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Surgery in adolescents

‘Last resort’ bariatric surgery beneficial in adolescents

Study demonstrates the safety and efficacy of weight reduction surgery in morbidly obese adolescents
'Bariatric surgical operation in kids is never a cosmetic practice'
Marc Michalsky

Researchers at Nationwide Children’s Hospital have reported that their patients have experienced a significant loss of excess body weight and showed improvement in many obesity-related diseases within the first one to two years following surgery. The retrospective study was published in the January 2012 print edition of Pediatric Blood & Cancer.

“Bariatric surgery in adolescents is never a cosmetic procedure,” said the study’s author Dr Marc Michalsky, Surgical Director of Bariatric Surgery at Nationwide Children’s Hospital and faculty member at The Ohio State University College of Medicine. “These teens are very sick, they are suffering and they can benefit from weight loss surgery. Our study demonstrates the safety and efficacy of weight reduction surgery in morbidly obese adolescents.” He added that although weight loss surgery can be a very effective intervention, it should be a last resort for teenagers.

According to the researchers the pediatric age group are the fastest growing sub-population of obese individuals in the US, which has been described as a a pandemic of the new millennium. In addition to the overall rise in obesity-related diseases in children, a mounting body of evidence highlights the negative impact of adolescent obesity on healthcare cost and delivery as well as psychosocial factors including educational attainment, job absenteeism, depression, and quality of life.

“We do not yet know whether the improvements of these patients will correspond to long-term resolution of weight-related diseases or reduce their risk for future weight-related diseases,” said Michalsky who also chairs the American Society for Metabolic and Bariatric Surgery Pediatric Committee’s best practice guidelines. “Although our findings suggest that the most significant metabolic impact occurred within the first post-operative year, findings may differ in studies involving more patients who are followed longer-term."

Study outline

As a result, the investigators performed a retrospective analysis of patients undergoing Roux-en-Y gastric bypass (RYGB) between 2004 and 2009 at their institution. Following approval from the Institutional Review Board (IRB), a retrospective analysis of data collected from the medical records of 15 morbidly obese adolescents (ten females and 5 males) who underwent RYGB by two experienced surgeons at Nationwide Children’s Hospital (Columbus, OH) between February, 2004 and July, 2009 was performed. 

Standard pre-operative screening of all bariatric surgical candidates consisted of history and physical examination, nutritional screening, psychological evaluation, social work, and physical activity screening. Pre-operative blood work, overnight sleep study, upper gastrointestinal study with contrast, abdominal ultrasound, bone age and pediatric cardiology evaluation, including transthoracic echocardiography, were performed. Clinical and demographic data were collected for analysis at baseline, then one and two years post-operatively. These included age, blood pressure, height, weight, body mass index (BMI), and measurement of several metabolic markers including: fasting serum hemoglobin A1C (HbA1C), insulin level, C-reactive protein (CRP), C-peptide, glucose, and serum lipid profile. Using tables provided by the Centers for Disease Control (CDC), percentiles were calculated to account for differences in the age of the patients including BMI, total cholesterol, TG, LDL, and HDL. 

Insulin resistance (IR) was determined by calculating HOMA-IR. This uses fasting glucose and insulin to estimate an index of IR, as well as percentage of pancreatic beta cell function (%B) and percentage of insulin sensitivity (%S). Post-operative anthropomorphic and laboratory analyses were examined at one year (n = 14) and two years (n = 9). Percentage excess weight loss was calculated and followed over time. This was defined as (weight loss/excess weight) × 100 where excess weight is total pre-operative weight − ideal weight.

Outcomes

Analysis of baseline clinical data showed that the mean BMI was 58.8 ± 10.7 kg/m2 (super morbid obesity) and a longitudinal analysis demonstrated a significant decrease from baseline over the two-year study period to a mean BMI of 34.9 ± 5.6 kg/m2 (range: 26.7–42.7 kg/m2, p≤ 0.001) with the most notable change within the first year (58.8 ± 10.7 kg/m2 vs. 37.6 ± 9.0 kg/m2, p≤ 0.001). The researcher note that although the BMI continued to decrease between the one and two-year time points, it did not reach statistical significance (37.6 ± 9.0 kg/m2 vs. 34.9 ± 5.6 kg/m2, p= 0.433).

The change in mean weight also achieved statistical significance over two years (p≤ 0.001) as did the change in overall body weight over the first (179.6 ± 42.5 kg vs. 112.6 ± 29.9 kg, p≤ 0.001) but not the second (112.6 ± 29.9 kg vs. 104.9 ± 25.8 kg, p= 0.184) post-operative year. 

Complications

Three of the patients (20%) experienced short-term including one readmission for post-operative ileus, one port-site hernia and one revision of the gastro-jejunal anastomosis secondary to bleeding and anastomotic leak. Long-term complications included one port-site hernia diagnosed at 14 weeks post-operatively and one gastrojejunal anastomotic stricture which responded to a single endoscopic dilation 14 months post-operatively.

Conclusion

According to the authors, the study demonstrated both safety and efficacy of weight-reduction surgery in morbidly obese adolescents and although the results suggest that the most significant metabolic impact occurred within the first post-operative year, this may have been a confounding influence of a low sample size as well as relatively short-term follow-up. They concluded that bariatric surgery is a safe and efficacious treatment option for morbidly obese adolescents with significant obesity-related comorbid conditions and that the early surgical intervention and management of comorbid diseases may reduce the long-term burden of physical and psychological chronic disease in morbidly obese adolescents. 

“The argument is quite compelling that we really do need to be doing it this young to avoid the chronic burden of disease these patients will suffer from if nothing is done. Bariatric surgical operation in kids is never a cosmetic practice,” Michalsky concluded. “These youngsters are pretty sick, they’re suffering and they are apt to reap the benefits of fat reduction surgical operation. Our study displays the safeness and efficacy of weight loss surgical operation in morbidly overweight kids.”

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