Perspectives on pediatric bariatric surgery: identifying barriers to referral. Surg Obes Relat Dis. 2009;5:88-93. [PMID: 18996760 DOI: 10.1016/j.soard.2008.08.023]

Longitudinal Outcomes in Adolescents After Referral for Metabolic and Bariatric Surgery

BACKGROUND

Metabolic and bariatric surgery (MBS) can be a well tolerated and effective treatment option for severe obesity in adolescents. We compared outcomes for adolescents that did and did not proceed to surgery.

METHODS

A single-center longitudinal study (2015-2020). Patients were identified as LSG if they completed laparoscopic sleeve gastrectomy within 6 months of initial visit and NoLSG if they did not. Chi-square, Fisher exact, nonparametric Kruskal-Wallis tests, and Linear Mixed Models (LMM) were used to compare outcomes over 2 years.

RESULTS

Three hundred fifty-two adolescents were referred with a mean age of 15.6 ± 1.4, 69% girls, 38% Hispanic, and 78% had noncommercial insurance. The median baseline weight was 135 kg and body mass index (BMI) was 48 kg/m2; 42% had a BMI >50. Seventy-nine (22%) underwent LSG whereas 273 (78%) did not complete MBS primarily because of lack of interest. LSG patients had 21% total weight loss and 22% total BMI loss at 24 months whereas NoLSG patients had 4% total weight gain and 3% BMI gain (P < 0.01). Obesity-associated conditions improved in the LSG group (P < 0.01). Follow-up in both groups was poor (≤30% at 24 months). Patients with public insurance and those with BMI from 50 to 59.9 kg/m2 were high performing LSG patients.

CONCLUSIONS

A minority (22%) of adolescents referred for MBS proceeded to surgery, despite its demonstrated efficacy and safety in adolescence. Those that did not undergo surgery continued to gain weight. Further research is needed to understand patient preferences or concerns related to MBS utilization during adolescence.

Referral and utilization of paediatric bariatric surgery in an academic freestanding children's hospital with dedicated paediatric bariatric programme

OBJECTIVE

This report estimates the percent of medically eligible adolescents who are referred for metabolic and bariatric surgery (MBS) evaluation or factors associated with referral.

METHODS

This cross-sectional retrospective review evaluated patients aged 13 to 18 years seen between 2017 and 2019 for demographics, insurance status, body mass index (BMI), obesity-related comorbidities, and compared these data to patients whom had been referred and received MBS.

RESULTS

Half of the patients (86 411/163137, 53%) between ages of 13 and 18 years identified had BMI documented, of which, 1974 (2.3%) were medically eligible for MBS, 238 (12%) were referred for MBS and 52 (22%) underwent MBS. Females had similar odds of being eligible for MBS [odds ratio (OR) = 1.01, 95% confidence interval (CI) 0.92-1.11, P = .9], but greater odds of referral (OR = 1.58, 95% CI 1.13-2.23, P = .009). Independently, miniorities and patients with public insurance had higher odds of being eligible for MBS, but similar odds of being referred as non-Hispanic white patients. Black patients with public insurance had greater odds of being referred for MBS (OR = 12.22, 95% CI 2.08-235.15, P = .022). Patients' multiple comorbidities had greater odds of being referred for MBS (OR = 2.16, 95% CI 1.29-3.68, P = .004).

CONCLUSIONS

Referral is barrier for patients medically eligible for MBS; however, this barrier is not uniformly faced by all patients.

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.

Bariatric surgery in the treatment of adolescent obesity: current perspectives in the United States

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.

The role of ethics consultation in decision making for bariatric surgery in pediatrics

The decision to pursue metabolic and bariatric surgery (MBS) for pediatric patients has become increasingly accepted by patients and their families and by health care professionals. The advancement of pre- and post-operative MBS guidelines, based on accumulating evidence for safety, efficacy, and cost-effectiveness help to map the clinical pathway for MBS consideration. Ethical issues remain possible for each case, however, and consultation with ethical experts can provide clarity in the consideration of MBS. Specifically, ethical issues related to principles of autonomy, justice, beneficence, and non-maleficence may need to be resolved based on patient characteristics, including preadolescent patients and those who present with intellectual disabilities. Institutions that offer MBS for pediatric patients will benefit from collaborating with ethics consultants to develop a structured approach that helps ensure that ethical principles have been adequately addressed for patients presenting for MBS.

