Comorbidities that are “more or less reversible” with bariatric surgery in adolescents and are the most common indications for surgery are diabetes, sleep apnea, and nonalcoholic steatohepatitis. Others in this category include hypertension, pseudotumor cerebri, gastroesophageal reflux disease, asthma, and poor self-esteem, said Dr. Janey S.A. Pratt, a bariatric surgeon at Massachusetts General Hospital in Boston. However, she noted, other obesity-linked conditions are generally not reversible, including glomerulosclerosis of the kidney, gallstones, flat feet, major orthopedic deformities, precocious puberty, and some body-image issues. “The most important reason to operate on obese adolescents is not to decrease their weight, but rather to treat or prevent the comorbidities associated with excess weight,” Dr. Pratt said. “Will all of the adolescents we operate on be obese as adults?” Dr. Pratt cited results from a recent study in which 100% of children with a BMI above the 99th percentile after age 10 years had BMIs greater than 35 kg/m
A similar interest in early intervention in adolescents exists among surgeons whose focus is gastric banding, which along with gastric sleeves are the surgical alternatives to bypass. Unlike the surgeons who perform gastric bypass surgery, those who do banding have consistently used adult criteria for surgical intervention in adolescent patients. The main limitation of banding has been that as of early 2010 neither of the band devices marketed in the United States for adults had received Food and Drug Administration approval for use in adolescents.
A few years ago, bariatric surgeons at New York University, Rush University, and elsewhere received FDA permission to perform gastric banding on adolescents on an investigational, off-label basis using adult entry criteria. Dr. Nadler, who was with the NYU program at the time, said that he and other surgeons who performed banding never saw a need to be more conservative in their patient-selection criteria than in adults because they viewed banding as less risky than bypass.
“Banding is less invasive and complications are lower and not as serious as with bypass,” he said.
“Gastric bypass is considered more invasive than banding,” agreed Dr. Holterman. Banding is reversible, and it also results in more gradual weight loss since it relies entirely on restricting gastric capacity rather than also on reducing absorption like bypass does, she noted. Dr. Holterman said she prefers an approach that tries banding first, reserving bypass as a later option if needed.
Regardless of which surgical approach is best, now that the field has arrived at a consensus that adolescent surgery is appropriate for patients with BMIs as low as 35 kg/m
Dr. Holterman said that she thinks starting a study of this approach is now reasonable.
The National Institutes of Health established the adult criteria in 1991, and they have not been revised since, Dr. Nadler noted. “I think the operation is safe enough that you can broaden the application. The adult criteria are expanding, and perhaps the adolescent criteria will expand, too.”
Disclosures: Dr. Inge has received research funding from Ethicon Inc., a company that markets a gastric banding device. Dr. Pratt has served as a consultant to Covidien, a company that works with Allergan Inc. to market a gastric banding device. Dr. Nadler has received research support from Allergan. Dr. Holterman and Dr. Michalsky had no financial disclosures.
Diabetes, sleep apnea, and nonalcoholic steatohepatitis are 'reversible' with bariatric surgery in adolescents.
Source DR. PRATT
The surgery 'is preventive in the sense that patients have more severe comorbidities if you wait.'
Source DR. HOLTERMAN
'There may be a window of opportunity to act before there is more permanent damage to the heart.'
Source DR. INGE