Bariatric and Metabolic Surgery in Adolescents: a Path to Decrease Adult Cardiovascular Mortality

Bariatric Surgery in Youth: the Perspective of Dutch Pediatricians, Parents, and Adolescents

BACKGROUND

Recent studies have indicated that bariatric surgery is effective for the treatment of youth with severe obesity. The attitudes of pediatricians, parents, and adolescents regarding this topic remain unclear. Therefore, the aim of this study was to assess the current thoughts and beliefs of Dutch pediatricians, parents, and adolescents regarding bariatric surgery in youth.

METHODS

An online survey containing twenty questions on bariatric surgery in youth was distributed to pediatricians of the Dutch Society of Pediatrics. Parents and adolescents who participated in an interdisciplinary care program for overweight, obesity, and severe obesity filled out an online survey of twelve questions.

RESULTS

One hundred and twenty-one pediatricians, 49 parents, and 19 adolescents completed the surveys. Seventy-two pediatricians (59.5%) considered bariatric surgery to be an effective treatment for youth with severe obesity when conventional treatment fails, and intend to refer patients for bariatric surgery. The most frequently suggested conditions for bariatric surgery were a minimum age of 16 years (n = 59, 48.7%), a BMI threshold of 40 kg/m² (n = 51, 42.2%), and a minimum Tanner stage of IV (n = 59, 48.8%). Thirty parents (61.2%) and fourteen adolescents (73.7%) responded that bariatric surgery should become available for youth with severe obesity.

CONCLUSION

Dutch pediatricians, parents, and adolescents increasingly accept bariatric surgery as a treatment modality in youth with severe obesity who do not respond successfully to lifestyle intervention. Whether pediatricians will actually refer youth for bariatric surgery remains to be seen when this treatment option will be implemented in the Netherlands.

Laparoscopic roux-en-Y gastric bypass versus sleeve gastrectomy for teenagers with severe obesity - TEEN-BEST: study protocol of a multicenter randomized controlled trial

BACKGROUND

Recent data support the use of bariatric surgery in adolescents with severe obesity following unsuccessful non-surgical treatments. Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) have demonstrated reasonably similar weight loss and reduction of obesity related comorbidities in randomized trials in adults. SG has internationally become the most commonly used procedure in adolescents, yet long-term outcome data are lacking. No randomized controlled trial comparing SG and RYGB has been performed in adolescents.

OBJECTIVE

Determine whether SG is non-inferior to RYGB in terms of total body weight (TBW) loss in adolescents with severe obesity.

METHODS

A multicenter randomized controlled non-inferiority trial. Two hundred sixty-four adolescents aged 13-17 (Tanner stage ≥IV) with severe obesity (corrected for age and sex) will be included. Adolescents agreeing to participate will be randomized to either RYGB or SG. The primary outcome is the proportion of participants achieving 20% TBW loss at 3 years postoperatively. Secondary outcomes include (i) change in body weight, body mass index (BMI) and BMI standard deviation score, (ii) incidence of adverse health events and need for additional surgical intervention, (iii) resolution of obesity-related comorbidities, (iv) prevalence of cardio metabolic risk factor measures, (v) bone health measures and incidence of bone fractures, (vi) quality of life including psychosocial health, patient satisfaction and educational attainment and (vii) body composition. Follow-up will extend into the long term.

RESULTS

Not applicable.

DISCUSSION

This study will, to our knowledge, be the first randomized controlled trial comparing SG and RYGB in adolescents with severe obesity.

TRIAL REGISTRATION

The trial is registered at the Netherlands Trial Register on July 26th, 2018 - NTR7191 - https://www.trialregister.nl/trial/7191 (protocol version 5.0 - February 3th 2020).

Diagnosis, treatment and prevention of pediatric obesity: consensus position statement of the Italian Society for Pediatric Endocrinology and Diabetology and the Italian Society of Pediatrics

The Italian Consensus Position Statement on Diagnosis, Treatment and Prevention of Obesity in Children and Adolescents integrates and updates the previous guidelines to deliver an evidence based approach to the disease. The following areas were reviewed: (1) obesity definition and causes of secondary obesity; (2) physical and psychosocial comorbidities; (3) treatment and care settings; (4) prevention.The main novelties deriving from the Italian experience lie in the definition, screening of the cardiometabolic and hepatic risk factors and the endorsement of a staged approach to treatment. The evidence based efficacy of behavioral intervention versus pharmacological or surgical treatments is reported. Lastly, the prevention by promoting healthful diet, physical activity, sleep pattern, and environment is strongly recommended since the intrauterine phase.

Should bariatric surgery be performed in adolescents?

