© Springer Science+Business Media New York 2015
Ninh T. Nguyen, Robin P. Blackstone, John M. Morton, Jaime Ponce and Raul J. Rosenthal (eds.)The ASMBS Textbook of Bariatric Surgery10.1007/978-1-4939-1206-3_3737. Adolescent Bariatric Surgery
(1)
Department of Pediatric Surgery, Center for Healthy Weight and Nutrition, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43215, USA
(2)
Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave., MLC 2023, Cincinnati, OH 45229, USA
Chapter Objectives
1.
Review recent data regarding the development and progression of several commonly encountered obesity-related comorbid illnesses in the pediatric population, which serve as an important foundation in support of the argument for adolescent surgical weight reduction.
2.
Review the current evidence-based recommendations regarding use of specific bariatric procedures.
3.
Discuss longitudinal outcomes and associated complications.
4.
Review the current recommendations for the multidisciplinary care of the adolescent bariatric patient.
Introduction
The prevalence of severe obesity among children and adolescents continues to increase and poses a serious healthcare challenge both in the United States and worldwide. Review of recent literature shows that 17 % of children and adolescents in this country are obese (body mass index [BMI] >95th percentile), with up to 4 % considered extremely obese (BMI >99th percentile) [1, 2]. In addition to a remarkable increase in the prevalence of childhood obesity over the past several decades (nearly fourfold), a mounting body of evidence has demonstrated the concurrent existence of many obesity-related comorbid illnesses (i.e., hypertension, insulin resistance, type 2 diabetes mellitus, obstructive sleep apnea, polycystic ovary disease, dyslipidemia, fatty liver disease, etc.) that were previously believed to only affect the severely obese adult population. These observations, in addition to a general increase in public health awareness, have added to the overall urgency within the medical and surgical communities to adapt to adolescent treatment approaches that make sense in adults. The primary justification is a very real need to abrogate the potential long-term physiological burden of chronic obesity-related disease that is associated with juvenile-onset obesity, which causes disability and disease burden currently and is expected to even more greatly impair the health and productivity of individuals as they age into morbidly obese adults [3–5]. Preliminary data regarding the application of bariatric surgical procedures in the adolescents have demonstrated measures of both safety and effectiveness in adolescents. Furthermore, studies have suggested that perioperative complication rates may be similar to or better than adults [6].
Although the actual number of adolescent weight-loss procedures being performed in the United States is uncertain at this time, one may infer from recent reports that a trend toward an increasing number of cases has been established. Current national evidence shows that bariatric cases performed in the pediatric population tripled from the late 1990s, with an estimated 2,000 procedures per year performed in 2004 [7]. In addition, analysis of data from California indicates that rates of laparoscopic adjustable gastric banding increased 6.9-fold from 2005 to 2007 (1.5 per 100,000 population in 2007) [8]. As the overall number of surgical procedures being performed is increasing, understanding the risks and multiple factors that predict longitudinal success is becoming correspondingly more important.
In addition to an increased interest in the use of surgical methods to reduce excess body weight and reverse associated comorbid diseases in this emerging population, there have been several recent reports highlighting the need for evidence-based best practice guidelines specifically addressing individual patient selection, overall components of pre-bariatric evaluation and multidisciplinary resources required to develop an effective adolescent bariatric team environment [9–11]. In this chapter, we will review recent data regarding the development and progression of several commonly encountered obesity-related comorbid illnesses in the pediatric population, which serve as an important foundation in support of the argument for adolescent surgical weight reduction. In addition, this chapter will review the current evidence-based recommendations regarding use of specific bariatric procedures, including discussion of longitudinal outcomes and associated complications as well as a brief review of the current recommendations for the multidisciplinary care of the adolescent bariatric patient.
