Pediatric Annals

CME 

Bariatric Surgery in Obese Adolescents: Opportunities and Challenges

Halley Wasserman, MD; Thomas H. Inge, MD, PhD

Abstract

Extreme obesity is defined by the Centers for Disease Control and Prevention as a body mass index (BMI) higher than 120% of the 95th percentile for age. Four to six percent of American youths fall into this subcategory and are at increased risk for developing comorbidities, including hypertension, dyslipidemia, nonalcoholic fatty liver disease, insulin resistance, sleep apnea, and bone and joint problems. Many studies have shown that nonsurgical treatment programs do not provide significant long-term improvements in BMI in adolescents with severe obesity. In adults, bariatric (weight loss) surgery has been shown to dramatically reduce BMI and to reverse or prevent many complications of obesity; thus, bariatric surgery is being used in an attempt to reverse clinically severe obesity in adolescents.

This review highlights the indications for bariatric surgery in adolescents and outlines practice guidelines for adolescent surgical weight loss programs. The authors summarize available data on the effects of adolescent weight loss surgery on metabolic comorbidities and highlight the important acute and long-term complications that must be monitored by their general pediatricians. After reading this article, the general pediatrician should be able to identify adolescents who may be candidates for weight loss surgery and have the knowledge to assist in their postoperative medical management. [Pediatr Ann. 2014;43(9):e230–e236.]

Abstract

Extreme obesity is defined by the Centers for Disease Control and Prevention as a body mass index (BMI) higher than 120% of the 95th percentile for age. Four to six percent of American youths fall into this subcategory and are at increased risk for developing comorbidities, including hypertension, dyslipidemia, nonalcoholic fatty liver disease, insulin resistance, sleep apnea, and bone and joint problems. Many studies have shown that nonsurgical treatment programs do not provide significant long-term improvements in BMI in adolescents with severe obesity. In adults, bariatric (weight loss) surgery has been shown to dramatically reduce BMI and to reverse or prevent many complications of obesity; thus, bariatric surgery is being used in an attempt to reverse clinically severe obesity in adolescents.

This review highlights the indications for bariatric surgery in adolescents and outlines practice guidelines for adolescent surgical weight loss programs. The authors summarize available data on the effects of adolescent weight loss surgery on metabolic comorbidities and highlight the important acute and long-term complications that must be monitored by their general pediatricians. After reading this article, the general pediatrician should be able to identify adolescents who may be candidates for weight loss surgery and have the knowledge to assist in their postoperative medical management. [Pediatr Ann. 2014;43(9):e230–e236.]

Despite recent data from the Centers for Disease Control and Prevention indicating a plateau in the overall prevalence of obesity among children and adolescents over the past decade, 17% of youth in the United States have a body mass index (BMI) higher than the 95th percentile for age and sex.1 In addition, severe obesity, defined as a BMI higher than 120% of the 95th percentile for age, affects 4% to 6% of American youth, and the prevalence of this subgroup has increased steadily over the past 3 decades.2,3 Severely obese children are at increased risk for comorbidities, including hypertension, dyslipidemia, nonalcoholic fatty liver disease (NAFLD), insulin resistance, sleep apnea, and bone and joint problems.2 In addition, obesity beginning in childhood commonly persists through adulthood,4 carrying the added risks of type 2 diabetes mellitus (T2D), cardiovascular disease, stroke, and various cancers.5 Complications are even more likely in severely obese adolescents, and nonsurgical treatment programs, including intensive lifestyle modification6,7 and medications,8 do not provide significant long-term reductions in BMI. On the other hand, bariatric (weight loss) surgery has been shown to dramatically reduce BMI and to reverse or prevent many complications of obesity in adults;9,10 importantly, a survival benefit has also been demonstrated in adults.11 Thus, increasingly bariatric surgery has been used in an attempt to reverse clinically severe obesity in adolescents.

Who Should Be Considered for Bariatric Surgery During Adolescence?

Adolescents with severe obesity and comorbidities should be considered candidates for bariatric surgery. As shown in Table 1, potential candidates include (a) adolescents with a BMI of 35 kg/m2 or higher with one or more serious comorbidities and (b) adolescents with a BMI of 40 kg/m2 or higher if they have any comorbidities and/or impaired quality of life.12 However, additional factors must be considered when making decisions about bariatric surgery. Extreme weight loss in a growing child can impair linear growth and pubertal development; however, little is known about how linear growth may be affected by surgical weight loss in a severely obese child. Nonetheless, conservative recommendations suggest that patients have a chronologic or bone age of at least 13 years for girls or 15 years for boys or have reached Tanner IV sexual maturity.12–14 Adolescents must also reside in a stable psychosocial environment conducive to carrying out the necessary lifestyle changes (adherence to dietary, micronutrient supplement, and physical activity guidelines) following bariatric surgery. Finally, although the parents or legal guardians provide informed consent for the bariatric procedure, the adolescents must provide informed assent that they understand the benefits and risks of both medical and surgical options, the possibility for acute and long-term complications, and the dietary and behavior changes required.15

Indications for Adolescent Bariatric Surgery

Table 1.

