Bariatric Surgery: A Major
Decision for Minors
ALEX KLOEHN, CAMI MANDELL
http://www.cdc.gov/nchs/data/hestat/obesity_child_09_10/obesity_child_09_10.htm
Childhood and Adolescent Obesity Statistics
 Obesity rates in children age 6-11 increased from 7% to 18% between
1980 and 2010 in the US (Ogden, 2012)
 Obesity rates in adolescents age 12-19 increased from 5% to 18.4%
between 1980 and 2010 in the US (Ogden, 2012)
http://arch1design.com/blog/latest_environmental_health_news/childhood-obesity-prevalence-and-prevention/
Concerns of Childhood Obesity
 Obese adolescents are
likely to be obese as adults
(Freedman, 2005)
 Increased risk of depressive
symptoms and lower
quality of life scores.
(Schwimmer, 2003)
 Increased risk of










Hypertension
Hypercholesterolemia
Hypertriglyceridemia
Hyperinsulinemia
Atherosclerosis
Metabolic syndrome
Obstructive sleep apnea
PCOS
Non-alcoholic fatty liver disease
Certain cancers
(Flynn, 2006)
Brief History of Bariatric Surgery
 1952- First recorded operation to
cure obesity was performed by
Viktor Henrikson as a small bowel
resection
 Shortly followed by jejunocolic
bypasses that led to loss of fluid,
electrolytes, and led to liver failure.
(On left)
 Mid 1950’s - Jejunoileal Bypass
came next and remained popular
through the 1970’s
(Deitel, 2012)
Brief History of Bariatric Surgery (Cont’d)
 1960’s - Gastric
Bypass was first
developed
 1970’s - Roux-enY GB was
developed and has
been modified
several times since.
(Deitel, 2012)
Brief History of Bariatric Surgery (Cont’d)
 1970’s -
Biliopancreatic
Diversion and
Duodenal Switch were
also introduced to
address concerns over
Blind Loop Syndrome.
 1980’s – Adjustable
gastric banding
procedures were
popularized
(Deitel, 2012)
Brief History of Bariatric Surgery (Cont’d)
 2000’s – The first
sleeve gastrectomy
procedures were
recorded.
(Deitel, 2012)
Common Types of BS Performed Today
http://www.hormone.org/questions-and-answers/2012/bariatric-surgery
Adolescent Bariatric Surgery (ABS) Statistics
 US Nationwide Inpatient Sample: 2,744 ABS
procedures were performed in the US between 1996
and 2003. (Black, 2013)
 Healthcare Cost and Utilization Project Kids’
Inpatient Database (KID), 1009 ABS procedures
were performed in 2009. (Kelleher, 2013)
 Trends towards minimally invasive procedures
 Plateau of ABS procedures since 2003.
Trends in Surgery Performed 2000-20009
1200
1000
800
Ages 10 - 17
600
Ages 18 - 19
total
400
200
0
2000
Adapted from data in Kelleher, 2013
2003
2006
2009
Physical & Psychological Benefits
 BMI reduction


Wide range, depending on study follow-up
length
Most occurs in first year
 Some alleviation of comorbid
conditions


Most occurs in first year
Hard to accurately assess due to follow-up loss
 Increased in quality of life


Pre-operative scores similar to children with
cancer (Loux, 2008)
Significantly increased scores post-operatively
(Loux, 2008)
BMI Reduction
 Very little long-term follow-up data
 Wide range of results
 RYGB, 12 month follow-up (Lawson, 2006)
 Pre-op 56.5±10.1
 Post-op 35.8±6.9
 RYGB, 17.1±12.3 month follow-up (Loux, 2008)
 Pre-op 54.1±7.6
 Post-op 35.1±9.3
 LSG, 12 month follow-up (Nadler, 2012)
 Pre-op 52±9,
 Post-op 39±8

RYGB, 24 month follow-up (Teeple, 2012)
Pre-op 58.8±10.7,
 Post-op mean 34.9±5.6

Co-morbid Conditions
 Most common pre-operative:






Impaired glucose tolerance
Insulin resistance
Hypertension
Sleep apnea
Dyslipidemia
Fatty liver disease
 Post-operative results




Improvement in glucose
tolerance and insulin
resistance
Resolution of dyslipidemia
Resolution of sleep apnea
Decrease in blood pressure
(Teeple, 2012; Nadler, 2012, Lennerz, 2013, Lawson, 2006, Loux, 2008)
Risks and Complications of Surgery
 Complications are similar to adults (Inge, 2013)
 Late weight regain (up to 20%) (Xanthakos, 2008)
 Recurrence of depression and eating disturbances that affect
QOL (Pratt, 2009)
 Marginal ulcers, small bowel obstruction, protein and
micronutrient deficiencies
 Gastric band slippage
 Pregnancy
Risks and Complications of Surgery (Cont’d)
 May cause problems with proper growth if children
are not done growing (Barnett, 2013)
 Low adherence to follow-up (Lennerz, 2013)
Best Practice Eligibility Criteria
 BMI
 >35 with severe comorbidities
 >40 with any comorbities
 Physiological Maturity
 Height ~ 95% adult height based on estimate of bone age
 Pubertal Maturity based on Tanner Stages (IV+)

