Is Weight Loss Surgery Appropriate for Children?

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Boy shocked at how much he weighs. Peter Dezeley/Getty Images

As the saying goes: Desperate times call for desperate measures, and the latest example is the childhood obesity epidemic. For kids and teens who qualify for the category of severe obesity, a treatment of last resort is increasingly being considered: Bariatric surgery.

Weight-loss surgery is now considered an appropriate intervention for severely obese adolescents who are suffering from weight-related health effects and have tried other methods to lose weight for more than six months—but without success.

Evidence suggests the surgery can help these kids avoid obesity-related complications such as diabetes, obstructive sleep apnea, and hypertension. Research from Saudi Arabia found that obese kids, ages 5 to 21, who underwent bariatric surgery lost 62 percent of their excess weight after two years—and the majority of them resolved their cholesterol abnormalities, high blood pressure, sleep apnea symptoms, and diabetes.

Yet, despite these achievable benefits, the use of bariatric surgery among adolescents has plateaued since 2003 in the U.S., according to a recent study. Cost and access to care are likely to be key factors in “low use of this potentially life-altering treatment in adolescent boys and girls of lower socioeconomic status,” the researchers concluded.

Different Techniques for Different Kids 

There are several different bariatric surgery techniques and which one is best for children or teens hasn’t been determined.

With Roux-en-Y gastric bypass surgery, a surgeon creates a small pouch at the top of the stomach, using surgical staples, and attaches the pouch to the middle part of the small intestine. This pouch can hold only a fraction of the food that a normal stomach can, so it forces the person to consume less food.

Moreover, because the food that’s consumed bypasses the larger part of the stomach and the upper intestine, fewer calories are absorbed from the food.

With gastric banding surgery, an adjustable silicone band is placed around the upper part of the stomach to create a small pouch; this limits the amount of food the person can consume and induces feelings of fullness more quickly. It’s the least invasive form of bariatric surgery, and it doesn’t interfere with nutrient absorption the way gastric bypass surgery does. The band can be adjusted, making it tighter or looser, to accommodate an individual’s shifting weight loss needs, and it can even be removed, if necessary.

Laparoscopic sleeve gastrectomy reduces the size of the stomach by 75 percent, leaving a narrow “sleeve” or tube in its place; this limits how much food the person can eat at one time. Because it doesn’t bypass the intestines, the procedure doesn’t interfere with the absorption of nutrients—but it may reduce the amount of ghrelin, the hunger hormone, that’s produced by the stomach, thereby contributing to long-term weight loss.

As with gastric bypass surgery, the procedure is not reversible.

Preliminary studies have found these bariatric procedures to be safe and effective among adolescents, with short-term results similar to those among adults. In a 2014 study of 345 procedures in teens and young adults, researchers in Germany found that the most frequently performed surgical techniques in this population were gastric banding and gastric bypass, followed by sleeve gastrectomy. After a year, gastric bypass had produced the greatest post-surgical weight reduction, followed by sleeve gastrectomy then gastric banding—but all three procedures led to lasting weight loss and few complications.

2013 study at the University of Miami School of Medicine also found that kids ages 10 to 19 who underwent gastric bypass surgery had more than twice the mean weight loss after a year as those who had adjustable gastric band surgery. Meanwhile, a 2012 study at Children’s National Medical Center in Washington, D.C., found that morbidly obese adolescents lost 40 percent of their excess body weight thanks to laparoscopic sleeve gastrectomy.

Big Picture Concerns

Despite these success rates, long-term follow-up on bariatric surgery in children and adolescents is lacking. Right now, there’s no way to know what happens over the course of a lifetime to kids who’ve had bariatric surgery since these procedures weren’t available to their parents’ generation when they were children. Gaining insights into the long-term success rates, the obesity relapse rates, and the kinds of complications that can occur years later (after all, kids’ bodies are still growing) is critical to determining the wisdom of using this procedure in those who are too young to vote.

It’s also important to remember that bariatric surgery isn’t a panacea for childhood obesity. As with adults, weight-loss surgery in obese kids is only part of the solution. Those who undergo the procedure need to adopt healthier eating habits and routine physical activity for life. Otherwise, they’re likely to gain back some or most of the weight they’ve lost.

Sources:

Alqahtani AR, Antonisamy B, Alamri H, Elahmedi M, Zimmerman VA. Laparoscopic sleeve gastrectomy in 108 obese children and adolescents aged 5 to 21. Annals of Surgery, August 2012 [Accessed online September 7, 2014]; 256(2): 266-73.
Kelleher DC, Merrill CT, Cottrell LT, Nadler EP, Burd RS. Recent National Trends in the Use of Adolescent Inpatient Bariatric Surgery: 2000 through 2009. JAMA Pediatrics 2013 [Accessed online September 7, 2014]; 167(20: 126-132.
Kelly AS, Barlow SE, Rao G, Inge TH, Hayman LL, Steinberger J, Urbina EM, Ewing LJ, Daniels SR. Severe Obesity in Children and Adolescents: Identification, Associated Health Risks, and Treatment Approaches A Scientific Statement From the American Heart Association Circulation, September 2013 (published online before in print). [Accessed online September 7, 2014]
Lennerz BS, Wabitsch M, Lippert H, Wolff S, Knoll C, Weiner R, Manger T, Kiess W, Stroh C. Bariatric surgery in adolescents and young adults—safety and effectiveness in a cohort of 345 patients. International Journal of Obesity, March 2014 [Accessed online September 7, 2014]; 38(3): 334-40.
Messiah SE, Lopez-Mitnik G, Winegar D, Sherif B, Arheart KL, Reichard KW, Michalsky MP, Lipshultz SE, Miller TL, Livingstone AS, de la Cruz-Munoz N. Changes in weight and co-morbidities among adolescents undergoing bariatric surgery: 1-year results from the Bariatric Outcomes Longitudinal Database. Surgery for Obesity and Related Diseases, July-August 2013 [Accessed online September 7, 2014]; 9(4): 503-13.
Nadler EP, Barefoot LC, Qureshi FG. Early results after laparoscopic sleeve gastrectomy in adolescents with morbid obesity. Surgery, August 2012 [Accessed online September 7, 2014]; 152(2): 212-7.   

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