Short- and long-term safety and efficacy of bariatric surgery for severely obese adolescents: a narrative review

The selection criteria, safety, and efficacy of bariatric surgery are well established in adults but are less well defined for severely obese adolescents. The number of severely obese adolescents who could benefit from weight loss surgery is increasing, although referral rates have plateaued. Surgical options for these adolescents are controversial and raise several questions. Recent studies, including the prospective Teen-Longitudinal Assessment of Bariatric Surgery Study and the Adolescent Morbid Obesity Surgery Study, help answer these questions. Early bariatric surgical intervention improves body mass index but, more importantly, improves cardiovascular and metabolic co-morbidities of severe obesity. A review of the medical, psychosocial, and economic risks and benefits of bariatric surgery in severely obese adolescents is a step toward improving the management of a challenging and increasing population. We describe the current knowledge of eligibility criteria, preoperative evaluation, surgical options, outcomes, and referral barriers of adolescents for bariatric surgery.

Parental attitudes toward bariatric surgery in adolescents with obesity

BACKGROUND

Parental underestimation of the severity and risks of their child's obesity and parents' potential implicit weight bias contribute to the reluctance to consider bariatric surgery for their adolescent children with obesity. Despite evidence for safety and efficacy of bariatric surgery in adolescents, pediatric providers may be hesitant or uncomfortable to discuss the benefits and refer patients for surgical evaluation. Understanding these barriers is an essential step toward effective long-term care in this patient population.

OBJECTIVES

We hypothesized that parental views on bariatric surgery are primarily influenced by personal experiences with bariatric surgery, their implicit bias, understanding of health risks of obesity, and counseling by pediatric providers.

SETTING

Data were collected and analyzed at an academic medical center in the United States.

METHODS

After a retrospective chart review of 192 adolescents with obesity, a telephone survey of patients' parents was conducted.

RESULTS

Parents of 71.4% of patients who received outpatient weight loss counseling had accurate recollection of that event. Only 12.8% of parents who were referred to lifestyle programs successfully enrolled. Neither prior personal exposure to bariatric surgery nor enrollment of the child in a lifestyle program increased parents' likelihood to consider bariatric surgery for their child (P = .10 and .70, respectively). Most parents (84.6%) who were counseled by their pediatric provider about bariatric surgery would consider it, compared with only 34.5% of the parents who did not receive counseling (P < .001).

CONCLUSIONS

Counseling by pediatric providers, not involvement in lifestyle programs or exposure to bariatric surgery, increased parents' willingness to consider bariatric surgery for their child. Given the current recommendations to incorporate bariatric surgery as a treatment modality in severe adolescent obesity, earlier counseling about the role of surgery by pediatric providers is essential. More detailed provider education on the current state of bariatric surgery in the treatment of severe adolescent obesity is also necessary.

A pilot study of laparoscopic gastric plication in adolescent patients with severe obesity

BACKGROUND

Metabolic and bariatric surgery in adolescents with severe obesity has been demonstrated to be safe and have long-term treatment efficacy. However, less than 0.1% of adolescents meeting criteria undergo surgery.

METHODS

A prospective pilot study of adolescents who underwent laparoscopic gastric plication (LGP) was conducted to evaluate safety and effects on anthropometrics and weight-related medical and psychological comorbidities.

RESULTS

Four adolescents enrolled and underwent LGP; two withdrew 90 days postoperatively and two were followed through 36 months. Preprocedure body mass index was 41.7-53.7 kg/m² with decreases in % change of BMI of 17.5% and 39.7% at 36 months after surgery. Patients reported early satiety, good hunger control, and limited nausea at all time points. There were no major complications. Mild gastroesophageal reflux and abdominal pain occurred; both resolved without surgical intervention. Minor improvements in psychological comorbidities were also reported.

CONCLUSIONS

LGP can be safely performed in adolescents with severe obesity and achieves modest weight loss. Although limited by its small sample size, this study provides preliminary support for LGP as an appropriate surgical option for adolescents. A larger, multidisciplinary study is planned.

TYPE OF STUDY

Prospective case series review.

LEVEL OF EVIDENCE

Level IV evidence: case series without comparison.

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.

Practices and attitudes of doctors and patients to downward referral in Shanghai, China

OBJECTIVES

In China, the rate of downward referral is relatively low, as most people are unwilling to be referred from hospitals to community health systems (CHSs). The aim of this study was to explore the effect of doctors' and patients' practices and attitudes on their willingness for downward referral and the relationship between downward referral and sociodemographic characteristics.

