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Surgical Management of Adolescent Obesity
Advances in Pediatrics 60 (2013) 311–325
ADVANCES IN PEDIATRICS Surgical Management of Adolescent Obesity Sean J. Barnett, MD, MS Division of Pediatric General & Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45215, USA
Keywords
Morbid obesity Adolescents Bariatric surgery Comorbidities Weight loss
Key points
Morbid obesity continues to see a rapid increase in pediatric and adolescent populations. Morbidly obese adolescents develop significant comorbidities that continue on into adulthood. Although medical management in the overweight population of children can be helpful, morbidly obese adolescents do not show significant long-term weight reduction with lifestyle modification.
Bariatric surgery is a safe and long-term solution in selected morbidly obese adolescents who are physically and psychosocially mature.
Adolescent bariatric surgical patients require lifelong dietary modification and follow-up to ensure adequate nutritional supplementation. Roux-en-Y gastric bypass (RYGB) remains the gold standard operation but sleeve gastrectomy (SG) continues to gain rapid prominence, given its simplicity and reduced postoperative complication rates.
The adjustable gastric band (AGB) in the adolescent population can be efficacious compared with medical therapy but has demonstrated significantly higher complication and reoperation rates compared with its use in adults. More longterm, longitudinal studies are necessary to firmly establish guidelines for patient selection and optimal procedure choice.
INTRODUCTION It has been estimated that approximately 18% of all children and adolescents meet the criteria of being overweight or obese in the United States, a rate that has almost tripled over the past 30 years [1]. Of these overweight children,
Disclosures: The author has no relevant financial relationships to disclose.
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50% to 77% will continue to be obese into adulthood, carrying with them all the associated comorbidities [2–4]. More alarming, however, are the approximately 4% to 7% of all children and adolescents (more than 2 million) considered morbidly obese (body mass index [BMI] >99th percentile) in this country [2,5,6]. These data parallel recent National Health and Nutrition Examination Survey (NHANES) data demonstrating that approximately two-thirds of US adults are considered overweight and more than one-third considered obese [7]. The importance of these data cannot be overlooked given the long-term health, psychosocial, and economic ramifications of childhood obesity. Although behavioral weight management programs have been shown to have lasting effects in some children, these approaches are ineffective in those patients who are morbidly obese [8]. Of those morbidly obese children undergoing behavioral weight loss, one-third to one-half cannot even complete a program. Those who complete a program lose, on average, 5 pounds (3% weight loss), which is not maintained 7 months later [8]. These findings lend toward performing bariatric surgery on morbidly obese adolescents to provide longer-lasting overall weight loss and comorbidity reduction. This article discusses the definition of pediatric obesity and the comorbidities of morbid obesity in children and adolescents, provides guidelines for performing bariatric surgery in adolescents, discusses the procedures and their outcomes in this patient population, and provides a framework for postoperative care. DEFINITION The prevailing standard for measurement of obesity in the adult population is body mass index (BMI kg/m2). This is a simple way to define obesity in those who have attained their full adult height. By definition, adults are considered overweight with a BMI greater than 25 kg/m2 and considered obese with a BMI greater than or equal to 30 kg/m2. These numbers can be extrapolated over different ethnic groups and populations to allow for easy formation of guidelines for treatment. In children and adolescents, the use of BMI becomes more complicated due to the physiologic changes in adiposity with height and weight changes during normal growth. Therefore, growth charts are used for most children and adolescents that are both age specific and gender specific to better define obesity throughout childhood [9]. General guidelines throughout the literature define pediatric obesity as a BMI greater than the 95th percentile for age and gender, with those greater than the 99th percentile considered severely obese (BMI >35 kg/m2, consistent with the definition for adults) [10]. These definitions present unique problems in defining those individuals at the extreme categories of obesity, given the relative paucity of population-based data to calculate these percentile boundaries. This definition is compounded by the small number of children and adolescents with a BMI greater than 40 kg/m2 represented in the data sets used to formulate pediatric growth charts, namely NHANES. Because most adolescents with a BMI greater than 35 kg/m2 are greater than the 99th BMI percentile for current growth charts [2], it is
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appropriate to use adult selection criterion for the use of bariatric surgery in this patient population. Thresholds should be considered general guidelines and those with significant comorbidities should also be considered for bariatric surgery despite regard for BMI. COMORBIDITIES ASSOCIATED WITH MORBID OBESITY IN ADOLESCENTS Given the relative explosion in the prevalence of pediatric obesity over the past 30 years, there has been a parallel increase in the frequency and severity of obesity-related comorbidities in morbidly obese adolescents. These disease states are frequently seen at a much younger age than previously encountered, encompass a wide range of organ systems, and carry subsequent increased risks into adulthood [11–14]. Glucose intolerance Although a frequent manifestation of adult obesity, it has been demonstrated that there has been a significant (more than 10-fold) increase in the prevalence of type 2 diabetes mellitus in adolescents over the past decade [15]. Even more striking is the finding that up to 25% of all obese children and adolescents have some form of impaired glucose intolerance [16]. Insulin resistance has been clearly linked with childhood obesity [17], and studies suggest that type 2 diabetes mellitus developing in childhood or in adolescence can progress more rapidly than in adults [18]. Type 2 diabetes mellitus in adolescents is considered a chronic and progressive disease associated with many other comorbidities, including dyslipidemia, hypertension, cardiac disease, and nonalcoholic liver disease [19,20]. In a recent study published by the Centers for Disease Control and Prevention, epidemiologists predict that type 2 diabetes mellitus is expected to develop in 33% to 50% of all Americans born in the year 2000 [21]. Cardiovascular disease Risk factors for atherosclerosis and coronary artery disease are common in obese adolescents [22–24], with approximately 60% of obese children in the Bogalusa Heart Study having 1 of these factors and 20% having 2 or more of these factors [25]. Hypertension occurs at a 9-fold increased rate in obese children [26] and is a well-known risk factor for the development of cardiac disease in adults. Furthermore, there has been a linear increase in the development of cardiovascular risk factors in relation to increased BMI in children [27]. The incidence of left ventricular hypertrophy has also been shown significantly increased in young adults as a direct consequence of comorbidities related to adolescent obesity, namely obstructive sleep apnea [28]. Obstructive sleep apnea Up to 20% of school-aged children with obesity are reported to have either moderate or severe sleep apnea [29]. Data associates poor school performance with sleep deprivation and disordered sleep patterns [30,31], both of which are common in obese children and adolescents,as well as placing them at increased
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risk for hyperactivity and learning difficulties throughout life [32]. Adolescents with sleep apnea also exhibit significant left ventricular hypertrophy [28] and abnormal ventricular dimensions [33], which have not been found improved with medical weight loss alone [34]. Nonalcoholic fatty liver disease and nonalcoholic steatohepatitis Approximately 38% of obese adolescents have steatosis and 9% have nonalcoholic steatohepatitis (NASH) compared with 5% and 1%, respectively, in their lean counterparts [35]. Of those undergoing bariatric surgery at Cincinnati Children’s Hospital, 83% have evidence of fatty liver disease, with 20% formally demonstrating NASH [36]. The most serious consequence of liver damage associated with obesity is fibrosis coupled with accelerated cirrhosis, ultimately leading to end-stage liver disease. Pseudotumor cerebri Pseudotumor cerebri is a rare progressive childhood disorder associated with increased intracranial pressure that often leads to papilledema and blindness. The relationship between obesity and symptom onset is unclear. As many as 50% of children with pseudotumor cerebri are obese [37] and, with extensive weight loss after bariatric surgery, it can improve in both adults [38] and in adolescents [39]. Psychological aspects A significant number of adolescents seeking treatment of their obesity present with differing stages of clinical depression [40]. Many obese adolescents have been found to have low self-esteem and can engage in high-risk behaviors [41], and obesity has been found to have a significant negative effect on their quality of life [42]. Obese adolescents also demonstrate significantly lower quality-of-life scores than lean children with scores and are comparable with pediatric cancer patients [43]. Women who were overweight as adolescents are also less likely to marry and have completed fewer years of school compared with their lean counterparts [44]. A recent longitudinal study demonstrated a significant improvement in depressive symptoms and quality of life over the first postoperative period after bariatric surgery in adolescents [45]. Summary The large mounting body of literature demonstrating the significant number of comorbidities associated with obesity coupled with their relative lack of resolution by medical weight loss means in the morbidly obese has led to a large body of evidence in support of the use of modern weight loss operations for selected, morbidly obese adolescents. Bariatric surgery has been shown to completely resolve type 2 diabetes mellitus in adolescents who have undergone gastric bypass [46]. It has also shown a dramatic reduction in the severity of obstructive sleep apnea symptoms in all patients, with complete resolution of symptoms in 90% [47]. A decrease in the degree of steatosis and regression of hepatic fibrosis has been found in some patients after bariatric surgery [48]. These data, coupled with the improvements in pseudotumor cerebri and
