Evidence Base for Multidisciplinary Care of Pediatric/Adolescent Bariatric Surgery Patients
Purpose of Review
Severe childhood obesity, defined as having a body mass index (BMI) greater than the 99th percentile for age and gender, is rising in most countries and is associated with early morbidity and mortality. Optimal management of the health of the child with obesity requires a multidisciplinary approach that identifies and treats associated derangements.
Lifestyle interventions such as diet, exercise, and behavioral therapy for the severely obese pediatric patient are generally not effective. Few centers worldwide offer bariatric surgery for adolescents in a multidisciplinary setting, and we are the only center that offers a multidisciplinary approach that incorporates bariatric surgery for severely obese children and adolescents across all age groups.
In this paper, we review up-to-date evidence in this subject including ours, and provide details on the multidisciplinary approach to pediatric obesity that accommodates bariatric surgery for children across all age groups.
KeywordsPediatric Children and adolescents Bariatric surgery Sleeve gastrectomy Multidisciplinary Obesity
Compliance with Ethical Standards
Conflict of Interest
Prof. Alqahtani and Dr. Elahmedi declare no conflicts of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 4.Kelly AS, Barlow SE, Rao G, Inge TH, Hayman LL, Steinberger J, et al. Severe obesity in children and adolescents: identification, associated health risks, and treatment approaches: a scientific statement from the American Heart Association. Circulation. 2013;128(15):1689–712.CrossRefPubMedGoogle Scholar
- 9.Oikonen M, Laitinen TT, Magnussen CG, Steinberger J, Sinaiko AR, Dwyer T, et al. Ideal cardiovascular health in young adult populations from the United States, Finland, and Australia and its association with cIMT: the International Childhood Cardiovascular Cohort Consortium. J Am Heart Assoc. 2013;2(3):e000244.CrossRefPubMedPubMedCentralGoogle Scholar
- 10.•• Alqahtani AR, Elahmedi MO, Al Qahtani A. Co-morbidity resolution in morbidly obese children and adolescents undergoing sleeve gastrectomy. Surg Obes Relat Dis. 2014;10(5):842–50. This is the first and largest study that closely examines the most common obesity-associated comorbidities in a cohort of 226 severely obese children and adolescents aged 5 to 21 years. Additionally, the paper examined the timeline of comorbidity remission and resolution after sleeve gastrectomy in this group of children and adolescents. CrossRefPubMedGoogle Scholar
- 11.• Schwimmer JB, Burwinkle TM, Varni JW. Health-related quality of life of severely obese children and adolescents. JAMA. 2017;289(14):1813–9. This paper assessed the quality of life of children and adolescents living with severe obesity. The study found that the quality of life in those children and adolescents was severely impaired and that it resembles that of children who have cancer. CrossRefGoogle Scholar
- 12.•• Alqahtani AR, Antonisamy B, Alamri H, Elahmedi M, Zimmerman VA. Laparoscopic sleeve gastrectomy in 108 obese children and adolescents aged 5 to 21 years. Ann Surg. 2012;256(2):266–73. This was the first large prospective study of bariatric surgery in severely obese children and adolescents. The study presents results of sleeve gastrectomy in 108 severely obese children and adolescents aged 5 to 21 years, highlighting the safety and efficacy of sleeve gastrectomy in this special group. The study included children with syndromic forms of obesity. CrossRefPubMedGoogle Scholar
- 13.•• Alqahtani A, Alamri H, Elahmedi M, Mohammed R. Laparoscopic sleeve gastrectomy in adult and pediatric obese patients: a comparative study. Surg Endosc. 2012;26(11):3094–100. In this study, we compared the outcomes of sleeve gastrectomy in pediatric and adult patients. Surgery yielded a similar weight loss and safety profile in both age groups. CrossRefPubMedGoogle Scholar
