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April 7, 2016/Digestive

Bariatric Surgery for Obese Adolescents: Weighing the Pros and Cons

Perspectives on the special considerations from a high-volume center

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By Philip Schauer, MD, and Kathryn Weise, MD, MA

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Although use of bariatric surgery for severely obese adolescents has expanded substantially over the past decade, it has not kept pace with the growth in teen obesity. Yet evidence of the benefits of bariatric surgery in this population mounts, most notably in the recent study published by the Teen-LABS Consortium in New England Journal of Medicine.1 This prospective trial demonstrated significant and durable improvements in weight, cardiometabolic health and weight-related quality of life three years after surgery, with complication rates that compare favorably to those in adults.

We believe that in carefully screened and selected adolescents with severe obesity, bariatric surgery is a safe and effective treatment option that offers clinical and psychosocial benefits that can last a lifetime. In fact, because the risk of obesity-related comorbidities increases with the duration of obesity, a strong case can be made that bariatric surgery should be more widely considered for appropriate obese adolescents who fail to respond to multiple nonsurgical weight-loss strategies. Yet many parents’ and providers’ traditional tendencies to defer weight-loss surgery until patients reach adulthood are understandable.

Cleveland Clinic is home to one of the busiest bariatric surgery programs in the nation, performing 750 to 800 procedures a year — including five to 12 adolescent cases annually for each of the past 10 years. This experience has given us valuable perspectives on the special considerations surrounding bariatric surgery in adolescents — and on the relative merits of earlier versus deferred intervention. We share some of those perspectives in this review.

Similarities between adults and adolescents abound …

In many respects, bariatric surgery is the same regardless of whether the patient is an adult or an adolescent. The clinical criteria to qualify as a candidate are similar, the same procedures are used (predominantly Roux-en-Y gastric bypass or sleeve gastrectomy) and virtually all procedures are done laparoscopically. And at Cleveland Clinic, the same bariatric surgeons perform the procedures in both populations, allowing them to apply their volume-based expertise gained in adults to adolescent patients as well.

Moreover, obesity contributes to many of the same consequences in pediatric patients as in adults, including type 2 diabetes, cardiovascular disease, hypertension, dyslipidemia, abnormal kidney function, fatty liver disease, asthma and sleep apnea.

… but important adolescent-specific issues remain

Despite these similarities, bariatric surgery in adolescents raises a number of considerations unique to this population, including:

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Potential effects on growth and development. Because bariatric procedures aim to reduce caloric intake, concerns about effects on growth in patients who may have not reached skeletal maturity are natural, even if theoretical. While longitudinal studies like the Teen-LABS trial1 are providing some reassurance about these concerns, our bariatric surgery team works closely with Cleveland Clinic Children’s endocrinologists and other pediatric subspecialists to evaluate the physical maturity of candidates and recommend deferral of surgery if needed from a growth/developmental standpoint.

Maturity and need for a stable psychosocial environment. Adolescents often require heightened assessment to confirm they are mature enough to adhere to postop instructions, such as taking vitamins and coming to follow-up appointments. Special vigilance may be needed to ensure they will steer clear of substance abuse and other risky behaviors. To address such concerns, our adolescent bariatric surgery candidates undergo screening and counseling by both a pediatric psychologist and an adult psychologist. The latter meets with the parent/guardian(s) as well, in part to ensure the child has an adequate support system at home.

Need for both assent and consent. Bariatric surgery in patients under 18 involves obtaining both the legally required informed consent of a parent/guardian and the assent of the child to demonstrate that he/she understands and accepts the potential risks and benefits.

Other special ethical questions. It’s essential that adolescents understand the permanency and long-term consequences of bariatric surgery and recognize the major lifestyle changes required. Ethics and psychological consults must include an assessment of emotional and intellectual maturity and ensure that adolescents don’t unrealistically view the procedure as a quick fix.

Other considerations may make a case for earlier intervention rather than deferring surgery until adulthood. These include:

Curbing obesity’s immediate and long-term health effects. The earlier we intervene in patient’s refractory to nonsurgical treatments, the greater the chance of reducing obesity-related comorbidities or attenuating their long-term effects.