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psychosocial behaviors (discussed previously), support the early use of bariatric surgical procedures in the adolescent population. GUIDELINES FOR SURGERY Best practice guidelines by the American Society for Metabolic and Bariatric Surgery have been recently updated and published [49]. As discussed previously, most adolescents with a BMI greater than 35 kg/m2 are greater than the 99th percentile; therefore, adult criteria for selection are considered appropriate for adolescents. Current recommendations have not changed significantly since the last best practice guidelines were set in 2009 (Table 1) [50]. In summary, these include those individuals with a BMI greater than or equal to 35 kg/m2 with significant major comorbidities, which include type 2 diabetes mellitus, pseudotumor cerebri, severe NASH, and moderate to severe obstructive sleep apnea (apnea-hypopnea index >15). Those individuals with a BMI greater than or equal to 40 kg/m2 with less severe comorbid disease, including glucose intolerance, hypertension, dyslipidemia, mild to moderate obstructive sleep apnea (apnea-hypopnea index >5), and impaired quality of life, are also thought to meet criteria for bariatric surgery [49]. Given that these are merely guidelines for treatment, exceptions can be made in extenuating circumstances if the potential long-term health risks outweigh the risks of bariatric surgery. Because adolescence represents an extensive period of growth, the timing for surgical treatment remains controversial and depends on the compelling needs of patients. For those adolescents who have attained the majority of linear growth (>95%), there is little reason to believe that bariatric surgery will impair growth. Physiologic maturation is generally complete by sexual maturation (Tanner stage 4) [51]. Skeletal maturation (adult stature) is normally attained by the age 13 to 14 in girls and age 15 to 16 in boys [52]. The onset of menarche is also a sign of physiologic maturity in girls, with growth usually complete within 2 years after menarche. For those patients for whom physical maturation is uncertain, bone age can be assessed by plain radiography of the hand or wrist and estimated by a radiologist via nomograms. Coupled with physiologic factors of maturation in adolescents is the determination of a patient’s psychosocial maturity level. Patients should not only be able to demonstrate a general understanding of the risks and benefits of surgery Table 1 Patient selection criteria for adolescent weight loss surgery BMI (kg/m2)
Comorbidities
>35
Type 2 diabetes mellitus, moderate of severe obstructive sleep apnea, pseudotumor cerebri, severe NASH Mild obstructive sleep apnea, hypertension, insulin resistance, glucose intolerance, dyslipidemia, impaired quality of life
>40
Data from Michalsky M, Reichard K, Inge T, et al. ASMBS pediatric committee best practice guidelines. Surg Obes Relat Dis 2012;8:1–7.
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but also the long-term ramifications after bariatric surgical procedures and ability to comply with vitamin and nutritional recommendations. Although the majority of patients cannot consent for themselves, it is expected that patients provide assent for the procedure. It is paramount that a patient’s parents are readily involved in the entire process in order to assess support mechanisms, determine and ensure the likelihood of postoperative compliance, and provide adequate consent for the procedure. Specific recommendations regarding team member qualifications have been made to maximize the multidisciplinary approach required for bariatric surgery in adolescents [49]. These include, but are not limited to, the following:
Surgeon: The surgeon performing adolescent bariatric surgery should meet the general certification requirements of the American Board of Surgery and have appropriate training and experience in performing bariatric procedures. The individual should be credentialed by the institution to perform such procedures, but it is not necessary to be boarded specifically in pediatric surgery. As an example, Cincinnati Children’s Hospital has 4 board-certified surgeons (adult and pediatric) who have extensive knowledge and training in the various bariatric surgical procedures performed. Medical specialist: Includes at least one physician with specialty training in endocrinology, gastroenterology, nutrition, or adolescent medicine. The main responsibilities of this team member are the screening and management of a patient’s comorbid conditions with the team and the patient’s primary care physician. My program uses a board-certified pediatric gastroenterologist as its medical director (which comes in handy for those patients who require preoperative and postoperative endoscopy) and a board-certified adolescent medicine physician who assists with the care of the majority of female patients who experience menstrual dysfunction. Registered dietitian: Arguably the most important part of the overall program, the dietitian should have extensive experience in treating adolescents and their families with obesity. The dietician sets the tone during the preoperative phase of the program and helps manage patient questions and concerns throughout the postoperative phase. Mental health specialist: Includes a psychologist, psychiatrist, or other independently licensed metal health provider with specific training in pediatric, adolescent, and family treatment. The individual should also have experience in treating those patients with obesity and eating disorders. My psychologist plays a pivotal role during the initial assessment to ensure that patients are psychologically ready to begin the program and to help garner the necessary resources required to move past the preoperative phase. Program coordinator: Includes a registered nurse, social worker, or business specialist whose main responsibility is the coordinating of care to help facilitate compliance and follow-up. My coordinator also works with patients’ insurance companies to ensure coverage for treatment and procedures. Exercise physiologist or specialist: This specialist provides safe physical activity education for morbidly obese patients. Social worker: A dedicated social worker is not required but is highly recommended. In my program, she monitors patients’ psychosocial health as well as
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communicates with patient therapists on a regular basis. She also manages the support group, access to resources, and various functions throughout the year. Nurse practioner: This position is not required but is an integral part of the team at Cincinnati Children’s Hospital. She has an ongoing dialogue with all my patients and literally has her hands on the pulse of the program. She also helps manage many of the medical problems of the patients within the program on a daily basis.
With the various team members comes a significant commitment of the institution to provide safe and quality care for these difficult patients. A recent article, published in Pediatrics in 2011, sought to develop certain criteria for pediatric/adolescent bariatric surgery programs [53]. Michalsky and colleagues [53] propose 10 criteria for proposed specialty programs, including (1) institutional commitment, (2) a defined medical home for patients, (3) routine experience in laparoscopic bariatric procedures, (4) program staffing (discussed previously), (5) multidisciplinary review for each patient, (6) specialized equipment (hospital beds, patient transfer systems, operating room tables, and adequate radiologic facilities), (7) standardized care using clinical pathways, (8) follow-up care, (9) support groups, and (10) transition of care as patients move into adulthood. The ability to meet these criteria help to ensure a wellrounded program that is able to meet all the needs of morbidly obese adolescents. PROCEDURES AND OUTCOMES The experience of several small series suggests that gastric bypass, AGB, and SG can be performed routinely, safely, and effectively in adolescents [54,55–65]. To date, however, adolescent bariatric surgery has not been evaluated in a longitudinal or prospective manner. To address these shortcomings in outcomes for adolescent bariatric surgery, a consortium of 5 pediatric institutions is currently involved in a National Institutes of Health–funded study, designed to collect standardized prospective preoperative and postoperative clinical data longitudinally (Teen–Longitudinal Assessment of Bariatric Surgery [Teen-Labs]). Accrual of patients for the study is complete and the initial data are being analyzed with initial results set to be published by the end of this year. There have been many bariatric operations performed in adolescents in the past but the remainder of this section focuses on the 3 most commonly performed operations to date. These include the AGB, RYGB, and SG (Fig. 1). All the operations are performed laparoscopically. Minimally invasive bariatric surgery has significant advantages over open surgery, namely the reduction of complications, length of stay, and pain postoperatively, but is one of the most technically difficult procedures performed [66]. ADJUSTABLE GASTRIC BAND The Food and Drug Administration approved the use of Lap-Band (Allergan, Irvine, California) for use in adults in the United States in 2001 and the Realize Band (Ethicon, Cincinnati, Ohio) shortly thereafter. Prior to its introduction
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Fig. 1. Bariatric procedures performed in adolescents: (A) AGB, (B) SG, and (C) RYGB.