- 14.•• Alqahtani AR, Elahmedi M, Alqahtani YA. Bariatric surgery in monogenic and syndromic forms of obesity. Semin Pediatr Surg. 2014;23(1):37–42. This study reviews evidence, including our experience, on the safety and efficacy of different weight loss procedures in children and adolescents with syndromic forms of obesity, especially Prader-Willi and Bardet-Biedl syndromes. Several procedures were reviewed including the intragastric balloon, laparoscopic sleeve gastrectomy, and roux-en-Y gastric bypass. CrossRefPubMedGoogle Scholar
- 15.•• Alqahtani AR, Elahmedi MO, Al Qahtani A. Laparoscopic sleeve gastrectomy in children younger than 14 years of age: refuting the concerns. Ann Surg. 2015;263(2):312–9. This study examined the outcomes of sleeve gastrectomy, performed within a multidisciplinary setting, in 274 severely obese children and adolescents. The paper compares outcomes of surgery in 118 children younger than 14 years of age with 158 older adolescents. Additionally, it assesses the growth of children after surgery in comparison to an age-, gender-, and height z -score-matched group of children who received lifestyle and dietary intervention but did not undergo a weight loss procedure. CrossRefGoogle Scholar
- 16.•• Alqahtani AR, Elahmedi MO, Al Qahtani AR, Lee J, Butler MG. Laparoscopic sleeve gastrectomy in children and adolescents with Prader-Willi syndrome: a matched-control study. Surg Obes Relat Dis. 2016;12(1):100–10. This paper examines the safety, weight loss, resolution of comorbidities, and growth associated with sleeve gastrectomy in 25 severely obese children and adolescents with Prader-Willi syndrome compared with non-syndromic children and adolescents. Sleeve gastrectomy resulted in significant weight loss over a period of up to 5 years with no mortality, readmissions, prolonged hospital stay, or significant morbidity. CrossRefPubMedGoogle Scholar
- 17.•• Alqahtani AR, Elahmedi MO. Pediatric bariatric surgery: the clinical pathway. Obes Surg. 2015;25(5):910–21. This paper provided information on the pediatric bariatric surgery clinical pathway employed in our institution. We provide details on the weight management program, the multidisciplinary follow-up protocol, bariatric surgery selection criteria, pre-operative and postoperative care, and results obtained through following the protocol. CrossRefPubMedGoogle Scholar
- 21.Office of the Surgeon General, Office of Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, National Institutes of Health. The surgeon general’s call to action to prevent and decrease overweight and obesity. Rockville: Office of the Surgeon General (US); 2001.Google Scholar
- 22.Institute of Medicine Committee on Prevention of Obesity in Children and Youth. The National Academies Collection: reports funded by National Institutes of Health. In: Koplan JP, Liverman CT, Kraak VI, editors. Preventing childhood obesity: health in the balance. Washington (DC): National Academies Press (US)National Academy of Sciences; 2005.Google Scholar
- 23.Kumanyika SK, Obarzanek E, Stettler N, Bell R, Field AE, Fortmann SP, et al. Population-based prevention of obesity: the need for comprehensive promotion of healthful eating, physical activity, and energy balance: a scientific statement from American Heart Association Council on Epidemiology and Prevention, Interdisciplinary Committee for Prevention (formerly the expert panel on population and prevention science). Circulation. 2008;118(4):428–64.CrossRefPubMedGoogle Scholar
- 25.National Clinical Guideline Centre. Obesity: identification, assessment and management of overweight and obesity in children, young people and adults: partial update of CG43. National Institute for Health and Clinical Excellence: Guidance. London: National Institute for Health and Care Excellence (UK); 2014.Google Scholar
- 31.• Sim LA, Lebow J, Wang Z, Koball A, Murad MH. Brief primary care obesity interventions: a meta-analysis. Pediatrics. 2016;138(4):e20162497. This paper examines the effect of primary care interventions on the BMI of children and adolescents with obesity, and highlights the fact that primary care interventions have poor benefit in terms of weight reduction. CrossRefGoogle Scholar
