Bariatric surgery for adolescents

Comparing bariatric surgery and medical therapy for obese adolescents with type 2 diabetes

BACKGROUND

Mounting evidence in recent years has demonstrated that the number of obese adolescents has continued to rise. Obese adolescents are more likely to be diagnosed with type 2 diabetes, which causes additional harm. This study aimed to compare the clinical outcomes of bariatric surgery and medical treatment.

METHODS

We conducted a multicenter, nonrandomized, retrospective study on 202 obese adolescents with type 2 diabetes who received surgery or medical treatment in three hospitals from 2017 to 2019. We analyzed the effects of surgery and medical treatment in terms of weight loss, glycemic control and the remission of type 2 diabetes. Propensity score matching was conducted to balance the confounding factors.

RESULTS

Among the 202 adolescents, 109 adolescents underwent surgery, and the remaining 93 adolescents received nonsurgical treatment. Both in the entire cohort and in the propensity-score matching cohort, the mean body mass index (BMI) and total weight in the surgery group notably decreased. Similarly, the effect of surgery on glycemic control (with respect to HBG, HbA1c, HOMA-IR) was superior to that of medical treatment. In the surgery group, the remission rate of diabetes was 76.1% in the entire cohort and 80.5% in the matched group, which was significantly higher than that in the control group (6.5% and 5.7%, respectively). In addition, LRYGB had better effects on weight loss and glycemic control than LSG.

CONCLUSION

Bariatric surgery is more effective in the control of weight loss and type 2 diabetes than medical treatment. The effects between different types of bariatric surgeries remain to be further investigated, and longer follow-up times are needed.

Changes in Dietary Intake and Eating Behavior in Adolescents After Bariatric Surgery: an Ancillary Study to the Teen-LABS Consortium

BACKGROUND

A growing number of studies suggest that bariatric surgery is safe and effective for adolescents with severe obesity. However, surprisingly little is known about changes in dietary intake and eating behavior of adolescents who undergo bariatric surgery.

OBJECTIVE

Investigate changes in dietary intake and eating behavior of adolescents with obesity who underwent bariatric surgery (n = 119) or lifestyle modification (LM) (n = 169).

SETTING

University-based health systems METHODS: A prospective investigation of 288 participants (219 female and 69 male) prior to bariatric surgery or LM and again 6, 12, and 24 months (surgery patients only) after treatment. Measures included changes in weight, macronutrient intake, eating behavior, and relevant demographic and physiological variables.

RESULTS

Adolescents who underwent bariatric surgery experienced significantly greater weight loss than those who received LM. The two groups differed in self-reported intake of a number of macronutrients at 6 and 12 months from baseline, but not total caloric intake. Patients treated with surgery, compared to those treated with LM, also reported significantly greater reductions in a number of disordered eating symptoms. After bariatric surgery, greater weight loss from postoperative month 6 to 12 was associated with self-reported weight consciousness, craving for sweets, and consumption of zinc.

CONCLUSIONS

Adolescents who underwent bariatric surgery, compared to those who received LM, reported significantly greater reductions in weight after 1 year. They also reported greater reductions in disordered eating symptoms. These findings provide new information on changes in dietary intake and eating behavior among adolescents who undergo bariatric surgery.

Is there a role for shared decision-making in pediatric weight management?

Shared decision-making (SDM) is central to personalising health and medical decisions. This decisional model encourages patients to act as managers of their own care while maintaining a partnership with health professionals. Although applied to some conditions, SDM has been used infrequently in pediatric weight management (PWM). Herein, we highlight the applicability and usefulness of SDM in making several important decisions related to PWM, including referral-making to different levels of care and treatment initiation and implementation. We conclude by describing possible challenges that may arise when implementing this model and suggest strategies to optimise the use of SDM in PWM.

Laparoscopic sleeve gastrectomy in severely obese adolescents: effects on metabolic profile

OBJECTIVE

The objective was to conduct clinical and metabolic evaluations of obese adolescents before and after laparoscopic sleeve gastrectomy (LSG) (up to 24 months).

SUBJECTS AND METHODS

This was designed as a retrospective, descriptive series of cases study, conducted in Instituto da Criança, São Paulo, Brazil. Analysis of clinical and laboratory data from 22 obese adolescents between 14 and 19 years old submitted to LSG between 2007 and 2014. Patients had BMI > 40 kg/m2 or BMI > 35 kg/m2 with comorbidities. Anthropometric, clinical and laboratory assessments were performed: before surgery, 6, 12, 18, and 24 months after surgery. We assessed weight loss and metabolic changes up to 24 months after LSG.