into the United States, the AGB procedure was the most commonly performed procedure in Europe, Latin America, and Australia. It is not currently approved for patients under age 18 by the Food and Drug Administration, with results of an ongoing national study awaiting publication. Given its current restrictions, studies in adolescents are generally found to originate from outside the United States. The laparoscopically placed gastric band creates a small pouch in the upper portion of the stomach, acting solely as a restrictive procedure. A balloon on the inside of the band is connected to a port placed in the subcutaneous tissues of the upper abdomen (see Fig. 1A). The port can be accessed by a smallgauge needle to perform periodic adjustments by placing or removing sterile water into the system. This in turn changes the size of the balloon around the stomach, thus changing the size of the functional stoma that it creates. These periodic adjustments are critical for the overall success of the band and require as many as 10 visits over the course of the first postoperative year. The procedure generally requires 45 to 60 minutes to complete, patients
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are discharged on the same day or next day, and there is no cutting or stapling of the stomach or intestine. Complications include gastric prolapse, stomal obstruction, band erosion, and, most commonly, access port or tubing problems. These seem similar when comparing adolescent AGBs with their adult counterparts. A recent study from Australia followed patients with a BMI greater than 35 for 2 years randomized to either supervised lifestyle intervention or gastric banding [57]. The main outcomes were weight loss and adverse outcomes; 24 of the 25 gastric banding patients and 18 of 25 lifestyle modification patients completed the study. A mean excess weight loss of 78.8% was seen in the banding group and 13.2% in the lifestyle modification group. The study also noted significant improvement in features of the metabolic syndrome and quality of life in the gastric banding group. Alarmingly, however, 8 reoperations (33%) were required in 7 patients, with an overall complication rate of 48% over the 2-year period [57]. Smaller studies have achieved similar results with many experiencing marked improvement of obesity-related comorbidities [63,64]. Given these studies, AGB seems more effective than lifestyle modification alone and can result in a significant reduction in comorbidities. Given the much higher complication rate in adolescents compared with adults, the surgeon must be careful when considering AGB in this population. Additional long-term data are forthcoming from industry-sponsored trials before any recommendation can be made regarding their use in patients under age 18. SLEEVE GASTRECTOMY The SG is rapidly gaining acceptance as a primary operation in both adult and adolescent populations. Once considered only part of the larger duodenal switch operation, it has been shown to offer significant weight loss with fewer complications than gastric bypass [67]. This restrictive procedure involves the longitudinal resection of the stomach along a narrow 34-French bougie. The resection extends approximately 6 cm from the pylorus to the angle of His, thus creating a long gastric tube along the lesser curve of the stomach. The fundus and greater curvature of the stomach are removed (see Fig. 1B). The mechanism of weight loss is not yet understood but may be the result of both restriction and alteration of appetite and satiety signals from the gut to the brain, including changes in ghrelin and peptide YY levels [68]. Literature regarding its effectiveness in the pediatric population is growing [62,67–72] but continues to be sparse. The largest single institutional study to date reported outcomes of 108 adolescents undergoing SG in Saudi Arabia [62]. The investigators reported a significant reduction in BMI of 37% at 1 year, similar to previously reported studies in this country after gastric bypass [73], with no major complications or deaths. Significant reductions in type 2 diabetes mellitus, sleep apnea, hypertension, and dyslipidemia were also noted. Given these promising findings, and with the help of additional longitudinal prospective studies like the current Teen-Labs study, SG seems a viable option for bariatric surgery in adolescents.
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ROUX-EN-Y GASTRIC BYPASS RYGB is both a restrictive and malabsorptive procedure and is considered the gold standard for bariatric surgical procedures in the United States. The restrictive component is a small gastric pouch (approximately 15–20 mL in size) coupled with a small gastric outlet (2–3 cm in diameter) that results in early and sustained satiety. The malabsorptive component involves re-establishing intestinal continuity with a gastric bypass segment of varying lengths between 100 cm and 150 cm (see Fig. 1C). Currently, there have been no procedure-related deaths reported in adolescents undergoing RYGB. Early complications include pulmonary embolism, wound infections, stomal stenosis, and marginal ulcers. Late complications have included small bowel obstruction, incisional hernias, symptomatic cholelithiasis, protein calorie and micronutrient deficiencies, and late weight regain (10%–15% incidence) [53,65,73]. These complications parallel their adult counterparts and stress the requirement of lifelong follow-up. The majority of weight can be expected to be lost within the first 18 to 24 months after surgery. Two recent studies in adolescents have demonstrated similar postoperative outcomes compared with adults. A recent meta-analysis of 6 studies involving adolescent RYGB demonstrated a significant reduction in excess body weight with improvement in associated comorbidities [74]. A recent report from Cincinnati Children’s Hospital demonstrated a significant reduction in BMI (35%–37%) within the first year after RYGB in adolescents [73]. One finding from that article showed an equal percentage of weight reduction despite the preoperative BMI. Unfortunately, those patients who started out heavier (BMI >60), despite losing a significant amount of weight, remained morbidly obese at 1 year. This demonstrates the need for earlier referral to ensure adequate weight loss to maximize comorbidity reduction. Several studies (cited previously in this review) demonstrate the resolution of numerous comorbid states in adolescents, including hypertension [74], sleep apnea [75], and type 2 diabetes mellitus [46], and psychosocial improvements [45]. Given these findings, the current literature supports the use of RYGB as a safe and efficacious means for significant weight loss and comorbidity reduction. As discussed previously, the Teen-Labs study should help strengthen the literature once outcomes are reported. POSTOPERATIVE MANAGEMENT It is of the utmost importance for a bariatric patient’s primary care physician to become familiar with the physiologic changes that occur after bariatric surgery. This allows for effective partnership between the bariatric team and the primary physician for the care of the patient after the operation. Patients generally spend between 2 and 3 nights after their operation in the hospital and are discharged home on clear liquids. They are advanced fairly quickly to a high-protein liquid diet, which is usually maintained for at least 1 month after surgery. The postoperative diet is methodically advanced by introducing new food choices toward the goal of a well-balanced, small-portion
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(approximately 1 cup) diet, ensuring a daily intake of 1 g of protein per kilogram of ideal body weight. Patients are encouraged to eat proteins first during every meal to ensure their adequate intake. Nonsteroidal anti-inflammatory medications are generally avoided to reduce the risk of ulcer formation. Postoperative nausea is common after SG and most patients are discharged home on antinausea medications. The nausea tends to resolve within the first week after surgery. Reflux is also common after SG with approximately half of my patients requiring proton pump inhibitors for at least the first 6 postoperative months. Routine postoperative vitamin supplementation is the key for all operations, given the significant reduction in nutrients (AGB and SG) and combined malabsorption (RYGB). The typical regimen consists of 2 pediatric chewable multivitamins, a calcium supplement, and an iron supplement for menstruating women. B-complex vitamins are also supplemented beyond the typical multivitamin primarily to augment thiamine and folate supplementation (Table 2) [76]. Severe complications can arise with their deficiency, specifically in those who undergo RYGB [77]. There are 5 basic rules that are routinely emphasized with patients and family at each visit: (1) eat protein first; (2) drink 64 oz to 96 oz of water or sugar-free liquids daily; (3) no snacking between meals; (4) exercise at least 30 minutes per day; and (5) always remember vitamins and minerals. All bariatric surgeries, to varying degrees, result in surgically enforced, lowcalorie, low-carbohydrate intake, which, in turn, requires intensive attention to ensure adequate intake of important macronutrients and micronutrients. Postoperative follow-up consists of an initial visit 2 weeks after surgery. After this initial visit, patients are seen during regular intervals within my program (6 weeks, and then generally every 3 months for the first 18 months postoperatively). Patients are then generally seen on an annual basis. Serum chemistries, complete blood cell count, urine specific gravity, prothrombin time (evidence of vitamin K adequacy), and representative B-complex vitamin levels (eg, B1, B12, and folate) are obtained at regular intervals. Upper gastrointestinal series are usually obtained yearly in our SG patients and on an as-needed basis otherwise. Table 2 Recommended nutritional supplementation after weight loss surgery Supplement
Recommendation
Multivitamin (with folic acid) Calcium citrate with vitamin D Vitamin D Vitamin B12 Elemental iron Vitamin B1 Vitamins A and K
1 to 2 Daily 1500–1800 mg/d 1000 IU/d (if deficiency found preoperatiavely) 500 lg/d Oral or 1000 lg/mo intramuscular 65 mg Elemental iron for menstruating women Consider 50 mg daily in first 6 mo Treat if symptomatic
Laboratory results are checked at 6 months postoperatively and then yearly unless symptoms arise. Data from Xanthakos SA. Nutritional deficiencies in obesity and after bariatric surgery. Pediatr Clin North Am 2009;56(5):1105–21.