- 35.• Olbers T, Gronowitz E, Werling M, Marlid S, Flodmark CE, Peltonen M, et al. Two-year outcome of laparoscopic roux-en-Y gastric bypass in adolescents with severe obesity: results from a Swedish Nationwide Study (AMOS). Int J Obes, 36. 2012;(11):1388–95. This is a report of the Adolescent Morbid Obesity Study, a nationwide obesity study in Sweden that reported 2-year outcomes in roux-en-Y gastric bypass in severely obese adolescents. Google Scholar
- 36.•• Michalsky MP, Inge TH, Teich S, Eneli I, Miller R, Brandt ML, et al. Adolescent bariatric surgery program characteristics: the Teen Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study experience. Semin Pediatr Surg. 2014;23(1):5–10. In this paper, the Teen-LABS consortium provides details of their multidisciplinary program for bariatric surgery in adolescents. CrossRefPubMedGoogle Scholar
- 37.• Lennerz BS, Wabitsch M, Lippert H, Wolff S, Knoll C, Weiner R, et al. Bariatric surgery in adolescents and young adults—safety and effectiveness in a cohort of 345 patients. Int J Obes. 2014;38(3):334–40. This study provides results on 118 adolescents who underwent gastric banding, 116 who had gastric bypass, and 78 who had sleeve gastrectomy and were enrolled in the German Bariatric Surgery Registry. The study provides complication and weight loss results for up to 30 months after surgery. CrossRefGoogle Scholar
- 40.• Castellani RL, Toppino M, Favretti F, Camoglio FS, Zampieri N. National survey for bariatric procedures in adolescent: long time follow-up. J Pediatr Surg. 2017; This paper reports outcomes on 173 adolescents aged 13–17 years who had data in the registry of the Italian society for bariatric surgery with a mean follow-up of 3 years. The paper demonstrates that sleeve gastrectomy is safe and effective in adolescents. Google Scholar
- 47.Enright PL, Goodwin JL, Sherrill DL, Quan JR, Quan SF. Tucson Children’s Assessment of Sleep Apnea study. Blood pressure elevation associated with sleep-related breathing disorder in a community sample of white and Hispanic children: the Tucson Children’s Assessment of Sleep Apnea study. Arch Pediatr Adolesc Med. 2003;157(9):901–4.CrossRefPubMedGoogle Scholar
- 53.•• Alqahtani A, Elahmedi M, Alswat K, Arafah M, Fagih M, Lee J. Features of non-alcoholic steatohepatitis in severely obese children and adolescents undergoing sleeve gastrectomy. Surg Obes Relat Dis. 2017; doi: 10.1016/j.soard.2017.04.005. In this paper, we report liver biopsy findings obtained from severely obese children and adolescents who underwent sleeve gastrectomy. Notably, almost three quarters of patients had non-alcoholic fatty liver disease, 40% had non-alcoholic steatohepatitis, and 37% had clinically significant (stage 2+) liver fibrosis. Those with NASH were significantly younger than those without NASH and were more likely to be male. The prevalence of NASH in children aged 10 years was 64.9%. Additionally, 60% of children in this age group had clinically significant liver fibrosis compared to 32% of older patients.
- 55.•• Inge TH, Courcoulas AP, Jenkins TM, Michalsky MP, Helmrath MA, Brandt ML, et al. Weight loss and health status 3 years after bariatric surgery in adolescents. N Engl J Med. 2016;374(2):113–23. This paper presents the Teen-LABS 3-year results of severely obese adolescents who underwent roux-en-Y gastric bypass or sleeve gastrectomy. CrossRefPubMedGoogle Scholar
- 59.Flegal KM, Cole TJ. Construction of LMS parameters for the Centers for Disease Control and Prevention 2000 growth charts. Centers for Disease Control and Prevention; 2013. Contract No.: 63.Google Scholar
- 64.• Benedix F, Krause T, Adolf D, Wolff S, Lippert H, Manger T, et al. Perioperative course, weight loss and resolution of comorbidities after primary sleeve gastrectomy for morbid obesity: are there differences between adolescents and adults? Obes Surg. 2017; doi: 10.1007/s11695-0\-2640-7. This paper compares outcomes of sleeve gastrectomy in adults and adolescents who were enrolled in the German Bariatric Surgery Registry. The paper concluded that sleeve gastrectomy yields similar results in both age groups.