Should Surgery Be Used to Treat the Childhood Obesity Epidemic?

Recommendations for Bariatric Surgery in Adolescents

In order to determine which adolescents should be referred for bariatric surgery, the degree to which their medical and psychologic health is being compromised by obesity must be assessed. Adolescents who are determined to be possible candidates for bariatric surgery should be referred to a center with a multidisciplinary team capable of managing the unique challenges of adolescents undergoing this surgery.^[19] This team should consist of a pediatric endocrinologist who can assess for obesity-related comorbidities and determine if puberty and growth are completed, a geneticist who can evaluate for genetic causes of obesity that would not be amendable to bariatric surgery, a psychologist who can assess patient readiness and understanding of the surgery and the necessity of long-term adherence to dietary restrictions, a nutritionist and exercise physiologist and a surgeon who has experience doing this procedure in adolescents.^[19] The whole family should also undergo psychological evaluation to determine factors that could either positively or negatively impact compliance. The importance of the child being mature enough to understand the consequences of this surgery and the family´s ability to maintain compliance with diet is paramount in making the decision about which children are viable candidates for this procedure.

Current recommendations are that adolescents with a BMI greater than 35 kg/m² and comorbidities of obesity, and those with a BMI greater than 40 kg/m², regardless of the presence of comorbidities, be considered for bariatric surgery.^[19,101,102] Several laboratory evaluations should be done to assess for the presence or absence of obesity-related comorbidities, including a hemoglobin A1c, oral glucose tolerance test, liver function tests, complete blood count, thyroid function tests, screening for micronutrient deficiencies and pregnancy tests for females.^[102] It may also be prudent to perform overnight polysomnography to evaluate for sleep apnea, to have a pulmonologist assess the child´s airway and breathing and to evaluate for orthopedic problems prior to surgery. Some institutions require preoperative weight loss, as the first 10% of weight loss is from visceral stores, which makes a difference in the time and ease of operation by allowing a greater intra-abdominal area when insufflated.^[22]

For those candidates who meet criteria to undergo surgery, there are four operations for bariatric surgery: the adjustable gastric band, Roux-en-Y gastric bypass, gastric sleeve and biliopancreatic bypass with a duodenal switch.^[23] The two most commonly used and well-studied procedures for adolescents are the adjustable gastric band and the Roux-en-Y gastric bypass.^[23–25] Of these, gastric bypass is the only approved surgical option for adolescents in the USA. While both gastric bypass and banding are effective in treating the medical consequences of obesity in adolescents, gastric bypass surgery has been shown to be the most effective for optimal weight loss, while the gastric band has been found to have a lower incidence of operative and postoperative complications.^[23,24] Polling of the members of the International Pediatric Endosurgery Group (IPEG; n = 125) as to the best operation for adolescents: 59% chose the gastric band, 22% chose the Roux-en-Y gastric bypass, 14% chose gastric sleeve, 1% chose biliopancreatic diversion and 3% chose other surgical treatments.^[24]

Cite this: Bariatric Surgery for Obese Adolescents: Should Surgery Be Used to Treat the Childhood Obesity Epidemic? - Medscape - Feb 01, 2009.

Known Genetic and Neuroendocrine Causes of Obesity Not Amenable to Bariatric Surgery
	Prader–Willi syndrome	Leptin deficiency	Leptin-receptor mutation	Melanocortin-4 receptor mutation	Proopiomelanocortin	Pseudohypo-parathyroidism
Phenotype	Hyperphagia, food-seeking behavior, short stature and small hands/feet	EMO, hyperphagia and decreased T-cell function	EMO, hyperphagia and aggressive food-seeking behavior	EMO, tall stature and increased lean muscle mass. Phenotype improves with time (adults report less intense hunger and have decreased insulin resistance)	EMO, hyperphagia and red hair	EMO, hyperphagia and can have tall stature
Laboratory abnormalities	Growth-hormone deficiency, hypogonadotropic hypogonadism. Central hypothyroidism and central adrenal insufficiency possible	Hypogonadotropic hypogonadism, hyperinsulinemia and hypothyroidism	Central hypothyroidism, low growth hormone and IGF-1 and absence of puberty	Hyperinsulinemia	Hypocortisolism and hypoglycemia	Primary hypothyroidism

EMO = Early-onset morbid obesity.

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