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Malhotra S, Czepiel KS, Akam EY, Shaw AY, Sivasubramanian R, Seetharaman S, Stanford FC. Bariatric surgery in the treatment of adolescent obesity: current perspectives in the United States. Expert Rev Endocrinol Metab 2021; 16:123-134. [PMID: 33879013 PMCID: PMC9912043 DOI: 10.1080/17446651.2021.1914585] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 04/06/2021] [Indexed: 02/06/2023]
Abstract
Introduction: Rates of severe obesity in adolescents have increased at an alarming rate. Unfortunately, there are limited successful treatments for severe obesity in adolescents. Metabolic and bariatric surgery (MBS) is the most effective treatment available for adolescents with Class 2 and above severe obesity and has demonstrated variable degrees of sustained long-term weight loss which leads to resolution of multiple associated conditions and an improved quality of life.Areas covered: We discuss the current landscape of MBS in adolescents and evidence to support its long-term safety and efficacy. A literature search through PubMed, ResearchGate and HOLLIS Harvard Library Online Catalog was performed from the date of inception until 3/15/2021. A combination of the following keywords was used: Pediatric metabolic/bariatric surgery; long term outcomes of Pediatric metabolic/bariatric surgery, perioperative assessment, pediatric metabolic/bariatric surgery barriers; attitudes toward metabolic/bariatric surgery.Expert opinion: MBS is emerging as a safe and effective treatment strategy for adolescents with severe obesity, with recent studies demonstrating durable and sustainable weight loss. There remains an urgent need for longitudinal studies to assess durability of weight loss. Obesity stigma and bias, limited access to tertiary care centers, and skepticism around the treatment of obesity poses a major challenge.
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Affiliation(s)
- Sonali Malhotra
- Department of Medicine, MGH Weight Center, Boston, MA, USA
- Division of Pediatric Endocrinology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kathryn S. Czepiel
- Department of Pediatrics, Massachusetts Hospital and Harvard Medical School, Boston, MA, USA
| | - Eftitan Y. Akam
- Department of Pediatrics, Massachusetts Hospital and Harvard Medical School, Boston, MA, USA
- Departments of Internal Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ashley Y Shaw
- Department of Pediatrics, Massachusetts Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | - Fatima Cody Stanford
- Department of Medicine, MGH Weight Center, Boston, MA, USA
- Division of Pediatric Endocrinology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Departments of Internal Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Metabolism Unit, Nutrition Obesity Research Center at Harvard, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Xanthakos SA, Lavine JE, Yates KP, Schwimmer JB, Molleston JP, Rosenthal P, Murray KF, Vos MB, Jain AK, Scheimann AO, Miloh T, Fishbein M, Behling CA, Brunt EM, Sanyal AJ, Tonascia J. Progression of Fatty Liver Disease in Children Receiving Standard of Care Lifestyle Advice. Gastroenterology 2020; 159:1731-1751.e10. [PMID: 32712103 PMCID: PMC7680281 DOI: 10.1053/j.gastro.2020.07.034] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 06/19/2020] [Accepted: 07/19/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Nonalcoholic fatty liver disease (NAFLD) is the most common pediatric chronic liver disease. Little is known about outcomes in recognized youth. METHODS We compared paired liver biopsies from 122 of 139 children with NAFLD (74% male; 64% white; 71% Hispanic; mean age, 13 ± 3 years; age range, 8-17 years) who received placebo and standard of care lifestyle advice in 2 double-blind, randomized clinical trials within the nonalcoholic steatohepatitis (NASH) clinical research network from 2005 through 2015. We analyzed histologic changes with respect to baseline and longitudinal change in clinical variables using regression analysis. RESULTS At enrollment, 31% of the children had definite NASH, 34% had borderline zone 1 NASH, 13% had borderline zone 3 NASH, and 21% had fatty liver but not NASH. Over a mean period of 1.6 ± 0.4 years, borderline or definite NASH resolved in 29% of the children, whereas 18% of the children with fatty liver or borderline NASH developed definite NASH. Fibrosis improved in 34% of the children but worsened in 23%. Any progression to definite NASH and/or in fibrosis was associated with adolescent age, and higher waist circumference, levels of alanine or aspartate aminotransferase, total and low-density lipoprotein cholesterol at baseline (<0.05), and over follow-up time, with increasing level of alanine aminotransferase, hemoglobin A1C (P<.05), gamma-glutamyl transferase and development of type 2 diabetes (P<.01). Increasing level of gamma-glutamyl transferase was also associated with reduced odds of any improvement (P = .003). CONCLUSIONS One-third of children with NAFLD enrolled in placebo groups of clinical trials had histologic features of progression within 2 years, in association with increasing obesity and serum levels of aminotransferases and loss of glucose homeostasis.
