Systematic Review and Meta-Analysis of Bariatric Surgery for Pediatric Obesity

Jonathan R. Treadwell, PhD; Fang Sun, MD, PhD; Karen Schoelles, MD, SM

Disclosures

Annals of Surgery. 2008;248(5):763-776. 

In This Article

Abstract and Introduction

Objective: The prevalence of morbid obesity has risen sharply in recent years, even among pediatric patients. Bariatric surgery is used increasingly in an effort to induce weight loss, improve medical comorbidities, enhance quality of life, and extend survival. We performed a systematic review and meta-analysis of all published evidence pertaining specifically to bariatric surgery in pediatric patients.
Methods: We systematically searched MEDLINE, EMBASE, 13 other databases, and article bibliographies to identify relevant evidence. Included studies must have reported outcome data for ≥3 patients aged ≤21, representing ≥50% of pediatric patients enrolled at that center. We only included English language articles on currently performed procedures when data were separated by procedure, and there was a minimum 1-year follow-up for weight and body mass index (BMI).
Results: Eight studies of laparoscopic adjustable gastric banding (LAGB) reported data on 352 patients (mean BMI 45.8); 6 studies of Roux-en-Y gastric bypass (RYGB) included 131 patients (mean BMI 51.8); 5 studies of other surgical procedures included 158 patients (mean BMI 48.8). Average patient age was 16.8 years (range, 9-21). Meta-analyses of BMI reductions at longest follow-up indicated sustained and clinically significant BMI reductions for both LAGB and RYGB. Comorbidity resolution was sparsely reported, but surgery did appear to resolve some medical conditions including diabetes and hypertension. For LAGB, band slippage and micronutrient deficiency were the most frequently reported complications, with sporadic cases of band erosion, port/tube dysfunction, hiatal hernia, wound infection, and pouch dilation. For RYGB, more severe complications have been documented, such as pulmonary embolism, shock, intestinal obstruction, postoperative bleeding, staple line leak, and severe malnutrition.
Conclusions: Bariatric surgery in pediatric patients results in sustained and clinically significant weight loss, but also has the potential for serious complications.

Obesity among pediatric patients has increased sharply in recent years. The percentage of adolescents in the United States with a body mass index (BMI) above the 95th percentile for age and sex (based on Centers for Disease Control and Prevention (CDC) growth charts) nearly tripled between 1970 and 1999 (from 5% to 14%),[1] and an analysis of 1999 to 2002 data estimated this prevalence at 16%.[2]

Many studies have demonstrated the health risks of obesity in pediatric populations.[3,4,5,6,7,8,9,10,11,12,13,14] Becque[14] determined that 35 of 36 (97%) obese adolescents had 4 or more serious cardiovascular risk factors. (The factors under consideration were: (1) serum triglyceride >100 mg/dL; (2) HDL cholesterol below the 10th percentile for age and sex; (3) total cholesterol >200 mg/dL; (4) systolic BP above the 90th percentile for age and sex; (5) dystolic BP above the 90th percentile for age and sex; (6) maximal oxygen consumption <24 mL/kg of body weight; and (7) strong immediate family history of cardiovascular disease.) Weiss[11] found that 97 of 195 severely obese adolescents (50%) met criteria for the metabolic syndrome, as compared with 0 of 20 nonobese adolescents. Rhodes[12] studied 14 morbidly obese children and adolescents and found that 5 of them (36%) had sleep apnea, which was associated with more neurocognitive deficits (learning, memory). Additional risks of obesity among adolescents include musculoskeletal problems, asthma, gastroesophageal reflux disease (GERD), pseudotumor cerebri, gallstones, and menstrual abnormalities.[3,6,13]

Research has also demonstrated reduced quality of life[15] and social marginalization among obese pediatric patients.[16,17] Schwimmer[15] surveyed the quality of life of 106 obese patients aged 5 to 18 years and found an average score of only 67, as compared with 83 for nonobese pediatric patients (on their pediatric quality of life scale, 100 indicated excellent quality of life, and 0 indicated extremely poor quality of life). The impact of obesity was persistent for both psychosocial health and physical health. In another study of over 90,000 adolescents in the National Longitudinal Study of Adolescent Health,[16] the authors measured the number of friendship nominations received by other adolescents. This study defined a friendship nomination as when the obese adolescent is cited by another adolescent as a friend. The average was lower for overweight adolescents (3.4) than for nonoverweight adolescents (4.8). Also, obese adolescents were more likely to receive zero friendship nominations (which was true for 12% of overweight adolescents as compared with 7% of nonoverweight adolescents), suggesting social marginalization.

