Bariatric surgery in adolescents: What's the rationale? What's rational?

Abstract

Rates of obesity in adolescents continue to rise, and available lifestyle and pharmacological interventions have had limited success in reducing excess weight and risk for comorbid health issues. However, ongoing health risks, psychosocial issues, and increased risk of mortality place these adolescents in jeopardy and warrant ongoing investigation for available treatments. Bariatric surgery for adults has had positive medical and psychological outcomes. However, bariatric surgery is a relatively new option for adolescents. Initial findings suggest positive results for excess weight loss and psychosocial improvements, but not without possible risks. Selection of appropriate candidates is essential in the process, specifically considering developmental maturity, family support, and resultant disease burden without surgery. Surgery is not a panacea for the obesity epidemic. Outcome studies are limited and long-term results are unknown, but for extremely obese adolescents, bariatric surgery is promising and should be considered a viable option for appropriate adolescent candidates.

Introduction

Childhood obesity is increasing at an alarming rate and has elicited the involvement of public health agencies, healthcare clinicians, researchers, and the general public to determine possible causes and solutions. Overweight (defined as body mass index (BMI) between the 85th and 95th percentiles for age and gender) and obesity (BMI ≥ 95th percentile for age and gender) in childhood and adolescence has more than tripled in the last 20 years, with 18.1% of US adolescents aged 12–19 classified as overweight or obese (Ogden et al., 2010). Even more concerning is the prevalence of extreme obesity (BMI ≥ 99th percentile for age and gender) which continues to rise and is now estimated to affect approximately 4% of US adolescents , outnumbering those affected by childhood cancer, cystic fibrosis, HIV, and juvenile diabetes combined (Freedman et al., 2007). Left untreated, 80% of adolescents who are extremely obese are likely to remain extremely obese as adults (Freedman et al., 2007). Intervention and prevention of this urgent public health problem is important due to the associated long-term health consequences of obesity, including hypertension, high cholesterol, Type II diabetes and sleep apnoea, as well as psychosocial problems (Dietz, 1998). Clearly, obesity in childhood and adolescence is a pressing public health concern, and intervention is critical.

The psychosocial impact of obesity on youths is well documented. As early as 9 years old, children inaccurately stigmatize their peers who are obese, labelling them as unpopular, unhealthy and unsuccessful in academics (Hill & Silver, 1995). Relative to average-weight peers, obese adolescents are less likely to be identified by peers as friends and more likely to report higher rates of peer victimization (Strauss & Pollack, 2003). Difficulties with self-esteem and increased likelihood of engaging in high risk behaviours such as smoking and consuming alcohol have also been documented (Strauss, 2000). Not surprisingly, depression is a common comorbidity for adolescents seeking weight loss treatment (Erermis et al., 2004; Isnard et al., 2003; Levine et al., 2001; Zeller et al., 2004, 2006) noted to be three to four times higher than national base rates (Kilpatrick et al., 2003). Likewise, health-related quality of life (HRQoL) is reported to be worse for adolescents who are obese across all domains including physical functioning, emotional well-being, social relations, and school functioning than previous reports of youths with chronic disease, including diabetes, migraine headaches, asthma (Zeller et al., 2006), and even children diagnosed with cancer on chemotherapy treatment (Schwimmer et al., 2003).

Given the impact of obesity on medical and psychosocial risk factors in adolescents, clinicians and researchers remain focused on finding appropriate treatment options. Bariatric surgery for adults has long been accepted as a treatment which results in long-term, sustainable weight loss, and reduction of medical comorbidities associated with obesity (Weiss, 2010). Due to the limited effectiveness of other available treatments, bariatric surgery is increasingly considered as a viable treatment option for extremely obese adolescents, and initial findings indicate that the surgery is associated with many positive life changes, both medically and psychologically (Inge et al., 2007; Zeller et al., 2011). In this paper, justification is provided for the role of bariatric surgery as a treatment choice to address extreme obesity for appropriate adolescent candidates.

