Bariatric Surgery in Adolescents—Should We Do it?

Abstract

The rising prevalence of adolescent obesity poses significant health challenges, necessitating effective interventions. When nutritional management and lifestyle changes are insufficient, bariatric surgery has emerged as a potential therapeutic option to address severe obesity in this vulnerable population, at risk of developing various complications such as insulin resistance, type 2 diabetes mellitus and even cardiovascular disease, with its heterogenous implications. By carefully selecting patients, metabolic and bariatric surgery in adolescents presents a maximum of benefit, reducing the obesity complications. The most frequent procedures are represented by sleeve gastrectomy and Roux-en-Y Gastric Bypass. Current evidence supports metabolic and bariatric surgery in adolescents with severe obesity when most conservative lifestyle and pharmacologic interventions fail to ensure a healthier young population. We conducted a literature review with the aim to evaluate the current results regarding bariatric surgery in adolescents, highlighting the benefits and also disadvantages of surgical techniques.

Introduction

Obesity has become a global epidemic, affecting people of all age groups, including young ones, respectively, adolescents. Adolescence represents a fundamental period in life, a period of development, of cementing the basis of the young adult into society [1]. Alongside with identity growth, nutritional necessities also present a significant increase [2]. Adolescence obesity has been associated with a high risk of insulin resistance, followed by type 2 diabetes mellitus (T2DM), non-alcoholic fatty liver disease, cardiovascular issue such as hypertension, dyslipidaemia, etc. [3]. Type 2 diabetes mellitus shows a strong correlation with obesity. Each 1 kg increase in body weight raises the risk of developing T2DM by 4.5%. Insulin resistance is evident in 90% of individuals with T2DM and having insulin resistance doubles the risk of developing cardiovascular disease [4,5].

Approximately 65%–75% of hypertension cases can be attributed to obesity, impacting 1 out of 3 Americans. The exact mechanisms of hypertension in obese patients are not fully comprehended, but there is compelling evidence suggesting a link with the kidneys. The rise in chronic kidney disease incidence is closely associated with obesity, affecting around 20% of adults. Moreover, visceral obesity plays a significant role in both hypertension and diabetes, which are the primary contributors to chronic kidney disease [6].

When classifying adolescents depending on the nutritional status, there are growth charts that rely on age and sex specific body-mass index (BMI) percentiles; an adolescent with a BMI above the 85th and below the 95th percentile is considered overweight as adolescents with a BMI over the 95th percentile is obese [7]. For severely obese adolescents, traditional lifestyle interventions may not always guarantee significant and sustained weight loss. In such cases, there have been significant bariatric surgery has emerged as a potential solution. Over the past few years, there have been significant advancements in the field of bariatric surgery for adolescents, leading to improved safety and efficacy of these procedures. While medical management and lifestyle changes still represent an important pillar in weight management, metabolic and bariatric surgery has proven its superiority in improving the outcome of adolescence obesity [8].

As there are still question marks regarding the outcomes of bariatric surgery in adolescents, we have conducted a literature search in order to evaluate the advantages and disadvantages of bariatric procedures in adolescents.

Materials and Methods

We performed a literature search conducted in the PubMed databases which include original full-text articles, randomized control trials and clinical trials, in the last 10 years, published in English, with the “bariatric surgery AND adolescents” criteria. We identified 79 articles on PubMed database. The exclusion criteria were duplicates, articles that lack originality, published in languages other than English, and on non-human populations. Two researchers, BMM and TS, extracted the included studies’ titles and abstracts, screened them for relevance for the present study theme and selected the relevant ones by performing cross-screening. As a result, 9 articles were selected as shown in Figure 1.

Results

The primary results of the literature search are presented in

Table 1. Main results of the articles included in the selection.

