Abdominal Imaging

ª Springer Science+Business Media, LLC 2012 Published online: 3 March 2012

Abdom Imaging (2012) 37:725–729 DOI: 10.1007/s00261-012-9865-7

Adolescent bariatric surgery Seema Kumar,1 Abdalla E. Zarroug,2 James M. Swain3 1

Department of Pediatrics, Division of Pediatric Endocrinology and Metabolism, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA 2 Department of Surgery, Division of Pediatric Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA 3 Scottsdale Healthcare Bariatric Center, Scottsdale Healthcare, 10210 N. 92nd St, Suite 101, Scottsdale, AZ 85258, USA

Abstract Overall it is clear that bariatric surgical intervention in appropriately selected adolescents is effective at both adequate weight loss and resolution of weight related co-morbidities in the short and medium term. Long-term results are being conducted currently to assess durability of bariatric surgical interventions. We believe that adolescents undergoing bariatric evaluation have unique needs and until more long-term data are available, the indications for surgery should be stricter than those used in adults. All of the bariatric procedures discussed must be performed in the background of positive behavioral modifications over a period of time. If lifestyle modification fails, these adolescents can gain weight by overcoming the physiologic effects of the surgery as they eat high calorie foods at very frequent intervals. Finally, close postoperative follow-up is required with active management of weight loss/gain, co-morbidities, and postoperative complications should they occur. Key words: Bariatric surgery—Adolescents—Obesity

Epidemiology Obesity is a serious health concern for children and adolescents. According to the National Health and Nutrition Examination Surveys, the prevalence of obesity in preschool children (aged 2–5 years) and children (aged 6–11 years) from 1999 to 2002 was double that between 1976 and 1980; for adolescents (aged 12–19 years), triple [1]. Children 2–18 years of age with BMI of >30 kg/m2 or ‡the 95th percentile for age and gender (whichever is smaller) are considered obese [2]. Severe childhood obesity was recently defined as BMI ‡99th percentile for age and gender [3]. Recent prevalence data

Correspondence to: Seema Kumar; email: [email protected]

indicate that an estimated 17% of children and adolescents aged 2–19 years are obese [1] and 4% have a BMI ‡99th percentile [4]. Furthermore, the prevalence of overweight children is even higher among certain ethnic groups such as African Americans, Mexican Americans, and Native Americans [1]. An alarmingly high number of US adolescents, estimated 418,000 adolescents aged 12–19 years, have a BMI ‡40 kg/m2 [4].

Consequences of childhood obesity Childhood obesity is associated with several co-morbidities including type 2 diabetes mellitus [5–7], hypertension, dyslipidemia, sleep apnea, and non-alcoholic liver disease [8]. Fifty percent of obese adolescents have been found to meet criteria for metabolic syndrome [9]. Additional risks of obesity among adolescents include musculoskeletal problems, asthma, gastroesophageal reflux disease (GERD), pseudotumor cerebri, gallstones, and menstrual abnormalities [5]. Obese patients also experience reduced quality of life [10] and social marginalization [11]. 50%–77% of obese adolescents will become obese adults and this risk increases to 80% if there is just one obese parent [12–14]. Weight loss in obese individuals has been shown to lead to reversal or improvement of obesity related co-morbidities and improvement in quality of life. The mainstay of treatment for obesity in adolescents has been non-surgical interventions aimed at creating a negative energy balance by dietary modifications, increasing physical activity and decreasing sedentary behavior. Behavioral modifications have been shown to be modestly effective in achieving weight loss [15, 16] but results are influenced by high drop out rates [17] and overall the effects have been rather modest with small changes in weight and BMI compared with controls [18]. Studies using pharmacotherapeutic agents such as orlistat and sibutramine have demonstrated very modest effects on weight loss in adolescents [19, 20]. Average BMI decrease in the largest multicenter clinical trials with orlistat was

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found to be 0.55 BMI units [19] and sibutramine was -2.9 BMI units.

