March 15, 2011 — Bariatric surgery may be effective in obese children and adolescents, but a cautious approach is warranted, according to the results of a systematic review reported online March 3 in Clinical Obesity.
"The obesity epidemic now affects children as well as adults, with obesity and its associated morbidities and costs increasing in scale," said lead author Andrea Aikenhead, from the International Association for the Study of Obesity in London, United Kingdom, in a news release. "Establishing effective methods for treating severe obesity in children will not only reduce the prevalence of childhood obesity and related ill health, but inhibit the progression of obese children to obese adults, a crucial step in combating the epidemic."
The investigators searched PubMed, ISI Web of Science, EMBASE, and the Cochrane Library to September 6, 2010, and also did a manual search of reference lists of retrieved articles. Inclusion criteria were articles with English-language abstracts reporting on participants not older than 19 years, with 1 or more measurements of postoperative weight loss and at least 1 year of postoperative follow-up.
The 37 included studies enrolled a total of 831 children or adolescents, spanning 36 years. Among 13 studies of gastric banding, mean decreases in body mass index (BMI) ranged from 8.5 to 43 kg/m2, with weight gain reported in 1 case study. Mean BMI reductions ranged from 9 to 25 kg/m2 in 8 studies of Roux-en-Y gastric bypass (RYGB).
Other forms of bariatric surgery, including sleeve gastrectomies, vertical banded gastroplasty, biliopancreatic diversion, or a combination of procedures, were reported in 14 articles. These procedures resulted in mean BMI decreases ranging from 9 to 24 kg/m2, weight regain in several cases, and 3 deaths related to surgery.
Most studies reported resolution or improvement of comorbid conditions. Various surgical procedures were associated with a range of postoperative complications including ulcers, intestinal leakage, wound infection, anastomotic stricture, nutritional deficiencies, bowel obstruction, pulmonary embolism, disrupted staple lines, band slippage, psychological sequelae, and repeated vomiting.
Only 1 Australian modeling project studied cost-effectiveness, and results of this study suggested that laparoscopic adjustable gastric banding (LAGB) is cost effective for adolescents.
"Existing evidence — although based generally on underpowered, retrospective studies — suggests that bariatric surgery in older children results in significant weight loss and improvements in comorbidities and quality of life," the study authors write.
"However, postoperative complications, compliance and follow-up may be more problematic in adolescents than adults, and availability of long-term data on safety, effectiveness and cost-effectiveness remains largely unknown. Pending an improvement in the quality of available evidence, a cautious approach to child and adolescent bariatric surgery is warranted, and reversible techniques are advisable compared to approaches that permanently alter anatomy."
Limitations of this study include retrospective or observational design in most studies, insufficient power, generally small sample sizes, results not broadly comparable, and limited information for low-frequency outcomes such as mortality and complications. In addition, it was difficult to determine the degree of weight regain in adolescents, in part because of the bias introduced by patients lost to follow-up.
"Lifestyle modification and prevention should not be de-emphasized: the former is crucial to the long-term success of bariatric procedures," the study authors conclude. "There is an urgent need to develop alternatives to surgery, such as practical lifestyle programmes that are effective, even modestly, for overweight and obese children. Public health experts must continue to employ the precautionary principle to convince governments of the importance of implementing health-promoting public policies to support prevention programmes and adequate long-term research for treatment."
The project that led to this study was funded by the WHO Health Evidence Network of the World Health Organization. The study authors have disclosed no relevant financial relationships.
Clin Obesity. Published online March 3, 2011. Abstract
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