Background Increasing numbers of severely obese young people undergo bariatric surgery in the USA with reports of substantial weight loss after 1 year. National Institute for Clinical Excellence 2006 suggests considering surgery for young people in ‘exceptional circumstances’. We present six patients operated upon 2004–2012 at our centre in the UK.
Case series Six patients (4 male) aged 14–16 years (mean age 15.10) underwent surgery. Mean preoperative body mass index (BMI) was 62.7 kg/m2 and BMI SDS +4.4. Comorbidities included hypertension, insulin resistance, obstructive sleep apnoea, limited mobility, benign intracranial hypertension and psychosocial issues. All six patients had prior involvement with local lifestyle weight management services and had pharmacological intervention. Four laparoscopic gastric bypass procedures, one laparoscopic gastric banding (patient had a gastric balloon prior to band) and one laparoscopic sleeve gastrectomy were performed.
Results There were no major postoperative procedural complications (one patient had a port rotation). Mean percentage of weight loss, as a percentage of total body weight at 6 and 12 months, was 22 and 27%, respectively. Average absolute weight loss at current follow-up is 54 kg. Mean BMI at 12 months postprocedure was 46.5 kg/m2—a mean fall of 16.2 kg/m2. Mean BMI SDS fell from +4.4 to +3.8 at 12 months and +3.1 at 2 years. Resolution of hypertension, improved school attendance and no progression to T2DM were the benefits noted.
Conclusions Recent systematic reviews and meta-analyses suggest that bariatric surgery results in sustained and clinically significant weight loss in paediatric populations. The surgical option should continue to be exercised with extreme caution only in severely obese adolescents and done so in appropriate case results in positive outcomes.
- bariatric surgery
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What is already known on this topic?
Bariatric surgery results in clinically effective and sustained weight loss in adults and young people.
Increasing numbers of young people are undergoing bariatric surgery in the USA.
A number of guidelines exist regarding patient selection, presurgery and postsurgery protocols, and requirements of the team performing bariatric surgery in adolescents.
What this study adds?
We describe the demographics of the youngest adolescents being considered for bariatric surgery in the UK.
Weight loss profiles in our series are comparable to those of studies published in the American literature.
An improvement in obesity-related comorbidities was noted.
Currently, 30% of children in England aged 2–15 years are overweight or obese.1 Most school-age obese young people will become obese adults with a consequent decrease in life expectancy of anywhere between 5 and 20 years.2–4
Overweight and obesity also contribute to significant physical, mental and emotional morbidities.5 Direct National Health Service (NHS) costs of treating the overweight and obese, and their related morbidity in England ranged from 480 million in 1998 to £4.2 billion in 2007 with a projected cost of £6.3 billion for 2015.6
A very small proportion of young people are very severely obese with a body mass index (BMI) greater than 3.5 SDs above the mean of the UK reference chart for age and sex, which is roughly equivalent to an adult BMI of 40 kg/m2 or class III obesity.7 ,8 This puts them at greater risk of obesity-related health problems, including significant psychosocial problems like poor self-esteem, depression and poor school attendance.9–12
UK obesity services are patchy with significant regional variation. Bariatric surgery has been used successfully in the management of severe obesity in adults resulting in long-term weight loss and improvement in comorbidities.13 However, a review of the bariatric services offered by the Primary Care Trust's across England for adults showed that about 60% were effectively rationing surgery with some raising the threshold above that in the National Institute for Clinical Excellence (NICE) guidance.14 The first report from the UK national bariatric surgery register (April 2011) has called upon the government to improve access to bariatric surgery given that the cost of the procedure is recouped within 3 years and could save the NHS £56 million a year.15
There is understandable reluctance to consider bariatric surgery in young people. Some of the concerns relate to obtaining informed consent in minors, timing of surgery, its cost-effectiveness and impact on growth.16 However, for young people at the extreme end of the spectrum, non-surgical approaches are of only limited value.17 The NICE guidance in 2006 made provision for surgery in exceptional circumstances in young people, which are described in box 1.18
National Institute for Clinical Excellence recommendation for bariatric surgery in young people
Surgery is not generally recommended for children or young people.