Girls usually ≥13; Boys usually ≥15
 Lifestyle Change
 Demonstrate ability to make sustained dietary and physical
activity changes
(Pratt, 2009)
Best Practice Eligibility Requirements
 Psychosocial Maturity
 Appropriate decision making
skills and understanding of
risks and benefits
 Social support network
 Psychiatric conditions
managed under treatment
 Evidence of patient/family
ability to comply with
treatment plan pre- and postsurgery
(Pratt, 2009)
Future Directions
 Necessity of long-term data on physical and




psychological outcomes
Options of minimally invasive surgeries (Shebrain, 2013)
Need to address possibility of weight regain
Rethink criteria using BMI for weight loss surgery to
catch adolescents before they become
severely/morbidly obese
Assert that surgeons performing surgery are
qualified to do so with the special considerations of
adolescents
Questions?
References








Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index
among US children and adolescents, 1999-2010. Journal of the American Medical Association 2012;
307(5):483-490
Freedman DS, Kettel L, Serdula MK, Dietz WH, Srinvasan SR, Berenson GS. The relation of childhood
BMI to adult adiposity: the Bogalusa Heart Study. Pediatrics 2005; 115:22-27.
Schwimmer JB, Burwinkle TM, Varni JW. Health-Related Quality of Life of Severely Obese Children
and Adolescents. Journal of the American Medical Association 2003; 289(14):1813-1819
Flynn MAT, McNeil DA, Maloff B, Mutasingwa D, Wu M, Ford C, Tough SC. Reducing obesity and
related chronic disease risk in children and youth: a synthesis of evidence with “best practice”
recommendations. The International Association for the Study of Obesity: Obesity reviews 2006;
7(Suppl. 1):7-66
Deitel M, Crosby RD, Gagner M. The First International Consensus Summit for Sleeve Gastrectomy
(SG), New York City, October 25-27, 2007. Obesity Surgery. 18:487-496
Deitel, M. “History of Bariatric Surgery.” Bariatric Surgery: Technical Variations and Complications,
Ed. Michael Korenkov, New York: Springer, 2012. 1-8
Kelleher DC, Merrill CT, Cottrell LT, Nadler EP, Burd RS. Recent National Trends in the Use of
Adolescent Inpatient Bariatric Surgery. Journal of the American Medical Association Pediatrics 2013;
167(2):126-132
Black, JA, White B, Viner RM, Simmons RK. Bariatric surgery for obese children and adolescents: a
systematic review and meta-analysis. The International Association for the Study of Obesity: Obesity
reviews 2013; 14:634-644









Barnett SJ. Surgical management of adolescent obesity. Advances in Pediatrics 2013; 60:311325.
Garcia VF, DeMaria EJ. Adolescent bariatric surgery: treatment delayed, treatment denied, a
crisis invited. Obesity Surgery 2006; 16:1-4.
Inge TH, Zeller MH, Jenkins TM, Helmrath M, Brandt ML, Michalsky MP, Harmon CM, et al.
Perioperative outcomes of adolescents undergoing bariatric surgery: the Teen-Longitudinal
Assessment of Bariatric Surgery (Teen-LABS) Study. The Journal of the American Medical
Association Pediatrics 2013; doi:10.1001/jamapediatrics.2013.4296.
Kubik JF, Gill RS, Laffin M, Karmali S. The impact of bariatric surgery on psychological health.
Journal of Obesity 2013; 2013(837989):1-5.
Lennerz BS, Wabitsch M, Lippert H, Wolff S, Knoll C, Weiner R, Manger T, et al. Bariatric
surgery in adolescents and young adults-safety and effectiveness in a cohort of 345 patients.
International Journal of Obesity 2013; 1-7.
Nadler EP, Barefoot LC, Qureshi FG. Early results after laparoscopic sleeve gastrectomy in
adolescents with morbid obesity. Surgery 2012;152(2):212-217.
Teeple EA, Teich S, Schuster DP, Michalsky MP. Early metabolic improvement following
bariatric surgery in morbidly obese adolescents. Pediatric Blood Cancer 2012;58:112-116.
Xanthakos SA. Bariatric surgery for extreme adolescent obesity: indications, outcomes, and
physiologic effects on the gut-brain axis. Pathophysiology 2008;15:135-146.
Loux TJ, Haricharan RN, Clements RH, Kolotkin RL, Bledsoe SE, Haynes B, Leath T, et al.
Health-related quality of life before and after bariatric surgery in adolescents. Journal of
Pediatric Surgery 2008; 43:1275-1279.
 Lawson ML, Kirk S, Mitchell T, Chen MK, Loux TJ,
Daniels SR, Harmon CM, et al. One-year outcomes of
Roux-en-Y gastric bypass for morbidly obese
adolescents: a multicenter study from the Pediatric
Bariatric Study Group. Journal of Pediatric
Surgery; 2006: 41:137-143.
 Shebrain S, Patel N. Advances in foregut and
bariatric surgery in adolescents. Adolescent Medicine
2013; 024:242-263.