenile diabetes combined.2 ETIOLOGY
The obesity epidemic has been attributed to caloric imbalance, specifically to physical inactivity and intake of calorically dense foods. Increasing portions of fatty foods have become popularized, with one-third of children in the United States today between 4 and 19 years reporting intake of fast food daily. According to the 2011 National Youth Risk Behavior Survey of US high school students, 4.8% did not eat fruits or vegetables during the 7 days before the survey, whereas 27.8% drank soda 1 or more times per day during the same time period.5 Additionally, 13.8% reported not participating in at least 60 minutes of physical activity on any day in the week before the survey, and 32.4% reported watching television or using the computer for 3 or more hours per day on an average school day.5 The development of obesity, however, is likely more complex, with increased parental obesity, low parental education, social deprivation, abnormal infant feeding patterns, extreme birth weights, gestational diabetes, and various genetic, social, and environmental factors thought to potentially play a role.6,7 Hormones such as leptin and ghrelin play a role in weight regulation with brain activity in the hypothalamus noted to vary among obese and nonobese individuals.8 It has been shown that a person’s risk of becoming obese may be influenced by their relationships and associations with obese individuals and peers.9 Epigenetics may play a permissive role in the influences that increase one’s susceptibility of becoming obese. Obese children have a greater likelihood of having an obese parent than their normal-weight peers,10 and obese children have an increased risk of becoming obese adults themselves, thereby perpetuating the cycle. Associated Conditions
The US Surgeon General reports that obesity is the fastest growing cause of disease and death in the United States11 and, therefore, has been the focus of numerous public health initiatives. Although obesity alone may not directly lead to death, its association with comorbidities leads to increased mortality. Despite previous thoughts that certain comorbidities only impacted obese adults, reports have emerged showing such comorbidities at alarming rates among obese youth with increased morbidity and mortality.12–14 Neurologic
Pseudotumor cerebri, or idiopathic intracranial hypertension, is widely considered to be a complication of severe obesity.15 This condition leads to raised intracranial pressure that is not attributed to structural abnormalities or space-occupying masses and may lead to severe headaches, elevated cerebral spinal fluid pressure, and blindness or visual disturbances. Cardiovascular
Similar to obese adult patients, obese youth are afflicted with numerous cardiovascular obesity-related conditions including hypertension, atherosclerosis, and diastolic dysfunction for which consequences such as left ventricular hypertrophy may become irreversible with prolonged exposure.16–18 Chronic inflammation and metabolic dysfunction increase the risk of stroke and myocardial infarction among obese youth.
Bariatric Surgery in Youth
The effects of obesity are not only harmful during childhood but are associated with increased cardiovascular events during adulthood.19 Early intervention is warranted, as obese youth who lose weight have similar risks for cardiovascular disease as individuals who were never obese.20 Pulmonary
Obesity is associated with apnea, hypopnea, and snoring. Obese children who suffer from sleep-related disordered breathing, such as with obstructive sleep apnea (OSA) or obesity hypoventilation syndrome suffer from chronic fatigue; impaired performance at school, work, and activities; and cardiovascular dysfunction.12 Such conditions may, therefore, impair scholastic performance and the child’s ability to succeed academically. Gastrointestinal
Gastrointestinal complications such as cholelithiasis, gastroesophageal reflux disease, and nonalcoholic fatty liver disease have been linked to obesity. Liver disease associated with obesity encompasses an array of conditions ranging from simple, uncomplicated steatosis (seen in 38% of obese children) to nonalcoholic steatohepatitis, cirrhosis, and ultimate liver failure.21,22 Of adolescents undergoing bariatric surgery, 59% had evidence of nonalcoholic fatty liver disease, and mild fibrosis was seen in 18% of liver biopsies.23 Musculoskeletal
Growing pediatric patients have musculoskeletal conditions that require unique attention in the obese population. Obese youth are susceptible to conditions such as tibia vara (Blount disease),24,25 a disorder of the musculoskeletal system in which the effects of weight on the growth plates leads to abnormal development of the bones with a bowing of the legs that worsens as the child develops. Additionally, obese children sustain altered patterns of injury compared with their nonobese peers after traumatic insult.26 Children who are obese may have osteoarthritis, severe musculoskeletal pain, or extremity fractures with associated impaired mobility and physical limitations. Additionally, obese children are also more likely to suffer from slipped capital femoral epiphysis or displacement of the capital femoral epiphysis from the femoral neck through the physeal plate, thereby further impeding mobility.27 Endocrine
Although conditions such as type 2 diabetes mellitus (T2DM) were once thought of as occurring only in adults, we have seen an increase in prevalence of children with diabetes or prediabetes corresponding to high rates of pediatric obesity.28 It is thought that 17% to 25% of obese children and adolescents have impaired glucose tolerance, whereas 4% to 6% have T2DM.29 Early diagnosis and treatment of these conditions in obese children are crucial, as treatment may slow progressive complications such as neuropathy, nephropathy, retinopathy, and atherosclerotic cardiovascular disease.30 The prevalence of metabolic syndrome, defined by insulin resistance, T2DM, polycystic ovary syndrome, dyslipidemia, and hypertension increases exponentially among obese youth, with 6.8% of overweight adolescents afflicted by this condition compared with 28.7% of obese adolescents.31 Metabolic syndrome is associated with an increased risk of cardiovascular disease, as these obese youth become obese adults.32 Obesity is also associated with precocious puberty or early onset of sexual maturation.33 Additionally, hormonal influences impact the development of polycystic ovary syndrome with associated menstrual irregularities, hirsutism, acne, and decreased fertility among obese adolescent girls.
