Surgical Outcomes of Patients 21 Years and Younger
November 17, 2021Surgical Outcomes of Patients 21 Years and Younger: Childhood obesity is a serious health risk in the United States, affecting approximately one-fifth of all children and adolescents1. For comparison, obesity in the adult population is now 42.4% as per the 2017 – 2018 CDC census.
Obese children are more likely to become obese2. Unfortunately, childhood obesity leads to more severe obesity and associated risk factors in adulthood3. Conditions such as heart disease, stroke, type 2 diabetes, and certain types of cancer are among the leading obesity-related causes of preventable, premature death4.
Moreover, the significance of childhood obesity is that complications and mortality risk are higher when the child develops obesity in childhood, versus developing it during adulthood. Therefore, the goal should be oriented to developing treatments of obesity during childhood and adolescence before adulthood. The hope is that the risks are made less severe leading to impactful, long-term results.
The usual first line treatments for obesity are medical options. They consist of lifestyle modifications that attempt to increase activity and decrease caloric intake in regards to diet and exercise.
Sadly, long-term success with diet and exercise in severely obese children and adolescents has not been demonstrated. Most available weight loss or appetite suppressive medications are not FDA (Food and Drug Administration) approved for children and adolescents. Orlistat is the only FDA-approved medication.
Unfortunately, not only are most medications not as efficacious as surgical options but Orlistat has not been shown to be highly effective at significant weight loss. A growing number of pediatricians have begun to use FDA-approved adult appetite suppressive medications in an off-labeled approach to augment weight loss.
However, there are known serious side effects associated with these medications including seizures, suicidal thoughts, and liver failure. Hence, careful use with a multidisciplinary approach needs to be maintained.
Surgical Outcomes of Patients 21 Years and Younger
With growing documentation of surgical effectiveness over medical options, excellent safety profile combined with the ever-increasing evidence of serious risks from obesity and lack of medication options, surgical weight loss has become a more viable alternative.
Bariatric (weight loss) surgery in adolescents has been shown to be as safe and effective as bariatric surgery in adults5.
The most frequent bariatric procedures performed in adolescents are gastric bypass, adjustable gastric band, and sleeve gastrectomy. Deciding which procedure is appropriate is a complex task. The goal of bariatric surgery is to produce the most benefit with the lowest risk possible. Extensive research has been performed and is ongoing to assess outcomes of bariatric surgery in adolescents.
Obesity Health-Related Medical Conditions
There are many obesity health-related medical conditions that are mitigated with weight loss surgery. Type 2 diabetes is often found in adulthood spurred on by obesity. We are seeing more children and adolescents with obesity, develop Type 2 diabetes. The lasting effects of diabetes, if not treated early leads to high blood pressure, cardiovascular disease, and early death. Studies show that early intervention may produce a more complete and earlier remission of diabetes with bariatric surgery6.
Cardiovascular disease is also a significant factor to consider. Although research is still ongoing for adolescents, there is overwhelming evidence in adults that weight loss surgery can improve the damage to the cardiovascular system.
Childhood obesity does confer a higher risk of cardiovascular diseases, leading to the thought that cardiovascular disease in adolescents will also improve with weight loss surgery. Time is a factor here, as it will take many years to quantify this effect.
Obstructive sleep apnea is frequently increased with age and obesity. It is distinguished by pauses in breathing. It is associated with snoring, daytime sleepiness, focus, and behavioral changes in adolescents. A significant percentage of obese children and adolescents are diagnosed with obstructive sleep apnea7. Weight loss surgery has been shown to improve or completely ameliorate obstructive sleep apnea.
There are a significant number of other comorbidities (obesity-related health issues) that are impacted by weight loss surgery including acid reflux, depression, fatty liver, pseudotumor cerebri, different cancers, and quality of life. There are many conditions that obesity causes which are deleterious. Weight loss surgery can combat these conditions and either improve or cure them.
