Adolescent Obesity and Bariatric Surgery

Novel Insights into the Pathogenesis and Management of the Metabolic Syndrome

The metabolic syndrome, by definition, is not a disease but is a clustering of individual metabolic risk factors including abdominal obesity, hyperglycemia, hypertriglyceridemia, hypertension, and low high-density lipoprotein cholesterol levels. These risk factors could dramatically increase the prevalence of type 2 diabetes and cardiovascular disease. The reported prevalence of the metabolic syndrome varies, greatly depending on the definition used, gender, age, socioeconomic status, and the ethnic background of study cohorts. Clinical and epidemiological studies have clearly demonstrated that the metabolic syndrome starts with central obesity. Because the prevalence of obesity has doubly increased worldwide over the past 30 years, the prevalence of the metabolic syndrome has markedly boosted in parallel. Therefore, obesity has been recognized as the leading cause for the metabolic syndrome since it is strongly associated with all metabolic risk factors. High prevalence of the metabolic syndrome is not unique to the USA and Europe and it is also increasing in most Asian countries. Insulin resistance has elucidated most, if not all, of the pathophysiology of the metabolic syndrome because it contributes to hyperglycemia. Furthermore, a major contributor to the development of insulin resistance is an overabundance of circulating fatty acids. Plasma fatty acids are derived mainly from the triglycerides stored in adipose tissues, which are released through the action of the cyclic AMP-dependent enzyme, hormone sensitive lipase. This review summarizes the latest concepts in the definition, pathogenesis, pathophysiology, and diagnosis of the metabolic syndrome, as well as its preventive measures and therapeutic strategies in children and adolescents.

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.

Weight loss surgery for morbidly obese adolescents: a review

Obesity is common among adolescents resulting in substantial comorbidities and reduced life expectancy. Conservative treatments normally fail to ensure significant and sustained weight loss and suitable adolescents should be offered weight loss surgery. Laparoscopic Adjustable Gastric Banding and Roux-en-Y Gastric Bypass are commonly used in adolescents. Complications in RYGB tend to be more severe, but the procedure leads to more immediate results. LAGB complications are often device-related and less severe. Dietary adherence, eating behaviour and unrealistic patient expectations often cause problems. Significant and sustained weight loss of 50-70 per cent of excess weight is achievable, comorbidities and psychological problems improve. Meticulous patient selection and preparation and good post-operative care are vital for successful weight loss surgery. Weight loss surgery is safe, effective and economically viable with nurses playing a vital role at all stages of its application.

Effectiveness and cost-effectiveness of paediatric bariatric surgery: a systematic review

Strong evidence for successful and cost-effective obesity management strategies is still generally lacking, leading the medical profession to rely increasingly on surgical options to treat obesity in children and adolescents. We performed a systematic review to examine the effectiveness of surgical interventions to treat obese children and adolescents, and whether they are cost-effective. We searched PubMed, ISI Web of Science, Embase and the Cochrane Library to 6 September 2010, and hand-searched bibliographies. We included articles with English abstracts if they examined subjects ≤19 years of age, reported at least one postoperative weight loss measure and at least 1 year of postoperative follow-up. Thirty-seven relevant papers on bariatric surgery effectiveness in 831 children or adolescents were included, spanning 36 years. Thirteen studies examined gastric banding, with mean body mass index (BMI) reductions ranging from 8.5 to 43 kg m(-2) . Weight gain was reported in one case study. Eight papers examined Roux-en-Y gastric bypass, with mean BMI reductions ranging from 9 to 25 kg m(-2) . Fourteen publications studied other forms of bariatric surgery: sleeve gastrectomies, vertical banded gastroplasty, biliopancreatic diversion or a combination of procedures. Mean BMI reductions ranged from 9 to 24 kg m(-2) . Three surgery-related mortalities were reported, as was weight regain in several cases. The majority of studies reported resolution or improvement of comorbid conditions. A range of postoperative complications were identified across surgery types, including: ulcers, intestinal leakage, wound infection, anastomotic stricture, nutritional deficiencies, bowel obstruction, pulmonary embolism, disrupted staple lines, band slippage, psychological intolerance and repeated vomiting. Evidence on cost-effectiveness was limited to one Australian modelling project, which deemed laparoscopic adjustable gastric banding cost-effective for adolescents. Existing evidence - although based generally on underpowered, retrospective studies - suggests that bariatric surgery in older children results in significant weight loss and improvements in comorbidities and quality of life. However, postoperative complications, compliance and follow-up may be more problematic in adolescents than adults, and availability of long-term data on safety, effectiveness and cost-effectiveness remains largely unknown. Pending an improvement in the quality of available evidence, a cautious approach to child and adolescent bariatric surgery is warranted, and reversible techniques are advisable compared to approaches that permanently alter anatomy.