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Psychosocial
In addition to the myriad medical problems that occur among obese youth, psychosocial consequences of childhood obesity remain prevalent and underappreciated. Obese youth have more behavioral and self-esteem problems than their normalweight peers.34–36 Depression and aggression in adulthood are more frequently seen among those individuals with a history of pediatric obesity.37 Studies evaluating health-related quality of life find decreased physical, emotional, and social satisfaction with 30% of obese youth meeting criteria for clinically significant depressive symptoms.38,39 Studies show that health-related quality of life among obese adolescents may be indistinguishable from that of children with cancer.40 Obese youth may also suffer from alienation from peers, distorted body image, anxiety, and a poor ability to formulate healthy, supportive relationships. Obese adolescent girls have advanced to fewer years of formal education, have lower rates of marriage, higher rates of poverty, and decreased family income compared with their nonobese peers.30 Obese female adolescents have disproportionately high rates of maladaptive eating behaviors including binge eating disorders.41 Obese youth with binge eating disorders may be more susceptible to long-term problems of distorted body image, impaired social functioning, and substance abuse.42 Parallels are seen between mechanisms of obesity and addictive behaviors and must be considered in the management of obesity.43 Mortality
The gains in life expectancy which were previously increasing in the United States have slowed considerably.44 Although this trend is multifactorial, the increasing prevalence of obesity and associated comorbidities has contributed to the current trends, with severely obese individuals having a reduced length of life by 5 to 20 years.45 Obese youth are believed to be particularly susceptible to premature mortality as they spend more time in an at-risk state. Without effective public health interventions to combat or at least decrease the prevalence of obesity among youth today, the current generation of obese children and adolescents may be the first generation to have a shorter life expectancy than their parents.46 Nonoperative Management of Pediatric Obesity
First-line treatment for weight loss frequently consists of conservative, nonoperative therapies including structured diet and exercise programs in combination with behavioral therapy. These interventions teach patients to develop skills of self-monitoring, portion control, goal setting and coping mechanisms that are not centered on food. Stepwise approaches to successful weight loss have been advocated by the American Academy of Pediatrics, which begin with interventions recommended by the primary care doctor and progress to a multidisciplinary team or specialty program as needed.47 Despite some success at weight loss through moderate- to high-intensity programs, overall results tend to be modest at best. Mean decreases in BMI through structured diet, exercise, and behavioral modification programs are on the order of 2 to 3 kg/m2, for which substantial changes in obesity-related comorbidities remain limited. Weight loss is often a short-term phenomenon with weight regain occurring commonly.48 More drastic diet measures including meal replacements and the use of dietary supplements and prepackaged meals with portion control have had mixed results when used in some adult populations; however, the data among children and adolescents remain sparse. Although one small study did find increased weight loss when adolescents used meal replacements (6% decrease in BMI compared with 4% decrease in BMI among controls), the results achieved were not sustained.49 Additionally, the
Bariatric Surgery in Youth
nutritional ramifications and long-term consequences of such restricted caloric intake among growing children have not been well studied. Finally, the high costs of such meal replacements and meal plans may not allow for prolonged use and limit accessibility. Recently, we have seen growing interest in the use of pharmaceutical options for the treatment of obesity. This method remains limited in pediatric patients, as many weight-loss agents have not been approved for use in children. Safety and efficacy data are lacking, thereby leading to generalized reluctance to prescribe medications for weight loss to children. Orlistat, an oral lipase inhibitor that blocks the absorption of fat in the bowel is the only US Food and Drug Administration (FDA)-approved agent for weight loss in obese adolescents. Gastrointestinal side effects limit its use, and reductions in BMI have been modest.50 Two additional medications, metformin and exenatide, have also been evaluated as potential agents to induce weight loss in adolescent patients; however, reductions in BMI were minimal, and these agents have not yet been approved by the FDA for use in children.50 Most recently, there has been interest in the use of topiramate, an antiepileptic medication for weight loss in adolescent patients. Although an average decrease in BMI of 5% was seen in a recent retrospective study evaluating the use of this agent in adolescents, the associated cognitive side effects, including mental slowing, may preclude its use.51,52 Additional studies are needed to further evaluate the effectiveness and safety of medications used to promote weight loss in obese youth. Operative Management of Pediatric Obesity
Although the mainstay of weight management includes diet, exercise, medical therapies, and behavioral therapies, given the modest long-term effects of nonoperative approaches, there has been increasing interest in the utilization of surgical approaches to effectively and efficiently treat pediatric obesity and associated comorbidities. Among obese adult patients, bariatric surgery is found to be the most effective treatment available for obesity-related illnesses, including diabetes, hypertension, and hyperlipidemia.53 Bariatric surgery is more cost effective and has better long-term outcomes when compared with nonoperative approaches.54 Unfortunately, much of the data regarding long-term outcomes are only available for adult patients, with limited information available to guide pediatric patients. As such, there has been reluctance among health care providers to recommend and endorse bariatric surgery to their obese pediatric patients. Systematic evaluations of early outcomes for adolescent obese patients undergoing bariatric surgery, however, have thus far been promising. Adolescent patients who undergo bariatric surgery lose significant weight, have improvement or resolution of many comorbid conditions, and sustain few short-term complications in a cost-effective manner.55–57 Criteria for surgical intervention
Bariatric surgery is not without risks, and providing aggressive interventions earlier in life when disease processes are in early stages may improve surgical outcomes and decrease the risk of the intervention. Improvements in obesity-related comorbidities seen after bariatric surgery in carefully selected patients has led to continued support of this approach.58 Appropriate selection criteria remain critical in identifying those patients for whom bariatric surgery is most likely to be safe and successful. Although initial recommendations were conservative, with bariatric surgery only advocated for children with BMI 40 kg/m2 with comorbidities or BMI 50 kg/m2 regardless of comorbidities (based on the 1991 National Institutes of Health Consensus Development Conference,59 whereby recommendations of BMI 35 kg/m2 with
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comorbidities or BMI 40 kg/m2 regardless of comorbidities were established for adults), the pendulum has swung in the other direction. Updated recommendations recently published by the American Society for Metabolic and Bariatric Surgery pediatric committee in 2012 support more aggressive selection of pediatric patients.60 Because most adolescents with a BMI of 35 kg/m2 are greater than the 99th BMI percentile, this BMI threshold was considered acceptable for pursuing bariatric surgery. Similar to adult criteria, adolescents with a BMI 35 kg/m2 must also have major obesity-related comorbidities (T2DM, moderate-to-severe OSA, pseudotumor cerebri, or severe nonalcoholic steatohepatitis). Those adolescent patients with BMI 40 kg/m2 may still be candidates for bariatric surgery even with less severe comorbidities, including hypertension, dyslipidemia, mild-to-moderate OSA, insulin resistance, or glucose intolerance. Although a lower age limit was not defined in the American Society for Metabolic and Bariatric Surgery guidelines, most centers delay weight reduction surgery until patients show psychological maturity and reach markers of physical maturity including Tanner IV or V sexual maturity and 95% of predicted vertical growth as demonstrated by bone age.61 The indications for bariatric surgery will likely continue to evolve as more is learned about the procedures and their long-term consequences. It is important, however, that contraindications to surgery are equally considered. Patients who lack family support or depth of insight into their condition and cannot formulate realistic expectations should not undergo bariatric surgery. Additionally, those adolescents who have not adhered to recommendations for attempting weight loss or lack decision-making capacity, have medically correctable conditions leading to obesity, have major unstable psychosis or suicidal ideation, and will not adhere to postoperative lifestyle modification recommendations including the need for vitamin and mineral supplementation should not be offered bariatric surgery. Adolescent patients who are being considered for bariatric surgery should be evaluated by a multidisciplinary team at a center where the resources are available to meet their unique needs. These centers must have the ability to manage obesity-related medical comorbidities and must have resources to manage potential complications after surgery. A medical team comprising individuals with expertise in pediatric obesity evaluation and management (including bariatric surgeon and anesthesiologist), a coordinator, social worker, registered dietician, exercise physiologist, mental health specialist, adolescent medicine specialist, endocrinologist, pulmonologist, cardiologist, gastroenterologist, and orthopedist must be available. These providers must be committed to providing long-term follow-up of adolescent patients and ultimately assisting with the transition to adult care. Bariatric surgical procedures performed Malabsorptive procedures The first surgeries for weight management included
malabsorptive procedures such as the jejuno-ileal bypass and the jejunal-colonic bypass. Because these bypass operations were fraught with complications, including dehydration and metabolic derangements, they were soon abandoned. These procedures, however, set the stage for the development of additional malabsorptive procedures for weight loss. Although the biliopancreatic diversion with or without duodenal switch is still described, its use in pediatric patients remains limited. This procedure allows for mixing of ingested material and bile along a short (50 to 100 cm) segment of distal ileum, thereby resulting in decreased absorption with subsequent macronutrient and micronutrient deficiencies, flatus, and diarrhea. Concerns about nutritional deficiencies in growing children and the gastrointestinal side effects have rendered it not well suited for this population.
