Morbidity in obese adolescents who meet the adult National Institutes of Health criteria for bariatric surgery

Psychiatric Diagnoses and Weight Loss Among Adolescents Receiving Sleeve Gastrectomy

BACKGROUND AND OBJECTIVES

Severe obesity is associated with higher risk of psychiatric difficulties. Bariatric surgery is the most effective treatment of severe obesity. Few guidelines exist regarding the association of psychiatric diagnoses in adolescents and outcomes after surgery because of the lack of longitudinal research. Our objective is to evaluate the rates of psychiatric diagnoses in adolescents undergoing surgery compared with those not receiving surgery and the association of preoperative psychiatric diagnoses with postsurgical weight loss outcomes.

METHODS

Adolescents (N = 222) referred for psychological evaluation at one institution for bariatric surgery (2009-2017) completed semistructured clinical interviews to assess the presence and number of psychiatric diagnoses. Comparison analyses were conducted between those who did not end up receiving surgery (N = 53) and those who did (N = 169). Using longitudinal modeling, we assessed the association of preoperative diagnoses with weight loss outcomes between 3 and 12 months after surgery.

RESULTS

Seventy-one percent of adolescents qualified for a psychiatric disorder. There were no differences in rates of specific disorders or numbers of diagnoses between those receiving surgery and those not receiving surgery. The presence or absence or number of diagnoses before surgery was not associated with weight loss outcomes after surgery.

CONCLUSIONS

Psychiatric diagnoses are prevalent among adolescents with severe obesity. These diagnoses are not associated with weight loss outcomes. The presurgical psychological evaluation serves as an opportunity to identify adolescents experiencing psychiatric problems and provide them with care but should not necessarily be considered a contraindication to surgery.

Initial Approach to Childhood Obesity in Spain. A Multisociety Expert Panel Assessment

PURPOSE

In recent years, the incidence of childhood obesity in Europe, and Spain in particular, has increased dramatically. Bariatric surgery could play a major role in treating of adolescents with severe obesity. However, no specific guidelines for bariatric surgery currently exist in Spain.

METHODS

The Board of the Spanish Society for Obesity Surgery and Metabolic Diseases (SECO) proposed a study of childhood obesity by using the Delphi method. This prospective study involved 60 experts from nine national societies. Each society leader recruited experts from their society in obesity-related fields. Two online questionnaires were taken, and consensus on guidelines for various obesity treatments was reached according to the percentage of answers in favor or against inclusion of a given guideline. Based on these results, preoperative, surgical management and follow-up of childhood obesity management among others were analyzed.

RESULTS

The survey results indicated significant concern among all societies regarding obesity. There was strong consensus with regard to adolescents and obesity, medical treatment, dietary recommendations, environmental and social factors, and goals for adolescents with obesity. Consensus on the use of intragastric balloons and other techniques was not reached. However, biliopancreatic diversion was rejected as a primary treatment, and mandatory psychological/psychiatric assessment was agreed upon. Inclusion criteria accepted were similar to those for adults with the exception of surgery in those with a body mass index <40.

CONCLUSIONS

Spanish obesity-related societies are aware of the societal problem of childhood obesity. Multisociety development of national approaches may arise from consensus-building studies among specialists.

Thirty-day outcomes for children and adolescents undergoing laparoscopic sleeve gastrectomy at a free-standing children's hospital

The obesity epidemic continues to affect millions of children and adolescents. Non-surgical options do not result in significant or sustained weight loss; thus bariatric surgery has become increasingly utilized. Limited data exist regarding safety for paediatric bariatric surgery, especially outside of National Institutes of Health (NIH)-funded centres. We hypothesized that the perioperative outcomes of paediatric patients undergoing laparoscopic sleeve gastrectomy (LSG) at our free-standing children's hospital would provide adequate safety profiles. We retrospectively reviewed demographics, comorbidities and 30-d outcomes for all patients who underwent LSG from 2010 to 2015 at a free-standing children's hospital. A total of 105 patients underwent 107 LSG procedures (two revisions). Mean age was 17.2 ± 2.4 years. Male to female ratio was 1:4. The majority were Black (57.1%), followed by White (21.0%) and Hispanic (18.1%). The mean body mass index was 51.0 ± 9.8 kg/m² . Comorbidities included obstructive sleep apnea (59.0%), hypertension (15.2%), polycystic ovarian disease (16.7% of females only), depression (12.4%) and diabetes (11.4%). Median length of stay was 2.0 d (1-7 d). There were no deaths. Major complications occurred in four patients (3.8%); three required reoperation. Four patients (3.8%) experienced minor complications. Laparoscopic sleeve gastrectomy can be safely performed for children and adolescents at a free-standing children's hospital without NIH-support.