Bariatric Surgery Outcomes of Patients 21 Years and Younger
The outcomes of gastric bypass show that there are lasting effects with comparable results as adults in the adolescent population. Although the sleeve gastrectomy is being performed increasingly, there is less long-term data versus the gastric bypass or adjustable gastric band.
Preliminary data show promising results that mirror the adult population in mitigating comorbidities and excellent weight reduction. The adjustable gastric band is only FDA-approved for patients 18 years old and older. The ability to remove the device is a provocative choice for patients, but it is tempered by the fact of frequent re-operations and less weight loss compared to the gastric bypass or sleeve gastrectomy.
So, who should be considered for surgery?
Patients with a BMI of 35 kg/m2 or higher with major co-morbidities (such as type 2 diabetes, moderate or severe sleep apnea, pseudotumor cerebri, or severe fatty liver disease).
As well as patients with a BMI 40 kg/m2 or higher with other less severe comorbidities (such as high blood pressure, high cholesterol, mild or moderate sleep apnea)
However, despite these criteria, the patient should be assessed for comprehension and maturity along with an ability to adhere to lifestyle modifications. Patients who have cognitive, behavioral, or psychological limitations that prevent them from following a bariatric diet plan after surgery should not undergo surgery. Additionally, insurance companies have their own set of criteria for approval or they may not cover bariatric surgery at all.
The takeaway for Surgical Outcomes of Patients 21 Years and Younger
The key to managing the care of the adolescent bariatric patient is the multidisciplinary team approach. This typically includes a bariatric surgeon, pediatric endocrinologist, nutritionist, mental health specialist, gastroenterologist, and coordinator.
It is important to acknowledge that bariatric surgery is a significant surgical procedure with inherent risks, complications, and limitations, as all surgical procedures are associated with. Early bariatric surgery in combating health related issues will decrease long-term related comorbidities in children and adolescents in adulthood. Benefits and risks and should be weighed carefully.
References:
- www.cdc.gov/obesity/data/childhood.html
- Gordon-Larsen P, The NS, Adair LS. Longitudinal trends in obesity in the United States from adolescence to the third decade of life. Obesity. 2010;18(9):1801-–804.
- Bass R, Eneli I. Severe childhood obesity: an under-recognized and growing health problem. Postgrad Med J. 2015;91(1081):639-45. doi: 10.1136/postgradmedj-2014-133033.
- Jensen MD, Ryan DH, Apovian CM, et al, for the American College of Cardiology/American Heart Association Task Force on Practice Guidelines; Obesity Society. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. J Am Coll Cardiol. 2014;63(25 Pt B):2985–3023. doi: 10.1016/j.jacc.2013.11.004.
- Pratt J, Browne A, et al. ASMBS pediatric metabolic and bariatric surgery guidelines, 2018 Surg Obes Relat Dis. 2018 Jul;14(7):882-901.
- M A Stefater, T H Inge. Bariatric Surgery for Adolescents with Type 2 Diabetes: an Emerging Therapeutic Strategy Curr Diab Rep . 2017 Aug;17(8):62. doi: 10.1007/s11892-017-0887-y.
- Jill L Kaar1, Nazeen Morelli2, Samuel P Russell3, Ishaah Talker3, Jaime M Moore2, Thomas H Inge2, Kristen J Nadeau2, Stephen M M Hawkins2, Mark S Aloia4, Stacey L Simon2 Obstructive sleep apnea and early weight loss among adolescents undergoing bariatric surgery. Surg Obes Relat Dis 2021 Apr;17(4):711-717. doi: 10.1016/j.soard.2020.12.003. Epub 2020 Dec 17.
 | ABOUT THE AUTHOR Dr. Jun Levine is a bariatric and minimally invasive surgeon with Winthrop Surgical Associates. She attended medical school at SUNY Downstate Medical School and practiced in New York City before moving to NYU Winthrop. Beyond bariatric surgical procedures such as gastric bypass and gastric sleeve, Dr. Levine also specializes in minimally invasive hernia repair, minimally invasive gallbladder removal and surgical treatment for gastroesophageal reflux disease (GERD). |
