Teens and WLS

Teens and WLS: What are the Long-Term Results?

March 20, 2019

I’d like to start by discussing the term "metabolic surgery" in order to clear the air. Metabolic surgery is a term that is used to describe any procedure that is used to treat a metabolic illness, particularly diabetes mellitus.

The terms "obesity surgery" and "weight loss surgery" fail to recognize that the weight loss is only a benefit of the surgical procedure while the curing of the medical problem is the greater gain.

While it is true that there is a correlation between obesity and metabolic medical conditions, curing obesity but still having diabetes is leaving something to be desired. For this reason, the term metabolic surgery is more encompassing.

Teens and WLS: Obesity is on the Rise

It is estimated that obesity affects over 12 million children and young adults in the United States.1 While childhood obesity remains stable, teenage obesity is on the rise. The body mass index (BMI) is a tool that is used to categorize a patient’s weight as it relates to their height. A higher BMI has been linked to multiple medical conditions including metabolic syndrome, heart disease, diabetes, high cholesterol, fatty liver disease, and obstructive sleep apnea.2-5,9

In order to combat obesity, metabolic surgery has consistently proven to be the best option for sustained weight loss and curing of comorbid medical conditions.

Metabolic surgery was initially used as a tool for adults, however, it has recently been approved by the National Institute of Health as a safe and effective procedure for long-term and sustained weight loss for adolescents.3 In 2012, the American Society for Metabolic and Bariatric Surgery Pediatric Best Practice Guidelines recommended metabolic surgery for adolescents with a BMI greater than 35 with one of the following medical conditions: Obstructive sleep apnea, which is a sustained lack of breathing during sleep. Non-Alcoholic steatohepatitis or replacement of liver tissue with fat that can lead to liver failure. Diabetes mellitus type 2, which is a condition of uncontrolled sugar regulation in the bloodstream. Pseudotumor cerebrii, which causes elevated pressures in the brain.

The Society also recommends metabolic surgery for any adolescent with a BMI over 40 regardless of a comorbid medical condition recognizing obesity’s deleterious effects on health. 2,3,8-9

Two metabolic procedures have been approved to cure obesity and its associated medical conditions in adolescents; Roux-en-Y gastric bypass (RYGB) and Sleeve Gastrectomy (SG). RYGB creates a small stomach pouch which decreases the volume of food ingested before feeling a sensation of fullness. In addition, RYGB limits the absorption of food by delaying the breakdown of ingested food as it bypasses the first portion of the intestine. Delaying the breakdown of food limits the surface area of intestine that is exposed to food particles that can be absorbed.

Sleeve Gastrectomy (SG) works by decreasing the volume of the gastric reservoir. There are also hormonal changes occur as a result of removing a large portion of the gastric cell mass. Both of these surgical options are largely completed laparoscopically which utilizes several small incisions versus one large incision. This results in less postoperative pain, fewer wound complications, and faster return to work just to name a few advantages.

Teens' Health With WLS

Studies have shown that metabolic surgery has led to an improvement in blood pressure, resolution of type 2 diabetes, and an increase in the quality of life for adolescents.6,7,9,11-13  A review of 23 studies looking at 637 children and adolescents who had weight loss surgery found that at one year they decreased their BMI by more than 13 points.9-10 Replacement of the liver with fat, or hepatic steatosis, can lead to permanent liver damage known as cirrhosis.

When comparing lifestyle changes with Sleeve Gastrectomy for the reversal of fatty liver disease, Sleeve Gastrectomy is far more effective.15

When looking at long term results, the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study has been collecting information on teenagers who have had metabolic surgery at five different hospitals in the United States. The participants in the study had either a Roux-en-Y gastric bypass or a Sleeve Gastrectomy. They were followed for a period of three years.

At the end of the follow-up period, 26% of teenagers were no longer obese.6  In addition, a large majority of them no longer had high blood pressure, high cholesterol or diabetes mellitus type 2. Inge, et al. performed a study that looked at 75 adolescents who had Roux-en-Y gastric bypass surgery and followed the patients for five to twelve years.13 They found similar results to the Teen-LABS study in that their patients had a significant decrease in their BMI at follow-up. In addition, there were significant decreases in those who had high blood pressure and high cholesterol.

There are many more studies that all show very similar results and support the conclusion that metabolic surgery in adolescents is more beneficial than diet and exercise alone. Metabolic surgery also seems to have good results within the three to five-year period postoperatively.

Teens and WLS Conclusion

In conclusion, the medium to long term results of metabolic surgery in adolescents is promising. The results that adolescents see are comparable to those that adults who have undergone metabolic surgery have experienced.

While the results are promising, it was found that less than 10% of pediatric health care providers refer their patients for surgery.14 It is important for doctors and patients to know the risks and benefits of surgery to make an informed decision. While cost and the risk of a surgical procedure is essential to consider the results across multiple studies indicate that metabolic surgery improves health and the quality of life of adolescents.