Wernicke Encephalopathy in Adolescents After Bariatric Surgery: Case Report and Review

Roughly 1% of all weight loss surgery is performed in adolescents. There is strong evidence demonstrating significant postsurgical weight loss, improvement in quality of life, and reduction in comorbidities such as hypertension and diabetes. Reports of postoperative complications in adolescents are few because of the small sample size in most series. Despite vitamin supplementation, nutritional deficiencies requiring hospitalization occur occasionally after Roux-en-Y gastric bypass. Wernicke encephalopathy, a triad of ophthalmoplegia, ataxia, and altered mental status, is a serious consequence of thiamine (vitamin B₁) deficiency. Few cases of Wernicke encephalopathy after weight loss surgery have been reported in the literature and even fewer in the pediatric population. Here we describe a teenage girl who develops vomiting after Roux-en-Y gastric bypass and presented with nystagmus, irritability, and ataxia. The clinical presentation, diagnosis, and treatment of Wernicke encephalopathy in adolescents after bariatric surgery are discussed.

Long-Term (7 Years) Follow-Up of Roux-en-Y Gastric Bypass on Obese Adolescent Patients (<18 Years)

BACKGROUND

Few data are available about obesity surgery in adolescent patients.

OBJECTIVE

To assess long-term outcomes after laparoscopic Roux-en-Y gastric bypass (LRYGB) in patients <18 years.

SETTING

University Hospital, Europe.

METHODS

A retrospective study of prospectively collected data of patients <18 years (childhood group; ChG) (n = 28) treated by LRYGB of which 19 were available for follow-up between 2.4 and 10.2 years (mean 7.2 years). This group of patients was matched with an adult control group (AdG) of randomly chosen patients with similar characteristics who underwent LRYGB during the same period. The extensive survey included a telephonic questionnaire.

RESULTS

19 (12 females) of the 28 patients (67.9%) were available for follow-up. Preoperatively, 3 had type 2 diabetes mellitus (T2DM), 1 arterial hypertension, 5 dyslipidemia and 1 sleep apnea. In the ChG, average BMI after 7 years dropped from 38.9 kg/m2 preoperatively to 27.5 kg/m2. In the AdG, average BMI decreased from 39.4 to 27.1 kg/m2 in the same time period (nonsignificant between groups). One patient in the ChG needed a reoperation (internal hernia) versus 3 patients in the AdG (1 leak, 2 obstructions). All patients resolved their initial comorbidities. Two of 12 female patients in the ChG became pregnant 6 and 8 years after surgery, respectively, despite seemingly adequate oral contraception. Compliance with postoperative guidelines was good in 16/19 patients in ChG and in 14/18 patients in the AdG. Overall degree of satisfaction was high: 8.2/10 (SD 1.2, range 6-10) in the ChG and 8.9/10 (SD 1.7, range 5-10) in the AdG.

CONCLUSION

LRYGB seems to be safe, provide good weight loss, and cure comorbidities in an adolescent population. Satisfaction degree is high. Inadvertent pregnancy despite conventional contraception is a possible issue.

Psychosocial status and mental health in adolescents before and after bariatric surgery: a systematic literature review

OBJECTIVE

As long-term results of conservative treatment for obesity are discouraging, bariatric surgery is becoming a treatment option for extremely obese adolescents. However, mental and behavioral problems need to be respected when treating this vulnerable target group.

METHODS

A detailed systematic literature review on pre- and post-operative depressive, anxiety and eating disorder symptoms of adolescent patients was performed in PsychINFO, PubMed and Medline electronic databases.

RESULTS

Twelve studies met the inclusion criteria. Although strength of evidence was limited, results suggested that pre-operatively a third of adolescents suffered from moderate to severe depressive disorder symptoms and a quarter from anxiety disorder symptoms, while a substantial number showed eating disorder symptoms. Post-operatively, levels of depressive disorder symptoms significantly improved. Original articles on outcomes of eating and anxiety disorder symptoms after weight loss surgery were not found.