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Reducing psychosocial stigma and deferred opportunities. Adolescence and young adulthood are highly formative years. Enabling patients to shed excess weight and improve their health at an earlier point in those crucial years may yield significant and enduring payoffs in self-esteem, social development, quality of life, and college and job prospects.

Resilience of youth. Even among the severely obese, adolescents are generally healthier than adults (even young adults) and thus may face low complication rates, as suggested by the Teen-LABS study,1 and the prospect of quicker recovery.

Who’s a candidate?

Intensive weight-management programs (such as those offered by Cleveland Clinic Children’s Be Well Kids Clinic) can be successful for obese teens. However, for those who fail to reach weight-loss targets despite repeated attempts, few options exist because most weight-loss medications are not approved for use in children.

Requests for evaluation for bariatric surgery typically come from the teen’s parents (many of whom have had bariatric surgery themselves) or primary care pediatrician. Coexistent type 2 diabetes often triggers referral from pediatric endocrinologists as well. At Cleveland Clinic Children’s, adolescent surgical candidates and their families meet with a multidisciplinary team consisting of a bariatric surgeon, pediatric and adult psychologists, an adolescent medicine specialist, a bioethicist and other pediatric subspecialists as dictated by comorbidities. Dedicated bariatric nurses and pediatric dietitians also are involved in the preop workup and postop care.

Cleveland Clinic Children’s follows American Academy of Pediatrics guidelines2 in qualifying adolescent patients for weight-loss surgery. These focus on patients’ BMI (morbid obesity is the general threshold) and obesity-related health issues, the duration and adequacy of previous physician-supervised weight-loss attempts, and the attainment/near attainment of physiologic and skeletal maturity. The guidelines also underscore the need to rule out underlying medical issues (e.g., thyroid deficiency) that could be treated nonsurgically.

Defining success: More than weight loss

Bariatric surgery in adolescents may be seen as having multiple objectives. In the strictest sense, success is defined as sustained loss of a majority of the patient’s excess weight over five years (after which the weight is unlikely to be regained). Yet success should also be conceived in terms of overall well-being. If a teen achieves meaningful and enduring weight loss that translates to improved overall health and quality of life, that is a worthwhile result even if less than 50 percent of excess weight was lost.

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Success is also measured in terms of eliminating or improving obesity-related comorbidities. Key among these is type 2 diabetes, which figures in up to 30 or 40 percent of our adolescent bariatric surgery cases. In the STAMPEDE study of adult diabetics, our group showed that bariatric surgery resulted in glycemic control (hemoglobin A1c ≤ 6 percent) in significantly more patients than did intensive medical therapy,3 and we have observed similarly positive effects on glycemic control in our adolescent diabetic patients to date. In fact, findings from the Teen-LABS study led those investigators to hypothesize that adolescents may have a greater potential than adults for reversal of the cardiometabolic consequences of obesity.1

While hypotheses like this require confirmation in future trials, it is clear that bariatric surgery can put young patients on a path to improved lifelong health — and that the case for intervening as early as during adolescence looks increasingly compelling.

Inset Bariatric Surgery

References

  1. Inge TH, Courcoulas AP, Jenkins TM, et al; for Teen-LABS Consortium. Weight loss and health status 3 years after bariatric surgery in adolescents. N Engl J Med. 2015 Nov 6 [Epub ahead of print].
  2. Inge TH, Krebs NF, Garcia VF, et al. Bariatric surgery for severely overweight adolescents: concerns and recommendations. Pediatrics. 2004;114:217-223.
  3. Schauer PR, Bhatt DL, Kirwan JP, et al; for STAMPEDE Investigators. Bariatric surgery versus intensive medical therapy for diabetes — 3-year outcomes. N Engl J Med. 2014;370:2002-2013.

Dr. Schauer is Director of Cleveland Clinic’s Bariatric & Metabolic Institute and Professor of Surgery at Cleveland Clinic Lerner College of Medicine.

Dr. Weise is a pediatric hospitalist in the Department of Pediatric Hospital Medicine and a member of the Department of Bioethics, where she chairs the Cleveland Clinic Pediatric Ethics Subcommittee.

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