Indications for Adolescent Bariatric Surgery

Some obese adolescents are not good candidates for bariatric surgery, including patients with medically correctable causes of obesity, current substance abuse, current or planned pregnancy or breastfeeding, unstable or untreated psychiatric disorders, inability to adhere to postoperative treatment plans, or inability to provide informed assent. Depression is present preoperatively in approximately half of adolescents seeking weight management;16 however, it is not known or suspected to be associated with adverse outcomes after bariatric surgery. Therefore, depression is not a contraindication to bariatric surgery.

When Should Bariatric Surgery Be Considered in Adolescents?

Current evidence strongly suggests that behavioral treatment of severe pediatric obesity is more successful when the intervention is initiated in preadolescent years. In a Swedish study, 58% of severely obese 6- to 9-year-olds obtained a clinically significant response to behavioral treatment compared with only 2% of severely obese adolescents.7 Likewise, a smaller US study of 12 severely obese adolescents enrolled in a comprehensive pediatric weight management program showed that mean BMI decreased from 47 to 45.8 kg/m2 over 1 year.17 These data suggest that severely obese adolescents demonstrate poor responses to nonsurgical weight management, whereas younger children are more likely to respond to behavioral modification and lifestyle interventions.

In contrast to nonsurgical interventions, bariatric surgery during adolescence results in a 33% to 37% reduction of BMI over the first year, irrespective of initial BMI.18–20 This indicates that the nadir BMI following surgery correlates strongly with baseline BMI. For example, patients with a BMI of 55 kg/m2 typically achieve a postoperative nadir BMI of approximately 35 kg/m2, whereas patients with a baseline BMI of 45 kg/m2 are expected to achieve a postoperative nadir closer to 30 kg/m2. Thus, when surgery is performed earlier in the course of massive weight gain, the likelihood of attaining a nonobese weight postoperatively is much greater. The American Academy of Pediatrics recommends that surgery be considered in severely obese adolescents with medical comorbidities and/or psychosocial problems when they fail to achieve a healthy BMI with lifestyle intervention.12,13,21 Delaying surgical referral in an obese adolescent may be detrimental to long-term health because late referral may result in a missed opportunity to reverse obesity.20

What Type of Bariatric Surgical Procedure Should Be Performed?

Expert consensus supports the use of a multidisciplinary team approach for surgical weight loss in adolescents.12,14,22 Selection of the bariatric procedure is tailored to the skills and experience of the surgeon. Laparoscopic roux-en-y gastric bypass (RYGB), adjustable gastric banding (AGB), and sleeve gastrectomy (SG) have been performed in adolescents with comparable short-term benefits (58% to 73% loss of excess body weight). Risk profiles have not yet been characterized long term but are considered better than biliopancreatic diversion and duodenal switch.23

Roux-en-Y Gastric Bypass

RYGB procedures are considered to involve restrictive and diversionary components. In the first step, a 15- to 30-mL gastric pouch is created just distal to the gastroesophageal junction. Next, the roux limb of the jejunum is anastomosed to the pouch, bypassing the remaining stomach, duodenum, and small portion of the jejunum. Finally, the biliopancreatic limb is connected to the distal jejunum. There is a risk of malabsorption of micronutrients (but not macronutrients) owing to the bypass of the duodenum.24

RYGB is effective for promoting weight loss, with an average BMI reduction of 33% to 37% in the first year postoperatively.25 A recently published prospective study showed that adolescents maintained 34% weight loss over 2 years.19 A retrospective study of 20 adolescents followed for 5 years and 14 adolescents followed for 10 years demonstrated 37% and 35% reductions in weight, respectively.25 This magnitude of weight loss following RYGB in adolescents is modestly greater than the 25% weight loss beyond 5 years expected in the adult bariatric population.11

Adjustable Gastric Banding

AGB is a purely restrictive procedure. A synthetic band with an adjustable inner balloon is placed around the stomach just below the esophagogastric junction, creating a small pouch to limit the passage of food into the gastrointestinal tract. Through the use of a subcutaneous port, the band can be inflated or deflated if necessary, with little change to the anatomy of the gastrointestinal tract. Outcomes in pediatric patients are encouraging, with a 28% BMI reduction and improvement in comorbid conditions over 2 years.26 The potential reversibility of AGB makes it an attractive option for many adolescents; however, the US Food and Drug Administration has not approved AGB for patients younger than 18 years.

