The prevalence of obesity among children and adolescents is rapidly increasing and is associated with substantial co-morbid disease states. At present, a mounting body of evidence supports the use of modern surgical weight loss procedures for carefully selected, extremely obese adolescents. Scientiﬁc evidence demonstrating the high propensity of severely obese adolescents to become severely obese adults and the greater associated risk among adults with “juvenile-onset” obesity (i.e., obese adults who became obese during childhood; approximately 25%) combined with the evidence demonstrating improvement in obesity-related co-morbid diseases after weight loss induced by bariatric surgery support the concept of “early” intervention in carefully selected adolescents patients. Although current evidence is not sufﬁciently robust to allow a precise recommendations among speciﬁc bariatric procedures, an increasing body of data demonstrating evidence of safety and efﬁcacy exists for 2 of the more commonly performed bariatric procedures for this age group (i.e., Roux-en-Y gastric bypass [RYGB] and adjustable gastric band.
Type 2 diabetes mellitus
A steep increase in the prevalence of type 2 diabetes is occurring worldwide, in parallel with the increasing rate of obesity in children and adolescents. Type 2 diabetes is widely considered a chronic, progressive disease, and, among children and adolescents, it is associated with an increased risk of hypertension, dyslipidemia, and non alcoholic fatty liver disease. In contrast to the signiﬁcant challenges encountered in achieving adequate glycemic control with medical and behavioral approaches in this age group, recent data suggest that diabetes can go into complete remission in adolescents who undergo RYGB. Thus, established type 2 diabetes a strong indication for bariatric surgery in morbidly obese adolescents.
Up to 20% of children and adolescents with obesity have moderate to severe obstructive sleep apnea. Approximately 15% have central sleep apnea, which is often associated with episodes of severe oxygen desideration during sleep (< 85%) with the prevalence of obstructive sleep apnea even greater among adolescents presenting for bariatric surgery, recent data have demonstrated substantial improvement and/or resolution after bariatric surgery in adolescents consistent with the outcomes in adults. Thus, moderate or severe obstructive sleep apnea (e.g., apnea – hypopnea) is a strong indication for early bariatric surgery in adolescents.
Approximately 38% of obese children and adolescents have steatosis compared with 5% of lean subjects, and about 9% have nonalcoholic steatohepatitis (NASH) compared with 1% of the lean population. Although the risk factors for the progression of steatosis and NASH to frank cirrhosis are not fully understood, recent data have demonstrated a decrease in the degree of steatosis and inﬂammatory markers in most patients and regression in hepatic ﬁbrosis after bariatric surgery in some patients. Therefore, NASH should be considered as a strong indication for early bariatric surgery in adolescent patient compared with steatosis alone.
Bariatric surgery is considered the long-term procedure of choice among adults with pseudotumor cerebri. Just as observed in adults, the symptoms of pseudotumor cerebri improve several months after bariatric surgery in adolescents. Thus, pseudotumor cerebri is a strong indication for bariatric surgery in morbidly obese adolescents.
Bariatric surgery can result in improvement of the metabolic and inﬂammatory parameters of the metabolic syndrome, including hyperinsulinemia, insulin resistance, and abnormal lipid metabolism.
Research has clearly shown that obesity has a negative effect on quality of life in adolescents. Several recent studies have also shown signiﬁcant improvement in postoperative quality of life after RYGB and AGB in adolescents similar to the improvements seen in adult cohorts. Therefore, bariatric surgery might have important beneﬁts to the emotional health and quality of life in extremely overweight adolescents.
Many obese adolescents seeking weight management treatment present with signs of clinical depression. Available data, however, indicate that the presence of depression before bariatric surgery does not adversely affect the rate of anticipated weight loss after bariatric surgery. Current data demonstrate that depression improves markedly in adolescents after bariatric surgery. Thus, depression is not an exclusion criterion for bariatric surgery. However, suicide can be a risk after bariatric surgery in adults, and it is important that adolescents with preoperative depression be monitored for recurrence of depression postoperatively.
Binge eating and self-induced purging occur in 5–30% of obese adolescents seeking bariatric surgery. The presence of such eating disturbances before bariatric surgery does not appear to affect weight loss outcome after bariatric surgery in adult cohorts, at least in the short term. Therefore, although not studied speciﬁcally in adolescents seeking bariatric surgery, the presence of eating disturbances is not an exclusion criterion. If an eating disorder is identiﬁed, treatment should be initiated and the patient should be considered stable before bariatric surgery.