Currently available treatment options

Lifestyle interventions

Most common in the treatment of obese youths are lifestyle interventions which incorporate a multidisciplinary approach, including medical treatment, nutrition education, physical activity education, family involvement, and behaviour modification (AAP, 2003; Barlow & Expert Committee, 2007; Jefferson, 2005; Zametkin et al., 2004). Education regarding nutrition and physical therapy, along with individualized goal-setting are paramount (Ward-Begnoche et al., 2008). However, significant barriers to treatment success have been noted (Ward-Begnoche & Gance-Cleveland, 2005; Ward-Begnoche & Speaker, 2006) and suboptimal weight reduction for youths with extreme obesity have been reported (Lawson et al., 2006; Levine, et al., 2001; Weiss, 2010; Zeller et al., 2004). Lifestyle interventions have the most success with mild to moderate obese youths (Oude Luttikhuis et al., 2009; Raynor, 2008). Limited positive results for these interventions with the extremely obese are likely related to the multifactorial etiology of obesity in youths. Genetic or biological factors have an impact (O’Rahilly & Farooqi, 2008). However, several other areas likely impact successful weight loss, including presence of a comorbid psychiatric disorder (Young-Hyman et al., 2003; Zametkin et al., 2004), personal beliefs about ability to impact weight (Uzark et al., 1987), motivation to make changes in exercise (McWhorter et al., 2003; Sallis et al., 2000) and diet (Carruth & Skinner, 2001), parent characteristics and beliefs about weight loss (e.g. Adams et al., 2005; Baughcum et al., 2000; Epstein et al., 2006), and sociocultural factors (Drewnowski & Darmon, 2005; Kumanyika & Greer, 2006; Sallis & Glanz, 2006; Weir et al., 2006).

Pros

Overall, treatments that combine nutrition, physical activity, and behavioural change with parent participation show improvements in the weight status of children and adolescents (Barlow & Dietz, 1998; Oude Luttikhuis et al., 2009; Raynor, 2008) and thereby positively affect morbidity and mortality, hence the recommendation of its use in national guidelines (AAP, 2003). Lifestyle interventions are minimally invasive, do not have negative side effects medications can have, and have few, if any, risky outcomes other than lack of change and its impact on medical status. Furthermore, this option serves to both educate youths and their families regarding nutrition, physical activity, and behavioural change and to shape these behaviours over time which is necessary to maintain weight loss (whether by this intervention, medication, or surgical options).

Cons

No known risks exist for lifestyle interventions, other than ongoing weight gain and risk for serious health outcomes, if unsuccessful. Positive results take significant time to achieve. Unfortunately, for adolescents that demonstrate initial weight loss success, few weight loss maintenance interventions have been developed and studied to assist with ongoing success. For the extremely obese youths who are at significant risk for medical comorbidities and higher rates of mortality, this is of significant concern. In addition, barriers to treatment success are numerous. Weight management is not simply the result of individual choice in health-related behaviours, but a myriad of individual, familial, and sociocultural factors. Consistent with this diverse etiology beyond individual choice and control, suboptimal weight reduction for youths with extreme obesity have been reported for lifestyle interventions (Lawson et al., 2006; Levine, et al., 2001; Weiss, 2010, and Zeller et al., 2004). Interventions are also costly in terms of clinicians’ time, patient's time for repeated visits, and the need for multiple disciplines on the team. Associated high cost, coupled with a significant lack of coverage for some or all of the health care providers involved also limits treatment availability.

Summary

Lifestyle interventions are efficacious for youths with mild to moderate obesity, and remain an important weight management tool. However, for the extremely obese, lifestyle interventions have not be shown to be significantly effective, leaving the need for further research in this area as well as additional treatment options for this population.

Pharmacological treatments

Pharmacological treatment of the obese adolescent is often considered in conjunction with lifestyle change. Moreover, since the removal of sibutramine (Meridia) from the market in 2010 due to its association with heart disease, the only currently available, long-term pharmacotherapy agent for obesity in adolescents is orlistat (Kanekar & Sharma, 2010; Sarwer & Dilks, 2011). Orlistat (Xenical) is a lipase inhibitor and functions to reduce fat malabsorption by blocking about 30% of dietary fat with the typical 120-mg dose three times a day for adolescents (Greydanus et al., 2011; Rogovik et al., 2010). An over-the-counter version of orlistat (Ali) was approved by the FDA in 2003 for use in children over 12 (Barlow & Expert Committee, 2007). Although not presently approved for use with weight loss in adolescents, Metformin is another medication that has shown weight reduction (up to 3 kg) in obese adolescents in clinical trials. However, more research is needed to pinpoint its efficacy for this purpose (Atabek & Pirgon, 2008; Freemark, 2007).