Consider surgery for young people only in exceptional circumstances, and if
They have achieved or nearly achieved physiological maturity.
They have a body mass index of 40 kg/m2 or more, or between 35 and 40 kg/m2 and other significant disease (eg, type 2 diabetes, high blood pressure) that could be improved if they lost weight.
All other appropriate non-surgical measures have failed to achieve or maintain adequate clinically beneficial weight loss for at least 6 months.
They are receiving or will receive intensive specialist management.
They are generally fit for anaesthesia and surgery.
They commit to the need for long-term follow-up.
Advocates of bariatric surgery point out that it is generally well tolerated and provides significant and sustained weight loss.19 ,20 Important strides have been made in providing guidance and universally applicable international recommendations for the employment of bariatric surgery in obese adolescents.18 ,21 However, public and media perception of bariatric surgery in adolescents is still largely negative.22 We present the results of bariatric surgery performed at Sheffield Children's Hospital NHS Trust, one of three UK centres currently offering this service for adolescents.
Data were retrospectively extracted from case notes of all adolescents who had bariatric surgery from 2004 onwards.
Information was collected on the patients’ weight (kilograms), height (centimetres) and BMI (kg/m2). The BMI was converted to a SD score (BMI SDS) to allow for easier interpretation and comparison of results.23 Baseline readings were compared with serial postprocedure readings.
The presence of comorbidities preprocedure and postprocedure was noted: insulin resistance (IR) was considered to be present if the HOMA-IR was greater than or equal to 4.58 ,24 or if Acanthosis nigricans was noted on examination.25 Hypertension was defined as a systolic blood pressure greater than the 95th centile for age, sex and height. Obstructive sleep apnoea (OSA) was documented as present if the young person reported symptoms of sleep-disordered breathing or if a sleep study had been reported as abnormal. Sleep studies were not routinely undertaken.
Mobility issues were reported as described by the patient, as were psychosocial issues including non-attendance at school.
We reviewed the surgical notes for the procedure type and any postsurgical complications. Weight loss was expressed in both absolute terms and a percentage of their initial weight and change in BMI SDS.
A total of six patients (four male, two of whom were Asian) were identified. Four out of the six had a family history of bariatric surgery with parents or siblings having undergone surgery. Age range was from 14.7 to 15.9 years (average 15.1 years, median 15.0 years). All the patients were Tanner stage 4 or above. A multidisciplinary team including a paediatric endocrinologist, paediatric and adult bariatric surgeon, paediatric dietician, psychologist assessed all the children prior to surgery. Follow-up to date ranges from 12 to 72 months (mean 33.6 months, mode 24 months).
The hospital clinical ethics committee discussed the initial cases to ensure that the procedure was considered to be in the best interest of the young person. All the candidates met the NICE guidance criteria. Local paediatricians had referred three young people while the other three were referrals from tertiary centres outside the region.
All the young people had previously taken part in community-based weight management programmes, with little or no success. They had all tried orlistat while four out of six had used both orlistat and sibutramine. One of the young people had used his mother's sibutramine on a trial basis for 2 weeks. One young person had been on slow release metformin. None of the young people were on liraglutide. One young person had been admitted twice for weight loss and showed a good response but relapsed subsequently.
None of the patients had an identified gene mutation to account for their early-onset severe obesity.
A range of comorbidities were identified in the young people related to their significant obesity, including hypertension, IR, OSA, impaired mobility, psychosocial issues, poor school attendance, benign intracranial hypertension and elevated liver enzymes and cholesterol/triglycerides (figure 1).
The choice of procedure performed was based on the eating pattern described by the young person and subsequent team discussion with the surgeon with gastro-ileal bypass being the procedure of choice for the ‘grazers’ and the band for the ‘bingers’.26
Average hospital stay following the procedure was less than 48 h. The only procedural-related complication was a port rotation in the male who had the band procedure. In another patient, an incidental umbilical hernia was noted during the bypass that was repaired laparoscopically. However, the patient presented 1 month later with adhesion obstruction necessitating an open repair.