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SUMMARY Morbid obesity continues to see a rapid increase in pediatric and adolescent populations. These patients develop significant comorbidities that continue into adulthood. Although medical management in the overweight population of children can be helpful, the morbidly obese adolescents do not show significant long-term weight reduction with lifestyle modification. Bariatric surgery is a safe and long-term solution in selected morbidly obese adolescents who are physically and psychosocially mature. Adolescent bariatric surgical patients require lifelong dietary modification and follow-up to ensure adequate nutritional supplementation. RYGB remains the gold standard operation but SG continues to gain rapid prominence, given its simplicity and reduced postoperative complication rates. AGB in the adolescent population can be efficacious compared with medical therapy but has demonstrated significantly higher complication and reoperation rates compared with its use in adults. It remains to be approved by the Food and Drug Administration only for those 18 years of age and older. More long-term, longitudinal studies are necessary to firmly establish guidelines for patient selection and optimal procedure choice. References [1] Ogden CL, Carroll MD, Curtin LR, et al. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA 2006;295(13):1549–55. [2] Freedman DS, Mei Z, Srinivasan 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] Strauss RS, Pollack HA. Epidemic increase in childhood overweight. 1986-1998. JAMA 2001;286:2845–8. [4] Parsons TJ, Powers C, Logan S, et al. Childhood predictors of adult obesity: a systematic review. Int J Obes Relat Metab Disord 1999;23(Suppl 8):S1–107. [5] Skelton JA, Cook SR, Auinger P, et al. Prevalence and trends of severe obesity among US children and adolescents. Acad Pediatr 2009;9:322–9. [6] Koebnick C, Smith N, Coleman KJ, et al. Prevalence of extreme obesity in a multiethnic cohort of children and adolescents. J Pediatr 2010;157:26–31.e2. [7] Flegal KM, Carroll MD, Kit BK, et al. Prevalence of obesity and Trends in the distribution of body mass index amoung US adults, 1999-2010. JAMA 2012;307:491–7. [8] Levine MD, Ringham RM, Kalarchian MA, et al. Is family-based behavioral weight control appropriate for severe pediatric obesity? Int J Eat Disord 2001;30(3):318–28. [9] Michels KB. Early life predictors of chronic disease. J Womens Health (Larchmt) 2003;12(2):157–61. [10] Wahlqvist ML. Chronic disease prevention: a life-cycle approach which takes account of the environmental impact and opportunities of food, nutrition and public health policies—the rationale for an eco-nutritional disease nomenclature. Asia Pac J Clin Nutr 2002;11(Suppl 9):S759–62. [11] Pi-Sunyer FX. The obesity epidemic: pathophysiology and consequences of obesity. Obes Res 2002;10(Suppl 2):97S–104S. [12] Whitaker RC. Understanding the complex journey to obesity in early adulthood. Ann Intern Med 2002;136(12):923–5. [13] Must A, Jacques PF, Dallal GE, et al. Long-term morbidity and mortality of overweight adolescents; A follow-up of the Harvard Growth Study of 1922-1935. N Engl J Med 1992;327:1350–5.
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[37] Weisberg LA, Chutorian AM. Pseudotumor cerebri of childhood. Am J Dis Child 1977;131:1243–8. [38] Sugarman HJ, Felton WL III, Sismanis A, et al. Gastric surgery for pseudotumor cerebri associated with severe obesity. Ann Surg 1999;229:634–42. [39] 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. [40] Zeller MH, Modi AC. Predictors of health-related quality of life in obese youth. Obesity (Silver Spring) 2006;14:122–30. [41] Strauss RS. Childhood obesity and self-esteem. Pediatrics 2000;105:e15. [42] Ball K, Crawford D, Kenardy J. Longitudinal relationships among overweight, life satisfaction, and aspirations in young women. Obes Res 2004;12:1019–30. [43] Schwimmer JB, Burwinkle TM, Varni JW. Health-related quality of life of severely obese children and adolescents. JAMA 2003;289:1813–9. [44] 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. [45] Zeller MH, Modi AC, Noll JG, et al. Psychosocial functioning improves following adolescent bariatric surgery. Obesity (Silver Spring) 2009;17:985–90. [46] 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(1):214–22. [47] Kaira M, Inge T. Effect of bariatric surgery on obstructive sleep apnea in adolescents. Paediatr Respir Rev 2006;7(4):260–7. [48] Kral JG, Thung SN, Biron S, et al. Effects of surigcal treatment of the metabolic syndrome on liver fibrosis and cirrhosis. Surgery 2004;135:48–58. [49] Michalsky M, Reichard K, Inge T, et al. ASMBS pediatric committee best practice guidelines. Surg Obes Relat Dis 2012;8:1–7. [50] Pratt JS, Lenders CM, Dionne EA, et al. Best practice updates for pediatric/adolescent weight loss surgery. Obesity (Silver Spring) 2009;17:901–10. [51] Tanner JM. Growth at adolescence. 2nd edition. Oxford (United Kingdom): Blackwell Scientific Publications; 1962. [52] Tanner JM, Davies PS. Clinical longitudinal standards for height and weight velocity for North American children. J Pediatr 1985;107:317–29. [53] Michalsky M, Kramer RE, Fullmer MA, et al. Developing criteria for pediatric/adolescent bariatric surgery programs. Pediatrics 2001;128(2):S65. [54] Sugerman HJ, Sugerman EL, DeMaria EJ, et al. Bariatric surgery for severely obese adolescents. J Gastrointest Surg 2003;7:102–8. [55] Rand CS, MacGregor AM. Adolescents having obesity surgery: a 6 year follow-up. South Med J 1999;87:1208–13. [56] Barnett SJ, Stanley C, Hanlon M, et al. Long-term follow-up and the role of surgery in adolescents with morbid obesity. Surg Obes Relat Dis 2005;1:394–8. [57] O’Brien PE, Sawyer SM, Laurie S, et al. Laparoscopic adjustable gastric banding in severeley obese adolescents; a randomized trial. JAMA 2010;303:519–26. [58] Alqahtani AR, Antonisamy B, Alamri H, et al. Laparoscopic sleeve gastrectomy in 108 obese children and adolescents aged 5 to 21 years. Ann Surg 2012;256(2): 266–73. [59] Jen HC, Rickard DG, Shew SB, et al. Trends and outcomes of adolescent bariatric surgery in California, 2005-2007. Pediatrics 2010;126:e746–53. [60] Zitsman JL, Fennoy I, Witt MA, et al. Laparoscopic adjustable gastric banding in adolescents: short-term results. J Pediatr Surg 2011;46:157–62. [61] 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.