Medical criteria for bariatric surgery Bariatric surgery is a safe and effective modality of treatment for severe obesity in adults [21, 22]. Currently, adults with BMI ‡35 with co-morbidities and those with BMI >40 even without co-morbidities are considered candidates for bariatric surgery [23]. However, there is limited information on the long-term efficacy and safety of bariatric surgery in children and adolescents. There is currently no uniformly accepted consensus on the BMI criteria that would make adolescents candidates for bariatric surgery. Some experts recommend stringent BMI criteria for the pediatric population: BMI ‡50, or ‡40 kg/m2 in the presence of one or more medical co-morbidities [24–27]. Others have suggested that the adult BMI criteria should apply equally to this population [28, 29]. Additional suggested criteria prior to adolescent bariatric surgery include (i) the failure of ‡6 months of organized attempts at weight management, as determined by the primary care provider and (ii) attainment of physical maturity as reflected by Tanner stage IV pubertal development or a bone age of ‡13 years in girls or ‡15 years in boys [24–27]. In addition, the adolescents should have decisional capacity and also demonstrate commitment to comprehensive medical and psychological evaluations both before and after surgery. A supportive family environment is extremely crucial and necessitates a complete evaluation of the home environment by trained personnel [24–27]. Although it has been documented in case reports, bariatric surgery should not be performed for preadolescent children, for any patient who has not mastered the principles of healthy dietary and activity habits, and for those with unresolved eating disorder, untreated psychiatric disorder, or Prader–Willi syndrome. Pregnant, breast-feeding adolescents and those planning to become pregnant within 2 years of surgery should certainly not be considered candidates for bariatric surgery. The family should be evaluated to determine if adequate emotional, social, and financial support would be available for the adolescent before and after surgery. Each adolescent and family should be extensively evaluated by a multidisciplinary team with experience in pediatric weight management. The team should consist, at a minimum, of an experienced bariatric surgeon, pediatrician with expertise in obesity, behavioral clinician (i.e., pediatric psychiatrist or psychologist), and a registered dietitian. Again, we emphasize that health care providers with expertise in dealing with adolescents should provide all of these services. Consent in the case of a minor requires full consent of the legal guardian as well as the patient; the adolescent component of consent should be documented. Specifically, adolescent patients should participate in the

S. Kumar et al.: Adolescent bariatric surgery

consent process and have a complete understanding of surgical and non-surgical alternative treatments for obesity, possible short- and long-term complications, and behavior changes required to achieve a successful outcome.

Types of bariatric procedures Although traditionally there have been two types of procedures that are offered to adolescents that meet criteria for surgical weight loss (i) open and laparoscopic Roux-en-Y gastric bypass (RYGB) and (ii) laparoscopic adjustable gastric banding (AGB), recently a third surgical weight loss procedure has been increasingly performed in both adults and adolescents called laparoscopic sleeve gastrectomy (SG). Each procedure has its own advantages and disadvantages and a basic understanding of the procedures is useful in determining how adolescent bariatric procedures are chosen for well-selected patients.

Roux-en-Y gastric bypass RYGB is the most common type of procedure performed in adolescents and it involves stapling and excluding almost all of the stomach (Fig. 1). This creates a small (15–30 mL) gastric pouch that is attached directly to the jejunum, bypassing almost all of the stomach, duodenum, and first portion of the jejunum. RYGB is both a restrictive procedure, since the proximal stomach pouch is small, and also a minimal malabsorptive procedure by bypassing the duodenum and a portion of the jejunum. Although older studies included open RYGB, we believe the laparoscopic approach has become the current standard of care for all types of first-time adolescent bariatric procedures. There are numerous studies with short-term and medium follow-up in adolescents that have demonstrated that RYGB offers significant reduction in weight and co-morbidities at a fairly quick pace [30]. Although, we do not have decades of long-term follow-up and effects of any bariatric procedure in adolescents, RYGB is the most well-studied procedure in adolescents with the best outcomes regarding weight loss and resolution of co-morbidities. Adolescents should expect to loose approximately 50%–85% of their excess body weight with nearly complete resolution of comorbidities [31]. Specifically, type 2 diabetes mellitus appears to have even better outcomes than adults after RYGB. Inge et al. [32] demonstrated complete remission of diabetes mellitus in almost all adolescents after RYGB; levels of fasting glucose, insulin, and HbA1c and associated insulin sensitivity were all improved. In adults, RYGB has been shown to reverse non-alcoholic fatty liver disease, moderate to severe obstructive sleep apnea, pseudotumor cerebri, cardiovascular dysfunction, and hypertension and short-term data in adolescents appear

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Fig. 2.