CONCLUSIONS

Further attention is needed on consistent clinical assessment of mental health disturbances and their consecutive treatment in adolescents. Future research should also focus on psychological and psychosocial predictors of weight loss after bariatric surgery.

The increasing incidence of adolescent bariatric surgery

BACKGROUND

Morbid obesity continues to be a significant problem within the United States, as overweight/obesity rates are nearing 33%. Bariatric surgery has had success in treating obesity in adults and is becoming a viable treatment option for obese adolescents.

METHODS

We studied 1615 inpatient admissions for children ≤20 years of age undergoing a bariatric procedure for morbid obesity in 2009 using the Kids' Inpatient Database (KID). Patients had a principal diagnosis of obesity and a bariatric procedure listed as one of their first 5 procedures. Procedures (open gastric bypass, laparoscopic gastric bypass, sleeve gastrectomy, laparoscopic gastroplasty, and laparoscopic gastric band) and complications were defined by ICD-9 codes.

RESULTS

There were 90 open gastric bypasses, 906 laparoscopic gastric bypasses, 150 sleeve gastrectomies, 18 laparoscopic gastroplasties, and 445 laparoscopic gastric bandings. The length of stay for each procedure was 2.44, 2.20, 2.33, 1.10, and 1.02 days, respectively (P<0.001). The complication rates were 3.3%, 3.5%, 0.7%, 0.0%, 0.2%, respectively (P=0.004).

CONCLUSIONS

Bariatric surgery is an increasingly utilized option for the treatment of morbid obesity among adolescents. The procedures can be performed safely as evidenced by low complication rates. Additional long-term follow-up is necessary.

Position of the Academy of Nutrition and Dietetics: interventions for the prevention and treatment of pediatric overweight and obesity

It is the position of the Academy of Nutrition and Dietetics that prevention and treatment of pediatric overweight and obesity require systems-level approaches that include the skills of registered dietitians, as well as consistent and integrated messages and environmental support across all sectors of society to achieve sustained dietary and physical-activity behavior change. This position paper provides guidance and recommendations for levels of intervention targeting overweight and obesity prevention and treatment from preschool age through adolescence. Methods included a review of the literature from 2009 to April 2012, including the Academy's 2009 evidence analysis school-based reviews. Multicomponent interventions show the greatest impact for primary prevention; thus, early childhood and school-based interventions should integrate behavioral and environmental approaches that focus on dietary intake and physical activity using a systems-level approach targeting the multilevel structure of the socioecological model as well as interactions and relationships between levels. Secondary prevention and tertiary prevention/treatment should emphasize sustained family-based, developmentally appropriate approaches that include nutrition education, dietary counseling, parenting skills, behavioral strategies, and physical-activity promotion. For obese youth with concomitant serious comorbidities, structured dietary approaches and pharmacologic agents should be considered, and weight-loss surgery can be considered for severely obese adolescents. Policy and environmental interventions are recommended as feasible and sustainable ways to support healthful lifestyles for children and families. The Academy supports commitment of resources for interventions, policies, and research that promote healthful eating and physical-activity behaviors to ensure that all youth have the opportunity to achieve and maintain a weight that is optimal for health.

Severe obesity in children and adolescents: identification, associated health risks, and treatment approaches: a scientific statement from the American Heart Association

Severe obesity afflicts between 4% and 6% of all youth in the United States, and the prevalence is increasing. Despite the serious immediate and long-term cardiovascular, metabolic, and other health consequences of severe pediatric obesity, current treatments are limited in effectiveness and lack widespread availability. Lifestyle modification/behavior-based treatment interventions in youth with severe obesity have demonstrated modest improvement in body mass index status, but participants have generally remained severely obese and often regained weight after the conclusion of the treatment programs. The role of medical management is minimal, because only 1 medication is currently approved for the treatment of obesity in adolescents. Bariatric surgery has generally been effective in reducing body mass index and improving cardiovascular and metabolic risk factors; however, reports of long-term outcomes are few, many youth with severe obesity do not qualify for surgery, and access is limited by lack of insurance coverage. To begin to address these challenges, the purposes of this scientific statement are to (1) provide justification for and recommend a standardized definition of severe obesity in children and adolescents; (2) raise awareness of this serious and growing problem by summarizing the current literature in this area in terms of the epidemiology and trends, associated health risks (immediate and long-term), and challenges and shortcomings of currently available treatment options; and (3) highlight areas in need of future research. Innovative behavior-based treatment, minimally invasive procedures, and medications currently under development all need to be evaluated for their efficacy and safety in this group of patients with high medical and psychosocial risks.