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[62] Al-Qahtani AR. Laparoscopic adjustable gastric banding in adolescents: safety and efficacy. J Pediatr Surg 2007;42:894–7. [63] Dolan K, Creighton L, Hopkins G, et al. Laparoscopic gastic banding in morbidly obese adolescents. Obes Surg 2003;13:101–5. [64] Angrisani L, Favretti F, Furbetta F, et al. Obese teenagers treated by Lap-Band System: the Italian experience. Surgery 2005;138:877–81. [65] Strauss RS, Bradley LJ, Brolin RE. Gastric bypass in adolescents with morbid obesity. J Pediatr 2001;138:499–504. [66] Schauer PR, Ikramuddin S. Laparoscopic surgery for morbid obesity. Surg Clin North Am 2001;81:1145–79. [67] Rosenthal RJ. International sleeve gastrectomy expert panel consensus statement: best practice guidleines based on experience of > 12,000 cases. Surg Obes Relat Dis 2012;8:8–19. [68] Langer FB, Reza Hoda MA, Bohdjalian A, et al. Sleeve gastrectomy and gastric banding: effects on plasma ghrelin levels. Obes Surg 2005;15:1024–9. [69] Lee CM, Cirangle PT, Jossart GH. Vertical gastrectomy for morbid obesity in 216 patients: resport of two year results. Surg Endosc 2007;21:1810–6. [70] Till H, Bluher S, Hirsch W, et al. Efficacy of laparoscopic sleeve gastrectomy (LGS) as a stand-alone techniwque for children with morbid obesity. Obes Surg 2008;18:1047–9. [71] Till H, Muenstere O, Keller A, et al. Laparoscopic sleeve gastrectomy acheives substantial weight loss ni an adolescnet girl with morbid obesity. Eur J Pediatr 2008;1:47–9. [72] Boza C, Viscido G, Salina J, et al. Laparscopic sleeve gastrectomy I obese adolescents: results in 51 patients. Surg Obes Relat Dis 2012;8:133–9. [73] Inge TH, Jnekins TM, Zeller M, et al. Baseline BMI is a strong predictor of nadir BMI after adolescent gastric bypass. J Pediatr 2010;156:103–8. [74] Treadwell JR, Sun F, Schoelles K. Systematic review and meta-analysis of bariatric surgery for pediatric obesity. Ann Surg 2008;248(5):763–76. [75] Ippisch HM, Inge TH, Daniels SR, et al. Reversibility of cardiac abnormalities in morbidly obese adolescents. J Am Coll Cardiol 2008;51:1342–8. [76] Xanthakos SA. Nutritional deficiencies in obesity and after bariatric surgery. Pediatr Clin North Am 2009;56(5):1105–21. [77] Towbin A, Inge TH, Garcia VF, et al. Beriberi after gastric bypass surgery in adolescence. J Pediatr 2004;145(2):263–7.
ADVANCES IN PEDIATRICS Surgical Management of Adolescent Obesity Sean J. Barnett, MD, MS Division of Pediatric General & Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45215, USA
Keywords
Morbid obesity Adolescents Bariatric surgery Comorbidities Weight loss
Key points
Morbid obesity continues to see a rapid increase in pediatric and adolescent populations. Morbidly obese adolescents develop significant comorbidities that continue on into adulthood. Although medical management in the overweight population of children can be helpful, morbidly obese adolescents do not show significant long-term weight reduction with lifestyle modification.
Bariatric surgery is a safe and long-term solution in selected morbidly obese adolescents who are physically and psychosocially mature.
Adolescent bariatric surgical patients require lifelong dietary modification and follow-up to ensure adequate nutritional supplementation. Roux-en-Y gastric bypass (RYGB) remains the gold standard operation but sleeve gastrectomy (SG) continues to gain rapid prominence, given its simplicity and reduced postoperative complication rates.
The adjustable gastric band (AGB) in the adolescent population can be efficacious compared with medical therapy but has demonstrated significantly higher complication and reoperation rates compared with its use in adults. More longterm, longitudinal studies are necessary to firmly establish guidelines for patient selection and optimal procedure choice.
INTRODUCTION It has been estimated that approximately 18% of all children and adolescents meet the criteria of being overweight or obese in the United States, a rate that has almost tripled over the past 30 years [1]. Of these overweight children,
Disclosures: The author has no relevant financial relationships to disclose.
E-mail address: [email protected] 0065-3101/13/$ – see front matter http://dx.doi.org/10.1016/j.yapd.2013.04.014
Ó 2013 Elsevier Inc. All rights reserved.
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50% to 77% will continue to be obese into adulthood, carrying with them all the associated comorbidities [2–4]. More alarming, however, are the approximately 4% to 7% of all children and adolescents (more than 2 million) considered morbidly obese (body mass index [BMI] >99th percentile) in this country [2,5,6]. These data parallel recent National Health and Nutrition Examination Survey (NHANES) data demonstrating that approximately two-thirds of US adults are considered overweight and more than one-third considered obese [7]. The importance of these data cannot be overlooked given the long-term health, psychosocial, and economic ramifications of childhood obesity. Although behavioral weight management programs have been shown to have lasting effects in some children, these approaches are ineffective in those patients who are morbidly obese [8]. Of those morbidly obese children undergoing behavioral weight loss, one-third to one-half cannot even complete a program. Those who complete a program lose, on average, 5 pounds (3% weight loss), which is not maintained 7 months later [8]. These findings lend toward performing bariatric surgery on morbidly obese adolescents to provide longer-lasting overall weight loss and comorbidity reduction. This article discusses the definition of pediatric obesity and the comorbidities of morbid obesity in children and adolescents, provides guidelines for performing bariatric surgery in adolescents, discusses the procedures and their outcomes in this patient population, and provides a framework for postoperative care. DEFINITION The prevailing standard for measurement of obesity in the adult population is body mass index (BMI kg/m2). This is a simple way to define obesity in those who have attained their full adult height. By definition, adults are considered overweight with a BMI greater than 25 kg/m2 and considered obese with a BMI greater than or equal to 30 kg/m2. These numbers can be extrapolated over different ethnic groups and populations to allow for easy formation of guidelines for treatment. In children and adolescents, the use of BMI becomes more complicated due to the physiologic changes in adiposity with height and weight changes during normal growth. Therefore, growth charts are used for most children and adolescents that are both age specific and gender specific to better define obesity throughout childhood [9]. General guidelines throughout the literature define pediatric obesity as a BMI greater than the 95th percentile for age and gender, with those greater than the 99th percentile considered severely obese (BMI >35 kg/m2, consistent with the definition for adults) [10]. These definitions present unique problems in defining those individuals at the extreme categories of obesity, given the relative paucity of population-based data to calculate these percentile boundaries. This definition is compounded by the small number of children and adolescents with a BMI greater than 40 kg/m2 represented in the data sets used to formulate pediatric growth charts, namely NHANES. Because most adolescents with a BMI greater than 35 kg/m2 are greater than the 99th BMI percentile for current growth charts [2], it is