Fig. 1.

Roux-en-Y gastric bypass.

to have similar outcomes [33]. This reliable and sustained weight loss with proven resolution of co-morbidities really is the greatest benefit of RYGB. However, RYGB also has the greatest and most significant potential for complications in adolescents, including mortality of approximately 0.5% [34]. Risks specific to RYBG include anastomotic leak, small bowel obstruction, dumping syndrome (symptoms that may include nausea, bloating, vomiting, cramps, diarrhea and/or other symptoms), protein-calorie malnutrition, and micronutrient deficiency related to malabsorption [35]. Many of these risks are minimized by close follow-up and providing a vitamin supplement regimen (iron, folate, calcium, vitamin B12, and thiamine) to help prevent nutritional deficiencies.

Adjustable gastric banding AGB performed laparoscopically also provides significant weight reduction and resolution of co-morbidities, though typically at a much slower rate [21]. Unlike RYGB, AGB is purely a restrictive procedure (Fig. 2). AGB involves placing a silicone band with an inflatable

Adjustable gastric banding.

and adjustable inner tube around the upper stomach. This creates a small pouch, restricts the passage of food, and delays the emptying of food into the distal stomach creating the feeling of satiety. The band can be inflated or deflated over time. The touted benefits include the reversibility of the band, meaning the band can be removed and the anatomy is unaltered. Currently, the Food and Drug Administration does not approve the use of AGB in adolescents. Complications related to the actual band include port problems/infection, band slippage, intolerance, erosion of the band into the stomach with subsequent infection, spontaneous deflation of the band, and enlargement of the stomach pouch [36]. Follow-up is crucial with any patient with a band as appropriate adjustments to the band are needed to ensure the band is not too tight causing obstruction or too loose allowing for increased intake. Therefore, families who cannot reliably and consistently bring adolescents to clinic regularly are poor candidates for AGB. Laparoscopic AGB is one of the few procedures where level one data supporting its use exists. In Australia, O’Brien et al. [37] performed a randomized controlled trial in 50 obese adolescents (BMI >35; age 14–18 years) comparing laparoscopic AGB versus a supervised lifestyle intervention with a 2 year follow-up. The AGB group lost 79% of their excess weight and showed a significant improvement of metabolic syndrome, which was reduced from 36% to 0%. There was also an improved quality of life. However, 33% required revision procedures either for proximal pouch dilatation or tubing injury during follow-up. Long-term results will be important regarding AGB as removal/reversal of a gastric banding may have a high rate of weight recidivism as noticed in adults. It is unknown how long an adolescent may tolerate a gastric band and the required follow-up.

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Sleeve gastrectomy Less is known about laparoscopic SG, yet SG is emerging as a potential alternative bariatric procedure in wellselected adolescents. During SG, about 85% of the stomach is removed so that it takes the shape of a tube or sleeve (Fig. 3). This resected portion of the stomach is permanently removed and therefore SG is essentially a restrictive, non-reversible procedure. Gastric sleeve dilatations, GERD, and staple line leaks are the most common complications [38]. There is limited data on short-term outcomes in adolescents and long-term data is lacking [39]. Possible long-term nutritional risks, sustained weight loss effectiveness, and durability of resolution of co-morbidities in growing children have not been adequately evaluated. However, results in the adult literature show weight reduction and resolution of comorbidities similar to or slightly less than that of RYGB with less significant malabsorption. Other advantages are that SG involves no foreign body, needs no invasive adjustments, and most likely avoids malabsorption of

many micronutrients. A further potential benefit of SG is that in some very selected cases, for example, if the patient has inadequate weight loss and co-morbidities remain, SG may be followed by a RYGB for further weight loss; however, this has not been preformed in adolescents yet, perhaps because SG is a relatively new procedure to be used in adolescents.

