Bariatric surgery in children and adolescents: procedures on the rise
As obesity rates in children and adolescents continue to climb, so do the number of bariatric surgeries performed. Studies have shown that more than half of pediatric patients who are obese carry their obesity into adulthood.
With that in mind, it is not surprising that bariatric surgery among teens has quadrupled in recent years, increasing from an estimate of 200 procedures in the United States in 2000, to almost 800 procedures in 2003, according to data published in the Archives of Pediatric and Adolescent Medicine.
Despite the increase, the results of a 2007 study suggested that the risks for adolescents undergoing weight loss surgery are relatively low, and perhaps even lower than in adults, according to one of the researchers, Thomas H. Inge, MD, PhD, surgical director of the Comprehensive Weight Management Center at Cincinnati Childrens Hospital Medical Center.
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Although these results were promising, without long-term data regarding the effects of surgery on children and adolescents, many in the field have said the lasting consequences are unable to be fully understood.
Perhaps the solution is the emergence of studies such as Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS), of which Inge is also the principal investigator. Teen-LABS is a large consortium made up of five clinical centers designed to determine the risks and benefits of gastric bypass bariatric surgery and compare them with adults.
Endocrine Today interviewed leading researchers in the field to get their perspective on bariatric surgery in children and adolescents, such as preferred methods, psychological and legal issues, and other ongoing studies. All said they are aware of the Teen-LABS study. Inge said the results of the ongoing study will become available over the next few years, but important information, such as the documentation of severity of cardiovascular, endocrine, renal and psychosocial comorbidities in morbidly obese teens, were released at Obesity 2009, the Obesity Societys annual meeting, in October.
What I hope we will see is that it makes a lot of sense to perform the surgery before comorbidities become irreversible, Inge said.
Inge said the lack of information on bariatric research may be because there has not been a great deal of funding. However, the Teen-LABS study has garnered interest from the National Institutes of Health and is funded by the National Institute of Diabetes and Digestive and Kidney Diseases.
The adult surgery is good for improving comorbidities of obesity, but there is good reason to believe that reversing morbid obesity early in life could more effectively reverse complications of obesity, Inge said.
In adults, bariatric surgery has shown prolonged weight control and improvement in serious obesity comorbidities. The two most commonly performed bariatric procedures in the United States are laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB). The surgery may not be as effective if it is performed late in the course of comorbid conditions, which is why many have said it is a highly beneficial option for select teens.
The Teen-LABS consortium began in June 2006, and in addition to Cincinnatis Childrens Hospital Medical Center, it includes Texas Childrens Hospital in Houston, Childrens Hospital of Alabama in Birmingham, University of Pittsburgh Medical Center and Nationwide Childrens Hospital in Columbus, Ohio. Teen-LABS is structured similar to the Longitudinal Assessment of Bariatric Surgery, established previously by the NIDDK.
The Teen-LABS study is examining standard clinical care of 200 adolescents aged 19 years and younger undergoing bariatric surgery.
In addition to the risks of bariatric surgery for adolescents, Teen-LABS will examine CV risk factors, fitness, endocrine changes, sleep disorders, weight loss and body composition, renal disease, liver function and size, nutrition deficiencies, adherence to nutritional supplements and psychosocial factors.
Inge said one of the interesting results to come from the study is learning what comorbidities bariatric teens have, some of which have not been described before.
For instance, were looking at the kidneys; not a lot is known about the effect of extreme adolescent obesity on renal function. And what we are finding in our early results is that there are very real and present signs of kidney dysfunction in teens with morbid obesity, he said.
Inge said that he and his co-investigators are committed to following the Teen-LABS cohort for a decade, and objectively documenting outcomes; this would require extended funding past the 2006 to 2012 initial funding period giving an even longer term look after the surgery.
Its great to see this type of support for this research, Inge said.
Support for bariatric surgery
Fernando B. Bonanni Jr., MD, director of the Institute for Metabolic and Bariatric Surgery at Abington Memorial Hospital, Pennsylvania, said bariatric surgery in adolescents was once a hot topic in the field, but it is beginning to simmer down.
There is no question that adolescents enjoy all the benefits of bariatric surgery, Bonanni said, adding that the reduction of comorbidities is the greatest selling point. Moreover, for adolescents, the psychosocial benefits are life changing. Like any other surgery, an adolescent will fare better with regard to handling the surgery.
The benefit of youth is that patients will have fewer comorbid problems going into the surgery. If they have comorbid diseases, they have had them for less time.
Chronic diseases, like diabetes, take its toll on a person, especially an obese patient. We must remember that the real problem with obesity is that our body systems are equipped with reserves to handle disease and injury. If you are 100 lb or more overweight, your system is working for two people or more, Bonanni said.
It is for this reason that adult obese patients are more likely to develop diseases and conditions at a higher incidence, such as type 2 diabetes, he said.
Inge was an investigator of a 2009 multicenter study that found teens who underwent gastric bypass surgery showed dramatic, often immediate remission of type 2 diabetes.
Teens who underwent LRYGB lost, on average, one-third of their body weight, and remission of diabetes was induced in all but one teen. In most cases, patients stopped taking their diabetes medications by the time they left the hospital.
The results have been quite dramatic, and, to our knowledge, there are no other antidiabetic therapies that result in more effective and long-term control than that seen with bariatric surgery, Inge said. He noted that the patients also showed significant improvement in blood pressure, insulin, glucose, cholesterol and triglyceride levels.
Impact of surgery
Nicole M. Chandler, MD, a pediatric surgeon at All Childrens Hospital, St. Petersburg, Fla., said although the technique of bariatric surgery and its immediate postoperative care is identical in the pediatric and adult populations, the adolescent population has unique metabolic and psychological demands.