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appropriate to use adult selection criterion for the use of bariatric surgery in this patient population. Thresholds should be considered general guidelines and those with significant comorbidities should also be considered for bariatric surgery despite regard for BMI. COMORBIDITIES ASSOCIATED WITH MORBID OBESITY IN ADOLESCENTS Given the relative explosion in the prevalence of pediatric obesity over the past 30 years, there has been a parallel increase in the frequency and severity of obesity-related comorbidities in morbidly obese adolescents. These disease states are frequently seen at a much younger age than previously encountered, encompass a wide range of organ systems, and carry subsequent increased risks into adulthood [11–14]. Glucose intolerance Although a frequent manifestation of adult obesity, it has been demonstrated that there has been a significant (more than 10-fold) increase in the prevalence of type 2 diabetes mellitus in adolescents over the past decade [15]. Even more striking is the finding that up to 25% of all obese children and adolescents have some form of impaired glucose intolerance [16]. Insulin resistance has been clearly linked with childhood obesity [17], and studies suggest that type 2 diabetes mellitus developing in childhood or in adolescence can progress more rapidly than in adults [18]. Type 2 diabetes mellitus in adolescents is considered a chronic and progressive disease associated with many other comorbidities, including dyslipidemia, hypertension, cardiac disease, and nonalcoholic liver disease [19,20]. In a recent study published by the Centers for Disease Control and Prevention, epidemiologists predict that type 2 diabetes mellitus is expected to develop in 33% to 50% of all Americans born in the year 2000 [21]. Cardiovascular disease Risk factors for atherosclerosis and coronary artery disease are common in obese adolescents [22–24], with approximately 60% of obese children in the Bogalusa Heart Study having 1 of these factors and 20% having 2 or more of these factors [25]. Hypertension occurs at a 9-fold increased rate in obese children [26] and is a well-known risk factor for the development of cardiac disease in adults. Furthermore, there has been a linear increase in the development of cardiovascular risk factors in relation to increased BMI in children [27]. The incidence of left ventricular hypertrophy has also been shown significantly increased in young adults as a direct consequence of comorbidities related to adolescent obesity, namely obstructive sleep apnea [28]. Obstructive sleep apnea Up to 20% of school-aged children with obesity are reported to have either moderate or severe sleep apnea [29]. Data associates poor school performance with sleep deprivation and disordered sleep patterns [30,31], both of which are common in obese children and adolescents,as well as placing them at increased
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risk for hyperactivity and learning difficulties throughout life [32]. Adolescents with sleep apnea also exhibit significant left ventricular hypertrophy [28] and abnormal ventricular dimensions [33], which have not been found improved with medical weight loss alone [34]. Nonalcoholic fatty liver disease and nonalcoholic steatohepatitis Approximately 38% of obese adolescents have steatosis and 9% have nonalcoholic steatohepatitis (NASH) compared with 5% and 1%, respectively, in their lean counterparts [35]. Of those undergoing bariatric surgery at Cincinnati Children’s Hospital, 83% have evidence of fatty liver disease, with 20% formally demonstrating NASH [36]. The most serious consequence of liver damage associated with obesity is fibrosis coupled with accelerated cirrhosis, ultimately leading to end-stage liver disease. Pseudotumor cerebri Pseudotumor cerebri is a rare progressive childhood disorder associated with increased intracranial pressure that often leads to papilledema and blindness. The relationship between obesity and symptom onset is unclear. As many as 50% of children with pseudotumor cerebri are obese [37] and, with extensive weight loss after bariatric surgery, it can improve in both adults [38] and in adolescents [39]. Psychological aspects A significant number of adolescents seeking treatment of their obesity present with differing stages of clinical depression [40]. Many obese adolescents have been found to have low self-esteem and can engage in high-risk behaviors [41], and obesity has been found to have a significant negative effect on their quality of life [42]. Obese adolescents also demonstrate significantly lower quality-of-life scores than lean children with scores and are comparable with pediatric cancer patients [43]. Women who were overweight as adolescents are also less likely to marry and have completed fewer years of school compared with their lean counterparts [44]. A recent longitudinal study demonstrated a significant improvement in depressive symptoms and quality of life over the first postoperative period after bariatric surgery in adolescents [45]. Summary The large mounting body of literature demonstrating the significant number of comorbidities associated with obesity coupled with their relative lack of resolution by medical weight loss means in the morbidly obese has led to a large body of evidence in support of the use of modern weight loss operations for selected, morbidly obese adolescents. Bariatric surgery has been shown to completely resolve type 2 diabetes mellitus in adolescents who have undergone gastric bypass [46]. It has also shown a dramatic reduction in the severity of obstructive sleep apnea symptoms in all patients, with complete resolution of symptoms in 90% [47]. A decrease in the degree of steatosis and regression of hepatic fibrosis has been found in some patients after bariatric surgery [48]. These data, coupled with the improvements in pseudotumor cerebri and
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psychosocial behaviors (discussed previously), support the early use of bariatric surgical procedures in the adolescent population. GUIDELINES FOR SURGERY Best practice guidelines by the American Society for Metabolic and Bariatric Surgery have been recently updated and published [49]. As discussed previously, most adolescents with a BMI greater than 35 kg/m2 are greater than the 99th percentile; therefore, adult criteria for selection are considered appropriate for adolescents. Current recommendations have not changed significantly since the last best practice guidelines were set in 2009 (Table 1) [50]. In summary, these include those individuals with a BMI greater than or equal to 35 kg/m2 with significant major comorbidities, which include type 2 diabetes mellitus, pseudotumor cerebri, severe NASH, and moderate to severe obstructive sleep apnea (apnea-hypopnea index >15). Those individuals with a BMI greater than or equal to 40 kg/m2 with less severe comorbid disease, including glucose intolerance, hypertension, dyslipidemia, mild to moderate obstructive sleep apnea (apnea-hypopnea index >5), and impaired quality of life, are also thought to meet criteria for bariatric surgery [49]. Given that these are merely guidelines for treatment, exceptions can be made in extenuating circumstances if the potential long-term health risks outweigh the risks of bariatric surgery. Because adolescence represents an extensive period of growth, the timing for surgical treatment remains controversial and depends on the compelling needs of patients. For those adolescents who have attained the majority of linear growth (>95%), there is little reason to believe that bariatric surgery will impair growth. Physiologic maturation is generally complete by sexual maturation (Tanner stage 4) [51]. Skeletal maturation (adult stature) is normally attained by the age 13 to 14 in girls and age 15 to 16 in boys [52]. The onset of menarche is also a sign of physiologic maturity in girls, with growth usually complete within 2 years after menarche. For those patients for whom physical maturation is uncertain, bone age can be assessed by plain radiography of the hand or wrist and estimated by a radiologist via nomograms. Coupled with physiologic factors of maturation in adolescents is the determination of a patient’s psychosocial maturity level. Patients should not only be able to demonstrate a general understanding of the risks and benefits of surgery Table 1 Patient selection criteria for adolescent weight loss surgery BMI (kg/m2)
Comorbidities
>35
Type 2 diabetes mellitus, moderate of severe obstructive sleep apnea, pseudotumor cerebri, severe NASH Mild obstructive sleep apnea, hypertension, insulin resistance, glucose intolerance, dyslipidemia, impaired quality of life
>40
Data from Michalsky M, Reichard K, Inge T, et al. ASMBS pediatric committee best practice guidelines. Surg Obes Relat Dis 2012;8:1–7.