Bariatric surgery in young massively obese diabetic patients

Obesity is the most important lifestyle-related risk factor for type 2 diabetes (T2DM). The prevalence of T2DM in adolescents is increasing in parallel with the increasing incidence of major obesity. In adult obese subjects, the greatest degree of T2DM prevention, improvement or recovery has been reported in patients who have undergone bariatric surgery. However, few studies are available on the benefits and risks of bariatric surgery in adolescents with T2DM. The indications for obesity surgery in this population are unusual, and should only be considered in academic settings after comprehensive interdisciplinary evaluation.

Polycystic ovary syndrome in the adolescent

Polycystic ovary syndrome (PCOS) is now recognized as a heterogeneous disorder that results in overproduction of androgens, primarily from the ovary, leading to anovulation and hirsutism and is associated with insulin resistance. Long-term sequellae of PCOS include higher risk for diabetes, obesity, metabolic syndrome, endometrial hyperplasia, and anovulatory infertility. Symptoms in the adolescent include oligomenorrhea, hirsutism, acne, and weight gain. Insulin resistance, impaired glucose tolerance, and diabetes have also been demonstrated in adolescents who have PCOS. Treatment should be instituted early to decrease symptoms and long term sequellae of PCOS. Weight loss, oral contraceptives, and antiandrogens are effective in treating the symptoms of this disorder. Insulin-sensitizing medications have been shown to be effective but should be used with caution until larger randomized trials have shown short- and long term benefits and efficacy over traditional therapies in the adolescent population.

[Bariatric surgery for morbid obesity in childhood and adolescence: where do we stand in 2008?]