It is important that ongoing nutritional and psychological support is provided to this younger age group and long-term follow-up is provided far into adulthood, Chandler said.
It is difficult to assess the effect that bariatric surgery may have on the lives of adolescents and their family.
While surgical options may provide sustained weight loss and resolution of comorbid diseases, they also carry potentially life-threatening complications, the need for continued life-long compliance with eating and behavioral modifications, and uncertain long-term problems decades after the operation, Chandler said.
Bonanni said herein lies the controversy with bariatric surgery in adolescents.
The question is not: Will they do well with surgery, he said. There is no question they do better than adults; however, the problem lies in the fact that adolescents have not suffered from comorbid problems for a prolonged period. Therefore, they sometimes do not realize and appreciate the benefit of the weight loss. This sometimes leads to complacency when it comes to the life changes that are required to succeed long term. This includes exercise, supplemental vitamins, portion control and good eating habits.
It is important that adolescents participate in a rigorous preoperative screening that includes educational information and how to manage expectations. The program they enter should require adolescents to attend support group sessions.
Most importantly, the patients family must be actively engaged in the entire process. In adolescents, the support system they rely on is paramount to their success. This is a support system that unfortunately in many cases is already broken and needs repair. A good program for surgical weight loss will take all of this into consideration, Bonanni said.
Legal and ethical dilemmas
Although there are benefits to bariatric surgery, the procedure is still a major surgery that has long-reaching consequences, said Brian M. Fidlin, PsyD, program director of the NEW (Nutrition, Exercise and Weight Management) Kids Program at Childrens Hospital of Wisconsin.
There are questions that remain about whether a younger individual possesses the maturity to make such a decision, Fidlin said.
He said not all insurance plans consider bariatric surgery a viable option for adolescents; in addition, many of these younger individuals may be dropped from their parents insurance plans at some point.
One of the major risks is determining if this adolescent and his or her support system will be capable of making and maintaining the necessary changes to promote a weight loss. It is essential that an individual understand the procedure, risks and benefits, as well as postsurgical requirements, Fidlin said.
Evan P. Nadler, MD, co-director of the Obesity Institute at Childrens National Medical Center in Washington, D.C., said there are many legal and ethical issues with adolescents and bariatric surgery.
Firstly, [LAGB] is not yet FDA-approved for children younger than 18 years of age so the safest option isnt even approved for children/adolescents, said Nadler, a leading researcher of bariatric surgery in adolescents. So its an ethical question: Do you perform a safe procedure or make a 300-lb 15-year-old with diabetes wait another year or two until the band gets approved?
He said it is not a question that is easily answered.
My personal feeling is that its less ethical to withhold a procedure that you know can help, than it is to perform a procedure that doesnt necessarily have long-term studies to prove its durability, Nadler said.
Effectiveness of LAGB
Nadler was an investigator of a 2007 NYU Medical Center study that showed LAGB to be an effective procedure to combat obesity in adolescents.
The study was the first to evaluate LAGB in patients younger than 17 and revealed that patients on average lost about 50% of their excess weight by one year after surgery. The surgery was performed on 53 morbidly obese adolescents aged between 13 and 17, and, in addition to the weight loss, none of the patients regained any of the weight. Complications were found to be significantly less severe with LAGB, as well.
Nadler said the results of the study suggest that LAGB provides a safer and equally effective weight loss compared with LRYGB.
George Woodman, MD, medical director of the Baptist Weight Loss Center in Memphis, Tenn., agrees.
In general, I would not consider a gastric bypass on an adolescent. This is an excellent procedure, but one that is not reversible. The lap band and gastric sleeve procedures, I believe, are a much better option, Woodman said, citing that LAGB is reversible and has been documented to be safe in many studies.
The sleeve procedure, although not reversible, is safer than a bypass and does not have the same complication possibilities. The stomach is made smaller, but the intestines are not rearranged. Therefore, absorption is normal, and the procedure is less morbid, he said.
Paucity of data
Saurabh Khandelwal, MD, an acting assistant professor at the Center for Videoendoscopic Surgery in the department of surgery at the University of Washington, Seattle, said bariatric surgery in the adolescent population is still a controversial topic because of the lack of data.
For example, Khandelwal said performing LRYGB in children and adolescents may cause potentially harmful effects on development and growth and affect physical maturation.
Long-term data, at this time, do not exist that can give insight into outcomes from procedures such as the gastric band or sleeve gastrectomy. We dont know the long-term consequences of placing a band in an adolescent, in which case he or she may have it for 60 years or longer, Khandelwal said. Young patients undergoing such procedures should be carefully followed and assessed, preferably through participation in studies.
However, despite the lack of data, Nadler said studies such as the Teen-LABS gastric bypass study and the NYU gastric banding study show that weight loss is as good if not better than the similar procedures in adults.
And the procedures are as safe if not safer in adolescents, Nadler added.
I personally believe that 10 to 20 years from now, there will be as many teenagers getting bariatric surgery as adults, especially since they do likely have better outcomes, he said. More studies are needed on the topic, and Nadler plans to investigate the topic further in his program at Childrens National Medical Center.
Almost all of the researchers Endocrine Today spoke with viewed bariatric surgery as a means for helping obese adolescents.
Bariatric surgery is not a magic bullet, Bonanni said. It is a tool. If you do not take the tool out of the shed, it will not work for you. by Angelo Milone
For more information:
- Inge TH. Pediatrics. 2009;123:214-222.
- Inge TH. J Pediatr Surg. 2007;42:1969-1971.
- Tsai WS. Arch Pediatr Adolesc Med. 2007;161:217-221.