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Affiliation(s)
- Stavra A Xanthakos
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Joel E Lavine
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Columbia Vagelos College of Physicians and Surgeons, New York, New York.
| | - Katherine P Yates
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jeffrey B Schwimmer
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California San Diego School of Medicine, La Jolla, California
| | - Jean P Molleston
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Indiana University School of Medicine/Riley Hospital for Children, Indianapolis, Indiana
| | - Philip Rosenthal
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, Benioff Children's Hospital, San Francisco, California
| | - Karen F Murray
- Pediatrics Institute, Cleveland Clinic Children's, Cleveland, Ohio
| | - Miriam B Vos
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Ajay K Jain
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, St. Louis University, St. Louis, Missouri
| | | | - Tamir Miloh
- Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - Mark Fishbein
- Department of Pediatrics, Feinberg Medical School of Northwestern University, Chicago, Illinois
| | - Cynthia A Behling
- Department of Pathology, Sharp Memorial Hospital; Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego, California
| | - Elizabeth M Brunt
- Department of Pathology and Immunology, Washington University, St. Louis, Missouri
| | - Arun J Sanyal
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - James Tonascia
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Black DD. Impact of Bariatric Surgery on Adipose Tissue and Liver Inflammation in Adolescents with Nonalcoholic Steatohepatitis. J Pediatr 2020; 216:7-9. [PMID: 31587862 DOI: 10.1016/j.jpeds.2019.08.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 08/30/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Dennis D Black
- Department of Pediatrics, University of Tennessee Health Science Center, and the Children's Foundation Research Institute at Le Bonheur Children's Hospital, Memphis, Tennessee.
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Franchitto A, Carpino G, Alisi A, De Peppo F, Overi D, De Stefanis C, Romito I, De Vito R, Caccamo R, Sonia B, Alessandra S, Mosca A, Alterio A, Onori P, Gaudio E, Nobili V. The Contribution of the Adipose Tissue-Liver Axis in Pediatric Patients with Nonalcoholic Fatty Liver Disease after Laparoscopic Sleeve Gastrectomy. J Pediatr 2020; 216:117-127.e2. [PMID: 31526528 DOI: 10.1016/j.jpeds.2019.07.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 06/16/2019] [Accepted: 07/12/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate the histopathologic modifications in liver and visceral adipose tissue (VAT), and to correlate these changes with clinical measures, adipokine production, and proinflammatory cytokines in a population of adolescents with obesity with nonalcoholic fatty liver disease (NAFLD) who underwent laparoscopic sleeve gastrectomy (LSG). STUDY DESIGN Twenty adolescents with obesity who underwent LSG and with biopsy-proven NAFLD were included. Patients underwent clinical evaluation and blood tests at baseline and 1 year after the surgical procedure. Liver and VAT specimens were processed for routine histology, immunohistochemistry, and immunofluorescence. RESULTS In adolescents with obesity and NAFLD, hepatic histologic alterations were uncorrelated with VAT inflammation. LSG induced in both liver and VAT tissue histopathology amelioration and macrophage profile modification that were correlated with body mass index and improvement in insulin resistance. The adipokine profile in liver and VAT was associated with weight loss and histologic improvement after LSG. Serum proinflammatory cytokines were correlated with liver and VAT histopathology and IL-1β and IL-6 levels were independently predicted by liver necroinflammatory grade. CONCLUSIONS This study suggests a unique adipose tissue/fatty liver crosstalk in pediatric patients. LSG induces a similar pattern of histologic improvement in the liver and in VAT. Besides VAT, our results strengthen the role of the liver in adipocytokine production and its contribution to systemic inflammation in pediatric patients with NAFLD.