Pros

Weight loss medications may be beneficial in weight loss for obese adolescents. This option is less invasive than surgical options, and therefore carries relatively less risk. Furthermore, medication can be used in conjunction with lifestyle interventions for a cumulative beneficial effect.

Cons

Weight loss with the use of medications is limited (typically < 3 kg more than control subjects) and maintaining the weight loss and long-term effects of pharmacotherapy for obesity in adolescents is largely unknown (Kanekar & Sharma, 2010; Rogovik et al., 2010). Insurance often does not pay for weight loss medication, and cost often prohibits its use. In addition, orlistat is often poorly tolerated due to negative side effects, including flatulence, faecal urgency, faecal incontinence, and abdominal pain (Ozkan et al., 2004). Thus, compliance with the medication is often affected.

Summary

Overall, with only one weight-loss pharmacological intervention available to adolescents and with limited evidence of its long-term efficacy, the utility of pharmaceutical treatments for the extremely obese population remains unclear.

Adolescent bariatric surgery

Bariatric surgery is the most effective weight control option for extremely obese adults (Sarwer & Dilks, 2011); for adolescents, outcome data are limited but positive. Adolescents currently constitute a very small proportion of the total number of bariatric surgeries; estimated to be less than 1% (770 total procedures) based on hospital discharge rates in 2003 (Tsai et al., 2007). Rates were similar based on data collected in 2010 in the American Society for Metabolic and Bariatric Surgery (ASMBS) centre-of-excellence programmes (Michalsky et al., 2011). However, numbers have increased significantly in recent years; 3-fold between 1996 and 2003 (Tsai, et al., 2007). The number of adolescents who choose surgery will likely grow, heightening the need for thorough discussion of the risks/benefits of bariatric surgery (Michalsky et al., 2012; Syskoi et al., 2011). The effectiveness of bariatric surgery in adolescents depends on the type of surgery performed. The two most common surgical procedure choices for adolescents are laparoscopic adjustable banding (LAGB) and the Roux-en-Y gastric bypass (RYGB) (Ibele & Matar, 2011).

Laparoscopic adjustable banding

The LAGB procedure facilitates weight loss by placing a restrictive device around the stomach that limits intake (Ibele & Matar, 2011). Results of LAGB with adolescents have shown significant weight loss, ranging from 10.6–13.7 decrease in BMI (Treadwell et al., 2008), and 41%–79% excess weight loss (EWL) (Bondada et al., 2011). Percentage EWL is calculated by dividing the total weight loss (e.g. lost 100 pounds post-surgery) by the initial excess weight based on estimated ideal body weight (e.g. 200 pounds overweight pre-surgery) and multiplying by 100 (e.g. result would be 50% excess weight loss). Improvements in comorbidites (Treadwell et al., 2008) such as diabetes (80–100% resolution), hypertension (50–100%), and metabolic syndrome (82%) have also been documented.

Pros

The only randomized, controlled clinical trial comparing LAGB to lifestyle modification in adolescents showed significant reduction of overall comorbidities and an excess weight loss of 78.8% in the bariatric group after 2 years compared to 13.2% in the lifestyle group (O’Brien et al., 2010). LAGB is also reversible which is a significant plus for patients who are able to maintain their weight loss via lifestyle changes later on, or for those females who wish to become pregnant and limiting intake is not advisable. The LAGB is also adjustable without additional surgery (via inflation or deflation of the tube through a port in the patient's abdomen). In addition, there is a lower risk of malnutrition than can occur with malabsorptive procedures such as RYGB.

Cons

LAGB requires recurrent visits to the physician for adjusting the saline levels in the tube, which is not optimal for all patients. When too tight, the LAGB can cause reflux and/or vomiting. Further, LAGB is not without complications. According to a meta-analysis involving six studies, 8% of LAGB adolescents required re-operation with band slippage. This was the most common complication (3% of patients). Small rates of iron deficiency and hair loss were also reported (Treadwell et al., 2008). However, in more recent studies higher rates of complication have been noted, including high rates of re-operation for the LAGB patients (Bondada et al., 2011), estimated at 33% at 2 years because of slippage, pouch dilation, or injury to the port site tubing (O’Brien et al., 2010).

Roux-en-Y gastric bypass

Similar to LAGB, RYGB procedures facilitate weight loss by restricting intake. For RYGB this is achieved through the surgical creation of a gastric pouch at the base of the oesophagus which bypasses part of the small intestine. As a result of bypassing the small intestine, the RYGB procedure is also thought to have a secondary method of facilitating weight loss through the combination of gastric restriction and altered gut peptide release (Ibele & Matar, 2011).

