Surgical Options
From 2000 to 2003, there was a threefold increase in utilization of weight-loss procedures (90% gastric bypass) in adolescents.[26,27] Estimates indicate that approximately 2700 adolescents per year undergo bariatric surgery in the USA.[26] However, only 0.7% of the 140,000–150,000 bariatric surgery cases per year are actually performed on adolescents.[28] These data underscore the fact that surgeons who will perform bariatric surgery on adolescents should undergo subspecialty training in bariatric medical and surgical care as detailed by the American College of Surgeons and the American Society for Bariatric Surgery.[28]
Gastric bypass has become the most commonly used surgical intervention for weight loss and is considered the most effective operation against which all other bariatric procedures should be judged.[25] Roux-en-Y gastric bypass dates back to the 1960s for adults and the 1980s for adolescents. The operation entails the creation of a 15–30 ml gastric pouch just beyond the gastroesophageal junction. A section of the jejunum is connected to the gastric pouch using a 1–1.5 cm anastomosis, which impairs rapid emptying of the pouch.[23,28] The pouch restricts meal size, which results in a period of negative energy balance leading to a 25–30% weight loss initially (Figures 1A & 1B).[28] Subsequently, equilibrium of the energy balance occurs and the weight is stabilized at the reduced level. This procedure is increasingly being performed through minimally invasive methods, which result in quicker recovery and fewer potential complications. Even in the hands of the most experienced surgeons, gastric bypass carries a 1% mortality rate.[29]
Most commonly used bariatric surgical procedures in adolescents.
(A) Normal stomach. (B) Roux-en-Y gastric bypass. (C) Gastric banding.
In 2001, the LAP-BAND® was approved by the US FDA for patients who are at least 18 years of age. A small number of facilities have approval for an investigational study of gastric banding in adolescents under the age of 18 years. Gastric banding is a restrictive bariatric procedure in which an adjustable silicone band is placed around the stomach to create a small proximal gastric pouch that enhances early satiety and consequently induces weight loss (Figure 1c).[30] The size of the gastric pouch can be adjusted by inflation or deflation of a balloon lining the lumen of the band. Small studies have demonstrated that adolescents treated with gastric banding lost 55% of their excess bodyweight in the first 2 years, had resolution or improvement of comorbidities of obesity and had minimal morbidity as compared with those undergoing gastric bypass.[24,29–31] There is growing support and evidence of the safety and efficacy of gastric banding as an adolescent procedure. Compared with other surgical procedures, gastric banding is the only operation that is reversible and it is the least invasive procedure.[30] Although gastric banding requires a commitment to return for frequent office visits for adjustment of the band, adolescents are capable of making this type of commitment. Gastric banding works the best for individuals with a BMI of less than 50 kg/m2 who are willing to change their eating habits and to increase physical activity after surgery.[31] The super morbidly obese patients (i.e., those with a BMI > 50 kg/m2) have a better success rate with gastric bypass than with gastric banding.[31] Bariatric surgery can positively change the health of a severely obese adolescent and should be considered as a treatment option for certain adolescents with morbid obesity.
Pediatr Health. 2009;3(1):33-40. © 2009 Future Medicine Ltd.
Cite this: Bariatric Surgery for Obese Adolescents: Should Surgery Be Used to Treat the Childhood Obesity Epidemic? - Medscape - Feb 01, 2009.
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