METHODS

Doctors and patients of 13 tertiary hospitals in Shanghai were stratified through random sampling. The questionnaire surveyed their sociodemographic characteristics, attitudes towards CHSs and hospitals, understanding of downward referral, recognition of the community first treatment system, and downward referral practices and willingness. Descriptive statistics, χ2 test and stepwise logistic regression analysis were employed for statistical analysis.

RESULTS

Only 20.8% (161/773) of doctors were willing to accept downward referrals, although this proportion was higher among patients (37.6%, 326/866). Doctors' willingness was influenced by education, understanding of downward referral, and perception of health resources in hospitals. Patients' willingness was influenced by marital status, economic factors and recognition of the community first treatment system. Well-educated doctors who do not consider downward referral would increase their workloads and those with a more comprehensive understanding of hospitals and downward referral process were more likely to make a downward referral decision. Single-injury patients fully recognising the community first treatment system were more willing to accept downward referral. Patients' willingness was significantly increased if downward referral was cost-saving. A better medical insurance system was another key factor for patients to accept downward referral decisions, especially for the floating population.

CONCLUSIONS

To increase the rate of downward referral, the Chinese government should optimise the current referral system and conduct universal publicity for downward referral. Doctors and patients should promote understandings of downward referral. Hospitals should realise the necessity of downward referral, effectively reduce workloads and provide continuing education for doctors. Increasing monetary reimbursement is urgent, as is improving the medical insurance system.

Timing of bariatric surgery for severely obese adolescents: a Markov decision-analysis

PURPOSE

Although controversial, bariatric surgery is increasingly being performed in adolescents. We developed a model to simulate the effect of timing of gastric bypass in obese adolescents on quantity and quality of life.

METHODS

A Markov state-transition model was constructed comparing two treatment strategies: gastric bypass surgery at age 16 versus delayed surgery in adulthood. The model simulated a hypothetical cohort of adolescents with body mass index of 45kg/m(2). Model inputs were derived from current literature. The main outcome measure was quality and quantity of life, measured using quality-adjusted life-years (QALYs).

RESULTS

For females, early gastric bypass surgery was favored by 2.02 QALYs compared to delaying surgery until age 35 (48.91 vs. 46.89 QALYs). The benefit was even greater for males, where early surgery was favored by 2.9 QALYs (48.30 vs. 45.40 QALYs). The absolute benefit of surgery at age 16 increased; the later surgery was delayed into adulthood. Sensitivity analyses demonstrated that adult surgery was favored only when the values for adverse events were unrealistically high.

CONCLUSIONS

In our model, early gastric bypass in obese adolescents improved both quality and quantity of life. These findings are useful for surgeons and pediatricians when counseling adolescents considering weight loss surgery.

Outcomes of bariatric surgery in the young: a single-institution experience caring for patients under 21 years old

BACKGROUND

Medical weight loss options are rarely successful long term in young patients. Bariatric surgery has been shown to be safe and effective in this population.

METHODS

Patients ≤21 years old who had bariatric surgery at our institution between January 2009 and December 2013 were evaluated to determine the safety and efficacy of bariatric surgery in this population. The primary end point was excess weight loss (EWL). Secondary end points included surgical morbidity, improvement in obesity-related metabolic parameters, and subjective obesity-related symptoms at 1 year.

RESULTS

Fifty-four patients were identified who had a laparoscopic Roux-en-Y gastric bypass (LGBP) or laparoscopic sleeve gastrectomy (LSG). Fourteen patients were male (25.9 %), and 40 patients were female (74.1 %). Thirty-seven patients (68.5 %) underwent LGBP, and 17 patients (31.5 %) underwent LSG. Median follow-up was 13.3 months. The baseline BMI was 51.7 kg/m² for the LGBP group and 51.0 kg/m² for the LSG group. EWL was 35.2, 47.6, 62.4, 58.1, and 61.8 % for the LGBP group; 29.7, 44.7, 57.4, 60.3, and 59.0 % for the LSG group at 3, 6, 12, 24, and 36 months, respectively. Our complications included 1 anastomotic bleed, 1 postoperative stricture, and 1 patient who developed vitamin deficiency that manifested as a peripheral neuropathy in the LGBP group. LGBP was more successful than LSG in improving lipid panel parameters and HbA1c at 1 year, and it also seemed to offer better subjective improvement in obesity-related symptoms.