Adolescent obesity has markedly increased worldwide in both its extent and prevalence in recent decades and obesity prevention strategies are failing. As a result, effective treatment strategies are urgently needed. As behavioral and pharmacological treatment approaches have only moderate effects in severe obesity, bariatric surgery has begun to emerge as a treatment option. In this debate article, we offer arguments opposing and supporting bariatric surgery in the treatment of severe obesity in adolescents. Bariatric surgery has superior therapeutic outcomes with respect to weight loss and resolution of comorbid diseases over other existing treatments. However, long-term outcomes after bariatric surgery in adolescents are only just beginning to emerge. Furthermore, the procedures are generally considered irreversible, apart from gastric banding. Most importantly, not all adolescents seem to benefit greatly from bariatric surgery and we are not yet able to reliably identify those who stand to gain the greatest benefit. The authors agree that adolescent bariatric surgery should be offered exclusively within formal adolescent obesity programs, delivered by specialist multidisciplinary child/adolescent obesity teams, and within specialist centers, in order to optimize outcomes and minimize potential detrimental effects. Patients and their family/carers must be educated regarding the benefits and risks, potential side effects, expected changes in eating behavior and the lifelong requirement for regular medical follow-up after surgery. Before embarking upon a surgical treatment pathway in adolescents with severe obesity, it may also be beneficial to ensure compliance to treatment is demonstrated, in order to minimize the risk of nutritional deficiencies and associated potential complications.

Laparoscopic Roux-en-Y gastric bypass in adolescents with severe obesity (AMOS): a prospective, 5-year, Swedish nationwide study

BACKGROUND

Severe obesity in adolescence is associated with reduced life expectancy and impaired quality of life. Long-term benefits of conservative treatments in adolescents are known to be modest, whereas short-term outcomes of adolescent bariatric surgery are promising. We aimed to compare 5-year outcomes of adolescent surgical patients after Roux-en-Y gastric bypass with those of conservatively treated adolescents and of adults undergoing Roux-en-Y gastric bypass, in the Adolescent Morbid Obesity Surgery (AMOS) study.

METHODS

We did a nationwide, prospective, non-randomised controlled study of adolescents (aged 13-18 years) with severe obesity undergoing Roux-en-Y gastric bypass at three specialised paediatric obesity treatment centres in Sweden. We compared clinical outcomes in adolescent surgical patients with those of matched adolescent controls undergoing conservative treatment and of adult controls undergoing Roux-en-Y gastric bypass. The primary outcome measure was change in BMI over 5 years. We used multilevel mixed-effect regression models to assess longitudinal changes. This trial is registered with ClinicalTrials.gov, number NCT00289705.

FINDINGS

Between April, 2006, and May, 2009, 100 adolescents were recruited to the study, of whom 81 underwent Roux-en-Y gastric bypass (mean age 16·5 years [SD 1·2], bodyweight 132·8 kg [22·1], and BMI 45·5 kg/m² [SD 6·1]). 80 matched adolescent controls and 81 matched adult controls were enrolled for comparison of outcomes. The change in bodyweight in adolescent surgical patients over 5 years was -36·8 kg (95% CI -40·9 to -32·8), resulting in a reduction in BMI of -13·1 kg/m² (95% CI -14·5 to -11·8), although weight loss less than 10% occurred in nine (11%). Mean BMI rose in adolescent controls (3·3 kg/m², 95% CI 1·1-4·8) over the 5-year study period, whereas the BMI change in adult controls was similar to that in adolescent surgical patients (mean change -12·3 kg/m², 95% CI -13·7 to -10·9). Comorbidities and cardiovascular risk factors in adolescent surgical patients showed improvement over 5 years and compared favourably with those in adolescent controls. 20 (25%) of 81 adolescent surgical patients underwent additional abdominal surgery for complications of surgery or rapid weight loss and 58 (72%) showed some type of nutritional deficiency; health-care consumption (hospital attendances and admissions) was higher in adolescent surgical patients compared with adolescent controls. 20 (25%) of 81 adolescent controls underwent bariatric surgery during the 5-year follow-up.

INTERPRETATION

Adolescents with severe obesity undergoing Roux-en-Y gastric bypass had substantial weight loss over 5 years, alongside improvements in comorbidities and risk factors. However, gastric bypass was associated with additional surgical interventions and nutritional deficiencies. Conventional non-surgical treatment was associated with weight gain and a quarter of patients had bariatric surgery within 5 years.

FUNDING

Swedish Research Council; Swedish Governmental Agency for Innovation Systems; National Board of Health and Welfare; Swedish Heart and Lung Foundation; Swedish Childhood Diabetes Foundation; Swedish Order of Freemasons Children's Foundation; Stockholm County Council; Västra Götaland Region; Mrs Mary von Sydow Foundation; Stiftelsen Göteborgs Barnhus; Stiftelsen Allmänna Barnhuset; and the US National Institute of Diabetes, Digestive, and Kidney Diseases (National Institutes of Health).

Bariatric Surgery in Youth

Bariatric surgery provides a clinically effective and cost-effective means of achieving sustained weight reduction and management of associated comorbidities and has been met with increasing enthusiasm for application in obese youth. Following trends seen among obese adults, carefully selected obese youth are now undergoing bariatric surgical procedures with excellent short-term and intermediate-term outcomes. Although long-term data are not yet available, the results thus far hold great promise in the management of this population.