Bariatric surgical management of adolescents with morbid obesity

PURPOSE OF REVIEW

Adolescent obesity continues to be a significant public health issue. To date, there are no medical therapies that provide significant, durable weight loss. Bariatric surgery has been shown in the adult and now the adolescent population to provide a reasonable alternative for weight loss.

RECENT FINDINGS

Recent publications have focused on the revision of the current guidelines for bariatric surgery in adolescents to more closely align with their well-established adult counterparts. These guidelines now introduce the establishment of multidisciplinary teams for the care of this subset of adolescent surgical patients. Numerous manuscripts in the past 2-3 years have demonstrated the overall effectiveness of Roux-en-Y gastric bypass, adjustable gastric banding, and most recently sleeve gastrectomy for both significant weight loss and comorbidity reduction with safety profiles similar to those found in adults. Despite these data, a recently published study showed that the trend for adolescent bariatric surgery has been stagnant over a 6-year period. There is also an ongoing shift in the type of procedure performed for morbid obesity in the United States toward sleeve gastrectomy and away from the adjustable gastric band.

SUMMARY

With the growing number of morbidly obese adolescents in the United States coupled with the relative ineffectiveness of medical therapy in this group of patients, bariatric surgery consistently provides a means for significant weight loss and the resolution of substantial comorbidities. Its approval is slowly increasing, and the growing fund of knowledge in regard to complication rates and the efficacy of bariatric surgery will ultimately result in its more widespread acceptance.

Contemporary surgical management of the obese adolescent

PURPOSE OF REVIEW

Adolescent obesity is rapidly becoming a significant public health issue. To date, there are no medical therapies that provide significant and durable weight loss. The surgical treatment of adolescent obesity is a rapidly evolving field.

RECENT FINDINGS

Recent publications have focused on the increase in the morbidity and mortality of adolescent obesity into adulthood. There have been significant findings that overweight children and adolescents progress towards severe obesity as adults. Firm guidelines for bariatric surgery in adults have been established for over 15 years, but there have been insufficient data in regards to guidelines for adolescents. The trend has always been to be more conservative, but a recent paper reviews the available literature to establish new guidelines. Adolescents can see a significant amount of weight loss in the first year after bariatric surgery with a resolution of diabetes and other cardiovascular risk factors. Bariatric surgery is well tolerated and effective, but carries with it long-term nutritional deficiencies, which need to be assessed and supplemented.

SUMMARY

Given the recent rise in obesity seen in this population, the surgical management of the adolescent has increased in popularity. Bariatric surgery is well tolerated and provides significant weight loss in those who are severely obese.

Long-term experience with duodenal switch in adolescents

BACKGROUND

Severe or extreme obesity in children and adolescents is a progressive damaging disease, increasingly requiring surgical treatment. Timing and choice of operation are controversial.

METHOD

In the last 16 years, we performed open biliopancreatic diversion with duodenal switch (DS) in 13 adolescents aged 15-17 years, who have been followed up for 2-16 years (mean, 10.6 years); three with Prader-Willi syndrome (PWS) are presented separately.

RESULTS

Among the ten non-PWS children (7 girls), no deaths or perioperative complications were reported, mean body mass index (BMI) decreased from 55.9 ± 14.0 to 28.8 ± 3.7 kg/m(2) (% excess weight loss (EWL) = 82.1 ± 10.5%), and none have regained weight. All comorbidities were cured except asthma, which improved in one patient. There were two reoperations: one for intestinal obstruction and one for post-anastomotic ulcer. Glucose and lipid metabolism improved, while vitamin and mineral deficiencies were mild and rare. Five of the seven girls gave birth to 11 children, aged 2-12 years, two of whom are overweight but not severely obese. Neurodevelopment is age-appropriate in all 11 individuals. PWS children, aged 15-16 years, had postoperative respiratory and infectious complications necessitating hospitalizations of 13-22 days (versus 5.1 ± 1.2 days in non-PWS). Weight loss and comorbidity improvement lasted approximately 5 years, providing improved quality of life for patient and family. One PWS patient died from complications after reoperation for weight regain after 4 years. One was reoperated after 6 years and the third is considering reoperation 14 years after primary DS.

CONCLUSION

The beneficial effects of DS in adolescents exceed the risks, even in the presence of PWS.