Obese pediatric patients are more likely to become obese adults than their nonobese peers.[7,18,19,20] In a review of 15 studies, Serdula[18] estimated that 42% to 63% of obese school-age children become obese adults; the comparative risk of becoming an obese adult was 4 to 6.5 times higher for obese school-age children than nonobese school-age children. Power[7] used data from a 1958 birth cohort and found similar relative risks of adulthood obesity based on adolescent obesity. Whitaker[19] found that 23 of 30 patients (77%) who had been severely obese at age 15 to 17 years were still obese as adults, and this same percentage (77%) was observed in a study by Freedman[20] that included 186 obese adolescents.

Obesity during adolescence has also been tied directly to health problems in adulthood.[7,20,21,22] Power[7] reviewed 5 pertinent studies and found correspondence between adolescent obesity and adulthood all-cause mortality, coronary heart disease, atherosclerosis, colorectal cancer, gout, arthritis, and menstrual problems. Also, Abraham[22] found higher prevalence rates of 4 medical conditions (diabetes, atherosclerosis, hypertension, and cardiovascular disease) among 19 adolescents whose weight was ≥120% of the average weight for age and height.

Treatments for obesity are intended to induce weight loss, improve medical comorbidities, enhance quality of life, and (ultimately) extend survival. Nonsurgical treatments, including dietary modification, physical activity, behavioral modification, and pharmacotherapy, have turned in generally unsatisfactory results thus far. Studies have observed high dropout rates, and among patients who remain in the studies, only modest weight loss is achieved. For example, in 3 recent trials (Chanoine et al,[23] Savoye et al,[24] and Berkowitz et al[25]) followed obese pediatric patients for 1 year after initiation of treatment. Chanoine et al[23] enrolled 357 pediatric patients in a group to receive orlistat, hypocaloric diet, exercise, and behavioral modification, but only 232 of them (65%) completed 1-year follow-up, and their average BMI loss was only 0.55 units (from a baseline BMI of 35.6). Similarly, Savoye et al[24] observed 1-year completion in only 71% (75/105) of patients assigned to a weight management program, and the average 1-year BMI reduction was only 1.7 units (baseline BMI 35.9). Berkowitz et al[25] observed somewhat greater BMI reduction (3.2 units from a baseline of 37.5) among 33 of 43 patients (77%) who completed 1-year follow-up.

One invasive treatment option for severely obese pediatric patients is bariatric surgery. Its overall use has increased dramatically in recent years, from approximately 13,000 operations in 1998 to approximately 121,000 operations in 2004 (these figures include adults).[26] Patients under age 18 years comprise about 0.1% to 1% of bariatric surgery patients.[27,28,29] The estimated adolescent bariatric rate (per 100,000 population) in the United States increased from 0.7 in 2000 to 2.3 in 2003.[30] A 2005 survey of bariatric surgeons in the United States found that 49% of them had performed bariatric surgery on one or more adolescents in the previous year, 75% were planning to perform adolescent bariatric surgery in the coming year, and 55% either had a bariatric program with pediatric specialists or were creating one.[31]

Among adults, bariatric surgery is typically reserved for those with a BMI ≥ 40 kg/m2, or ≥35 kg/m2 in the presence of one or more medical comorbidities.[32,33,34] Some authors have proposed more stringent BMI criteria for the pediatric population: BMI ≥50 kg/m2, or ≥40 kg/m2 in the presence of one or more medical comorbidities.[35,36,37] Others have suggested that the adult BMI criteria should apply equally to this population.[38,39,40] Additional suggested criteria prior to adolescent bariatric surgery included the attainment of physical maturity, demonstrated decisional capacity, and a supportive family environment.[36]

A wide variety of surgical procedures have been used to treat obesity. The 2 most commonly performed bariatric surgical procedures are laparoscopic adjustable gastric banding (LAGB) and the Roux-en-Y (RYGB) gastric bypass. The LAGB is a purely restrictive procedure in which the surgeon places a silicone band around the entire upper portion of the stomach, creating a tiny pouch where food empties from the esophagus to the upper stomach. The RYGB restricts intake through the creation of a small gastric pouch, and also reduces food absorption via bypass of the proximal small intestine. Other bariatric surgical procedures include vertical banded gastroplasty (VBG), biliopancreatic diversion (BPD), biliopancreatic diversion with duodenal switch (BPD/DS), banded bypass (BB), and laparoscopic sleeve gastrectomy (LSG).

The health consequences of obesity in pediatric patients, considered together with the potential for bariatric surgery to prevent or resolve these consequences, motivate the need for a comprehensive summary of the relevant evidence. Consequently, we performed a systematic review and meta-analysis of published studies of pediatric patients who have received bariatric surgery.

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