Bariatric Surgery in Youth
Malabsorptive and restrictive procedures Significant weight loss and appetite suppression was first noted when gastrectomies with gastrojejunostomies were performed in the management of gastric ulcer disease. These findings led pioneers in bariatric surgery to hypothesize that bypass of a large portion of the stomach would yield similar results. As such, the gastric bypass operation in which a 15- to 30-mL gastric pouch is created just beyond the gastroesophageal junction and anastomosed to a roux limb of jejunum, thereby bypassing much of the proximal gastrointestinal tract, was developed. More recently, minimally invasive (laparoscopic) approaches to this operation have come in favor. Gastric bypass is a restrictive and a malabsorptive procedure and, thus, leads to significant and sustained weight reduction that has been associated with marked improvements or resolution of obesity-related comorbidities, including insulin resistance, T2DM, hypertension, and hyperlipidemia.62 Laparoscopic Roux-en-Y gastric bypass (RYGB) has become the mostly commonly performed weight reduction operation in the world and is considered the gold standard of weight loss surgery, to which other procedures and approaches are often compared. Obese adolescents with obesity-related comorbidities who have not responded to nonoperative weight management strategies should be considered for bariatric surgery, including gastric bypass. A cross-sectional study looking at national surgical trends in obese adolescent patients found that RYGB was the most commonly performed weight reduction procedure for patients between 10 and 19 years of age in the United States, with RYGB comprising 67.6% of all interventions performed on this population.63 Much like in adults, excellent results have been reported for adolescents undergoing RYGB with 35% reduction in weight seen at 1 year after surgery.64 A meta-analysis of all bariatric surgery in pediatric patients reported decreases in BMI of 17.8 to 22.3 units.65 One of the largest multicenter studies of adolescents undergoing laparoscopic RYGB reported substantial improvements in triglyceride and total cholesterol levels (decreases of 47% and 16%, respectively) and a 13% decrease in mean fasting glucose levels, 70% decrease in fasting insulin levels, and 90% of patients having complete resolution of OSA.66 Severe complications in the short and intermediate term after RYGB are rare but have been reported and must be discussed with any patient considering this procedure. Complications include anastomotic leak, sepsis, bleeding complications, bowel obstructions (from intra-abdominal adhesions, strictures, or internal hernias), deep vein thrombosis with or without thromboembolic disease, and death. Although longer-term data are slowly being acquired and evaluated, the numbers of adolescent subjects followed up to late time points currently remains limited; thus, much remains unknown about long-term risks of the operation. Factors such as weight regain, the need for revisions or complications related to altered anatomy with some portions of the gastrointestinal tract rendered not easily accessible (biliary tract), and ongoing concerns about potential long-term risks of micronutrient deficiencies including iron, vitamin D, calcium, and B vitamins in growing adolescents warrant further evaluation. Restrictive procedures As opposed to malabsorptive procedures in which nutritional deficiencies are of great concern, restrictive procedures were designed to restrict the intake of calories, thereby promoting a hypocaloric, negative energy balanced state with subsequent weight loss. One such approach that has been described in adolescents,67 however, that has recently fallen out of favor is the vertical banded gastroplasty (VBG). This technique may be performed via a laparoscopic approach and involves the creation of a small gastric pouch just distal to the gastroesophageal junction with banding of the pouch. The distal-most aspect of the pouch remains in
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continuity with the remainder of the stomach to allow for the passage of ingested material to the remainder of the gastrointestinal tract. Gastric bypass proved to be superior to VBG in several randomized trials,68,69 and the VBG now has been largely abandoned. More recently, there has been great interest in the implantation of a removable, adjustable gastric band (AGB) to accomplish restriction of stomach size. Implantation of the AGB may be performed under laparoscopic guidance and does not require alteration of normal anatomic alignment. There is no anastomoses necessary nor are the risks of vitamin deficiencies relevant. The band is placed circumferentially around the upper portion of the stomach and is attached to a subcutaneous port, which can be accessed to tighten or release the band as necessary. Despite lack of FDA approval of the AGB for patients younger than 18 years, there had been a surge of AGBs implanted into adolescent patients in recent years with AGB insertions comprising almost one-third of all bariatric procedures performed in 2009 (approval for implantation was granted through investigational device exemption from the FDA).63 Although initially thought to have an excellent safety profile with substantial loss of excess body weight (37%–63%) achieved during a 6-month to 7-year follow-up period,70 reoperation rates of 8% to 10% for mechanical device failure, band slippage, band erosion, or band removal limited their use.65 Although implantation of AGBs results in greater weight loss and improvement in quality of life indices and health status compared with nonoperative weight reduction approaches, there has been a drastic decline in the numbers of AGB devices implanted in pediatric patients in the United States today.71 To this end, there is increased enthusiasm for an alternate restrictive procedure, the sleeve gastrectomy (SG), in which the stomach shape and size is significantly reduced to resemble a long, thin tubular structure.71 The restrictive nature of this procedure limits one’s ability to consume large volumes of food, thereby inducing a hypocaloric state. It does not, however, alter the ability to absorb critical nutrients nor alter anatomic continuity. The SG, too, may be performed laparoscopically with minimal complications and excellent short-term outcomes. This procedure, however, is not without risks, including staple line leaks, bleeding, strictures or narrowing of the stomach, infectious processes, and venous thrombosis with thromboembolisms. Multiple studies found weight loss and improvement in comorbidities after a laparoscopic SG comparable to results that followed RYGB but with fewer complications.72,73 Because the anatomy is only minimally altered in an SG, the ability to convert to an RYGB in the future remains, as does the ability to easily access all parts of the gastrointestinal tract (biliary system), findings that make the SG particularly attractive for pediatric patients. Special considerations
Many ethical concerns must be acknowledged and addressed when considering bariatric surgery for weight management among obese children and adolescents. Although adolescents must show an understanding of the procedure being considered, the indications, risks, and benefits of the procedure, and the long-term consequences and commitment required when undergoing bariatric surgery, how do health care providers ensure that they have the maturity and capacity to make such life-altering decisions? Given that adolescence is a time of vulnerability and that obese adolescents are more likely to be bullied or ridiculed by peers and face unique psychosocial stressors, how can we be confident that their interest in bariatric surgery is genuine and not simply in response to pressures placed on them by peers? Without standardized procedures available, is it possible to adequately evaluate adolescents for their ability to truly formulate realistic expectations and understanding of outcomes and risks as they relate to bariatric surgery?