Comorbid Diseases of Childhood Obesity
Many of the comorbid illnesses previously linked with severe obesity in adulthood have now been well documented in the pediatric population. Specific examples of commonly encountered comorbid illnesses include hypertension, sleep-disordered breathing, impaired glucose tolerance, type 2 diabetes mellitus, gastroesophageal reflux disease, left ventricular hypertrophy, pseudotumor cerebri, and polycystic ovary syndrome to name a few [3, 5, 12, 13]. In addition to the fact that a significant proportion of the obese adolescent population suffers from significant comorbid diseases that affects nearly every bodily system, an important distinction has emerged regarding the cumulative pathophysiological effect(s) associated with obesity that develops during childhood (juvenile-onset) versus adult-onset obesity. Although 75 % of obese adults and 25–50 % of severely obese adults suffer from adult-onset obesity, an emerging consensus has been established suggesting that these patients might not suffer from the same degree of cumulative obesity-related disease burden (also referred to as “pound years”) as individuals who suffer from the longitudinal effects of obesity established much earlier in life. Correspondingly, it has been hypothesized that improvement in disease burden, including the potential for complete disease reversal, may be more likely in the adolescent bariatric population.
Glucose Impairment
Recent reports have demonstrated a striking association between childhood obesity and the development of a spectrum of abnormalities with regard to normal glucose regulation including hyperinsulinemia (60–80 %), impaired glucose tolerance 12–35 %, and type 2 diabetes mellitus (1–6 %) [5]. Although the exact mechanisms responsible for the observed disruption in the normal regulatory processes are presently unclear, there is a growing consensus that ectopic deposition of triglyceride and a generalized state of low-grade, chronic inflammation may be key components in the pathophysiological mechanism(s) leading to insulin resistance and glucose dysregulation. Data demonstrate an association between severe obesity (BMI ≥ 40 kg/m2) and insulin resistance, as determined by homeostatic model assessment (HOMA-IR), as well as elevated levels of hemoglobin A1c and C-reactive protein (CRP) among groups of adolescent patients undergoing bariatric surgery (i.e., RYGB) [13, 14]. In addition, recent investigations have demonstrated significant improvements in nearly all physiologic markers of metabolic dysfunction within the first year following surgical weight reduction [13, 14].
Cardiovascular Disease
Although a link between obesity and the development of cardiovascular disease has been well established in the adult population and has been identified as the primary cause of obesity-related mortality [15], there is a relative paucity of investigations specifically focusing on the cardiovascular health of severely obese adolescents, including reports examining the potential longitudinal changes in cardiovascular status following surgically induced weight loss. Although the major clinical manifestations of obesity-related cardiovascular disease (i.e., atherosclerosis, myocardial infarction, heart failure, peripheral vascular disease, and stroke) are not typically apparent until later in life (i.e., adulthood), the pathophysiologic processes that lead to their development and progression begin during childhood. Recent evidence demonstrates the presence of increased cardiovascular risk factors (including hypertension, hypertriglyceridemia, elevated fasting serum glucose and LDL cholesterol, and low serum HDL cholesterol) as well as cardiac structural and functional abnormalities in the obese childhood population [12–14]. Adolescent data also demonstrate improvements following surgical weight loss, including marked improvements in left ventricular hypertrophy, diastolic performance, and cardiac work load [12], as well as improvement in numerous serum biomarkers of cardiovascular risk (mentioned previously) following bariatric surgery in the adolescent population—similar to results observed in adult populations [16]. Additional large prospective studies investigating cardiovascular health in the severest subset of the obese adolescent population are needed.