The average preoperative weight, BMI and BMI SDS were 177 kg, 62.7 kg/m2 and +4.4, respectively.
Patient demographics including age, sex, preoperative BMI and surgical procedure performed are described in table 1.
The average weight loss at current follow-up is 54.1 kg (median=45 kg, range 36–86 kg) (one self-reported weight). The average percentage reduction in body weight is 14% at 3 months, 21.7% at 6 months, 26.5% at 12 months and 30% at 24 months.
The percentage weight loss as a percentage of total body weight for each patient at 3, 6, 12 and 24 months is depicted in figure 2.
Average BMI SDS fell from +3.75 at 1 year to +3.1 two years postsurgery (data available for 5/6 patients at 2 years).
We also noted resolution of hypertension (in 1/2) and improvement in fasting insulin in 3/6 cases.
Non-attendance at school was an issue for four of the young people of whom two went back into full-time education. Three of the young people said ‘their lives were transformed’ postsurgery. At last report, only one young person was ‘Not in Education, Employment, or Training’ (NEET).
Previous studies have shown that bariatric surgery results in significant weight loss. A recent systematic review and meta-analysis of bariatric surgery for paediatric obesity (641 young people, 19 studies, average age 16.8 years, average BMI 48.8) showed significant decreases in BMI in both the gastric band and the bypass group (−13.7 to −10.6 kg/m2 in the banding group and −22.3 to 17.8 kg/m2 in the bypass group). More importantly, though comorbidity resolution was sparsely reported, surgery did seem to lead to resolution of diabetes, hypertension, sleep apnoeas and dyslipidemia.19
In adults, it is well recognised that a 5–10% reduction in weight is sufficient to improve several cardiovascular risk factors and reduce the incidence of type 2 diabetes,27 but only a few studies have looked at what constitutes a clinically significant weight reduction in young people. In the Treadwell meta-analysis, this equated to a decrease in BMI of 3–4 units or 7% of body weight. In our series, our young people experienced weight loss far in excess of that.
There are understandable concerns from paediatricians, commissioners and the general public regarding the use of bariatric procedures in severely obese adolescents even though the postsurgical weight loss and safety profiles are not dissimilar to that reported in adults. This stems from the irreversible nature of the procedure in some cases, concerns about malabsorption and the long-term metabolic consequences including effect on skeletal health.28
Only one study has demonstrated the effects of profound weight loss on bone in adolescents following obesity surgery. This showed significant initial bone loss (7.4%) with decrease in both bone mineral content and density though longer-term predicted bone density was appropriate for age 2 years after Roux-en-Y gastric bypass (RYGB).29 Obesity in itself results in reduced bone mineral density in children and it remains to be seen whether bariatric surgery could attenuate or reverse the negative effect of obesity on adolescent skeletal health or if it leads to decreased bone density seen in adults.28–31
A number of surgical procedures have been used to treat severe obesity, but the ones most commonly used now include laparoscopic RYGB (LRYGB), laparoscopic adjustable gastric banding (LAGB) and laparoscopic sleeve gastrectomy (LSG) surgery.
