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Adolescent bariatric surgery in the United Kingdom; a call for continued study and open dialogue
  1. Marc P Michalsky
  1. Correspondence to Professor Marc P Michalsky, Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive—ED-379, Columbus, OH 43205, USA; Marc.michalsky{at}nationwidechildrens.org

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Childhood obesity has reached alarming levels and has established itself as a major threat to the health and welfare of millions of children and adolescents worldwide. Data from the US estimate that approximately 17% of the paediatric and adolescent populations are considered obese (ie, body mass index (BMI) ≥95th percentile) while corresponding evidence demonstrates that 4–7% of affected youth are considered severely obese (ie, BMI ≥120% of the 95th percentile).1 An increasing number of reports citing the association between childhood obesity and obesity-related comorbid conditions (ie, hypertension, obstructive sleep apnoea, liver disease and type 2 diabetes mellitus, etc), in combination with data showing a high propensity of severely obese children becoming severely obese adults (BMI ≥40 kg/m2), has led to an increase in the use of bariatric surgery among adolescents.2 While current national data (2009) suggests that 2.4 per 100 000 adolescents undergo bariatric surgery annually in the USA, representing an increase in procedural prevalence from 2000 yet unchanged when compared with data from 2006, it is widely agreed that the accuracy of the current estimated national experience is uncertain.2 One explanation for the inability to obtain an accurate picture may be related to the lack of a centralised system of data collection and reporting in this country, and may result in the inability to capture all adolescent bariatric cases being performed.

Despite increasing evidence supporting the use of adolescent bariatric surgery,1 a general consensus related to the attitudes among healthcare providers in the USA remains mixed.3 In a recent report by Woolford et al,3 survey results of a national random sample of paediatricians and family physicians demonstrated that nearly half (48%) of those surveyed would never consider referring an adolescent patient for bariatric intervention. Interestingly, a recent survey of primary care providers as well as surgical and non-surgical specialists examining attitudes related to the use of adolescent bariatric surgery in the UK appears to demonstrate a somewhat less reluctance when compared to their US counterparts.4

In the current study, Sachdev and colleagues5 describe comprehensive outcomes related to a retrospective analysis of a small (4 males and 2 females) but meaningful institutional experience of adolescent bariatric surgery patients (age range 14–16 years) between 2004 and 2012. Although the ability to offer broad and conclusive statements related to overall safety and efficacy of adolescent weight loss surgery is certainly limited by the small and retrospective nature of the current study, several aspects of the report are noteworthy and serve to confirm previously reported observations. The result of this study, therefore, lends important information to the body of literature supporting this controversial treatment paradigm. In addition to demonstrating the presence of numerous obesity-related comorbid illnesses prior to bariatric intervention similar to previous reports,1 including hypertension (33%), obstructive sleep apnoea (33%), insulin resistance (83%), elevated serum triglycerides (33%) and hepatic enzymes (50%), the current study demonstrates an average percentage reduction in body weight as high as 30% at the 24-month timepoint following surgery. While only limited information is offered with regards to the effects of surgically induced weight loss on comorbid disease, the investigators state that they observed resolution in hypertension which is consistent with numerous previous studies evaluating the impact of adolescent bariatric surgery. With regards to overall safety and short-term outcomes, the authors report a 33% short-term complication rate, including one subject with a malpositioned subcutaneous port (presumably involving the subject who underwent insertion of an adjustable gastric band) and one subject who returned to the operating table within 1 month of the primary procedure (gastric bypass) for repair of an adhesive bowel obstruction.

Of particular interest in the current report, as illustrated in table 2, summary demographics of the study cohort demonstrate a mean preoperative BMI of 62.7 kg/m2 (range 38.6–78.9 kg/m2) which is similar to previous adolescent bariatric reports,1 ,6 and representative of the large spectrum of severe obesity observed among adolescents considering surgical weight loss intervention. While much of the current literature related to defining appropriate indications for adolescent bariatric surgery focuses on minimal age of the patient and minimal required BMI, there is a paucity of data investigating optimal timing for surgical intervention as it relates to the potential for an ‘ideal’ BMI range. In a recent single centre longitudinal assessment of 61 adolescents undergoing laparoscopic roux-en-Y gastric bypass (RYGB) (mean preoperative BMI 60.2 kg/m2); investigators demonstrated reversal of several cardiovascular risk factors in conjunction with a reduction in BMI of approximately 37%, regardless of the starting BMI (subjects were stratified into three classifications of BMI; low (40–54.9 kg/m2), medium (55–64.9 kg/m2), and high (65–95 kg/m2)). Similar to previous reports in adult study cohorts, the authors concluded that the use of preoperative BMI is an accurate indicator of nadir BMI following bariatric surgery, and suggests that the timing of surgical intervention is an important and mostly overlooked consideration with respect to the adolescent population. In conjunction with the potential ‘ceiling effect’ observed in this study, and results demonstrating that only 17% of subjects (the majority of whom were part of the lowest BMI stratification group) became non-obese following surgical intervention (BMI <30 kg/m2), the investigators concluded that ‘late’ referral for bariatric intervention (ie, referral for patients with preoperative BMI of approximately 55 kg/m2 or greater) may preclude the ability to reverse obesity or extreme obesity within the first postoperative year and, furthermore, may increase the risk of weight regain over the long term.6

In addition to collecting subject demographics and information pertaining to commonly encountered obesity-related comorbidities, the authors also attempted to collect self-reported information pertaining to subject mobility and psychosocial data (including school attendance). While the results related to psychosocial issues among the study cohort lack detail, it would appear that loss of excess body weight had a positive impact on school attendance which was used as a surrogate for psychosocial comorbidity. While some literature pertaining to psychosocial health and quality of life related to severely obese teens undergoing bariatric surgery are present, there is a great need for additional uniform prospective analysis of the potential impact of bariatric surgery on multiple adolescent quality of life measures.

While the authors of the current study5 have correctly stated that long-term longitudinal data for adolescent bariatric surgery are presently lacking, several ongoing studies, including Teen-LABS (Longitudinal Assessment of Bariatric Surgery), a National Institutes of Health sponsored prospective observational study of severely obese adolescent (n=242) who have undergone bariatric surgery in the USA, is anticipated to yield important new insights pertaining to baseline health and demographics, as well as longitudinal outcomes beyond the typical 1–2-year reporting period in the majority of current literature. Since the publication submission of the current study, the multi-institutional team of Teen-LABS investigators has reported very favourable short-term safety and complication outcomes.1 Additional prospective clinical data, including the anticipated longitudinal outcomes from the Teen-LABS consortium, as well as ongoing national and international dialogue among healthcare providers and all related stakeholders (ie, healthcare providers, clinical researchers, patients and families, etc) will undoubtedly help with the continued development of guidelines for the use of bariatric surgery in this evolving and vulnerable population.

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Footnotes

  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed.

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