Other bariatric procedures Although SG has been used as part of a staged operation in the duodenal switch procedure, we believe duodenal switch is quite an aggressive (malabsorptive) surgical approach to be used in adolescents. Having stated this, a recent paper published medium-term results of adolescents after duodenal switch, however, we disagree with their conclusion that duodenal switch is the procedure of choice for bariatric procedures in adolescents [40]. We also do not recommend biliopancreatic diversion as a first-line surgical intervention in adolescents until its nutritional effects are better studied. On the other spectrum is the intra-gastric balloon. Although the intragastric balloon can achieve some weight loss, it is only a short-term solution (it has to be removed) and those meeting criteria for bariatric surgical intervention should have RYGB, AGB, or SG as their primary intervention.

Conclusions and future directions Overall it is clear that bariatric surgical intervention in appropriately selected adolescents is effective at both adequate weight loss and resolution of weight-related comorbidities in the short and medium term. Long-term results are being conducted currently to assess durability of bariatric surgical interventions. We believe that adolescents undergoing bariatric evaluation have unique needs and until more long-term data is available, the indications for surgery should be stricter than those used in adults. All of the bariatric procedures discussed must be performed in the background of positive behavioral modifications over a period of time. If lifestyle modification fails, these adolescents can gain weight by overcoming the physiologic effects of the surgery as they eat high calorie foods at very frequent intervals. Finally, close postoperative follow-up is required with active management of weight loss/gain, co-morbidities and postoperative complications should they occur. Disclosures No financial or research disclosures.

References

Fig. 3.

Sleeve gastrectomy.

1. Ogden CL, Carroll MD, Curtin LR, Lamb MM, Flegal KM (2010) Prevalence of high body mass index in US children and adolescents, 2007–2008. JAMA 303:242–249 2. Krebs NF, Himes JH, Jacobson D, et al. (2007) Assessment of child and adolescent overweight and obesity. Pediatrics 120(Suppl 4): S193–S228

729

S. Kumar et al.: Adolescent bariatric surgery

3. Barlow SE (2007) Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 120(Suppl 4):S164–S192 4. Skelton JA, Cook SR, Auinger P, Klein JD, Barlow SE (2009) Prevalence and trends of severe obesity among US children and adolescents. Acad Pediatr 9:322–329 5. Must A, Jacques PF, Dallal GE, Bajema CJ, Dietz WH (1992) Long-term morbidity and mortality of overweight adolescents. A follow-up of the Harvard Growth Study of 1922 to 1935. N Engl J Med 327:1350–1355 6. Fontaine KR, Redden DT, Wang C, Westfall AO, Allison DB (2003) Years of life lost due to obesity. JAMA 289:187–193 7. Pinhas-Hamiel O, Dolan LM, Daniels SR, et al. (1996) Increased incidence of non-insulin-dependent diabetes mellitus among adolescents. J Pediatr 128:608–615 8. Dietz WH (1998) Health consequences of obesity in youth: childhood predictors of adult disease. Pediatrics 101:518–525 9. Weiss R, Dziura J, Burgert TS, et al. (2004) Obesity and the metabolic syndrome in children and adolescents. N Engl J Med 350:2362–2374 10. Schwimmer JB, Burwinkle TM, Varni JW (2003) Health-related quality of life of severely obese children and adolescents. JAMA 289:1813–1819 11. Strauss RS, Pollack HA (2003) Social marginalization of overweight children. Arch Pediatr Adolesc Med 157:746–752 12. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH (1997) Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med 337:869–873 13. Guo SS, Huang C, Maynard LM, et al. (2000) Body mass index during childhood, adolescence and young adulthood in relation to adult overweight and adiposity: the Fels longitudinal study. Int J Obes Relat Metab Disord 24:1628–1635 14. Serdula MK, Ivery D, Coates RJ, et al. (1993) Do obese children become obese adults? A review of the literature. Prev Med 22: 167–177 15. Epstein LH, Valoski A, Wing RR, McCurley J (1994) Ten-year outcomes of behavioral family-based treatment for childhood obesity. Health Psychol 13:373–383 16. Nemet D, Barkan S, Epstein Y, et al. (2005) Short- and long-term beneficial effects of a combined dietary-behavioral-physical activity intervention for the treatment of childhood obesity. Pediatrics 115:e443–e449 17. Savoye M, Shaw M, Dziura J, et al. (2007) Effects of a weight management program on body composition and metabolic parameters in overweight children: a randomized controlled trial. JAMA 297:2697–2704 18. Kamath CC, Vickers KS, Ehrlich A, et al. (2008) Clinical review: behavioral interventions to prevent childhood obesity: a systematic review and metaanalyses of randomized trials. J Clin Endocrinol Metab 93:4606–4615 19. Chanoine JP, Hampl S, Jensen C, Boldrin M, Hauptman J (2005) Effect of orlistat on weight and body composition in obese adolescents: a randomized controlled trial. JAMA 293:2873–2883 20. Berkowitz RI, Fujioka K, Daniels SR, et al. (2006) Effects of sibutramine treatment in obese adolescents: a randomized trial. Ann Intern Med 145:81–90 21. Christou NV, Sampalis JS, Liberman M, et al. (2004) Surgery decreases long-term mortality, morbidity, and health care use in

