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Current Issues in Bariatric Surgery for Adolescents with Severe Obesity: Durability, Complications, and Timing of Intervention.

ABSTRACT: Conventional nonsurgical management of severe obesity in the pediatric population and adolescents has focused on a multidisciplinary approach involving diet, exercise, behavioral modification, and to some extent, pharmaceuticals. Although nonsurgical strategies provide a certain degree of effective weight reduction, most of the severely obese adolescents suffer from a high relapse rate. In recent studies, long-term outcomes of bariatric surgery for severely obese adolescents have shown sustainable effects on weight loss and resolution of related comorbidities, such as hypertension and type 2 diabetes mellitus in this vulnerable age group. Notably, the role and practical benefits of bariatric surgery as a multidisciplinary therapeutic approach to adolescent obesity is gaining attention and acceptance. However, a surgical approach has many obstacles that prevent the timely evaluation and optimal intervention for adolescent obesity and its comorbidities. In the present review, the latest data on long-term outcomes after bariatric surgery for severely obese adolescents in terms of durability, effects on metabolic risk factors, complications, and optimal timing were summarized. The results showed the sustainability of weight loss and comorbidity resolution in adolescents following bariatric surgery. In addition, earlier surgery in patients without an extremely high body mass index increases the likelihood of a healthier life in adulthood. This review can help clarify the beneficial effects of bariatric surgery on weight reduction and resolution of comorbidities in severely obese adolescents and remove the barriers to referral of adolescents for bariatric surgery.

SUBMITTER: Ahn SM

PROVIDER: S-EPMC7118002 | biostudies-literature | 2020 Mar

REPOSITORIES: biostudies-literature

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Current Issues in Bariatric Surgery for Adolescents with Severe Obesity: Durability, Complications, and Timing of Intervention.

Ahn Soo Min SM

Journal of obesity & metabolic syndrome 20200301 1

Conventional nonsurgical management of severe obesity in the pediatric population and adolescents has focused on a multidisciplinary approach involving diet, exercise, behavioral modification, and to some extent, pharmaceuticals. Although nonsurgical strategies provide a certain degree of effective weight reduction, most of the severely obese adolescents suffer from a high relapse rate. In recent studies, long-term outcomes of bariatric surgery for severely obese adolescents have shown sustainab ...[more]

PMID: 32183507

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Project description:Inflammation, oxidative stress and dysregulation of adipokines are thought to be pathophysiological mechanisms linking obesity to the development of insulin resistance and atherosclerosis. In adults, bariatric surgery reduces inflammation and oxidative stress, and beneficially changes the levels of several adipokines, but little is known about the postsurgical changes among adolescents.In two separate longitudinal cohorts we evaluated change from baseline of interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), monocyte chemo-attractant protein-1 (MCP-1), oxidized low-density lipoprotein cholesterol (oxLDL), adiponectin, leptin and resistin up to 12 months following elective laparoscopic Roux-en-Y gastric bypass (RYGB) or vertical sleeve gastrectomy (VSG) surgery in adolescents with severe obesity.In cohort 1, which consisted of 39 adolescents (mean age 16.5±1.6 years; 29 females) undergoing either RYGB or VSG, IL-6 (baseline: 2.3±3.4 pg ml(-1) vs 12 months: 0.8±0.6 pg ml(-1), P<0.01), leptin (baseline: 178±224 ng ml(-1) vs 12 months: 41.4±31.9 ng ml(-1), P<0.001) and oxLDL (baseline: 41.6±11.6 U l(-1) vs 12 months: 35.5±11.1 U l(-1), P=0.001) significantly decreased and adiponectin significantly increased (baseline: 5.4±2.4 μg ml(-1) vs 12 months: 13.5±8.9 μg ml(-1), P<0.001). In cohort 2, which consisted of 13 adolescents (mean age 16.5±1.6 years; 10 females) undergoing RYGB, results were similar: IL-6 (baseline: 1.7±0.9 pg ml(-1) vs 12 months: 0.4±0.9 pg ml(-1), P<0.05) and leptin (baseline: 92.9±31.3 ng ml(-1) vs 12 months: 37.3±33.4 ng ml(-1), P<0.001) significantly decreased and adiponectin significantly increased (baseline: 6.1±2.9 μg ml(-1) vs 12 months: 15.4±8.0 μg ml(-1), P<0.001). When the cohorts were combined to evaluate changes at 12 months, oxLDL also significantly decreased (baseline: 39.8±16.7 U l(-1) vs 12 months: 32.7±11.9 U l(-1), P=0.03).Bariatric surgery produced robust improvements in markers of inflammation, oxidative stress and several adipokines among adolescents with severe obesity, suggesting potential reductions in risk for type 2 diabetes and cardiovascular disease.