CONCLUSIONS

LGBP and LSG seem to confer comparable weight loss benefit in patients ≤21 years old with acceptable surgical morbidity.

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.

Understanding Academic Clinicians' Decision Making for the Treatment of Childhood Obesity

BACKGROUND

Although most clinicians agree that obesity is a major problem, treatment rates remain low. We conducted this discrete choice experiment (DCE) to understand academic clinicians' decisions in treating childhood obesity.

METHODS

A total of 198 academic pediatric surgeons, pediatricians, family physicians, and allied health professionals were recruited from 15 teaching hospitals across Canada to participate in this DCE. Participants completed 15 tasks choosing between three obesity treatment scenarios to identify the scenario in which they would most likely treat pediatric obesity.

RESULTS

Latent class analysis revealed two classes with early intervention and late intervention preferences. Participants in the early intervention group (30%) were sensitive to variations in patient and family support. They would likely intervene if patients were obese, with normal lipid levels, were prediabetic, had high blood pressure, and when obesity was lifestyle associated. Late intervention clinicians (70%) were more likely to intervene if patients were morbidly obese, had abnormal lipid levels, required insulin for diabetes, had very high blood pressure, or when obesity impacted the patient's mental health. Simulations predicted that increasing colleague support for intervention, providing expert consultation, and mobilizing multidisciplinary support would increase the likelihood of treating pediatric obesity earlier from 16.1% to 81.5%.

CONCLUSIONS

This DCE was implemented to understand the factors clinicians use in making decisions. Most academic clinicians choose to intervene late in the clinical course when more-severe obesity-related morbidities are present. Increased support from colleagues, expert consultation, and multidisciplinary support are likely to lead to earlier treatment of obesity among academic clinicians caring for children.

Clinical experience of weight loss surgery in morbidly obese Korean adolescents

PURPOSE

Comprehensive multidisciplinary weight management programs encompassing various conservative measures have shown only modest weight loss results in obese children and adolescents; therefore, bariatric surgery for this population has become a matter of discussion. This study aimed to present our experience with and outcomes for laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in morbidly obese Korean adolescents.

MATERIALS AND METHODS

The prospectively established database of all patients undergoing bariatric surgery at Soonchunhyang University Seoul Hospital, Korea between January 2011 and January 2013 was retrospectively reviewed. Adolescents aged 14 to 20 years were included in the present analyses.

RESULTS

Twenty-two adolescents underwent bariatric surgery during the study period; 14 underwent LSG and 8, LRYGB. Of these, 17 were female and 5 were male. The mean age was 19 years. Their mean body weight and body mass index (BMI) before surgery were 115 kg and 40.1 kg/m². The only postoperative complication was intraluminal bleeding in 1 patient, which was managed conservatively. The mean BMI decreased to 29.1 kg/m² after a mean follow-up of 10 months. The percent excess weight loss (%EWL) at 1, 3, 6, and 12 months postoperatively were 19.6, 39.9, 52.6, and 74.2%, respectively. Only 1 patient showed %EWL less than 30% at 12 months after surgery. All patients with diabetes and sleep apnea were cured of their disease, and other comorbidities also improved or resolved after surgery.

CONCLUSION

Bariatric surgery leads to significant short-term weight loss along with resolution of obesity-related comorbidities in obese children and adolescents.

Pediatric health care provider perceptions of weight loss surgery in adolescents

This study explored pediatric health care providers' obesity treatment practices and perceptions about adolescent weight loss surgery (WLS). Surveys were e-mailed to pediatric listservs. After descriptive analyses, correlations, chi-squares, and one-way analyses of variance compared responses by provider characteristics. Surveys were completed by 109 providers. Almost half do not routinely measure body mass index. Providers typically counsel patients about lifestyle change, with limited perceived benefit; <10% have ever referred patients for WLS, citing cost (20%), risk (49%), or "not indicated in pediatrics" (17%) as reasons. However, when presented with patient scenarios of different ages and comorbidities, likeliness to refer for WLS increased substantially. Surgeons, younger providers and those with fewer years of experience were more likely to refer for WLS (P < .05). Despite expert consensus recommendations supporting WLS as part of a comprehensive obesity treatment plan, significant pediatric provider resistance to refer obese adolescents remains. Improved referral and management practices are needed.

