Bariatric Procedures Among Teens Level Off

Jenni Laidman

December 19, 2012

Although bariatric surgery rose in popularity among adolescents from 2000 to 2003, the rate of inpatient bariatric surgery has remained relatively flat since then, with 2.4 procedures performed for every 100,000 adolescents in 2009, according to a study published online December 17 in the Archives of Pediatric & Adolescent Medicine.

Deirdre C. Kelleher, MD, from the Division of General and Thoracic Surgery, Joseph E. Robert Jr Center for Surgical Care, Children's National Medical Center, Washington, DC, and colleagues found that the rate of inpatient surgeries stabilized, after rising from 0.8 per 100,000 in 2000 to 2.3 per 100,000 in 2003 (328 vs 987 procedures), despite an increase in adolescent obesity.

"Despite the suggestion that adolescent bariatric surgery has increased in popularity and continued to grow exponentially, inpatient surgery use leveled off from 2003 through 2009, reaching a plateau of about 1000 procedures annually," the authors write. The surgical rate in adolescents mirrors the data for adults, the authors note.

What has changed in adolescent inpatient bariatric surgery is the kind of procedures favored, the authors report. In 2000, 90.6% of inpatient bariatric procedures in teenagers were open Roux-en-Y gastric bypass (RYGB). By 2009, only 7.0% were open RYGB procedures. Although the US Food and Drug Administration has not approved the use of laparoscopic adjustable gastric bands (LAGB) in adolescents younger than 18 years, their use encompassed nearly a third of all inpatient procedures (32.1%) in 2009. Of the rest of the procedures performed in 2009, 60.6% of inpatient surgeries were laparoscopic RYGB.

The researchers conducted a retrospective cross-sectional analysis of data from the Healthcare Cost and Utilization Project Kids' Inpatient Database (KID), which tallies inpatient hospitalization information for those younger than 21 years. The study was based on information from 2000, 2003, 2006, and 2009. Because KID data only address hospital discharges, the increasing role of outpatient surgery for LAGB procedures is not reflected in the numbers, the authors note.

KID statistics show that the number of adolescent inpatient bariatric procedures rose sharply from 328 procedures (95% confidence interval [CI], 239 - 417 procedures; P < .001) in 2000 to 987 procedures (95% CI, 839 - 1135 procedures) in 2003 but remained relatively constant in 2006 (925 procedures; 95% CI, 769 - 1081 procedures) and 2009 (1009 procedures; 95% CI, 850 - 1168 procedures).

Bariatric surgery was performed in patients as young as 12 years but was more often performed in 18- and 19-year-olds (70.8% in 2003 and 77.5% in 2009; P = .03.) In 2000, 226 of the 328 patients were aged 18 to 19 years, and 102 were aged 10 to 17 years (P < .001). In 2009, 781 of the 1009 were in the 18- to 19-year age group and 228 were in the 10- to 17-year category.

More than 70% of the patients were girls in all years: 77.9% in 2000, 76.1% in 2003, 76.8% in 2006, and 74.0% in 2009.

Patients were more likely to have 2 or more comorbidities in 2009 than in earlier years. In 2003, 18.3% of the participants had 2 or more comorbidities compared with 25.2% in 2009 (P = .005). The main comorbidities were chronic pulmonary disease, hypertension, diabetes, depression, liver disease, and hypothyroidism.

Initially, adolescent bariatric patients tended to come from higher-income Zip codes: Only 7.6% of patients in 2000 were from the lowest-income Zip codes, whereas 43.4% came from the highest-income areas. By 2009, however, the income distribution was more even, with 27.3% from the highest-income Zip codes and 24.1% from the lowest-income areas.

The authors note that the reasons for the plateau are unclear but may be in part a result of physician attitude. Recommendations and regulations put in place in 2003 to protect adolescents may have caused physicians to limit referrals for surgery. "Hesitancy to refer adolescents may have been warranted in the early development of bariatric surgery; however, increasing evidence suggests that weight loss procedures are as safe and effective in adolescents as they are in adults," the authors write. "In this study we observed a low complication rate and no in-hospital deaths, despite the increasing prevalence of comorbidities among those undergoing surgery."

In addition, the observations that most procedures are paid for by private insurance and few patients are boys suggest there are economic and social barriers to the procedure, the authors note.

Arch Pediatr Adolesc Med. Published online December 17, 2012. Abstract