Sleeve Gastrectomy

SG involves the irreversible resection of 85% of the stomach, leaving behind a narrow gastric remnant based on the lesser curvature. Because there is no alteration in the small intestine or mesentery, the SG carries less risk of malabsorption of micronutrients and lower risk of postoperative bowel obstruction than RYGB.

Weight loss following SG is similar to RYGB. Adolescents undergoing SG showed 35% (n=41) decrease in BMI by 12 months and 36% (n=8) decrease in BMI by 24 months postoperatively, along with high rates of resolution or improvement of comorbid conditions.27 Other studies of SG outcomes confirm high rates of excess weight loss27; however, all studies are limited by small sample sizes at mid-term (1- to 2-year) follow-up. Outcome data in adolescents will emerge from 67 SG patients enrolled in the ongoing Teen-Longitudinal Assessment of Bariatric Surgery study.28

How Safe Are These Procedures?

Acute risks associated with bariatric surgery include stricture of the gastrojejunal anastomosis, leakage from the anastomotic site, dehydration, and small bowel obstruction. Specific potential complications related to the AGB include port misplacement or slippage, leakage from the tubing, foreign body infection, enlargement of the gastric pouch above the band, and band erosion into the stomach. One study found that 33% of patients required surgical revision for complications associated with AGB during the 2-year study period.26 In a small study of 8 adolescent AGB patients, 50% required subsequent RYGB because of insufficient initial weight loss or significant weight regain.29 Likewise, a 12-year study of AGB in adults revealed that nearly 1 in 3 patients had major gastric complications and nearly 50% required explantation of the band,30 raising concern about use of the device in morbidly obese adolescents who require a weight management solution for many decades.

Perioperative risks of RYGB include leakage of intestinal contents, bleeding, bowel obstruction, and various other risks of major gastrointestinal surgery.31 The multicenter Teen-Longitudinal Assessment of Bariatric Surgery study provides the largest and most comprehensive report of perioperative complications in the adolescent population.28 This study enrolled 242 adolescents from 5 centers across the United States and classified adverse events as major (life-threatening) or minor (nonlife-threatening but unplanned). During the first 30 days postoperatively, 8% of patients experienced major complications, including intestinal obstruction, bleeding, and gastrointestional leak. Minor complications (eg, urinary tract infections, solid organ injury, atelectasis/pneumonia, postoperative bleeding without the need for transfusion) occurred in approximately 15% of patients. The study was not designed to test differences in safety outcomes by surgical type; however, major complication rates were as follows: RYGB, 17%; vertical sleeve gastrectomy (VSG), 5%; and AGB, 7%. One concerning long-term complication after RYGB is an internal hernia with bowel obstruction or infarction. Severe abdominal pain with signs of bowel obstruction necessitates prompt cross-sectional imaging and surgical evaluation.

How Does Bariatric Surgery Affect Comorbidities of Obesity?

Weight loss surgery has been shown to improve and even resolve many obesity-related comorbidities;9 however, no studies in adolescents directly compare the three surgical procedures for these outcomes.

Glucose Homeostasis

Numerous studies in adults show that RYGB can improve glucose homeostasis even prior to weight loss, with superior rates of remission of T2D compared with conventional lifestyle and medical management. A recent meta-analysis of 16 adult studies (randomized, controlled trials and observational studies; 6131 patients; mean follow-up, 17 months) found that T2D remission rates for surgery and conventional therapy were 64% and 16%, respectively.32 Research in adolescents with T2D is more limited; however, fasting glucose, insulin, and insulin sensitivity normalize in most insulin-resistant adolescents after RYGB despite persistence of obesity.20,33 In one study, T2D remitted in 10 of 11 patients;34 the sole exception was insulin dependent preoperatively but required significantly lower insulin doses postoperatively. Diabetes remission was also seen in 15 of 16 pediatric patients who underwent SG.35 An additional randomized trial found that AGB caused significant improvement in insulin resistance in severely obese adolescents.26

Cardiovascular Outcomes

Cardiovascular outcome data following adolescent RYGB demonstrate significant improvements in both systolic and diastolic blood pressure in those with T2D; rates of hypertension declined from 46% to 20%.34 Likewise, in patients without diabetes, there were significant decreases in systolic and diastolic blood pressures (mean, −8 mm Hg and −7 mm Hg, respectively) 1 year after RYGB.19 There were also reductions in total cholesterol, triglycerides, and low-density lipoprotein cholesterol and an increase in high-density lipoprotein cholesterol.19,20,33 A unique finding in the adolescent RYGB population is the reduction of left ventricular mass and geometric changes suggesting favorable remodeling of the myocardium and improved diastolic function.36

Hypertension improved in 75% of adolescent AGB patients, and 87.5% had improvement in hyperlipidemia.37 O’Brien et al.26 also found significant improvements in systolic and diastolic blood pressures after AGB in adolescents, but there were no between-group differences when compared with controls undergoing lifestyle intervention.