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Adolescents younger than 18 years cannot legally provide consent for procedures; therefore, a parent or legal guardian must be counseled and involved with the patient providing assent. Health care providers have, thus, raised the question as to whose decision it is to ultimately undergo surgery and how to ensure that adolescents aren’t simply responding to overt or subtle coercion by family members. This is particularly true in cases in which patient and parent or guardian disagree about the impact of the patient’s weight and the role that surgery may play. Additionally, many adolescents are not the sole individuals responsible for buying food or preparing family meals; therefore, how best to encourage the family to actively participate and engage in the patient’s new lifestyle must be considered. Unfortunately, many adolescents with chronic medical problems are found to be noncompliant with medical regimens and recommendations.74 Because patients who undergo bariatric surgical procedures are at higher risks for macronutritional and micronutritional deficiencies, it is imperative that they not only remain compliant with vitamin and mineral supplements prescribed, but also follow up with routine blood work and monitoring. Adolescents who undergo bariatric surgery may become at risk for abnormal bone development with subsequent fractures given reduced intake of calcium and vitamin D. Cases of beriberi have been described, resulting from noncompliance with vitamins prescribed. As adolescents move away from home and are no longer under the care of their parents or guardians, the prospect of compliance becomes an important consideration when evaluating for surgical candidacy. After bariatric surgery, an increase in fertility and the rate of pregnancy has been reported among adolescent girls.75 Although outcomes of pregnancy immediately after bariatric surgery in the adolescent population have not been well studied, counseling regarding increased fertility after surgery should be provided and contraception made available, as it is believed that pregnancy during the first 18 months after surgery, when the rate of weight loss is most rapid and susceptibility to nutritional compromise is highest, may be dangerous to the developing fetus. Once the patient’s weight has stabilized and nutritional deficiencies have been excluded, the risks of pregnancy are reduced after bariatric surgery compared with obese women.76 Future work
Bariatric surgery can be a life-altering opportunity for obese youth. Although the longterm data are still pending, we have seen continued interest and enthusiasm for this approach to weight and comorbidity management. As we continue our evaluation of long-term effects of bariatric surgery, including assessment of nutritional parameters, bone growth and development, the need for additional revisional procedures after the initial operation, it is important to engage adolescent patients who have undergone bariatric surgery and to elicit feedback about their experiences. Were their expectations met? What was their perspective on the their ability to accurately make such an important decision? What challenges did they face as they went through the process of preoperative evaluation, surgery, recovery, and management of daily life after their procedure? If given the opportunity, would they do it all again? Engaging patients in these important discussions will lead health care providers and parents to having a more comprehensive understanding of bariatric surgery and its role in the treatment of obese youth. SUMMARY
Childhood and adolescent obesity has reached epidemic proportions worldwide. Until a comprehensive understanding of the etiology of obesity is identified and novel interventions are available to treat obesity and halt progression of obesity-related
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comorbidities, bariatric surgical approaches should be considered in carefully selected pediatric patients. To date, bariatric surgery has been more effective and has allowed for more rapid health benefits when compared with nonoperative weight management approaches. The optimal type of procedure and conditions under which maximum long-term benefits will be achieved have yet to be determined. Detailed long-term outcomes after bariatric surgery must be systematically evaluated so that management of obese youth can be optimized. REFERENCES
1. Available at: http://www.merriam-webster.com/dictionary/obesity. Accessed January 4, 2016. 2. Freedman DS, Mei Z, Sriniavasan SR, et al. Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the Bogalusa Heart Study. J Pediatr 2007;150:12–7. 3. Available at: http://www.who.int/mediacentre/factsheets/fs311/en/. Accessed January 4, 2016. 4. Ogden CL, Carroll MD, Kit BK, et al. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA 2014;311:806–14. 5. Available at: http://www.cdc.gov/mmwr/pdf/ss/ss6104.pdf. Accessed January 4, 2016. 6. Catalano PM, Farrell K, Thomas A, et al. Perinatal risk factors for childhood obesity and metabolic dysregulation. Am J Clin Nutr 2009;90:1303–11. 7. Katzmarzyk PT, Barlow S, Bouchard C, et al. An evolving scientific basis for the prevention and treatment of pediatric obesity. Int J Obes 2014;38:887–905. 8. Matsuda M, Liu Y, Mahankali S, et al. Altered hypothalamic function in response to glucose ingestion in obese humans. Diabetes 1999;48:1801–6. 9. Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N Engl J Med 2007;357:370–9. 10. Whitaker RC, Wrigth JA, Pepe MS, et al. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med 1997;337:869–73. 11. Available at: http://www.surgeongeneral.gov/news/testimony/obesity07162003. html. Accessed January 4, 2016. 12. Brandt ML, Harmon CM, Helmrath MA, et al. Morbid obesity in pediatric diabetes mellitus: surgical options and outcomes. Nat Rev Endocrinol 2010;6:637–45. 13. Inge TH, Miyano G, Bean J, et al. Reversal of type 2 diabetes mellitus and improvements in cardiovascular risk factors after surgical weight loss in adolescents. Pediatrics 2009;123:214–22. 14. Teeple EA, Teich S, Schuster DP, et al. Early metabolic improvement following bariatric surgery in morbidly obese adolescents. Pediatr Blood Cancer 2012; 58:112–6. 15. Chandra V, Dutta S, Albanese CT, et al. Clinical resolution of severely symptomatic pseudotumor cerebri after gastric bypass in an adolescent. Surg Obes Relat Dis 2007;3:198–200. 16. Cuspidi C, Rescaldani M, Tadic M, et al. Effects of bariatric surgery on cardiac structure and function: a systematic review and meta-analysis. Am J Hypertens 2014;27:146–56. 17. Ippisch HM, Inge TH, Daniels SR, et al. Reversibility of cardiac abnormalities in morbidly obese adolescents. J Am Coll Cardiol 2008;51:1342–8. 18. Beamish AJ, Olbers T. Bariatric and metabolic surgery in adolescents: a path to decrease adult cardiovascular mortality. Curr Atheroscler Rep 2015;17:53.
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19. Baker JL, Olsen LW, Sorensen TI. Childhood body-mass index and the risk of coronary heart disease in adulthood. N Engl J Med 2007;357:2329–37. 20. Juonala M, Magnussen CG, Berenson GS, et al. Childhood adiposity, adult adiposity, and cardiovascular risk factors. N Engl J Med 2011;365:1876–85. 21. Schwimmer JB, Deutsch R, Kahen T, et al. Prevalence of fatty liver in children and adolescents. Pediatrics 2006;118:1388–93. 22. Matteoni CA, Younossi ZM, Gramlich T, et al. Nonalcoholic fatty liver disease: a spectrum of clinical and pathological severity. Gastroenterology 1999;116: 1413–9. 23. Xanthakos SA, Jenkins TM, Kleiner DE, et al. High prevalence of nonalcoholic fatty liver disease in adolescents undergoing bariatric surgery. Gastroenterology 2015;149:623–34. 24. Henderson RC. Tibia vara: a complication of adolescent obesity. J Pediatr 1992; 121:482–6. 25. Dietz WH Jr, Gross WL, Kirkpatrick JA Jr. Blount disease (tibia vara): another skeletal disorder associated with childhood obesity. J Pediatr 1982;101:735–7. 26. Pomerantz WJ, Timm NL, Gittelman MA. Injury patterns in obese versus nonobese children presenting to a pediatric emergency department. Pediatrics 2010;125:681–5. 27. Taylor ED, Theim KR, Mirch MC, et al. Orthopedic complications of overweight in children and adolescents. Pediatrics 2006;117:2167–74. 28. Williams DE, Cadwell BL, Cheng YJ, et al. Prevalence of impaired fasting glucose and its relationship with cardiovascular disease risk factors in US adolescents, 1999-2000. Pediatrics 2005;116:1122–6. 29. Sinha R, Fisch G, Teague B, et al. Prevalence of impaired glucose tolerance among children and adolescents with marked obesity. N Engl J Med 2002;346: 802–10. 30. Gortmaker SL, Must A, Perrin JM, et al. Social and economic consequences of overweight in adolescence and young adulthood. N Engl J Med 1993;329: 1008–12. 31. Cook S, Weitzman M, Auinger P, et al. Prevalence of a metabolic syndrome phenotype in adolescents: findings from the third National Health and Nutrition Examination Survey, 1988-1994. Arch Pediatr Adolesc Med 2003;157:821–7. 32. Gidding SS, Leibel RL, Daniels S, et al. Understanding obesity in youth. A statement for healthcare professionals from the Committee on Atherosclerosis and Hypertension in the Young of the Council on Cardiovascular Disease in the Young and the Nutrition Committee, American Heart Association. Circulation 1996;94: 3383–7. 33. Kaplowitz PB, Slora EJ, Wasserman RC, et al. Earlier onset of puberty in girls: relation to increased body mass index and race. Pediatrics 2001;108:347–53. 34. Mustillo S, Worthman C, Erkanli A, et al. Obesity and psychiatric disorder: developmental trajectories. Pediatrics 2003;111:851–9. 35. Strauss RS. Childhood obesity and self-esteem. Pediatrics 2000;105:e15. 36. French SA, Story M, Perry CL. Self-esteem and obesity in children and adolescents: a literature review. Obes Res 1995;3:479–90. 37. Pine DS, Goldstein RB, Wolk S, et al. The association between childhood depression and adulthood body mass index. Pediatrics 2001;107:1049–56. 38. Zeller MH, Roehrig HR, Modi AC, et al. Health-related quality of life and depressive symptoms in adolescents with extreme obesity presenting for bariatric surgery. Pediatrics 2006;117:1155–61.