RESULTS

The mean preoperative weight and BMI were 128.5 kg (SD = 23.1) and 46.5 kg/m2 (SD = 74), respectively. There was an average weight loss of 34.5 kg in the first 12 months' post LSG, corresponding to a 60% excess weight loss (EWL), as well as an average reduction in BMI of 12.3 kg/m2. However, after 24 months, the average EWL was 45%, corresponding to an average weight regain (WR) of 13.3 kg (15%) within two years. LSG improved dyslipidemia in 67.8% of patients, a significant remission of hepatic steatosis 47% and 37.7% systemic arterial hypertension; type 2 diabetes remission was complete.

CONCLUSIONS

LSG proved to be a safe and effective procedure and seems to be the new hope for the obesity epidemic.

Laparoscopic sleeve gastrectomy for morbidly obese adolescents in Singapore

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) outcomes among adolescents and factors associated with adolescent obesity in Singapore were evaluated.

METHODS

Prospectively collected data of patients aged 16-19 years who underwent LSG was retrospectively reviewed. A lifestyle questionnaire, Berlin and Epworth scores, and Patient Health Questionnaire-9 scores were collected. Preoperative anthropometrics, comorbidities, weight loss and body composition outcomes were recorded.

RESULTS

Among 208 LSGs, 13 (6.3%) were performed on obese adolescents. Mean age and body mass index (BMI) at first presentation were 19.1 ± 0.9 (range 16.8-19.8) years and 46.2 ± 6.3 (range 36-57) kg/m², respectively. There was family history of obesity (n = 7) and regular consumption of high-calorie drinks (n = 12). Most patients had comorbidities (n = 12), including hypertension (n = 5), asthma (n = 4), diabetes mellitus (n = 3), hernia (n = 3) and obstructive sleep apnoea requiring continuous positive airway pressure support (n = 3). At one year, excess weight loss was 64.3% ± 34.7% (range 21.8%-101.5%), while BMI and fat mass dropped to 31.2 ± 7.6 (range 23-40) kg/m² and 17.4 kg, respectively. Pain score was 2/10 at 24 hours after surgery. Mean postoperative stay was 2.7 days. No complications or readmissions occurred. Remission of diabetes mellitus and hypertension was reported in two of three and four of five adolescents, respectively, within one year of surgery.

CONCLUSION

LSG is a safe option for adolescents with good short-term weight loss outcomes and remission of metabolic comorbid conditions.

Bariatric surgery: is it reasonable before the age of 16?

Objective:

to assess the severity of obesity in children and adolescents through the presence of comorbidities and the potential indication of bariatric surgery.

Methods:

we conducted a cross-sectional study with clinical and laboratory data of the first consultation of patients at the childhood obesity clinic at a tertiary hospital from 2005 to 2013. We divided the patients into groups with or without potential indication for surgery, and recorded age, gender, birth weight, age of obesity onset, BMI Z score, presence of acanthosis nigricans, blood pressure, total cholesterol and fractions, triglycerides, blood glucose and fasting insulin, HOMA1-IR, CRP and ESR. The group with potential indication for surgery included: BMI > 40 or between 35-40 with comorbidities (Triglycerides >130mg/dl, glucose levels >100mg/dl, HOMA1-IR >3.16, Total Cholesterol >200mg/dl, LDL >130mg/dl and HDL <45mg/dl), regardless of age, epiphysis consolidation and previous treatment.

Results:

of the 296 patients included in the study, 282 (95.3%) were younger than 16 years. The most frequent change was the HDL (63.2%), followed by HOMA1-IR (37.5%). Of the group of 66 patients with potential indication for surgery (22.3%), only ten (15.1%) had more than 16 years. Acanthosis nigricans, the average HOMA1-IR, insulin, CRP, ESR, age, BMI Z score and systolic and diastolic blood pressure were significant in the group with potential surgical indication.

Conclusion:

bariatric surgery might be indicated by BMI and comorbidities in children and adolescents under 16 years.

Objetivo:

avaliar a gravidade da obesidade em crianças e adolescentes pela presença de comorbidades e pela potencial indicação de cirurgia bariátrica.

Métodos:

estudo transversal com dados clínicos e laboratoriais da primeira consulta de pacientes do ambulatório de obesidade infantil em um hospital terciário no período de 2005 a 2013. Os pacientes foram divididos em grupos com ou sem potencial indicação cirúrgica, e associados com idade, sexo, peso de nascimento, idade de início da obesidade, escore z de IMC, presença de acantose nigricans, pressão arterial, colesterol total e frações, triglicérides, glicemia e insulina de jejum, HOMA1-IR, PCR e VHS. O grupo com potencial indicação cirúrgica incluiu: IMC >40 ou IMC entre 35-40 com comorbidades (Triglicérides >130mg/dl, Glicemia >100mg/dl, HOMA1-IR >3,16, Colesterol total >200mg/dl, LDL >130mg/dl e HDL <45mg/dl), independente da idade, consolidação das epífises e tratamento prévio.