Nonalcoholic Fatty Liver Disease
Nonalcoholic fatty liver disease (NAFLD)—a disease spectrum that ranges in severity from uncomplicated steatosis to nonalcoholic steatohepatitis (NASH)—is strongly linked to obesity and insulin resistance and has further been shown to be associated with hepatic cirrhosis in up to 25 % of affected adult populations [17]. With the reported rise in childhood obesity and uncertainty surrounding the longitudinal effects of untreated chronic disease, recent investigations have offered a sobering account of the impact of obesity on the adolescent liver. Xanthakos et al. showed that 83 % of liver biopsies obtained from a cohort (n = 41) of severely obese (BMI 59 kg/m2) adolescents undergoing RYGB were determined to have NAFLD [18]. In addition, the authors showed that 24 % had steatosis alone, 7 % has isolated fibrosis with steatosis, and as many as 20 % had NASH. Although the results of the histologic analysis demonstrate less severe disease and a lower prevalence of NASH when compared to adult bariatric patients, the investigators raise the concern regarding the inability to demonstrate strong correlations between the observed histopathology and clinical features, such as the presence of individual components of metabolic syndrome, in an effort to discriminate patients who have NASH in addition to NAFLD. Therefore, the observed differences in hepatic histopathology when compared to adult studies, as well as the inability to demonstrate a strong correlation to clinical features of metabolic syndrome, support the need for a modification of the current NASH scoring system in an effort to improve the ability to determine the overall extent of this “silent” but significant disease. Although recent data report a 13-fold increase in the associated risk of death or liver failure requiring liver transplantation compared to age-matched and sex-matched controls [19], reduction in excess body weight results in improvement in the degree of steatosis and inflammation and therefore lends support to the use of weight-loss surgery in the adolescent population [20].
Obstructive Sleep Apnea
Sleep-disordered breathing—a spectrum of symptoms including heavy snoring, intermittent periods of apnea, hypopnea, and chronic fatigue—is strongly associated with childhood as well as adult obesity [21, 22]. Recent evidence has shown that up to 46 % of obese children have documented obstructive sleep apnea (OSA), with rates reported as high as 55 % among a cohort of severely obese children undergoing bariatric surgery [22, 23]. If left untreated, OSA can lead to significant functional impairment, including personality changes and poor performance in school-related educational metrics secondary to chronic fatigue. In addition, more serious physiological consequences related to chronic OSA include the development and progression of hypertension and cardiac dysfunction, consisting of right and left ventricular dysfunction and associated cardiac remodeling, resulting in an associated increased in the risk of sudden death [5]. Despite the serious clinical implications associated with OSA, recent evidence examining longitudinal outcomes in severely obese adolescents undergoing surgical weight reduction demonstrates significant improvement in the severity of OSA as determined by comparative pre- and postoperative polysomnogram testing (improved apnea-hypopnea score).
Psychological Disorders
Compared to a notable increase in the body of literature pertaining to medical comorbidities of childhood obesity, a relative paucity of data exists regarding the associated impact of the obesity epidemic on various complex developmental processes involved in the delicate transition from childhood to adulthood. Despite this, however, a general consensus has emerged in recent years suggesting that overweight and obesity have the potential to result in a devastating impact on this fragile time period in psychological development. Recent evidence has demonstrated a link between overweight and obesity in adolescents with an increased risk for the development of depression [24]. In addition, the significance of associated depressive symptoms has been further highlighted by a recent large prospective cohort study designed to test the association between overweight and/or obesity during childhood and young adulthood and the risk of depression. In this investigation, researchers predicted an increased risk for adult depression among subjects who self-identified as being overweight and/or obese at 5 years of age, with an even stronger association among subjects who were identified as being overweight or obese at 20 years of age [25]. Additional reported associations include low self-esteem and low self-reported health measures [5, 26].
Adolescent Bariatric Care Model
The use of bariatric surgery in the treatment of carefully selected adolescents has been an evolving process over the past decade. Adolescent bariatric surgery has become widely accepted in parallel with the increasing body of scientific literature supporting its use and the establishment of a number of regional centers throughout the United States designed to address specific needs of this emerging bariatric population. Early guidelines addressing the use of bariatric surgery in the adolescents, first presented in 2004 [27], have been updated several times and should be referred to for an in-depth discussion [9, 10, 28]. As the surgical care of the severely obese adolescents has become more routine and the number of healthcare institutions offering such services continues to expand, several key elements regarding the need for an adolescent-centered multidisciplinary team approach have been established and will be briefly reviewed herein. Specifically, it has been widely agreed that the development of a multidisciplinary approach to the surgical treatment of severe adolescent obesity be done under the auspices of an institution that has developed a clear interdisciplinary commitment to the care of its overweight and/or obese patients [10]. In addition to institutional commitment, it is important to acknowledge that the administration of such specialized care occur in conjunction with identification and/or establishment of a relationship with the patient’s “medical home” (i.e., a physician or appropriately credentialed healthcare practitioner specializing in general pediatrics or family practice) in an effort to coordinate and optimize long-term management of obesity-related comorbid diseases as well as general health maintenance concerns. Such general health maintenance includes routine health screening, preventative medicine, and family planning, among other issues. Although recommendation for core members of an interdisciplinary team designed to evaluate and treat severe adolescent obesity is somewhat influenced by specific institution resource allocation, a list of key team members includes:
1.