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39. Lindekilde N, Gladstone BP, Lubeck M, et al. The impact of bariatric surgery on quality of life: a systematic review and meta-analysis. Obes Rev 2015;16:639–51. 40. Schwimmer JB, Burwinkle TM, Varni JW. Health-related quality of life of severely obese children and adolescents. JAMA 2003;289:1813–9. 41. Sorbara M, Geliebter A. Body image disturbance in obese outpatients before and after weight loss in relation to race, gender, binge eating, and age of onset of obesity. Int J Eat Disord 2002;31:416–23. 42. Mann AP, Accurso EC, Stiles-Shields C, et al. Factors associated with substance use in adolescents with eating disorders. J Adolesc Health 2014;55:182–7. 43. Acosta MC, Manubay J, Levin FR. Pediatric obesity: parallels with addiction and treatment recommendations. Harv Rev Psychiatry 2008;16:80–96. 44. Bell FC, Miller ML. Life tables for the United States social security area, 1900-2100. Actuarial study no. 116. Baltimore (MD): Social Security Administration; 2002. 45. Fontaine KR, Redden DT, Wang C, et al. Years of life lost due to obesity. JAMA 2003;289:187–93. 46. Olshansky SJ, Passaro DJ, Hershow RC, et al. A potential decline in life expectancy in the United States in the 21st century. N Engl J Med 2005;352:1138–45. 47. Spear BA, Barlow SE, Ervin C, et al. Recommendations for treatment of child and adolescent overweight and obesity. Pediatrics 2007;120:S254–88. 48. Whitlock EP, O’Connor EA, Williams SB, et al. Effectiveness of weight management interventions in children: a targeted systematic review for the USPSTF. Pediatrics 2010;125:e396–418. 49. Berkowitz RI, Wadden TA, Gehrman CA, et al. Meal replacements in the treatment of adolescent obesity: a randomized controlled trial. Obesity (Silver Spring) 2011; 19:1193–9. 50. Viner RM, Hsia Y, Tomsic T, et al. Efficacy and safety of anti-obesity drugs in children and adolescents: systematic review and meta-analysis. Obes Rev 2010;11: 593–602. 51. Fox CK, Marlatt KL, Rudser KD, et al. Topiramate for weight reduction in adolescents with severe obesity. Clin Pediatr 2015;54:19–24. 52. Sommer BR, Mitchell EL, Wroolie TE. Topiramate: effects on cognition in patients with epilepsy, migraine headache and obesity. Ther Adv Neurol Disord 2013;6: 211–27. 53. Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med 2012;366:1567–76. 54. Picot J, Jones J, Colquitt JL, et al. The clinical effectiveness and costeffectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation. Health Technol Assess 2009;13:215–357. 55. Black JA, White B, Viner RM, et al. Bariatric surgery for obese children and adolescents: a systematic review and meta-analysis. Obes Rev 2013;14:634–44. 56. Inge TH, Zeller MH, Jenkins TM, et al, Teen-LABS Consortium. Perioperative outcomes of adolescents undergoing bariatric surgery: the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study. JAMA Pediatr 2014;168: 47–53. 57. Bairdain S, Samnaliev M. Cost-effectiveness of adolescent bariatric surgery. Cureus 2015;7:e248. 58. Inge TH, Zeller MG, Lawson ML, et al. A critical appraisal of evidence supporting a bariatric surgical approach to weight management for adolescents. J Pediatr 2005;147:10–9.
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59. Gastrointestinal surgery for severe obesity: NIH consensus development conference, March 25-27, 1991. Nutrition 1996;12:397–404. 60. Michalsky M, Reichard K, Inge T, et al. ASMBS pediatric committee best practice guidelines. Surg Obes Relat Dis 2012;8:1–7. 61. McGinty S, Richmond TK, Desai NK. Managing adolescent obesity and the role of bariatric surgery. Curr Opin Pediatr 2015;27:434–41. 62. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292:1724–37. 63. Kelleher DC, Merrill CT, Cottrell LT, et al. Recent national trends in the sse of adolescent inpatient bariatric surgery: 2000 through 2009. JAMA Pediatr 2013; 167:126–32. 64. Inge TH. Bariatric surgery for morbidly obese adolescents: is there a rationale for early intervention? Growth Horm IGF Res 2006;16:S15–9. 65. Treadwell JR, Sun F, Schoelles K. Systematic review and meta-analysis of bariatric surgery for pediatric obesity. Ann Surg 2008;248:763–76. 66. Lawson ML, Kirk S, Mitchell T, 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;41:137–43. 67. Mason EE, Scott DH, Doherty C, et al. Vertical banded gastroplasty in the severely obese under age twenty-one. Obes Surg 1995;5:23–33. 68. Maggard MA, Shugarman LR, Suttorp M, et al. Meta-analysis: surgical treatment of obesity. Ann Intern Med 2005;142:547–59. 69. Howard L, Malone M, Michalek A, et al. Gastric bypass and vertical banded gastroplasty- a prospective randomized comparison and 5-year follow-up. Obes Surg 1995;5:55–60. 70. Pratt JS, Lenders CM, Dionne EA, et al. Best practice updates for pediatric/ adolescent weight loss surgery. Obes 2009;17:901–10. 71. Pallati P, Buettner S, Simorov A, et al. Trends in adolescent bariatric surgery evaluated by UHC database collection. Surg Endosc 2012;26:3077–81. 72. D’Hondt M, Vanneste S, Pottel H, et al. Laparoscopic sleeve gastrectomy as a single-stage procedure for the treatment of morbid obesity and the resulting quality of life, resolution of comorbidities, food tolerance, and 6-year weight loss. Surg Endosc 2011;25:2498–504. 73. Aurora AR, Khaitan L, Saber AA. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4, 888 patients. Surg Endosc 2012;26:1509–15. 74. Rianthavorn P, Ettenger RB. Medication non-adherence in the adolescent renal transplant recipient: a clinician’s viewpoint. Pediatr Transplant 2005;9:398–407. 75. Roehrig HR, Stavra A, Xanthakos MD, et al. Pregnancy after gastric bypass surgery in adolescents. Obes Surg 2007;17:873–7. 76. Maggard MA, Yermilov I, Li Z, et al. Pregnancy and fertility following bariatric surgery: a systematic review. JAMA 2008;300:2286–96.
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KEYWORDS Bariatric surgery Obesity Adolescent obesity Childhood obesity Gastric bypass Sleeve gastrectomy KEY POINTS Pediatric obesity is at epidemic proportions and has been associated with numerous medical conditions that increase morbidity and mortality. Bariatric surgery is found to be the most clinically effective and cost-effective means of achieving sustained weight reduction and management of obesity-related comorbidities. Similar to adult patients, laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy are the favored approaches to managing obesity in youth undergoing weight reduction procedures.
DEFINITION
Obesity is defined as an excessive accumulation and storage of fat in the body relative to lean body mass that may greatly impair health or present a risk to an individual’s health.1 Classification of overweight and obesity is typically based on body mass index (BMI), which is calculated by dividing an individual’s weight in kilograms by the height in meters squared. Overweight is characterized by a BMI between 25 to 30 and obese by a BMI exceeding 30 in an adult.2 Although BMI does not directly measure body fat, it is correlated with such measurements.2 The dynamics of obesity, however, are more complicated in a growing child; therefore, pediatric classification depends not only on the BMI but also on the child’s gender, age, and growth curve percentiles. A normal-weight child has a BMI between the fifth and 85th percentile for age; overweight is characterized by a BMI between the 85th and 95th percentile and obese by a BMI greater than the 95th percentile for age.2 EPIDEMIOLOGY
Rates of obesity worldwide have continued to increase to epidemic proportions with more than 42 million children younger than 5 years considered overweight or obese in 2013.3 Although in the United States, the prevalence of obesity has recently declined among preschool-age children between 2 and 5 years,4 childhood obesity
Disclosure Statement: The author has nothing to disclose. Division of Pediatric General and Thoracic Surgery, Department of Surgery, The Mount Sinai Hospital, 5 East 98th Street, 10th Floor, Box 1259, New York, NY 10029-6574, USA E-mail address: [email protected] Endocrinol Metab Clin N Am - (2016) -–http://dx.doi.org/10.1016/j.ecl.2016.02.003 0889-8529/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
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remains among the most serious health concerns of this generation. Currently, in the United States, a reported 17% (12.7 million) of children and adolescents between the ages of 2 and 19 years are characterized as obese, with extreme obesity outnumbering those US children afflicted by childhood cancer, cystic fibrosis, human immunodeficiency virus, and juvenile diabetes combined.2 ETIOLOGY
The obesity epidemic has been attributed to caloric imbalance, specifically to physical inactivity and intake of calorically dense foods. Increasing portions of fatty foods have become popularized, with one-third of children in the United States today between 4 and 19 years reporting intake of fast food daily. According to the 2011 National Youth Risk Behavior Survey of US high school students, 4.8% did not eat fruits or vegetables during the 7 days before the survey, whereas 27.8% drank soda 1 or more times per day during the same time period.5 Additionally, 13.8% reported not participating in at least 60 minutes of physical activity on any day in the week before the survey, and 32.4% reported watching television or using the computer for 3 or more hours per day on an average school day.5 The development of obesity, however, is likely more complex, with increased parental obesity, low parental education, social deprivation, abnormal infant feeding patterns, extreme birth weights, gestational diabetes, and various genetic, social, and environmental factors thought to potentially play a role.6,7 Hormones such as leptin and ghrelin play a role in weight regulation with brain activity in the hypothalamus noted to vary among obese and nonobese individuals.8 It has been shown that a person’s risk of becoming obese may be influenced by their relationships and associations with obese individuals and peers.9 Epigenetics may play a permissive role in the influences that increase one’s susceptibility of becoming obese. Obese children have a greater likelihood of having an obese parent than their normal-weight peers,10 and obese children have an increased risk of becoming obese adults themselves, thereby perpetuating the cycle. Associated Conditions
The US Surgeon General reports that obesity is the fastest growing cause of disease and death in the United States11 and, therefore, has been the focus of numerous public health initiatives. Although obesity alone may not directly lead to death, its association with comorbidities leads to increased mortality. Despite previous thoughts that certain comorbidities only impacted obese adults, reports have emerged showing such comorbidities at alarming rates among obese youth with increased morbidity and mortality.12–14 Neurologic
Pseudotumor cerebri, or idiopathic intracranial hypertension, is widely considered to be a complication of severe obesity.15 This condition leads to raised intracranial pressure that is not attributed to structural abnormalities or space-occupying masses and may lead to severe headaches, elevated cerebral spinal fluid pressure, and blindness or visual disturbances. Cardiovascular
Similar to obese adult patients, obese youth are afflicted with numerous cardiovascular obesity-related conditions including hypertension, atherosclerosis, and diastolic dysfunction for which consequences such as left ventricular hypertrophy may become irreversible with prolonged exposure.16–18 Chronic inflammation and metabolic dysfunction increase the risk of stroke and myocardial infarction among obese youth.