Adolescent bariatric surgery--thoughts and perspectives from the UK

Opinions of healthcare professionals in the United Kingdom regarding bariatric surgery in adolescents are largely unknown. This study aims to explore the perspectives of medical professionals regarding adolescent bariatric surgery. Members of the British Obesity and Metabolic Surgery Society and groups of primary care practitioners based in London were contacted by electronic mail and invited to complete an anonymous online survey consisting of 21 questions. Ninety-four out of 324 questionnaires were completed. 66% of professionals felt that adolescents with a body mass index (BMI) >40 or BMI >35 with significant co-morbidities can be offered surgery. Amongst pre-requisites, parental psychological counseling was chosen most frequently. 58% stated 12 months as an appropriate period for weight management programs, with 24% regarding 6 months as sufficient. Most participants believed bariatric surgery should only be offered ≥ 16 years of age. However, 17% of bariatric surgeons marked no minimum age limit. Over 80% of the healthcare professionals surveyed consider bariatric surgery in adolescents to be acceptable practice. Most healthcare professionals surveyed feel that adolescent bariatric surgery is an acceptable therapeutic option for adolescent obesity. These views can guide towards a consensus opinion and further development of selection criteria and care pathways.

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.

Effect of ethnicity on weight loss among adolescents 1 year after bariatric surgery

AIM: To investigate whether or not bariatric surgery weight outcomes vary by ethnicity in a large, nationally representative sample of adolescents.

METHODS: The Bariatric Outcomes Longitudinal Database was used for analysis and contains data on surgeries performed on adolescents from 2004 to 2010 from 423 surgeons at 360 facilities across the United States Adolescents (n = 827) between 11 and 19 years old who underwent either gastric bypass or adjustable gastric banding surgery were included in the analysis. Outcome measures included changes in anthropometric measurements [weight (kg) and body mass index] from baseline to 3 (n = 739), 6 (n = 512), and 12 (n = 247) mo after surgery.

RESULTS: A year after patients underwent either gastric bypass (51%) or adjustable gastric banding (49%) surgery, mean estimated weight loss for all ethnic groups differed by a maximum of only 1.5 kg, being 34.3 kg (95%CI: 30.0-38.5 kg) for Hispanics, 33.8 kg (95%CI: 27.3-40.3 kg) for non-Hispanic blacks, and 32.8 kg (95%CI: 30.9-34.7 kg) for non-Hispanic whites. No overall pairwise group comparisons were significant, indicating that no ethnic group had better weight loss outcomes than did another.

CONCLUSION: Bariatric surgery substantially reduces the weight of severely obese adolescents at 1 year post-procedure with little variation by ethnicity and/or gender. These results suggest that bariatric surgery is a safe and reasonable treatment for all severely obese adolescents with the appropriate indications.

Changes in weight and co-morbidities among adolescents undergoing bariatric surgery: 1-year results from the Bariatric Outcomes Longitudinal Database

BACKGROUND

Bariatric surgery is 1 of the few effective treatments of morbid obesity. However, the weight loss and other health-related outcomes for this procedure in large, diverse adolescent patient populations have not been well characterized. Our objective was to analyze the prospective Bariatric Outcomes Longitudinal Database (BOLD) to determine the weight loss and health related outcomes in adolescents. The BOLD data are collected from 423 surgeons at 360 facilities in the United States.

METHODS

The main outcome measures included the anthropometric and co-morbidity status at baseline (n = 890) and at 3 (n = 786), 6 (n = 541), and 12 (n = 259) months after surgery. Adolescents (75% female; 68% non-Hispanic white, 14% Hispanic, 11% non-Hispanic black, and 6% other) aged 11 to 19 years were included in the present analyses.

RESULTS

The overall 1-year mean weight loss for those who underwent gastric bypass surgery was more than twice that of those who underwent adjustable gastric band surgery (48.6 versus 20 kg, P < .001). Similar results were found for all other anthropometric changes and comparisons within 1 year between surgery types (P < .001). In general, the gastric bypass patients reported more improvement than the adjustable gastric band patients in co-morbidities at 1 year after surgery. A total of 45 readmissions occurred among gastric bypass patients and 10 among adjustable gastric band patients, with 29 and 8 reoperations required, respectively.