Sleep Apnea

Approximately half of adolescents presenting for bariatric surgery have sleep apnea.28 Reports of obstructive sleep apnea syndrome outcome after RYGB have generally showed dramatic improvements (77% to 100% resolution).38 Other studies estimated a 60% to 70% rate of resolution after AGB and SG.39

Psychosocial Outcomes

RYGB during adolescence has been shown to improve health-related quality of life measures, including self-concept and depressive symptoms, by 1 year postoperatively, with scores being similar to nonobese peers by 2 years postoperatively.16,40 Prior to RYGB, severely obese adolescents had marked impairments on both generic and weight-related quality of life.16 By 12 months after RYGB, quality of life improved significantly, with the largest gains shown in physical comfort and body self-esteem subscales. The vast majority of improvement was seen in the first 6 months, with little additional change thereafter. Improvement in social life was more consistent over the entire year and showed no deceleration at 6 months. Beyond the first year postoperatively, single-center data showed a distinct deceleration in gains in quality of life measures by 24 months.40 Similar trajectories of significant improvement in depressive symptoms have been noted by 6 months after RYGB in adolescents,16 with little change thereafter.40 There are few reported data on psychosocial outcomes following SG or AGB in adolescents, although O’Brien et al.26 found improvements in physical functioning, general health, self-esteem, family activities, and change in health at 2 years after AGB.

To date, meaningful bariatric outcome data are not available for other important comorbidities, including NAFLD, polycystic ovary syndrome, pseudotumor cerebri, and obesity-related renal dysfunction. The Teen-Longitudinal Assessment of Bariatric Surgery study collects detailed self-reported and objectively measured data that in coming years will describe changes in many of these important domains.41

What Are the Long-Term Outcomes and Complications the General Pediatrician Needs to Know?

As bariatric surgery in adolescence becomes more commonplace, the pediatrician will assume an increasingly vital role. Pediatricians need to be aware that bariatric surgery patients are at risk for nutritional deficiencies, impaired bone health, and acute abdominal complications such as cholecystitis or internal hernias. In addition, due to the restoration of normal menstrual cycles, adolescent girls are at increased risk for pregnancy.42

Nutritional Concerns

Micronutritional (vitamin and mineral) deficits due to restricted intake and malabsorption can occur in patients who undergo bariatric surgery. A consortium with representatives from the American Association of Clinical Endocrinologists, the Obesity Society, and the American Society for Metabolic and Bariatric Surgery have published expert consensus guidelines for monitoring nutritional outcomes in bariatric surgery patients.24 From a physiologic standpoint, one would expect patients undergoing non-bypass procedures (SG and AGB) to be at lower risk for nutrient deficiencies than those undergoing bypass procedures; however, because dietary consumption decreases after all procedures, adherence to the recommended nutritional supplementation guidelines is vital for all patients.

Iron deficiency is the most common and earliest micronutrient deficiency to present in bariatric surgery patients, especially in menstruating females who may have low ferritin stores preoperatively. Reduced dietary intake of iron-rich foods may result in diminished iron availability. Duodenal diversion and reduced production of gastric acid reduces further the absorption of iron after RYGB. Treatment for iron deficiency may require addition of vitamin C for acidification to improve iron absorption.

Thiamin (vitamin B1) deficiency can cause symptoms of dry beriberi in adolescent (and adult) patients who do not receive appropriate supplementation.43 Patients typically report painful paresthesias, weakness, and difficulty walking within the first 6 months postoperatively. Routine postoperative supplementation with a multivitamin with minerals is recommended.

RYGB results in a 25% reduction of cholecalciferol absorption. 25-hydroxy vitamin D stores are often low in obese patients at baseline, and a reduction in vitamin D absorption puts patients at risk for poor bone mineralization. This is especially important in adolescence, when 50% of peak bone mass accrual occurs. Routine vitamin D and calcium supplementation is recommended to prevent secondary hyperparathyroidism. The combination of vitamin D deficiency and secondary hyperparathyroidism can cause hypophosphatemia. Phosphate supplementation is recommended when serum phosphorus levels are less than 2.5 mg/dL.