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The effects of obesity are not only harmful during childhood but are associated with increased cardiovascular events during adulthood.19 Early intervention is warranted, as obese youth who lose weight have similar risks for cardiovascular disease as individuals who were never obese.20 Pulmonary
Obesity is associated with apnea, hypopnea, and snoring. Obese children who suffer from sleep-related disordered breathing, such as with obstructive sleep apnea (OSA) or obesity hypoventilation syndrome suffer from chronic fatigue; impaired performance at school, work, and activities; and cardiovascular dysfunction.12 Such conditions may, therefore, impair scholastic performance and the child’s ability to succeed academically. Gastrointestinal
Gastrointestinal complications such as cholelithiasis, gastroesophageal reflux disease, and nonalcoholic fatty liver disease have been linked to obesity. Liver disease associated with obesity encompasses an array of conditions ranging from simple, uncomplicated steatosis (seen in 38% of obese children) to nonalcoholic steatohepatitis, cirrhosis, and ultimate liver failure.21,22 Of adolescents undergoing bariatric surgery, 59% had evidence of nonalcoholic fatty liver disease, and mild fibrosis was seen in 18% of liver biopsies.23 Musculoskeletal
Growing pediatric patients have musculoskeletal conditions that require unique attention in the obese population. Obese youth are susceptible to conditions such as tibia vara (Blount disease),24,25 a disorder of the musculoskeletal system in which the effects of weight on the growth plates leads to abnormal development of the bones with a bowing of the legs that worsens as the child develops. Additionally, obese children sustain altered patterns of injury compared with their nonobese peers after traumatic insult.26 Children who are obese may have osteoarthritis, severe musculoskeletal pain, or extremity fractures with associated impaired mobility and physical limitations. Additionally, obese children are also more likely to suffer from slipped capital femoral epiphysis or displacement of the capital femoral epiphysis from the femoral neck through the physeal plate, thereby further impeding mobility.27 Endocrine
Although conditions such as type 2 diabetes mellitus (T2DM) were once thought of as occurring only in adults, we have seen an increase in prevalence of children with diabetes or prediabetes corresponding to high rates of pediatric obesity.28 It is thought that 17% to 25% of obese children and adolescents have impaired glucose tolerance, whereas 4% to 6% have T2DM.29 Early diagnosis and treatment of these conditions in obese children are crucial, as treatment may slow progressive complications such as neuropathy, nephropathy, retinopathy, and atherosclerotic cardiovascular disease.30 The prevalence of metabolic syndrome, defined by insulin resistance, T2DM, polycystic ovary syndrome, dyslipidemia, and hypertension increases exponentially among obese youth, with 6.8% of overweight adolescents afflicted by this condition compared with 28.7% of obese adolescents.31 Metabolic syndrome is associated with an increased risk of cardiovascular disease, as these obese youth become obese adults.32 Obesity is also associated with precocious puberty or early onset of sexual maturation.33 Additionally, hormonal influences impact the development of polycystic ovary syndrome with associated menstrual irregularities, hirsutism, acne, and decreased fertility among obese adolescent girls.
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Psychosocial
In addition to the myriad medical problems that occur among obese youth, psychosocial consequences of childhood obesity remain prevalent and underappreciated. Obese youth have more behavioral and self-esteem problems than their normalweight peers.34–36 Depression and aggression in adulthood are more frequently seen among those individuals with a history of pediatric obesity.37 Studies evaluating health-related quality of life find decreased physical, emotional, and social satisfaction with 30% of obese youth meeting criteria for clinically significant depressive symptoms.38,39 Studies show that health-related quality of life among obese adolescents may be indistinguishable from that of children with cancer.40 Obese youth may also suffer from alienation from peers, distorted body image, anxiety, and a poor ability to formulate healthy, supportive relationships. Obese adolescent girls have advanced to fewer years of formal education, have lower rates of marriage, higher rates of poverty, and decreased family income compared with their nonobese peers.30 Obese female adolescents have disproportionately high rates of maladaptive eating behaviors including binge eating disorders.41 Obese youth with binge eating disorders may be more susceptible to long-term problems of distorted body image, impaired social functioning, and substance abuse.42 Parallels are seen between mechanisms of obesity and addictive behaviors and must be considered in the management of obesity.43 Mortality
The gains in life expectancy which were previously increasing in the United States have slowed considerably.44 Although this trend is multifactorial, the increasing prevalence of obesity and associated comorbidities has contributed to the current trends, with severely obese individuals having a reduced length of life by 5 to 20 years.45 Obese youth are believed to be particularly susceptible to premature mortality as they spend more time in an at-risk state. Without effective public health interventions to combat or at least decrease the prevalence of obesity among youth today, the current generation of obese children and adolescents may be the first generation to have a shorter life expectancy than their parents.46 Nonoperative Management of Pediatric Obesity
First-line treatment for weight loss frequently consists of conservative, nonoperative therapies including structured diet and exercise programs in combination with behavioral therapy. These interventions teach patients to develop skills of self-monitoring, portion control, goal setting and coping mechanisms that are not centered on food. Stepwise approaches to successful weight loss have been advocated by the American Academy of Pediatrics, which begin with interventions recommended by the primary care doctor and progress to a multidisciplinary team or specialty program as needed.47 Despite some success at weight loss through moderate- to high-intensity programs, overall results tend to be modest at best. Mean decreases in BMI through structured diet, exercise, and behavioral modification programs are on the order of 2 to 3 kg/m2, for which substantial changes in obesity-related comorbidities remain limited. Weight loss is often a short-term phenomenon with weight regain occurring commonly.48 More drastic diet measures including meal replacements and the use of dietary supplements and prepackaged meals with portion control have had mixed results when used in some adult populations; however, the data among children and adolescents remain sparse. Although one small study did find increased weight loss when adolescents used meal replacements (6% decrease in BMI compared with 4% decrease in BMI among controls), the results achieved were not sustained.49 Additionally, the