Pros

Reported excess weight loss and resolution of comorbidities with RYGB is typically reported higher than with LAGB in adolescents (Inge et al., 2004a; Nadler et al., 2007; O’Brien et al., 2010; Sugerman et al., 2003). Baseline BMIs are generally higher in adolescent RYGB samples (47 to 56.5) compared to adolescent LAGB samples (42.4 to 50.5; Treadwell et al., 2008), but reduction in BMI ranges from 17.8–22.3 for RYGB compared to the 10.6–13.7 for LAGB (Treadwell et al., 2008). Resolutions rates of 50% to 100% for hypertension and 100% for sleep apnoea were noted for adolescents getting RYGB. Numerous studies have found that the majority of adult bariatric patients experience psychological improvements post-operatively (Sarwer & Dilks, 2011). For adults, self-esteem, depressive symptoms, health-related quality of life, and body image reportedly improve dramatically in the first year after surgery, though long-term effects are unknown (Sarwer & Dilks, 2011). Studies in adolescent bariatric patients show improvements post-surgery in depression (Zeller et al., 2011) and quality of life (Zeller et al., 2011; Silberhumer et al., 2006) with quality of life improving to the level of healthy adolescents (Zeller et al., 2009). Effects of bariatric surgery on overall self-esteem and social interactions for adolescents are relatively unknown, although a recent study by Ratcliff et al. (2011) showed a significant decrease in body image dissatisfaction for adolescents post -RYGB.

Cons

The RYGB is more invasive than the LAGB. Regardless of its weight loss success rates, reports of significant post-operative complications cannot be neglected for RYGB. Recent meta-analysis examining RYGB reported one death due to severe Clostridium difficile colitis and resultant multisystem organ failure, as well as reported post-surgical complications in other patients including shock, pulmonary embolism, post-operative bleeding, severe malnutrition, bowel obstruction, protein-calorie malnutrition and micronutrient deficiency (Treadwell et al., 2008). Post-operative complications occur early in 5–10% of patients, while late complications have been reported in at least 25% of patients (Buchwald et al., 2004; Sugerman et al., 2003). Approximately 25% of patients fail to reach the typical post-operative weight loss or begin to regain large amounts of weight within the first few postoperative years (Sjostrom et al., 2004). Among adolescents weight regain within the first decade after surgery was also noted (Sugerman et al., 2003).

Laparoscopic sleeve gastrectomy

Laparoscopic sleeve gastrectomy (LSG) has recently gained popularity as a stand-alone procedure for adults though efficacy of sleeve gastrectomy in the long term is not yet known (Rao & Kini, 2011). Weight loss is thought to be in part related to resection of the gastric fundus, which leads to decreased levels of ghrelin, resulting in appetite suppression and earlier satiety (Frezza, Chiriva-Internati & Wachtel, 2008). LSG is an attractive surgical option for young patients; although not reversible, it is not malabsorptive. There is a dearth of data on LSG in adolescent patients. In fact, in a recent large review of bariatric surgery in paediatric obesity, there are no studies included that address youths (Treadwell et al., 2008). Recent data from adult series demonstrate mid-term results comparable with RYGB with an improved safety profile (Bondada, et al., 2011). Extrapolating from the emerging adult data, it is likely that this procedure will be strongly considered as a viable surgical option for teens who are extremely obese.

Summary and critique of adolescent bariatric surgery

Overall, findings suggest that surgical options have been effective in demonstrating initial weight loss and significant improvement in several comorbidities associated with extreme obesity. Further, it has been argued that bariatric surgery performed during the adolescent period is a more effective treatment for childhood-onset extreme obesity than delaying surgery until adulthood (Inge et al., 2007). However, there is difficulty in discerning long-term consequences, positive or negative, due to limited available research (Inge et al., 2004b).

Many of our best guesses regarding which adolescents will do well in surgery are extrapolated from the literature on adult bariatric surgery. However, we should be careful not to assume that adolescents are young obese adults. Appropriate evaluation requires understanding the adolescent bariatric candidate within the context of typical adolescent development. Maturity level of the adolescent is an important consideration in the ethical decision-making regarding bariatric surgery for this population. Parents and adolescents often differ in their conception of obesity and its impact (Fallon et al., 2005; Levine et al., 2001; Zeller & Modi, 2006). Parents tend to emphasize the negative psychosocial and medical impact of obesity. Hence, there is a risk for overt or covert coercion behind the adolescent's assent (Pratt et al., 2009). Thus, expecting adolescents to be informed, psychologically mature decision-makers in the process of choosing a life-altering surgery can be precarious (Caniano, 2009).