Surgical Specialist: A surgeon performing adolescent bariatric surgery must demonstrate certification by the American Board of Surgery, American Osteopathic Board of Surgery, and/or the Royal College of Physicians and Surgeons of Canada. In addition, he or she must have appropriate training and experience performing bariatric procedures and be institutionally credentialed to perform such procedures.
2.
Medical Specialist: A physician with specialty training in pediatrics (including possible subspecialty training in endocrinology, gastroenterology, cardiology, nutrition, etc.), adolescent medicine, or family practice experience. The medical specialist should have or obtain experience screening adolescents for bariatric surgery and be willing to assume responsibility for management of obesity-related comorbid conditions in coordination with the patient’s primary care provided (i.e., medical home).
3.
Registered Dietician: A dietician with experience treating children and families with obesity. Experience with bariatric surgical patients is ideal but not mandatory. Nutritional recommendations and structured educational content should be provided to the patient and associated caregivers (e.g., parents, grandparents, siblings) in an effort to establish an understanding of age-appropriate healthy nutritional guidelines by multiple family members in the home prior to undergoing a bariatric procedure.
4.
Behavioral Health Specialist: A behavioral health specialist may include a psychologist, psychiatrist, or other qualified and independently licensed mental health provider with specific experience treating children, adolescents, and families. In addition, the individual should have experience treating obesity and eating disorders as well as specific experience regarding pre-bariatric evaluation.
5.
Exercise Physiologist/Physical Therapist: An exercise physiologist, physical therapist, or other licensed provider with specialty training to provide safe physical activity education for the severely obese adolescent population.
6.
Bariatric Program Coordinator: A bariatric surgical coordinator may consist of a registered nurse or social worker or any other member of the bariatric team who serves to coordinate the preoperative and postoperative treatment and follow-up logistics.
7.
Social Worker: A dedicated social worker is not mandatory but highly recommended and may serve to assist in the evaluation of the patient’s psychosocial needs as well as perioperative logistics including transportation, access to community resources, insurance coverage, etc.
Finally, it is highly recommended that adolescent bariatric surgical programs maintain a multidisciplinary review committee designed to review individual cases prior to performing a bariatric procedure. Core members of the review committee should include the surgical and medical directors, behavioral and nutritional specialists, and the designated program coordinator. In addition, ad hoc members of the review committee may include subspecialists such as experts in adolescent pulmonary medicine, hematology, cardiology, endocrinology, and medical ethics (including formal involvement of the institutional ethics committee when considered necessary) [11].
Patient Selection
As mentioned earlier, development of criteria for adolescent patient selection has been an evolutionary process. The process was based on a modification of the adult surgical patient selection guidelines defined by the 1991 National Institutes of Health (NIH) consensus panel on bariatric surgery [9, 10, 27, 28]. Because all adolescent boys and most adolescent girls <18 years of age with a BMI of 35 kg/m2 correspond to BMI percentile of 99th percentile for age, the application of adult selection criterion based on BMI appears to be appropriate [3], with a more conservative approach regarding the incorporation of associated comorbid disease thresholds [10]. Currently, recommendations for selection criteria for adolescent bariatric surgery include:
BMI ≥35 kg/m2 with major comorbid disease
Type 2 diabetes mellitus
Pseudotumor cerebri
Severe NASH
Moderate to severe obstructive sleep apnea (apnea-hypopnea index >15)
BMI ≥ 40 kg/m2 with less severe comorbid disease
Glucose intolerance
Hypertension
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