22. 23.

24. 25. 26. 27.

28.

29.

30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40.

morbidly obese patients. Ann Surg 240:416–423 (discussion 423–414) Mun EC, Blackburn GL, Matthews JB (2001) Current status of medical and surgical therapy for obesity. Gastroenterology 120:669–681 Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: executive summary (1998) Expert Panel on the Identification, Evaluation, and Treatment of Overweight in Adults. Am J Clin Nutr 68:899-917 Inge TH, Krebs NF, Garcia VF, et al. (2004) Bariatric surgery for severely overweight adolescents: concerns and recommendations. Pediatrics 114:217–223 Daniels SR, Arnett DK, Eckel RH, et al. (2005) Overweight in children and adolescents: pathophysiology, consequences, prevention, and treatment. Circulation 111:1999–2012 Apovian CM, Baker C, Ludwig DS, et al. (2005) Best practice guidelines in pediatric/adolescent weight loss surgery. Obes Res 13:274–282 August GP, Caprio S, Fennoy I, et al. (2008) Prevention and treatment of pediatric obesity: an endocrine society clinical practice guideline based on expert opinion. J Clin Endocrinol Metab 93:4576–4599 Baker S, Barlow S, Cochran W, et al. (2005) Overweight children and adolescents: a clinical report of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 40:533–543 International Pediatric Endosurgery Group Standards and Safety Committee (2008) IPEG guidelines for surgical treatment of extremely obese adolescents. J Laparoendosc Adv Surg Tech A 18:xiv–xvi Fatima J, Houghton SG, Iqbal CW, et al. (2006) Bariatric surgery at the extremes of age. J Gastrointest Surg 10:1392–1396 Stanford A, Glascock JM, Eid GM, et al. (2003) Laparoscopic Roux-en-Y gastric bypass in morbidly obese adolescents. J Pediatr Surg 38:430–433 Inge TH, Miyano G, Bean J, et al. (2009) Reversal of type 2 diabetes mellitus and improvements in cardiovascular risk factors after surgical weight loss in adolescents. Pediatrics 123:214–222 Pratt JS, Lenders CM, Dionne EA, et al. (2009) Best practice updates for pediatric/adolescent weight loss surgery. Obesity (Silver Spring) 17:901–910 Flum DR, Belle SH, King WC, et al. (2009) Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med 361:445–454 Presutti RJ, Gorman RS, Swain JM (2004) Primary care perspective on bariatric surgery. Mayo Clin Proc 79:1158–1166 (quiz 1166) Al-Qahtani AR (2007) Laparoscopic adjustable gastric banding in adolescent: safety and efficacy. J Pediatr Surg 42:894–897 O’Brien PE, Sawyer SM, Laurie C, et al. (2010) Laparoscopic adjustable gastric banding in severely obese adolescents: a randomized trial. JAMA 303:519–526 Tucker ON, Szomstein S, Rosenthal RJ (2008) Indications for sleeve gastrectomy as a primary procedure for weight loss in the morbidly obese. J Gastrointest Surg 12:662–667 Till H, Bluher S, Hirsch W, Kiess W (2008) Efficacy of laparoscopic sleeve gastrectomy (LSG) as a stand-alone technique for children with morbid obesity. Obes Surg 18:1047–1049 Marceau P, Marceau S, Biron S, et al. (2010) Long-term experience with duodenal switch in adolescents. Obes Surg 20:1609–1616