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Affiliation(s)
- Antonio Franchitto
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, Sapienza University of Rome, Rome, Italy
| | - Guido Carpino
- Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Rome, Italy
| | - Anna Alisi
- Research Unit of Molecular Genetics of Complex Phenotypes, Bambino Gesù Children Hospital, Rome, Italy
| | - Francesco De Peppo
- Department of Pediatric Surgery, Pediatric Surgery Unit, "Bambino Gesù" Children's Hospital, Rome, Italy
| | - Diletta Overi
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, Sapienza University of Rome, Rome, Italy
| | - Cristiano De Stefanis
- Histology-Core Facility "Bambino Gesù" Children's Hospital- Institute of Hospitalization and Scientific Care, Rome, Italy
| | - Ilaria Romito
- Research Unit of Molecular Genetics of Complex Phenotypes, Bambino Gesù Children Hospital, Rome, Italy
| | - Rita De Vito
- Department of Pathology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Romina Caccamo
- Department of Pediatric Surgery, Pediatric Surgery Unit, "Bambino Gesù" Children's Hospital, Rome, Italy
| | - Battaglia Sonia
- Department of Pediatric Surgery, Pediatric Surgery Unit, "Bambino Gesù" Children's Hospital, Rome, Italy
| | | | - Antonella Mosca
- Hepatology, Gastroenterology and Nutrition Unit - Bambino Gesù Children's Hospital, Rome, Italy.
| | - Arianna Alterio
- Hepatology, Gastroenterology and Nutrition Unit - Bambino Gesù Children's Hospital, Rome, Italy
| | - Paolo Onori
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, Sapienza University of Rome, Rome, Italy
| | - Eugenio Gaudio
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, Sapienza University of Rome, Rome, Italy
| | - Valerio Nobili
- Hepatology, Gastroenterology and Nutrition Unit - Bambino Gesù Children's Hospital, Rome, Italy; Department of Pediatric - University "La Sapienza", Rome, Italy
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Nobili V, Carpino G, De Peppo F, Caccamo R, Mosca A, Romito I, Overi D, Franchitto A, Onori P, Alisi A, Gaudio E. Laparoscopic Sleeve Gastrectomy Improves Nonalcoholic Fatty Liver Disease-Related Liver Damage in Adolescents by Reshaping Cellular Interactions and Hepatic Adipocytokine Production. J Pediatr 2018; 194:100-108.e3. [PMID: 29198531 DOI: 10.1016/j.jpeds.2017.10.036] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 09/08/2017] [Accepted: 10/13/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To investigate whether the modulation of local cellular cross-talks and the modification of hepatic adipocytokine expression could mechanistically explain the improvement of liver histopathology after laparoscopic sleeve gastrectomy (LSG) in adolescents with nonalcoholic fatty liver disease (NAFLD). STUDY DESIGN Twenty obese (body mass index of ≥35 kg/m2) adolescents who underwent LSG and with biopsy-proven NAFLD were included. At baseline (T0) and 1 year after treatment, patients underwent clinical evaluation, blood tests, and liver biopsy. Hepatic progenitor cells, hepatic stellate cells (HSCs), macrophages, and adipocytokines were evaluated by immunohistochemistry and immunofluorescence. RESULTS Liver biopsy samples after LSG demonstrated a significant improvement of NAFLD Activity Score and fibrosis. Immunohistochemistry indicated a significant reduction of hepatocyte cell cycle arrest, ductular reaction, activated HSC, and macrophage number after LSG compared with T0. The activation state of HSC was accompanied by modification in the expression of the autophagy marker LC3. Hepatocyte expression of adiponectin was significant higher after LSG than into T0. Moreover, LSG caused decreased resistin expression in Sox9+ hepatic progenitor cells compared with T0. The number of S100A9+ macrophages was also reduced by LSG correlating with resistin expression. Finally, serum levels of proinflammatory cytokines significantly correlated with macrophages and activated HSC numbers. CONCLUSIONS The histologic improvement induced by LSG is associated with the reduced activation of local cellular compartments (hepatic progenitor cells, HSCs, and macrophages), thus, strengthening the role of cellular interactions and hepatic adipocytokine production in the pathogenesis of NAFLD.
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Affiliation(s)
- Valerio Nobili
- Hepatometabolic Unit, Bambino Gesù Children's Hospital, Rome, Italy; Department of Pediatrics and Infantile Neuropsychiatry, Sapienza University of Rome, Italy.
| | - Guido Carpino
- Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Rome, Italy
| | - Francesco De Peppo
- Pediatric Surgery Unit, Bambino Gesù Children's Hospital, Palidoro, Roma, Italy
| | - Romina Caccamo
- Pediatric Surgery Unit, Bambino Gesù Children's Hospital, Palidoro, Roma, Italy
| | - Antonella Mosca
- Hepatometabolic Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Ilaria Romito
- Liver Research Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Diletta Overi
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, Sapienza University of Rome, Rome, Italy
| | - Antonio Franchitto
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, Sapienza University of Rome, Rome, Italy
| | - Paolo Onori
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, Sapienza University of Rome, Rome, Italy
| | - Anna Alisi
- Liver Research Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Eugenio Gaudio
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, Sapienza University of Rome, Rome, Italy
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