Managing adolescent obesity and the role of bariatric surgery

British Obesity and Metabolic Surgery Society Guidelines on perioperative and postoperative biochemical monitoring and micronutrient replacement for patients undergoing bariatric surgery-2020 update

Bariatric surgery is recognized as the most clinically and cost-effective treatment for people with severe and complex obesity. Many people presenting for surgery have pre-existing low vitamin and mineral concentrations. The incidence of these may increase after bariatric surgery as all procedures potentially cause clinically significant micronutrient deficiencies. Therefore, preparation for surgery and long-term nutritional monitoring and follow-up are essential components of bariatric surgical care. These guidelines update the 2014 British Obesity and Metabolic Surgery Society nutritional guidelines. Since the 2014 guidelines, the working group has been expanded to include healthcare professionals working in specialist and non-specialist care as well as patient representatives. In addition, in these updated guidelines, the current evidence has been systematically reviewed for adults and adolescents undergoing the following procedures: adjustable gastric band, sleeve gastrectomy, Roux-en-Y gastric bypass and biliopancreatic diversion/duodenal switch. Using methods based on Scottish Intercollegiate Guidelines Network methodology, the levels of evidence and recommendations have been graded. These guidelines are comprehensive, encompassing preoperative and postoperative biochemical monitoring, vitamin and mineral supplementation and correction of nutrition deficiencies before, and following bariatric surgery, and make recommendations for safe clinical practice in the U.K. setting.

Teenagers with obesity: Long-term results of laparoscopic adjustable gastric banding

BACKGROUND

Obesity is a rapidly spreading chronic disease worldwide. Long-term results are critical to assess the effectiveness of a bariatric procedure, particularly in young patients who have long life expectancy.

METHODS

A retrospective study on adolescents with morbid obesity who underwent Laparoscopic Adjustable Gastric Banding (LAGB) at our institute from 1995 to 2018 was made. Primary endpoints were efficacy, in term of weight loss and comorbidity resolution, occurrence of complications and reoperations.

RESULTS

Fifty-nine patients underwent LAGB between 1995 and 2018. Intra- and post-operative mortality was absent. The patients' presence at follow-up at 5, 10 and 15 years was 38/50 (76%), 18/25 (72%) and 5/8 (63%), respectively. At those times the mean excess weight loss percentage was 61.7 ± 29.4, 48.1 ± 50.4 and 55.8 ± 51.2, respectively. Comorbidity resolution rates were 100% for patients with diabetes, 78% for patients with hypertension, 75% for joint pain suffers, 69% for patients with sleep apnea and 57% for patients with anxiety and depression. Total reoperation rate was 30.5%. The band was removed in 8 patients: 3 due to erosions, 3 by patients' choice and 2 conversions to other bariatric procedures.

CONCLUSION

LAGB, in combination with the patients' close follow-up performed by an interdisciplinary team, can be an effective long-term surgical treatment for teenagers with morbid obesity.

LEVEL OF EVIDENCE

Level IV.

Partnering Support Interventions with Bariatric Surgery to Maximize Health Outcomes in Adolescents with Severe Obesity

OBJECTIVE

Rates of adolescents with severe obesity continue to rise worldwide, with concurrent increases in metabolic and bariatric surgery (MBS) uptake. The gap between support (lifestyle, pharmacotherapy) interventions and MBS as treatment options for adolescents has been understudied. This review, couched in a socio-ecological framework, investigates how support interventions for adolescents with severe obesity could be combined or sequenced with MBS to optimize health outcomes.

METHODS

A comprehensive search revealed 36 published articles between 1995 and 2019 that included the combination of support interventions and MBS among adolescents.

RESULTS

There were no studies that specifically reported outcomes or effect sizes for the combination of lifestyle intervention with MBS. Previous studies have reported individual results for either lifestyle intervention or MBS but not for their compound effect.

CONCLUSIONS

As rates of adolescents with severe obesity are on the rise globally, future research should focus on how partnering support interventions with MBS can amplify positive short- and long-term health outcomes and within a socio-ecological framework. Understanding the sequence of these approaches will be of particular importance. High-risk and vulnerable populations such as ethnic minorities who have suffered a disproportionate burden of the obesity epidemic must be included in rigorously tested future trials of combination interventions to maximize health outcomes worldwide.

Bariatric Surgery in Children: Indications, Types, and Outcomes

PURPOSE OF REVIEW

The purpose of this review is to discuss the current state of surgical intervention for obesity in children and adolescents. Specifically, this review will discuss the different types of metabolic and bariatric surgery (MBS) procedures, guidelines for patient selection, and recent findings regarding surgical outcomes and complications.

RECENT FINDINGS

MBS is safe in adolescents and has also demonstrated sustainable long term weight loss and improvement in obesity-associated comorbidities. A recent prospective multi-institutional trial demonstrated BMI reductions of 3.8 kg/m² (8%) to 15.1 kg/m² (28%) after 3 years among adolescents undergoing the three most common MBS procedures. Moreover, MBS is associated with remission of type 2 diabetes, prediabetes, hypertension, dyslipidemia, and abnormal kidney function in 65-95% of patients in the study. Childhood and adolescent obesity is a continuing problem that has not been adequately addressed by the medical community. MBS is currently the most successful strategy for significant and sustained weight loss and improvement of associated comorbidities. This review focuses on the different types of MBS, the selection and preparation of patients for surgery, and the expected outcomes and common complications.

Bariatric Surgery Needs a Seat at the Children's Table: Bridging the Perception and Reality of the Role of Bariatric Surgery in the Treatment of Obesity in Adolescents

The long-term morbidity of obesity in adolescents is well recognized nationally and represents a major health concern for the population of the near future. Traditional medical management of obesity focuses on addressing behavioral modification, dietary and exercise programs, and, to a lesser degree, pharmaceuticals. Although these strategies are relatively effective, they suffer from the lack of sustained benefit, a high relapse rate, and, in case of pharmacotherapy, potentially dangerous adverse effects. Bariatric surgery in adolescents has often been characterized as a risky intervention with unknown long-term benefits. However, recent data establish that a sustained, clinically meaningful effect on weight loss, as well as a reduction in chronic morbidities related to obesity, can be achieved. The role of bariatric surgery as an accepted adjunctive strategy in the treatment of obesity in adolescents is becoming more recognized; however, a number of barriers exist that prevent the timely evaluation of adolescents with obesity for potential surgical intervention. We examine these barriers in light of recent advancements to help better define the role of bariatric surgery in the treatment of obesity in adolescent population.

Acanthosis nigricans in obese adolescents: prevalence, impact, and management challenges

Obesity in adolescence is a public health priority because it usually tracks into adulthood, resulting in enormous medical and social costs. This underscores the importance of early identification and intervention. Acanthosis nigricans (AN) was once considered a rare paraneoplastic dermatosis, but is now frequently observed in obese adolescents. Current understanding suggests that it is associated with insulin resistance and has a unique role in secondary prevention. The purpose of this narrative review is to provide a comprehensive overview of AN in obese adolescents, covering its history, current knowledge on the condition, its clinical significance, management challenges, and the direction of future research.

Bariatric Surgery in Youth

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