Project description:BACKGROUND/OBJECTIVES:We hypothesized that physical activity (PA) improves insulin sensitivity in adolescents with severe obesity beyond that attributable to metabolic bariatric surgery (MBS). SUBJECTS/METHODS:StepWatchTM monitors objectively measured PA in 88 participants in the Teen Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study. Primary outcomes included absolute change in fasting insulin, HOMA-IR, and fasting glucose from pre-surgery (baseline) to 6, 12, 24, and 36 months post-MBS. SAS PROC TRAJ generated activity trajectories based on probability and individual participant step count trajectories. Linear regression models were used, adjusted for baseline value, visit, surgical procedure, sex, and percent change in BMI. Additional models adjusted for percent change in iliac waist circumference (IWC) or percent body fat (BF), measured by bio-impedance. RESULTS:Two activity trajectories were identified: more active (MA, n = 13) and less active (LA, n = 75). MA baseline mean daily step count was >6000, increasing to >9000 at 2 years. LA mean daily step count remained at ~4000. Few participants recorded moderate step activity (cadence >80 steps/minute). Still, fasting insulin and HOMA-IR differed in association with activity trajectoy. MA was associated with a greater absolute decrease in fasting insulin (-7.8 ?U/ml [95% CI: (-11.8, -3.7)], p???0.001) and a greater decrease in HOMA-IR (-1.9 [95% CI: (-3.0, -0.7)], p = 0.001), when adjusted for percent change in BMI. The significant independent effect of MA remained when adjusted for percent change in IWC or percent BF. Clinically, 100% of MA trajectory participants normalized fasting insulin, HOMA-IR, and fasting glucose by 6 months and normalization remained throughout the 36 months follow up. In contrast, 76.3 and 65.8% of LA trajectory participants normalized fasting insulin and HOMA-IR, respectively, by 12 months with 28.6% of both remaining normalized at 36 months. CONCLUSIONS:PA is independently associated with improved insulin sensitivity beyond that attributable to MBS in adolescents with severe obesity.

Project description:BackgroundParental underestimation of the severity and risks of their child's obesity and parents' potential implicit weight bias contribute to the reluctance to consider bariatric surgery for their adolescent children with obesity. Despite evidence for safety and efficacy of bariatric surgery in adolescents, pediatric providers may be hesitant or uncomfortable to discuss the benefits and refer patients for surgical evaluation. Understanding these barriers is an essential step toward effective long-term care in this patient population.ObjectivesWe hypothesized that parental views on bariatric surgery are primarily influenced by personal experiences with bariatric surgery, their implicit bias, understanding of health risks of obesity, and counseling by pediatric providers.SettingData were collected and analyzed at an academic medical center in the United States.MethodsAfter a retrospective chart review of 192 adolescents with obesity, a telephone survey of patients' parents was conducted.ResultsParents of 71.4% of patients who received outpatient weight loss counseling had accurate recollection of that event. Only 12.8% of parents who were referred to lifestyle programs successfully enrolled. Neither prior personal exposure to bariatric surgery nor enrollment of the child in a lifestyle program increased parents' likelihood to consider bariatric surgery for their child (P = .10 and .70, respectively). Most parents (84.6%) who were counseled by their pediatric provider about bariatric surgery would consider it, compared with only 34.5% of the parents who did not receive counseling (P < .001).ConclusionsCounseling by pediatric providers, not involvement in lifestyle programs or exposure to bariatric surgery, increased parents' willingness to consider bariatric surgery for their child. Given the current recommendations to incorporate bariatric surgery as a treatment modality in severe adolescent obesity, earlier counseling about the role of surgery by pediatric providers is essential. More detailed provider education on the current state of bariatric surgery in the treatment of severe adolescent obesity is also necessary.

Project description:BackgroundLittle is known about the long-term outcomes of bariatric surgery for severe adolescent obesity, raising questions about the durability of early responses to surgery. We aimed to analyse long-term (>5 years) outcomes of Roux-en-Y gastric bypass in a cohort of young adults who had undergone the operation during adolescence, in the Follow-up of Adolescent Bariatric Surgery at 5 Plus Years (FABS-5+) extension study.MethodsA cohort of young people aged 13-21 years underwent Roux-en-Y gastric bypass for clinically severe obesity at a paediatric academic medical centre in the USA. We did a prospective follow-up analysis of these patients' outcomes 5-12 years after surgery. Outcomes assessed included BMI, comorbidities, micronutrient status, safety, and other risks. The FABS study is registered with ClinicalTrials.gov, number NCT00776776.FindingsBetween May, 2001, and February, 2007, 74 young people underwent Roux-en-Y gastric bypass in the FABS study. Of these, 58 individuals were eligible for the FABS-5+ study, could be located, and agreed to follow-up assessment. At baseline, the mean age of the cohort was 17·1 years (SD 1·7) and mean BMI was 58·5 kg/m2 (10·5). At mean follow-up of 8·0 years (SD 1·6; range 5·4-12·5), the mean age of the cohort was 25·1 years (2·4) and mean BMI was 41·7 kg/m2 (12·0; mean change in BMI -29·2% [13·7]). From baseline to long-term follow-up, significant declines were recorded in the prevalence of elevated blood pressure (27/57 [47%] vs 9/55 [16%]; p=0·001), dyslipidaemia (48/56 [86%] vs 21/55 [38%]; p<0·0001), and type 2 diabetes (9/56 [16%] vs 1/55 [2%]; p=0·03). At follow-up, 25 (46%) of 58 patients had mild anaemia (ie, not requiring intervention), 22 (45%) had hyperparathyroidism, and eight (16%) had low amounts of vitamin B12 (ie, below the normal cutpoint).InterpretationRoux-en-Y gastric bypass surgery resulted in substantial and durable bodyweight reduction and cardiometabolic benefits for young adults. Long-term health maintenance after Roux-en-Y gastric bypass should focus on adherence to dietary supplements and screening and management of micronutrient deficiencies.FundingEthicon Endosurgery, National Center for Advancing Translational Sciences (US National Institutes of Health).

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Current Issues in Bariatric Surgery for Adolescents with Severe Obesity: Durability, Complications, and Timing of Intervention.

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Current Issues in Bariatric Surgery for Adolescents with Severe Obesity: Durability, Complications, and Timing of Intervention.

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