References:

  1. Childhood Obesity Facts. https://www.cdc.gov/obesity/data/childhood.html. Accessed May 6, 2018.
  2. Klein, Samuel, Romijn JA. Obesity. In: Melmed, Shlomo, Polonsky, Kenneth S., Larsen, P. Reed, Kronenberg HM, ed. Williams Textbook of Endocrinology. Vol 13th ed. Philadelphia:Elsevier; 2016:1633-1659. https://www-clinicalkey-com.summa.ohionet.org/#!/content/book/3-s2.0-B9780323297387000368.
  3. Matei, Veronica, Popescu WM. Nutritional Diseases: Obesity and Malnutrition. In: Hines, Roberta L., Marschall KE, ed. Stoelting’s Anesthesia and Co-Existing Disease. Vol 7th ed. Philadelphia: Elsevier; 2018:385-405. https://www-clinicalkeycom.summa.ohionet.org/#!/content/book/3-s2.0-B978032340137100020X.
  4. Mameli C, Krakauer NY, Krakauer JC, et al. The association between a body shape index and cardiovascular risk in overweight and obese children and adolescents. PLoS One. 2018;13(1):1-12. doi:10.1371/journal.pone.0190426.
  5. Leitner DR, Frühbeck G, Yumuk V, et al. Obesity and type 2 diabetes: Two diseases with a need for combined treatment strategies - EASO can lead the way. Obes Facts. 2017;10(5):483-492. doi:10.1159/000480525.
  6. Inge TH, Courcoulas AP, Jenkins TM, et al. Weight Loss and Health Status 3 Years after Bariatric Surgery in Adolescents. N Engl J Med. 2016;374(2):113-123. doi:10.1056/ NEJMoa1506699.
  7. Inge, Thomas H.; Lori M. Laffel, Lori M.; Todd M. Jenkins, Todd M.; Marcus, Marsha D; Leibel, Natasha I.; Brandt, Mary L.; Haymond, Morey; Urbina, Elaine M.; Dolan, Lawrence M.; Philip S. Zeitler PS. Comparison of Surgical and Medical Therapy for Type 2 Diabetes in Severely Obese Adolescents. JAMA Pediatr. 2018;172(5):452-460.
  8. Barnett, Sean J., Inge TH. Bariatric Surgery in Adolescents. In: Holcomb, George W., Murphy J. Patrick, Ostlie DJ, ed. Ashcraft’s Pediatric Surgery. Vol 6th ed. Elsevier; 2014:1086-1098. https://www-clinicalkey-com.summa.ohionet.org/#!/content/book/3- s2.0-B978145574333900077X.
  9. Christison AL, Gupta SK. Weight Loss Surgery in Adolescents. Nutr Clin Pract. 2017;32(4):481-492. doi:10.1177/0884533617712702.
  10. Black, J.A., White, B., Viner, R. M., Simmons RK. Bariatric surgery for obese children and adolescents: a systematic review and meta-analysis. Obes Rev. 14(8):634-644.
  11. Alqahtani, Aayed R. MD; Antonisamy, Belavendra PhD; Alamri, Hussam MBBS; Elahmedi, Mohamed MBBS; Zimmerman VAP. Laparoscopic Sleeve Gastrectomy in 108 Obese Children and Adolescents Aged 5 to 21 Years. Ann Surg. 2012;256(2):266-273.
  12. Inge, Thomas H., Jenkins, Todd M., Xanthakos, Stavra A., Dixon, John B., Daniels, Stephen R., Zeller, Meg H., Helmrath MA. Long-term outcomes of bariatric surgery in adolescents with severe obesity (FABS-5+): a prospective follow-up analysis. Lancet Diabetes Endocrinol. 5(3):165-173.
  13. Vanguri P, Lanning D, Wickham EP, Anbazhagan A, Bean MK. Pediatric health care provider perceptions of weight loss surgery in adolescents. Clin Pediatr (Phila). 2014;53(1):60-65. doi:10.1177/0009922813500848.
  14. Manco M, Mosca A, De Peppo F, et al. The Benefit of Sleeve Gastrectomy in Obese Adolescents on Nonalcoholic Steatohepatitis and Hepatic Fibrosis. J Pediatr. 2017;180:31-37.e2. doi:10.1016/j.jpeds.2016.08.101.
Modupeola Diyaolu

ABOUT THE AUTHOR

Modupeola Diyaolu, MD is a PGY-2 General Surgery resident at Summa Health Akron City Hospital in Akron, Ohio. She attended Tufts University and obtained a Bachelor of Arts Degree in Biopsychology. Dr. Diyaolu earned her medical degree from the University of Massachusetts Medical School in Worcester, Massachusetts. She is interested in pursuing a career in pediatric surgery.