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but also the long-term ramifications after bariatric surgical procedures and ability to comply with vitamin and nutritional recommendations. Although the majority of patients cannot consent for themselves, it is expected that patients provide assent for the procedure. It is paramount that a patient’s parents are readily involved in the entire process in order to assess support mechanisms, determine and ensure the likelihood of postoperative compliance, and provide adequate consent for the procedure. Specific recommendations regarding team member qualifications have been made to maximize the multidisciplinary approach required for bariatric surgery in adolescents [49]. These include, but are not limited to, the following:
Surgeon: The surgeon performing adolescent bariatric surgery should meet the general certification requirements of the American Board of Surgery and have appropriate training and experience in performing bariatric procedures. The individual should be credentialed by the institution to perform such procedures, but it is not necessary to be boarded specifically in pediatric surgery. As an example, Cincinnati Children’s Hospital has 4 board-certified surgeons (adult and pediatric) who have extensive knowledge and training in the various bariatric surgical procedures performed. Medical specialist: Includes at least one physician with specialty training in endocrinology, gastroenterology, nutrition, or adolescent medicine. The main responsibilities of this team member are the screening and management of a patient’s comorbid conditions with the team and the patient’s primary care physician. My program uses a board-certified pediatric gastroenterologist as its medical director (which comes in handy for those patients who require preoperative and postoperative endoscopy) and a board-certified adolescent medicine physician who assists with the care of the majority of female patients who experience menstrual dysfunction. Registered dietitian: Arguably the most important part of the overall program, the dietitian should have extensive experience in treating adolescents and their families with obesity. The dietician sets the tone during the preoperative phase of the program and helps manage patient questions and concerns throughout the postoperative phase. Mental health specialist: Includes a psychologist, psychiatrist, or other independently licensed metal health provider with specific training in pediatric, adolescent, and family treatment. The individual should also have experience in treating those patients with obesity and eating disorders. My psychologist plays a pivotal role during the initial assessment to ensure that patients are psychologically ready to begin the program and to help garner the necessary resources required to move past the preoperative phase. Program coordinator: Includes a registered nurse, social worker, or business specialist whose main responsibility is the coordinating of care to help facilitate compliance and follow-up. My coordinator also works with patients’ insurance companies to ensure coverage for treatment and procedures. Exercise physiologist or specialist: This specialist provides safe physical activity education for morbidly obese patients. Social worker: A dedicated social worker is not required but is highly recommended. In my program, she monitors patients’ psychosocial health as well as
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communicates with patient therapists on a regular basis. She also manages the support group, access to resources, and various functions throughout the year. Nurse practioner: This position is not required but is an integral part of the team at Cincinnati Children’s Hospital. She has an ongoing dialogue with all my patients and literally has her hands on the pulse of the program. She also helps manage many of the medical problems of the patients within the program on a daily basis.
With the various team members comes a significant commitment of the institution to provide safe and quality care for these difficult patients. A recent article, published in Pediatrics in 2011, sought to develop certain criteria for pediatric/adolescent bariatric surgery programs [53]. Michalsky and colleagues [53] propose 10 criteria for proposed specialty programs, including (1) institutional commitment, (2) a defined medical home for patients, (3) routine experience in laparoscopic bariatric procedures, (4) program staffing (discussed previously), (5) multidisciplinary review for each patient, (6) specialized equipment (hospital beds, patient transfer systems, operating room tables, and adequate radiologic facilities), (7) standardized care using clinical pathways, (8) follow-up care, (9) support groups, and (10) transition of care as patients move into adulthood. The ability to meet these criteria help to ensure a wellrounded program that is able to meet all the needs of morbidly obese adolescents. PROCEDURES AND OUTCOMES The experience of several small series suggests that gastric bypass, AGB, and SG can be performed routinely, safely, and effectively in adolescents [54,55–65]. To date, however, adolescent bariatric surgery has not been evaluated in a longitudinal or prospective manner. To address these shortcomings in outcomes for adolescent bariatric surgery, a consortium of 5 pediatric institutions is currently involved in a National Institutes of Health–funded study, designed to collect standardized prospective preoperative and postoperative clinical data longitudinally (Teen–Longitudinal Assessment of Bariatric Surgery [Teen-Labs]). Accrual of patients for the study is complete and the initial data are being analyzed with initial results set to be published by the end of this year. There have been many bariatric operations performed in adolescents in the past but the remainder of this section focuses on the 3 most commonly performed operations to date. These include the AGB, RYGB, and SG (Fig. 1). All the operations are performed laparoscopically. Minimally invasive bariatric surgery has significant advantages over open surgery, namely the reduction of complications, length of stay, and pain postoperatively, but is one of the most technically difficult procedures performed [66]. ADJUSTABLE GASTRIC BAND The Food and Drug Administration approved the use of Lap-Band (Allergan, Irvine, California) for use in adults in the United States in 2001 and the Realize Band (Ethicon, Cincinnati, Ohio) shortly thereafter. Prior to its introduction
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Fig. 1. Bariatric procedures performed in adolescents: (A) AGB, (B) SG, and (C) RYGB.
into the United States, the AGB procedure was the most commonly performed procedure in Europe, Latin America, and Australia. It is not currently approved for patients under age 18 by the Food and Drug Administration, with results of an ongoing national study awaiting publication. Given its current restrictions, studies in adolescents are generally found to originate from outside the United States. The laparoscopically placed gastric band creates a small pouch in the upper portion of the stomach, acting solely as a restrictive procedure. A balloon on the inside of the band is connected to a port placed in the subcutaneous tissues of the upper abdomen (see Fig. 1A). The port can be accessed by a smallgauge needle to perform periodic adjustments by placing or removing sterile water into the system. This in turn changes the size of the balloon around the stomach, thus changing the size of the functional stoma that it creates. These periodic adjustments are critical for the overall success of the band and require as many as 10 visits over the course of the first postoperative year. The procedure generally requires 45 to 60 minutes to complete, patients
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are discharged on the same day or next day, and there is no cutting or stapling of the stomach or intestine. Complications include gastric prolapse, stomal obstruction, band erosion, and, most commonly, access port or tubing problems. These seem similar when comparing adolescent AGBs with their adult counterparts. A recent study from Australia followed patients with a BMI greater than 35 for 2 years randomized to either supervised lifestyle intervention or gastric banding [57]. The main outcomes were weight loss and adverse outcomes; 24 of the 25 gastric banding patients and 18 of 25 lifestyle modification patients completed the study. A mean excess weight loss of 78.8% was seen in the banding group and 13.2% in the lifestyle modification group. The study also noted significant improvement in features of the metabolic syndrome and quality of life in the gastric banding group. Alarmingly, however, 8 reoperations (33%) were required in 7 patients, with an overall complication rate of 48% over the 2-year period [57]. Smaller studies have achieved similar results with many experiencing marked improvement of obesity-related comorbidities [63,64]. Given these studies, AGB seems more effective than lifestyle modification alone and can result in a significant reduction in comorbidities. Given the much higher complication rate in adolescents compared with adults, the surgeon must be careful when considering AGB in this population. Additional long-term data are forthcoming from industry-sponsored trials before any recommendation can be made regarding their use in patients under age 18. SLEEVE GASTRECTOMY The SG is rapidly gaining acceptance as a primary operation in both adult and adolescent populations. Once considered only part of the larger duodenal switch operation, it has been shown to offer significant weight loss with fewer complications than gastric bypass [67]. This restrictive procedure involves the longitudinal resection of the stomach along a narrow 34-French bougie. The resection extends approximately 6 cm from the pylorus to the angle of His, thus creating a long gastric tube along the lesser curve of the stomach. The fundus and greater curvature of the stomach are removed (see Fig. 1B). The mechanism of weight loss is not yet understood but may be the result of both restriction and alteration of appetite and satiety signals from the gut to the brain, including changes in ghrelin and peptide YY levels [68]. Literature regarding its effectiveness in the pediatric population is growing [62,67–72] but continues to be sparse. The largest single institutional study to date reported outcomes of 108 adolescents undergoing SG in Saudi Arabia [62]. The investigators reported a significant reduction in BMI of 37% at 1 year, similar to previously reported studies in this country after gastric bypass [73], with no major complications or deaths. Significant reductions in type 2 diabetes mellitus, sleep apnea, hypertension, and dyslipidemia were also noted. Given these promising findings, and with the help of additional longitudinal prospective studies like the current Teen-Labs study, SG seems a viable option for bariatric surgery in adolescents.