RYGB and SG affect the distal portion of the stomach, impairing the ability of parietal cells to secrete intrinsic factor. This reduces vitamin B12 absorption. Vitamin B12 stores in the liver are often sufficient to last several years; however, postoperative B12 deficiency and changes in the enterohepatic circulation may cause macrocytic anemia or neuropsychiatric symptoms. Annual screening is recommended for patients at risk for developing vitamin B12 deficiency; annual supplementation with intramuscular vitamin B12 should suffice for prevention of complications.24

Folic acid supplementation (400 mcg daily) is required postoperatively; this is especially important for women of reproductive age to prevent neural tube defects. RYGB can also result in zinc, copper, and selenium deficiencies. Copper and zinc supplementation should be included as part of routine multivitamin with mineral preparation. Screening for zinc, copper, and/or selenium deficiency should be considered in the appropriate clinical context (eg, anemia not associated with iron deficiency or anemia unresponsive to iron supplementation).

The need for nutritional supplementation is considered to be lifelong for patients undergoing bariatric surgery; however, in a small study of 41 adolescent patients undergoing RYGB or SG, average adherence documented by electronic monitoring was only 27% at 6-month follow-up as compared with the self-report of 78%.44 It will be important to determine whether SG carries less risk of micronutrient deficiency because duodenal absorption is not impaired.

Fertility Concerns

Many women report resumption of regular menses after bariatric surgery, and fertility rates often improve. One observational study found a pregnancy rate of 12.8% in adolescent girls within 2 years of gastric bypass.42 Although pregnancy after bariatric surgery appears safe and data to recommend the ideal time to conceive after bariatric surgery are limited, most experts recommend delaying pregnancy for 1 to 2 years to avoid the risks to fetal growth during a time when the mother is in an energy-negative state.

Bone Health

Weight loss of 10% total body weight by lifestyle modifications has been associated with a 1% to 2% decrease in bone mass. Studies on bone health following bariatric surgery are limited; however, bone mineral density (BMD) in adults declines most rapidly in the first year, with slower but continued declines even after the nadir of weight loss has been reached.45 These studies show the most significant declines in BMD at the hip and lumbar spine over 12 to 36 months. Only one published study investigated bone health outcomes in the adolescent bariatric surgery population after bariatric surgery. Supranormal BMDs were noted prior to RYGB, with significant declines in BMD z-scores in the first 2 years postoperatively.46 BMD z-scores remained in the normal range for age and sex, but it is unclear whether the BMD was appropriate for body size or whether there were site-specific differences due to changes in load bearing.46 It is unclear whether there is an increase, further decline, or stabilization of BMD more than 2 years after RYGB. The effects of ABG or SG on adolescent bone health have not been studied.

Conclusion

Bariatric surgery as a weight loss option for severely obese adolescents presents a unique opportunity to affect health outcomes and quality of life. Available data suggest that adolescents are often referred for surgery late in the course of weight gain, at BMI values that may not return to normal despite dramatic weight loss following surgical procedures. If long-term safety and efficacy data mirror favorable short-term outcomes, it is likely that earlier surgical intervention will be considered for adolescents. By understanding the mechanism(s) of action of effective procedures, we may develop less invasive and safer interventions in the future.

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Indications for Adolescent Bariatric Surgery

BMI35 kg/m2 BMI40 kg/m2
PLUS at least one serious comorbidity: PLUS other comorbidities:
1. Type 2 diabetes mellitus 1. Insulin resistance or glucose intolerance
2. Moderate to severe obstructive sleep apnea 2. Mild obstructive sleep apnea
3. Pseudotumor cerebri 3. Hypertension
4. Severe steatohepatitis 4. Hyperlipidemia
5. Impaired weight-related quality of life
Recommended for all adolescent surgical candidates:
1. Sexual maturity rating Tanner IV or V or bone age ≥ 13 years in girls and ≥ 15 years in boys
2. Ability to understand and comply with lifestyle changes required postoperatively (dietary, physical activity, supplementation, medical follow-up)
3. Ability to provide informed assent
Authors

Halley Wasserman, MD, is a Clinical Fellow, Division of Endocrinology, Cincinnati Children’s Hospital and Medical Center. Thomas H. Inge, MD, PhD, is Professor of Surgery and Pediatrics, Division of Pediatric Surgery, Cincinnati Children’s Hospital and Medical Center.

Address correspondence to: Thomas H. Inge, MD, PhD, Division of Pediatric Surgery, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, MLC 2023, Cincinnati, OH 45229-3039; email: thomas.inge@cchmc.org.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00904481-20140825-10

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