The thorough pre-surgical evaluation process is a means to choose appropriate adolescent candidates for surgery. Readers are referred to the best practice guidelines for adolescents provided in 2011 by the ASMBS (Michalsky et al., 2012) for more detailed information and comments on the evaluation process and selection criteria. Recommended BMI cut-offs for surgery are ≥ 35 for adolescents with serious medical comorbidities and ≥ 40 for adolescents with moderate medical comorbidities. Bariatric surgery has not been the treatment of choice for the slightly overweight adolescent. Average pre-operative BMIs for extremely obese adolescents have been reported to be between 43 to 56.5 kg/m² (≥ 99th percentile) in research studies examining RYGB and LAGB between 2004 and 2007 (Pratt et al., 2009).

In addition to BMI inclusion/exclusion criteria, national guidelines recommend a pre-surgical evaluation by a psychologist or psychiatrist to assess barriers to positive outcome, identify contraindications, and make recommendations regarding readiness for surgery (Michalsky et al., 2012). These comprehensive assessments include not just an assessment of the individual but also the family, as family support and assistance plays a huge role in the decision-making process regarding surgery as well as adherence with post-surgical regimens. Careful multidisciplinary pre-surgical assessment to identify potential barriers to positive surgical outcome are critical (Inge et al., 2004b; Pratt et al., 2009), and research examining the predictors of optimal outcomes in adolescents is of primary importance.

Additional criticisms of surgery are more broadly focused. For example, some refer to the high cost of surgery to treat a societal epidemic (Garrett & McNolty, 2010), or suggest that that surgery is simply a medical treatment for society's concern with appearance (Hoffman, 2010) or society's overeating disorder (Garrett & McNolty, 2010). While it is true that the surgical option is an expensive choice for the masses and ought not to be based on cultural definitions of appropriate body shape/size, these criticisms ignore the medical plight of extremely obese individuals. Societal efforts at obesity prevention will not address the current healthcare needs of the extremely obese adolescent. Some obese adolescents may indeed benefit from lifestyle interventions, others from pharmacological treatments (or the combination of the two), but some will need additional treatment options. With careful adherence to national guidelines regarding inclusion/exclusion criteria and thorough pre-surgical evaluation to identify contraindications or significant barriers to treatment success, bariatric surgery has a place on the list of options for the extremely obese adolescent.

Conclusions and future directions

Paediatric obesity is a huge public health concern. An evaluation of available treatment options is necessary to determine which are most efficacious. Keeping the greatest numbers of individuals healthy at the lowest financial cost must prevail (Brandon et al., 2010). Certainly lifestyle interventions, pharmacological interventions, and bariatric surgery are all effective options for some patients. However, their advantages and disadvantages differ, none showing significant advantages with insignificant disadvantages, making the decision of which option is appropriate for any one individual complicated. Hence, all intervention options for adolescents, including bariatric surgery, call for special attention to benevolence, non-maleficence, and evidence (Hoffman, 2010). Future research regarding the risks, benefits, and expected outcomes of surgical options for adolescents is needed to inform this decision-making process. In addition, the development and analysis of behavioural/lifestyle interventions that compliment surgical interventions is key – especially with the lack of long-term adolescent surgical outcomes. Best practice guidelines for adult bariatric surgery patients recommend access to mental health specialists after the standard post-surgery period to address long-term concerns (Greenberg et al., 2009).

Bariatric surgery is a viable alternative for a select group of adolescents to manage a serious health condition. It is the most appropriate choice for those who have either attempted behavioural interventions and/or pharmacological interventions without success, or those who have significant medical comorbidities warranting a more immediately effective treatment to reduce health risk, disease burden, and possible mortality. It is not a panacea for the obesity epidemic, nor for all obese youths, but a currently available option that should be presented to adolescents and their families for careful decision-making.

Acknowledgements

The authors of this paper would like to acknowledge the contributions of Meg Zeller and the TeenVIEW research team for introducing the authors and assisting with concept development and formulation.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.