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ROUX-EN-Y GASTRIC BYPASS RYGB is both a restrictive and malabsorptive procedure and is considered the gold standard for bariatric surgical procedures in the United States. The restrictive component is a small gastric pouch (approximately 15–20 mL in size) coupled with a small gastric outlet (2–3 cm in diameter) that results in early and sustained satiety. The malabsorptive component involves re-establishing intestinal continuity with a gastric bypass segment of varying lengths between 100 cm and 150 cm (see Fig. 1C). Currently, there have been no procedure-related deaths reported in adolescents undergoing RYGB. Early complications include pulmonary embolism, wound infections, stomal stenosis, and marginal ulcers. Late complications have included small bowel obstruction, incisional hernias, symptomatic cholelithiasis, protein calorie and micronutrient deficiencies, and late weight regain (10%–15% incidence) [53,65,73]. These complications parallel their adult counterparts and stress the requirement of lifelong follow-up. The majority of weight can be expected to be lost within the first 18 to 24 months after surgery. Two recent studies in adolescents have demonstrated similar postoperative outcomes compared with adults. A recent meta-analysis of 6 studies involving adolescent RYGB demonstrated a significant reduction in excess body weight with improvement in associated comorbidities [74]. A recent report from Cincinnati Children’s Hospital demonstrated a significant reduction in BMI (35%–37%) within the first year after RYGB in adolescents [73]. One finding from that article showed an equal percentage of weight reduction despite the preoperative BMI. Unfortunately, those patients who started out heavier (BMI >60), despite losing a significant amount of weight, remained morbidly obese at 1 year. This demonstrates the need for earlier referral to ensure adequate weight loss to maximize comorbidity reduction. Several studies (cited previously in this review) demonstrate the resolution of numerous comorbid states in adolescents, including hypertension [74], sleep apnea [75], and type 2 diabetes mellitus [46], and psychosocial improvements [45]. Given these findings, the current literature supports the use of RYGB as a safe and efficacious means for significant weight loss and comorbidity reduction. As discussed previously, the Teen-Labs study should help strengthen the literature once outcomes are reported. POSTOPERATIVE MANAGEMENT It is of the utmost importance for a bariatric patient’s primary care physician to become familiar with the physiologic changes that occur after bariatric surgery. This allows for effective partnership between the bariatric team and the primary physician for the care of the patient after the operation. Patients generally spend between 2 and 3 nights after their operation in the hospital and are discharged home on clear liquids. They are advanced fairly quickly to a high-protein liquid diet, which is usually maintained for at least 1 month after surgery. The postoperative diet is methodically advanced by introducing new food choices toward the goal of a well-balanced, small-portion
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(approximately 1 cup) diet, ensuring a daily intake of 1 g of protein per kilogram of ideal body weight. Patients are encouraged to eat proteins first during every meal to ensure their adequate intake. Nonsteroidal anti-inflammatory medications are generally avoided to reduce the risk of ulcer formation. Postoperative nausea is common after SG and most patients are discharged home on antinausea medications. The nausea tends to resolve within the first week after surgery. Reflux is also common after SG with approximately half of my patients requiring proton pump inhibitors for at least the first 6 postoperative months. Routine postoperative vitamin supplementation is the key for all operations, given the significant reduction in nutrients (AGB and SG) and combined malabsorption (RYGB). The typical regimen consists of 2 pediatric chewable multivitamins, a calcium supplement, and an iron supplement for menstruating women. B-complex vitamins are also supplemented beyond the typical multivitamin primarily to augment thiamine and folate supplementation (Table 2) [76]. Severe complications can arise with their deficiency, specifically in those who undergo RYGB [77]. There are 5 basic rules that are routinely emphasized with patients and family at each visit: (1) eat protein first; (2) drink 64 oz to 96 oz of water or sugar-free liquids daily; (3) no snacking between meals; (4) exercise at least 30 minutes per day; and (5) always remember vitamins and minerals. All bariatric surgeries, to varying degrees, result in surgically enforced, lowcalorie, low-carbohydrate intake, which, in turn, requires intensive attention to ensure adequate intake of important macronutrients and micronutrients. Postoperative follow-up consists of an initial visit 2 weeks after surgery. After this initial visit, patients are seen during regular intervals within my program (6 weeks, and then generally every 3 months for the first 18 months postoperatively). Patients are then generally seen on an annual basis. Serum chemistries, complete blood cell count, urine specific gravity, prothrombin time (evidence of vitamin K adequacy), and representative B-complex vitamin levels (eg, B1, B12, and folate) are obtained at regular intervals. Upper gastrointestinal series are usually obtained yearly in our SG patients and on an as-needed basis otherwise. Table 2 Recommended nutritional supplementation after weight loss surgery Supplement
Recommendation
Multivitamin (with folic acid) Calcium citrate with vitamin D Vitamin D Vitamin B12 Elemental iron Vitamin B1 Vitamins A and K
1 to 2 Daily 1500–1800 mg/d 1000 IU/d (if deficiency found preoperatiavely) 500 lg/d Oral or 1000 lg/mo intramuscular 65 mg Elemental iron for menstruating women Consider 50 mg daily in first 6 mo Treat if symptomatic
Laboratory results are checked at 6 months postoperatively and then yearly unless symptoms arise. Data from Xanthakos SA. Nutritional deficiencies in obesity and after bariatric surgery. Pediatr Clin North Am 2009;56(5):1105–21.
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SUMMARY Morbid obesity continues to see a rapid increase in pediatric and adolescent populations. These patients develop significant comorbidities that continue into adulthood. Although medical management in the overweight population of children can be helpful, the morbidly obese adolescents do not show significant long-term weight reduction with lifestyle modification. Bariatric surgery is a safe and long-term solution in selected morbidly obese adolescents who are physically and psychosocially mature. Adolescent bariatric surgical patients require lifelong dietary modification and follow-up to ensure adequate nutritional supplementation. RYGB remains the gold standard operation but SG continues to gain rapid prominence, given its simplicity and reduced postoperative complication rates. AGB in the adolescent population can be efficacious compared with medical therapy but has demonstrated significantly higher complication and reoperation rates compared with its use in adults. It remains to be approved by the Food and Drug Administration only for those 18 years of age and older. More long-term, longitudinal studies are necessary to firmly establish guidelines for patient selection and optimal procedure choice. References [1] Ogden CL, Carroll MD, Curtin LR, et al. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA 2006;295(13):1549–55. [2] Freedman DS, Mei Z, Srinivasan 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] Strauss RS, Pollack HA. Epidemic increase in childhood overweight. 1986-1998. JAMA 2001;286:2845–8. [4] Parsons TJ, Powers C, Logan S, et al. Childhood predictors of adult obesity: a systematic review. Int J Obes Relat Metab Disord 1999;23(Suppl 8):S1–107. [5] Skelton JA, Cook SR, Auinger P, et al. Prevalence and trends of severe obesity among US children and adolescents. Acad Pediatr 2009;9:322–9. [6] Koebnick C, Smith N, Coleman KJ, et al. Prevalence of extreme obesity in a multiethnic cohort of children and adolescents. J Pediatr 2010;157:26–31.e2. [7] Flegal KM, Carroll MD, Kit BK, et al. Prevalence of obesity and Trends in the distribution of body mass index amoung US adults, 1999-2010. JAMA 2012;307:491–7. [8] Levine MD, Ringham RM, Kalarchian MA, et al. Is family-based behavioral weight control appropriate for severe pediatric obesity? Int J Eat Disord 2001;30(3):318–28. [9] Michels KB. Early life predictors of chronic disease. J Womens Health (Larchmt) 2003;12(2):157–61. [10] Wahlqvist ML. Chronic disease prevention: a life-cycle approach which takes account of the environmental impact and opportunities of food, nutrition and public health policies—the rationale for an eco-nutritional disease nomenclature. Asia Pac J Clin Nutr 2002;11(Suppl 9):S759–62. [11] Pi-Sunyer FX. The obesity epidemic: pathophysiology and consequences of obesity. Obes Res 2002;10(Suppl 2):97S–104S. [12] Whitaker RC. Understanding the complex journey to obesity in early adulthood. Ann Intern Med 2002;136(12):923–5. [13] Must A, Jacques PF, Dallal GE, et al. Long-term morbidity and mortality of overweight adolescents; A follow-up of the Harvard Growth Study of 1922-1935. N Engl J Med 1992;327:1350–5.
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