Gastric bypass was the first procedure described for weight loss surgery. Bypass surgery constitutes a permanent change in the anatomy of the gastrointestinal tract, with a higher risk of intraoperative complications and postoperative complications including malabsorption.32 A number of studies that have focused on hormonal changes after LRYGB have shown change in satiety factors with decreased ghrelin and increased GLP-1 that supports the possibility of hormonal effects in improving glycaemic control earlier and independent of the weight loss seen following surgery.33
Serious complications include pulmonary embolism, shock, intestinal obstruction, postoperative bleeding, staple line leak and severe malnutrition. However, no perioperative deaths have been reported in children/adolescents. The literature identifies only one incidence of mortality related to RYGB. This was in an 18-year-old patient with a preoperative BMI of 80 kg/m2 and multiple comorbidities, who died 9 months after surgery from complications of Clostridium difficile colitis.34
LAGB is a relatively safer operation than LRYGB and has lower risks for postoperative nutrient deficiencies and has been advocated for adolescents, as it is potentially reversible. The most common complication reported is band slippage (3–10%) and there are no reported deaths. Losses of excess body weight of between 37 and 63% have been reported.35 The only randomised control trial in young people comparing LAGB with lifestyle intervention (25 adolescents in each arm) showed that 84% of surgical patients experienced greater than 50% excess weight loss as compared with 12% in the lifestyle group though eight operations were required for revisional procedures during follow-up.36
LSG is a single-step surgery (initially used as a first-stage procedure prior to bypass or biliopancreatic diversion in high-risk patients) that has been successfully used in adults with reported excess weight loss of 54–62%.37 In a large Saudi Arabian cohort of 108 children and adolescents aged 5–21 years, the authors report median excess weight loss of 48.1–62.3% over 6–24 months with 70% or more comorbidity resolution. No serious postoperative complications or adverse sequelae were reported.38
Overall, in the USA, there has been a general trend to move towards bypass and sleeve procedures with the number of bands performed falling from 24% to 4% from 2008 to 2012. The laparoscopic sleeve procedure that has a length of hospital stay, morbidity and cost between that of the band and the bypass seems to be gaining in popularity comprising just over 1 in 3 bariatric procedures performed by 2012.39
Our case series included young people with an average BMI of 63 that is much higher than the one quoted in Treadwell's systematic review.19 Our results are similar to those described in the literature. The procedures were well tolerated, with no significant adverse effects. The surgical interventions resulted in significant weight loss, with resolution or improvement in comorbidities. We have 6-year follow-up data on one young person who has started showing some of the late weight regain quoted in some studies in up to one-third of patients though he is still 40 kg less than his pre-band weight.40 The 4-year follow-up data on one other young person is self-reported and shows a 40% reduction in his body weight.
Long-term outcome data are still lacking for the results of bariatric surgery in young people. The University of Miami Miller School of Medicine recently published an analysis of data from more than 400 surgeons at 360 facilities across the USA who performed weight loss surgery on nearly 900 very obese male and female patients aged 11–19 years. This is the first large-scale study of its kind in this age group and showed that bariatric surgery can safely and significantly reduced weight and related comorbidities at 1 year and could change the treatment options offered to very obese youth.41
Studies like the Teen-LABS (Longitudinal Assessment of Bariatric Surgery), which comprises a consortium of five US hospitals, will help describe the natural history of adolescents with morbid obesity, compare surgical and non-surgical outcomes and also create a cohort of young people who may be the subject of future research. However, these data will not be available till after 2016.42
Our experience of bariatric surgery in some of the youngest adolescents in the UK suggests that outcomes are positive in this highly selected population. We have had to invest in specialised equipment, up-to-date protocols, time and staff training to establish this service in a tertiary children's centre.
It is important to consider this option in the small group of young people with significant obesity with severe comorbidities related to their weight. We strongly believe that this should always be in a paediatric setting with access to appropriate equipment, paediatric anaesthetists, surgeons, as well as provision of adequate multidisciplinary support in keeping with the NICE guidance.
The authors would like to thank Dr Didi and Professor Sinha for referring a patient each for the procedure.
Collaborators Mohammed Didi.
Contributors All authors contributed to the conception and design of the paper. PS and TM contributed to the acquisition and collation of the data and drafting the article. PS analysed and interpreted the data. NPW, JKW, SSM and RA provided medical care to the patients. All authors contributed to revision of the article and have given final approval of the version to be published.
Competing interests None.
Patient consent Obtained.
Ethics approval Clinical Ethics Committee at Sheffield Children's Hospital.
Provenance and peer review Not commissioned; externally peer reviewed.