Resultados:

de 296 pacientes incluídos no estudo, 282 (95,3%) tinham menos de 16 anos. A alteração mais frequente foi a do HDL (63,2%), seguido do HOMA1-IR (37,5%). Do grupo de 66 pacientes com potencial indicação cirúrgica (22,3%), apenas dez (15,1%) tinham mais de 16 anos. Acantose nigricans, as médias de HOMA1-IR, insulina, PCR, VHS, idade, escore z de IMC e pressões sistólica e diastólica foram significantes no grupo com potencial indicação cirúrgica.

Conclusão:

os resultados sugerem que a cirurgia bariátrica, poderia estar indicada pelo IMC e presença de comorbidades, em crianças e adolescentes com menos de 16 anos.

Health-Related Quality of Life in Adolescents and Young Adults with Polycystic Ovary Syndrome: A Systematic Review

STUDY OBJECTIVE

To review recent data exploring the relationship between polycystic ovary syndrome (PCOS) and health-related quality of life (HRQoL) in adolescents and its implication for management of adolescents with this syndrome.

DESIGN AND SETTING

We performed a systematic literature search in MedLine, Embase and PsychInfo from 1980 to September 2015 and manual search in reference lists of selected articles. Inclusion criteria were articles in English or French with a focus on HRQoL in patients with PCOS aged between 13 and 24 years. Qualitative, cross-sectional, or interventional studies were considered as eligible. Two reviewers each independently selected and reviewed the relevant articles.

RESULTS

Of a total of 93 publications, 7 were selected through a systematic search, and 2 were added after a manual search. Seven studies used quantitative methods and 2 studies used a qualitative one. A meta-analysis was not possible because of the methodological diversity among the selected articles. All articles showed that PCOS has a negative influence on HRQoL in adolescents. Body weight issues and body mass index (BMI) appeared to have the strongest effect on HRQoL; some studies reported a normalization of HRQoL scores after adjustment for BMI. Patient information and patient-provider relationship were also reported to affect HRQoL. Elements in favor of the effectiveness of multidisciplinary management, associated lifestyle modifications, and psychological support, in improving HRQoL were identified.

CONCLUSION

PCOS significantly reduces HRQoL in adolescent girls. The extent to which body weight issues and BMI mediate this effect deserves further evaluation. A detailed understanding of the psychosocial challenges that patients with PCOS face is limited, mainly because of the small number of studies available, restricted sample size, and the methodological diversity of the questionnaires used. The effect of early lifestyle modification, and medical and psychological treatment should continue to be explored.

Psychological contributors to noncompletion of an adolescent preoperative bariatric surgery program

BACKGROUND

Noncompletion of preoperative bariatric programs is a significant problem among adolescents. Adult studies suggest that psychological factors contribute to noncompletion of preoperative bariatric programs.

OBJECTIVE

The aim of this study was to determine the association between adolescent psychological functioning and completion of the preoperative phase of a bariatric program.

SETTING

The study was conducted at a tertiary care children's hospital affiliated with a university medical center.

METHODS

Seventy-four adolescents and their parents completed an assessment measure of psychological functioning with the Behavior Assessment System for Children, Second Edition. We compared these scores between adolescents who completed the preoperative phase of the bariatric program and proceeded to surgery (completers) to those who did not (noncompleters) using multivariate analysis of covariance and logistic regression analyses, adjusting for demographic characteristics and baseline body mass index.

RESULTS

The mean age was 16.0 (1.1) years, most were female (79.8%), and the group was diverse (48.6%, Caucasian; 33.8%, black; 17.6%, other, including Hispanic, Asian, and biracial). Average body mass index was 50.5 (7.6) kg/m². Forty-two percent of participants were noncompleters. Noncompleters were reported by parents to have more clinically significant externalizing and internalizing behaviors and fewer adaptive behaviors. Noncompleters self-reported more clinically significant internalizing symptoms, emotional problems, and poor personal adjustment.

CONCLUSION

Adolescents who did not complete the preoperative phase of a bariatric surgery program had more clinically significant psychological symptoms across multiple domains compared with those who successfully proceeded to bariatric surgery. Early identification and treatment of psychological symptoms may be important in helping adolescents successfully proceed to surgery.

Assessment and preparation of obese adolescents for bariatric surgery

Obesity is generally considered an adult disease, although there has been a constant increase in the prevalence of overweight and obese children in the last few decades. Childhood obesity is not limited to developed countries, with increasing numbers being reported from developing countries as well as from Saudi Arabia. Young populations with obesity suffer from similar comorbidities as obese adults, including type 2 diabetes mellitus, dyslipidemia, obstructive sleep apnea, polycystic ovarian syndrome, pseudotumor cerebri, and fatty liver disease. Recent advances in weight loss surgery have given hope to obese adolescents who are refractory to lifestyle changes and low-calorie diet plans. This review emphasizes a holistic approach for obese adolescents and describes in detail a multidisciplinary team and their role in adolescent bariatric surgery. There are unique medical, psychological, and nutritional requirements during the pre-operative, immediate post-operative, and long-term phases to achieve a desirable outcome. Identification of an appropriate candidate for bariatric surgery is critical and must balance the risks and benefits of weight loss surgery. Different surgical procedures are available and should be tailored to the needs of the patient and the expertise of the surgeon.