CONCLUSIONS

The weight loss at 3, 6, and 12 months after surgery is approximately double in adolescent males and females who underwent gastric bypass surgery versus those who underwent adjustable gastric band surgery. Bariatric surgery can safely and substantially reduce weight and related co-morbidities in morbidly obese adolescents for ≥1 year.

The controversy over pediatric bariatric surgery: an explorative study on attitudes and normative beliefs of specialists, parents, and adolescents with obesity

Despite the reported limited success of conventional treatments and growing evidence of the effectiveness of adult bariatric surgery, weight loss operations for (morbidly) obese children and adolescents are still considered to be controversial by health care professionals and lay people alike. This paper describes an explorative, qualitative study involving obesity specialists, morbidly obese adolescents, and parents and identifies attitudes and normative beliefs regarding pediatric bariatric surgery. Views on the etiology of obesity-whether it should be considered primarily a medical condition or more a psychosocial problem-seem to affect the specialists' normative opinions concerning the acceptability of bariatric procedures as a treatment option, the parents' feelings regarding both being able to influence their child's health and their child being able to control their own condition, and the adolescents' sense of competence and motivation for treatment. Moreover, parents and adolescents who saw obesity as something that they could influence themselves were more in favor of non-surgical treatment and vice versa. Conflicting attitudes and normative views-e.g., with regard to concepts of disease, personal influence on health, motivation, and the possibility of a careful informed consent procedure-play an important role in the acceptability of bariatric surgery for childhood obesity.

Bariatric surgery for obese children and adolescents: a review of the moral challenges

BACKGROUND

Bariatric surgery for children and adolescents is becoming widespread. However, the evidence is still scarce and of poor quality, and many of the patients are too young to consent. This poses a series of moral challenges, which have to be addressed both when considering bariatric surgery introduced as a health care service and when deciding for treatment for young individuals. A question based (Socratic) approach is applied to reveal underlying moral issues that can be relevant to an open and transparent decision making process.

DISCUSSION

A wide range of moral issues with bariatric surgery for children and adolescents is identified in the literature. There is a moral imperative to help obese minors avoiding serious health problems, but there is little high quality evidence on safety, outcomes, and cost-effectiveness for bariatric surgery in this group. Lack of maturity and family relations poses a series of challenges with autonomy, informed consent, assent, and assessing the best interest of children and adolescents. Social aspects of obesity, such as medicalization, prejudice, and discrimination, raise problems with justice and trust in health professionals. Conceptual issues, such as definition of obesity and treatment end-points, present moral problems. Hidden interests of patients, parents, professionals, industry, and society need to be revealed.

SUMMARY

Performing bariatric surgery for obese children and adolescents in order to discipline their behavior warrants reflection and caution. More evidence on outcomes is needed to be able to balance benefits and risks, to provide information for a valid consent or assent, and to advise minors and parents.

Trends and outcomes of adolescent bariatric surgery in California, 2005-2007

OBJECTIVE

The goal of this study was to evaluate trends, and outcomes of adolescents who undergo bariatric surgery.

PATIENTS AND METHODS

Patients younger than 21 years who underwent elective bariatric surgery between 2005 and 2007 were identified from the California Office of Statewide Health Planning and Development database. Multivariate logistic regression was used to identify factors associated with the type of surgery.

RESULTS

Overall, 590 adolescents (aged 13-20 years) underwent bariatric surgery in 86 hospitals. White adolescents represented 28% of those who were overweight but accounted for 65% of the procedures. Rates of laparoscopic adjustable gastric banding (LAGB) increased 6.9-fold from 0.3 to 1.5 per 100,000 population (P<.01), whereas laparoscopic Roux-en-Y gastric bypass (LRYGB) rates decreased from 3.8 to 2.7 per 100 000 population (P<.01). Self-payers were more likely to undergo LAGB (relative risk [RR]: 3.51 [95% confidence interval: 2.11-5.32]) and less likely to undergo LRYGB (RR: 0.45 [95% confidence interval: 0.33-0.58]) compared with privately insured adolescents. The rate of major in-hospital complication was 1%, and no deaths were reported. Of the patients who received LAGB, 4.7% had band revision/removal. In contrast, 2.9% of those who received LRYGB required reoperations.

CONCLUSIONS

White adolescent girls disproportionately underwent bariatric surgery. Although LAGB has not been approved by the US Food and Drug Administration for use in children, its use has increased dramatically. There was a complication rate and no deaths. Long-term studies are needed to fully assess the efficacy, safety, and health care costs of these procedures in adolescents.