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nutritional ramifications and long-term consequences of such restricted caloric intake among growing children have not been well studied. Finally, the high costs of such meal replacements and meal plans may not allow for prolonged use and limit accessibility. Recently, we have seen growing interest in the use of pharmaceutical options for the treatment of obesity. This method remains limited in pediatric patients, as many weight-loss agents have not been approved for use in children. Safety and efficacy data are lacking, thereby leading to generalized reluctance to prescribe medications for weight loss to children. Orlistat, an oral lipase inhibitor that blocks the absorption of fat in the bowel is the only US Food and Drug Administration (FDA)-approved agent for weight loss in obese adolescents. Gastrointestinal side effects limit its use, and reductions in BMI have been modest.50 Two additional medications, metformin and exenatide, have also been evaluated as potential agents to induce weight loss in adolescent patients; however, reductions in BMI were minimal, and these agents have not yet been approved by the FDA for use in children.50 Most recently, there has been interest in the use of topiramate, an antiepileptic medication for weight loss in adolescent patients. Although an average decrease in BMI of 5% was seen in a recent retrospective study evaluating the use of this agent in adolescents, the associated cognitive side effects, including mental slowing, may preclude its use.51,52 Additional studies are needed to further evaluate the effectiveness and safety of medications used to promote weight loss in obese youth. Operative Management of Pediatric Obesity
Although the mainstay of weight management includes diet, exercise, medical therapies, and behavioral therapies, given the modest long-term effects of nonoperative approaches, there has been increasing interest in the utilization of surgical approaches to effectively and efficiently treat pediatric obesity and associated comorbidities. Among obese adult patients, bariatric surgery is found to be the most effective treatment available for obesity-related illnesses, including diabetes, hypertension, and hyperlipidemia.53 Bariatric surgery is more cost effective and has better long-term outcomes when compared with nonoperative approaches.54 Unfortunately, much of the data regarding long-term outcomes are only available for adult patients, with limited information available to guide pediatric patients. As such, there has been reluctance among health care providers to recommend and endorse bariatric surgery to their obese pediatric patients. Systematic evaluations of early outcomes for adolescent obese patients undergoing bariatric surgery, however, have thus far been promising. Adolescent patients who undergo bariatric surgery lose significant weight, have improvement or resolution of many comorbid conditions, and sustain few short-term complications in a cost-effective manner.55–57 Criteria for surgical intervention
Bariatric surgery is not without risks, and providing aggressive interventions earlier in life when disease processes are in early stages may improve surgical outcomes and decrease the risk of the intervention. Improvements in obesity-related comorbidities seen after bariatric surgery in carefully selected patients has led to continued support of this approach.58 Appropriate selection criteria remain critical in identifying those patients for whom bariatric surgery is most likely to be safe and successful. Although initial recommendations were conservative, with bariatric surgery only advocated for children with BMI 40 kg/m2 with comorbidities or BMI 50 kg/m2 regardless of comorbidities (based on the 1991 National Institutes of Health Consensus Development Conference,59 whereby recommendations of BMI 35 kg/m2 with
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comorbidities or BMI 40 kg/m2 regardless of comorbidities were established for adults), the pendulum has swung in the other direction. Updated recommendations recently published by the American Society for Metabolic and Bariatric Surgery pediatric committee in 2012 support more aggressive selection of pediatric patients.60 Because most adolescents with a BMI of 35 kg/m2 are greater than the 99th BMI percentile, this BMI threshold was considered acceptable for pursuing bariatric surgery. Similar to adult criteria, adolescents with a BMI 35 kg/m2 must also have major obesity-related comorbidities (T2DM, moderate-to-severe OSA, pseudotumor cerebri, or severe nonalcoholic steatohepatitis). Those adolescent patients with BMI 40 kg/m2 may still be candidates for bariatric surgery even with less severe comorbidities, including hypertension, dyslipidemia, mild-to-moderate OSA, insulin resistance, or glucose intolerance. Although a lower age limit was not defined in the American Society for Metabolic and Bariatric Surgery guidelines, most centers delay weight reduction surgery until patients show psychological maturity and reach markers of physical maturity including Tanner IV or V sexual maturity and 95% of predicted vertical growth as demonstrated by bone age.61 The indications for bariatric surgery will likely continue to evolve as more is learned about the procedures and their long-term consequences. It is important, however, that contraindications to surgery are equally considered. Patients who lack family support or depth of insight into their condition and cannot formulate realistic expectations should not undergo bariatric surgery. Additionally, those adolescents who have not adhered to recommendations for attempting weight loss or lack decision-making capacity, have medically correctable conditions leading to obesity, have major unstable psychosis or suicidal ideation, and will not adhere to postoperative lifestyle modification recommendations including the need for vitamin and mineral supplementation should not be offered bariatric surgery. Adolescent patients who are being considered for bariatric surgery should be evaluated by a multidisciplinary team at a center where the resources are available to meet their unique needs. These centers must have the ability to manage obesity-related medical comorbidities and must have resources to manage potential complications after surgery. A medical team comprising individuals with expertise in pediatric obesity evaluation and management (including bariatric surgeon and anesthesiologist), a coordinator, social worker, registered dietician, exercise physiologist, mental health specialist, adolescent medicine specialist, endocrinologist, pulmonologist, cardiologist, gastroenterologist, and orthopedist must be available. These providers must be committed to providing long-term follow-up of adolescent patients and ultimately assisting with the transition to adult care. Bariatric surgical procedures performed Malabsorptive procedures The first surgeries for weight management included
malabsorptive procedures such as the jejuno-ileal bypass and the jejunal-colonic bypass. Because these bypass operations were fraught with complications, including dehydration and metabolic derangements, they were soon abandoned. These procedures, however, set the stage for the development of additional malabsorptive procedures for weight loss. Although the biliopancreatic diversion with or without duodenal switch is still described, its use in pediatric patients remains limited. This procedure allows for mixing of ingested material and bile along a short (50 to 100 cm) segment of distal ileum, thereby resulting in decreased absorption with subsequent macronutrient and micronutrient deficiencies, flatus, and diarrhea. Concerns about nutritional deficiencies in growing children and the gastrointestinal side effects have rendered it not well suited for this population.