Weight loss surgery improves quality of life in pediatric patients with osteogenesis imperfecta

BACKGROUND

Osteogenesis imperfecta (OI) is an inherited disorder, which causes brittle bones resulting in recurrent fractures. The associated poor mobility of children with OI increases susceptibility to obesity, and obesity further dramatically limits mobility and increases fracture risk.

OBJECTIVES

The aim of this report is to describe outcomes of weight loss surgery (WLS) in 2 adolescents with severe obesity and OI.

SETTING

Two University Hospitals (in the United Kingdom and in the United States).

METHODS

Two cases of OI treated with WLS were identified. Pre- and postoperative anthropometric and biochemical data and clinical course were reviewed.

RESULTS

In these 2 cases, preoperative Body Mass Index (BMI) values were 38 and 46 kg/m². Following laparoscopic sleeve gastrectomy (LSG), BMI decreased by 55% and 60% by 26 and 24 months, respectively. There were no surgical complications, and both patients experienced improvement in their mobility and ability to perform activities of daily living.

CONCLUSION

WLS effectively treated severe obesity in 2 OI patients and substantially improved mobility and quality of life, theoretically reducing fracture risk.

Childhood Obesity Is a Chronic Disease Demanding Specific Health Care--a Position Statement from the Childhood Obesity Task Force (COTF) of the European Association for the Study of Obesity (EASO)

Childhood obesity is one of the greatest health challenges of the 21st century. The EASO COTF is convinced that classifying obesity as a chronic disease in children and adolescents is a crucial step for increasing individual and societal awareness, and for improving early diagnosis and intervention. Such a classification will enhance the development of novel preventive and treatment approaches, health care policies and systems, and the education of healthcare workers. The management of obesity prior to the appearance of co-morbidities may prevent their escalation into significant medical and psychosocial problems, and reduce their economic and societal impact. Childhood is a unique window of opportunity to influence lifetime effects on health, quality of life, prevention of non-communicable chronic diseases and disabilities. The Convention on the Rights of the Child by UNICEF states that parties shall strive to ensure that no child is deprived of his or her right of access to health care services. The EASO COTF is aiming to address these issues via educational activities for health care workers, identification of research agendas, and the promotion of collaborations among clinicians, researchers, health institutions, organizations and states across Europe.

Bariatric surgery for severely obese adolescents

Severe obesity is increasing in adolescents and is associated with cardiovascular disease, type 2 diabetes mellitus, obstructive sleep apnoea, polycystic ovarian syndrome and a range of musculoskeletal problems. Premature death is the inevitable outcome of persistent severe obesity in adolescents. In adults with severe obesity, medical and lifestyle interventions have been shown to be expensive and less effective in terms of weight loss than has bariatric surgery. The single completed randomised controlled trial in adolescents shows the same outcome. This is supported by meta analyses of bariatric surgery in adolescent subjects. A more aggressive approach to severe obesity, utilising bariatric surgery in selected cases, within the context of a multi-disciplinary team, is required.

Bariatric surgery for obese children and adolescents: a systematic review and meta-analysis

The number of obese young people continues to rise, with a corresponding increase in extreme obesity and paediatric-adolescent bariatric surgery. We aimed to (i) systematically review the literature on bariatric surgery in children and adolescents; (ii) meta-analyse change in body mass index (BMI) 1-year post-surgery and (iii) report complications, co-morbidity resolution and health-related quality of life (HRQoL). A systematic literature search (1955-2013) was performed to examine adjustable gastric band, sleeve gastrectomy, Roux-en-Y gastric bypass or biliopancreatic diversions operations among obese children and adolescents. Change in BMI a year after surgery was meta-analysed using a random effects model. In total, 637 patients from 23 studies were included in the meta-analysis. There were significant decreases in BMI at 1 year (average weighted mean BMI difference: -13.5 kg m(-2) ; 95% confidence interval [CI] -14.1 to -11.9). Complications were inconsistently reported. There was some evidence of co-morbidity resolution and improvements in HRQol post-surgery. Bariatric surgery leads to significant short-term weight loss in obese children and adolescents. However, the risks of complications are not well defined in the literature. Long-term, prospectively designed studies, with clear reporting of complications and co-morbidity resolution, alongside measures of HRQol, are needed to firmly establish the harms and benefits of bariatric surgery in children and adolescents.