Die Adipositaschirurgie bei Kindern und Jugendlichen findet in Deutschland bisher keine breite Akzeptanz, obwohl es auch bei uns zahlreiche Patienten gibt, die ihr Gewicht trotz intensiver Therapien nicht dauerhaft reduzieren kÖnnen. Wie auch bei Erwachsenen weisen viele dieser Kinder und Jugendlichen bereits eine oder mehrere metabolische und/oder kardiovaskulÄre VerÄnderungen des metabolischen Syndroms auf. Der folgende Artikel vergleicht die nationalen mit den internationalen Erfahrungen hinsichtlich der Leitlinien, Operationstechniken und Ergebnisse. Dabei zeigt sich, dass es in Deutschland bisher weder eine einheitliche Leitlinie noch ein zentrales Register fÜr Adipositaschirurgie bei Kindern und Jugendlichen gibt. Internationalgelten die Empfehlungen der Bariatric Scientific Collaborative Group (BSCG) auch fÜr Kinder als Standard. Operativ finden sich in der Literatur im Wesentlichen der Roux-Y-Magenbypass und das Magenband, in letzter Zeit auch die Schlauchmagenbildung (sleeve gastrectomy). Diese werden insbesondere in den USA in designierten pÄdiatrischen Zentren durchgefÜhrt. Deren Erfolgs- und Komplikationsraten scheinen Ähnlich wie bei Erwachsenen zu sein. Allerdings bleibt dabei vÖllig offen, wie diese Ergebnisse angesichts der sehr viel lÄngeren Lebenserwartung zu beurteilen sein werden. Als Konsequenz ergibt sich, dass fÜr Kinder und Jugendliche mit morbider Adipositas a) spezielle Zentren mit dem gesamten Behandlungsspektrum etabliert werden sollten, b) Leitlinien fÜr diese Adipositaschirurgie definiert werden mÜssen und c)eine langfristige Nachsorge aller Patienten im Rahmen einerzentralen Studie gewÄhrleistet sein mÜsste, um Erfahrungen fÜr die Zukunft zu generieren. Bariatric Surgery for Morbid Obesity in Childhood and Adolescence: Where Do We Stand in 2008? Bariatric surgery for children and adolescents with morbid obesity has not gained broad acceptance in Germany yet. Nevertheless, these children often fail to reduce weight despite intensive weight loss programmes and suffer from an associate metabolic syndrome, just like adults. Thus, bariatric surgery may be a favourable option. The present article compares national and international experiences concerning guidelines, surgical procedures, and results. It becomes obvious that Germany has neither specific guidelines for children and adolescents nor a central registry. Internationally, the recommendation from the Bariatric Scientific Collaborative Group (BSCG) should be taken as the standard. As in adults, most surgeons performRoux-Y gastric bypass or gastric banding. Additionally, sleeve gastrectomy is gaining some popularity. These procedures are performed in designated pediatric centres especially in the US. Their success and complication rates are similar to those found in adults. The overall long-term consequences, however, remain unclear. Thus, for bariatric surgery in children and adolescents it may be concluded that a) these patients should be treated in designated centres that offer the full range of therapeutic options, b) specific guidelines should be established, especially in Germany, and c) a long-term postoperative study of all patients is necessary to collect all data and refine the techniques used.

Management of the challenging bariatric surgical patient

Despite the continued increase in surgical procedures for weight loss, the dramatic increase in the prevalence of morbid obesity far outpaces the treatments to correct it. As a result, the primary care physician is increasingly more likely to be evaluating patients who are either candidates for weight loss surgery or who have already undergone a weight loss procedure. Unique medical and social situations must be considered when evaluating these patients, and it is anticipated that all physicians will be seeing a greater number of complex or challenging patients.

Bariatric surgery for pediatric extreme obesity: now or later?

Obesity is a multifactorial disease of epidemic and global proportions that poses the most significant threat to the health of our younger generations. Those who are the most extremely affected bear the largest burden of health problems. In the US, extreme obesity affects approximately 9 million adults and 2 million children, and is associated with both immediate health problems and later health risk, including premature mortality. Present medical and behavioral interventions for extreme obesity in adults and children rarely result in the significant, durable weight loss necessary to improve health outcomes, prompting a search for more aggressive measures. Weight loss (bariatric) surgery has been advocated as an intervention for those with extreme obesity. In adults, bariatric surgery results in prolonged weight control and improvement in serious obesity comorbidities, namely type 2 diabetes, dyslipidemias, hypertension and obstructive sleep apnea syndrome. A surge in weight loss operations for adolescents has been observed recently, with a threefold increase in case volumes nationwide from 2000 to 2003. Current evidence suggests that after bariatric surgery, adolescents lose significant weight and serious obesity-related medical conditions and psychosocial status are improved. Thus it is reasonable to propose that bariatric surgery performed in the adolescent period may be more effective treatment for childhood-onset extreme obesity than delaying surgery for extremely obese youth until adulthood. This position has been echoed by a number of groups and an independent systematic review. Finally, it is conceivable that bariatric surgery performed in adulthood for childhood onset extreme obesity may not be as effective for comorbidity treatment as surgery performed earlier during adolescence. The purpose of this review is to examine the evidence, which supports early rather than later use of bariatric surgery in the treatment of extreme obesity, and to present this information in light of the medical and surgical risks of bariatric surgery.