Bariatric Surgery in Youth
Malabsorptive and restrictive procedures Significant weight loss and appetite suppression was first noted when gastrectomies with gastrojejunostomies were performed in the management of gastric ulcer disease. These findings led pioneers in bariatric surgery to hypothesize that bypass of a large portion of the stomach would yield similar results. As such, the gastric bypass operation in which a 15- to 30-mL gastric pouch is created just beyond the gastroesophageal junction and anastomosed to a roux limb of jejunum, thereby bypassing much of the proximal gastrointestinal tract, was developed. More recently, minimally invasive (laparoscopic) approaches to this operation have come in favor. Gastric bypass is a restrictive and a malabsorptive procedure and, thus, leads to significant and sustained weight reduction that has been associated with marked improvements or resolution of obesity-related comorbidities, including insulin resistance, T2DM, hypertension, and hyperlipidemia.62 Laparoscopic Roux-en-Y gastric bypass (RYGB) has become the mostly commonly performed weight reduction operation in the world and is considered the gold standard of weight loss surgery, to which other procedures and approaches are often compared. Obese adolescents with obesity-related comorbidities who have not responded to nonoperative weight management strategies should be considered for bariatric surgery, including gastric bypass. A cross-sectional study looking at national surgical trends in obese adolescent patients found that RYGB was the most commonly performed weight reduction procedure for patients between 10 and 19 years of age in the United States, with RYGB comprising 67.6% of all interventions performed on this population.63 Much like in adults, excellent results have been reported for adolescents undergoing RYGB with 35% reduction in weight seen at 1 year after surgery.64 A meta-analysis of all bariatric surgery in pediatric patients reported decreases in BMI of 17.8 to 22.3 units.65 One of the largest multicenter studies of adolescents undergoing laparoscopic RYGB reported substantial improvements in triglyceride and total cholesterol levels (decreases of 47% and 16%, respectively) and a 13% decrease in mean fasting glucose levels, 70% decrease in fasting insulin levels, and 90% of patients having complete resolution of OSA.66 Severe complications in the short and intermediate term after RYGB are rare but have been reported and must be discussed with any patient considering this procedure. Complications include anastomotic leak, sepsis, bleeding complications, bowel obstructions (from intra-abdominal adhesions, strictures, or internal hernias), deep vein thrombosis with or without thromboembolic disease, and death. Although longer-term data are slowly being acquired and evaluated, the numbers of adolescent subjects followed up to late time points currently remains limited; thus, much remains unknown about long-term risks of the operation. Factors such as weight regain, the need for revisions or complications related to altered anatomy with some portions of the gastrointestinal tract rendered not easily accessible (biliary tract), and ongoing concerns about potential long-term risks of micronutrient deficiencies including iron, vitamin D, calcium, and B vitamins in growing adolescents warrant further evaluation. Restrictive procedures As opposed to malabsorptive procedures in which nutritional deficiencies are of great concern, restrictive procedures were designed to restrict the intake of calories, thereby promoting a hypocaloric, negative energy balanced state with subsequent weight loss. One such approach that has been described in adolescents,67 however, that has recently fallen out of favor is the vertical banded gastroplasty (VBG). This technique may be performed via a laparoscopic approach and involves the creation of a small gastric pouch just distal to the gastroesophageal junction with banding of the pouch. The distal-most aspect of the pouch remains in
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continuity with the remainder of the stomach to allow for the passage of ingested material to the remainder of the gastrointestinal tract. Gastric bypass proved to be superior to VBG in several randomized trials,68,69 and the VBG now has been largely abandoned. More recently, there has been great interest in the implantation of a removable, adjustable gastric band (AGB) to accomplish restriction of stomach size. Implantation of the AGB may be performed under laparoscopic guidance and does not require alteration of normal anatomic alignment. There is no anastomoses necessary nor are the risks of vitamin deficiencies relevant. The band is placed circumferentially around the upper portion of the stomach and is attached to a subcutaneous port, which can be accessed to tighten or release the band as necessary. Despite lack of FDA approval of the AGB for patients younger than 18 years, there had been a surge of AGBs implanted into adolescent patients in recent years with AGB insertions comprising almost one-third of all bariatric procedures performed in 2009 (approval for implantation was granted through investigational device exemption from the FDA).63 Although initially thought to have an excellent safety profile with substantial loss of excess body weight (37%–63%) achieved during a 6-month to 7-year follow-up period,70 reoperation rates of 8% to 10% for mechanical device failure, band slippage, band erosion, or band removal limited their use.65 Although implantation of AGBs results in greater weight loss and improvement in quality of life indices and health status compared with nonoperative weight reduction approaches, there has been a drastic decline in the numbers of AGB devices implanted in pediatric patients in the United States today.71 To this end, there is increased enthusiasm for an alternate restrictive procedure, the sleeve gastrectomy (SG), in which the stomach shape and size is significantly reduced to resemble a long, thin tubular structure.71 The restrictive nature of this procedure limits one’s ability to consume large volumes of food, thereby inducing a hypocaloric state. It does not, however, alter the ability to absorb critical nutrients nor alter anatomic continuity. The SG, too, may be performed laparoscopically with minimal complications and excellent short-term outcomes. This procedure, however, is not without risks, including staple line leaks, bleeding, strictures or narrowing of the stomach, infectious processes, and venous thrombosis with thromboembolisms. Multiple studies found weight loss and improvement in comorbidities after a laparoscopic SG comparable to results that followed RYGB but with fewer complications.72,73 Because the anatomy is only minimally altered in an SG, the ability to convert to an RYGB in the future remains, as does the ability to easily access all parts of the gastrointestinal tract (biliary system), findings that make the SG particularly attractive for pediatric patients. Special considerations
Many ethical concerns must be acknowledged and addressed when considering bariatric surgery for weight management among obese children and adolescents. Although adolescents must show an understanding of the procedure being considered, the indications, risks, and benefits of the procedure, and the long-term consequences and commitment required when undergoing bariatric surgery, how do health care providers ensure that they have the maturity and capacity to make such life-altering decisions? Given that adolescence is a time of vulnerability and that obese adolescents are more likely to be bullied or ridiculed by peers and face unique psychosocial stressors, how can we be confident that their interest in bariatric surgery is genuine and not simply in response to pressures placed on them by peers? Without standardized procedures available, is it possible to adequately evaluate adolescents for their ability to truly formulate realistic expectations and understanding of outcomes and risks as they relate to bariatric surgery?
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Adolescents younger than 18 years cannot legally provide consent for procedures; therefore, a parent or legal guardian must be counseled and involved with the patient providing assent. Health care providers have, thus, raised the question as to whose decision it is to ultimately undergo surgery and how to ensure that adolescents aren’t simply responding to overt or subtle coercion by family members. This is particularly true in cases in which patient and parent or guardian disagree about the impact of the patient’s weight and the role that surgery may play. Additionally, many adolescents are not the sole individuals responsible for buying food or preparing family meals; therefore, how best to encourage the family to actively participate and engage in the patient’s new lifestyle must be considered. Unfortunately, many adolescents with chronic medical problems are found to be noncompliant with medical regimens and recommendations.74 Because patients who undergo bariatric surgical procedures are at higher risks for macronutritional and micronutritional deficiencies, it is imperative that they not only remain compliant with vitamin and mineral supplements prescribed, but also follow up with routine blood work and monitoring. Adolescents who undergo bariatric surgery may become at risk for abnormal bone development with subsequent fractures given reduced intake of calcium and vitamin D. Cases of beriberi have been described, resulting from noncompliance with vitamins prescribed. As adolescents move away from home and are no longer under the care of their parents or guardians, the prospect of compliance becomes an important consideration when evaluating for surgical candidacy. After bariatric surgery, an increase in fertility and the rate of pregnancy has been reported among adolescent girls.75 Although outcomes of pregnancy immediately after bariatric surgery in the adolescent population have not been well studied, counseling regarding increased fertility after surgery should be provided and contraception made available, as it is believed that pregnancy during the first 18 months after surgery, when the rate of weight loss is most rapid and susceptibility to nutritional compromise is highest, may be dangerous to the developing fetus. Once the patient’s weight has stabilized and nutritional deficiencies have been excluded, the risks of pregnancy are reduced after bariatric surgery compared with obese women.76 Future work
Bariatric surgery can be a life-altering opportunity for obese youth. Although the longterm data are still pending, we have seen continued interest and enthusiasm for this approach to weight and comorbidity management. As we continue our evaluation of long-term effects of bariatric surgery, including assessment of nutritional parameters, bone growth and development, the need for additional revisional procedures after the initial operation, it is important to engage adolescent patients who have undergone bariatric surgery and to elicit feedback about their experiences. Were their expectations met? What was their perspective on the their ability to accurately make such an important decision? What challenges did they face as they went through the process of preoperative evaluation, surgery, recovery, and management of daily life after their procedure? If given the opportunity, would they do it all again? Engaging patients in these important discussions will lead health care providers and parents to having a more comprehensive understanding of bariatric surgery and its role in the treatment of obese youth. SUMMARY
Childhood and adolescent obesity has reached epidemic proportions worldwide. Until a comprehensive understanding of the etiology of obesity is identified and novel interventions are available to treat obesity and halt progression of obesity-related
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comorbidities, bariatric surgical approaches should be considered in carefully selected pediatric patients. To date, bariatric surgery has been more effective and has allowed for more rapid health benefits when compared with nonoperative weight management approaches. The optimal type of procedure and conditions under which maximum long-term benefits will be achieved have yet to be determined. Detailed long-term outcomes after bariatric surgery must be systematically evaluated so that management of obese youth can be optimized. REFERENCES
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