Author, year	Nr. of patients in the study group	Mean age (years)/Mean BMI (kg/m2)	Procedure	Controls (Number and type of intervention)	Outcome
Inge, 2018 [9]	30	16.9/54.4	Primary bariatric procedure (23 GBP, 1 adjustable GB, 6 SGT)	63 (metformin therapy alone or with rosiglitazone; insulin therapy in case of disease progression	After 2 years: -A1c hemoglobin: 6.8% -> 5.5% (SG) versus 6.4% -> 7.8% (CG); -20% of participants in the SG required a subsequent operation
Inge, 2017 [10]	58	17.1/59	GBP	-	Average BMI ↓: -after 1 year 23±6 kg/m2 -5-12 years (long-term): 30±14 kg/m2
Inge, 2014 [11]	242	17.1/50.5	GBP 66.5% Adjustabl e gastric band 5.8%, vertical SGT 27.7%	-	Prior to discharge: -7.9% major complications -14.9% minor complications. Between discharge and 30 days: -2.9% major complications -11.2% minor complications
Misra, 2020 [12]	22	17.0/42.4	SGT	22	In SG, at 12 months: - ↓ BMI of 12.8 kg/m2 (p<0.0001), - bone mass density ↓ in the femoral neck (6.9±1.6%, p=0.0007) and hips (4.7±0.9%, p=0.0004) - ↓ trabecular area in the distal tibia
Göthberg, 2014 [13]	81	16.5/45.5	Laparosco pic GBP	81 adolescent patients (conventionall y treated) and 81 adults undergoing bariatric surgery	After 2 years: -32% weight loss (SG), -31% weight loss (adult CG) -3% weight gain (adolescent CG) -15% patients underwent additional interventions
Ryder, 2021 [14]	30	16.9/54.4	Primary bariatric procedure (23 GBP, 1 adjustable GB, 6 SGT)	63 (metformin therapy alone or with rosiglitazone; insulin therapy in case of disease progression	Cardiovascular risk ↓ at 1 year after bariatric surgery: 6.79% (SG) vs 13.64% (CG), p<0.0001
Olbers, 2017 [15]	81	16.5/45.5	Roux-en- Y GBP	80 adolescents (conventional treatment) 81 adults (who underwent GBP)	Mean BMI evolution at 5 years: -13.1 kg/m2 ↓ (SG) - ↑ 3.3 kg/m2 (adolescent CG)
Hjelmesæth, 2020 [16]	39	16.7/45.6	GBP	96 adolescents (lifestyle intervention)	After 1 year: -↓ 14.1 kg/m2 BMI (SG) -↓ C-reactive protein and ↓ cholesterol (SG) -normoglycemic (all patients) -↓ bone mineral content and mineral density by 3.5% (p<0.001)
Bjornstad, 2020 [17]	30	16.9/54.4	Primary bariatric procedure (23 GBP, 1 adjustable GB, 6 SGT)	63 (metformin therapy alone or with rosiglitazone; insulin therapy in case of disease progression	After 5 years: -renal function remained stable (SG) versus ↑ in hyperfiltration by 41% (CG) (OR 17.2, p=0.003) -a 27-fold ↑ in urinary albumin excretion (p=0.0001) (CG)

GBP—gastric bypass; GB—gastric banding, SGT—sleeve gastrectomy; ↓—decrease, SG—study group; CG—control group; BMI—body mass index; ↑—increase.

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In a prospective study by Inge et in al in 2017 [10] the long-term (5 to 12 years) postoperative, they observed that adolescents who underwent bariatric surgery, 87% of participants achieved a ≥10% BMI decrease over time but 64% still had a BMI≥35. The prevalence of type 2 diabetes decreased from 16% to 2% (p=0.03) with diabetes remission in 88% cases, the prevalence of hypertension decreased from 47% at baseline to 16% at follow-up (p<0.01), but regarding micronutrient deficiencies, there was a decrease in iron (69%), ferritin (63%), hemoglobin (46%), vitamin D (78%), vitamin B12 (16%). 22.4% of patients required upper endoscopy, 20.7% required cholecystectomy, 3.4% necessitated colonoscopy and 5.2% required additional procedures for repairing a gastrointestinal perforation. There was 1 death due to infectious colitis.

In another prospective, observational study published in 2017 conducted on 242 adolescents who underwent bariatric surgery, Inge et al. [11] observed that prior to dischar/ge there were 7.9% cases of major complication (reoperation for bowel obstruction, bleeding, leak, sepsis; deep venous thrombosis, unplanned splenectomy for injury) and 14.9% cases of minor complications (minimal leak, bowel injury, urinary tract events, over sedation, solid organ injury, mesenteric bleeding or hematoma, atelectasis or pneumonia, postoperative bleeding with no transfusion required). In the first 30 days after discharge, the prevalence of major complications was 2.9% (anticoagulation for pulmonary embolus, gastrointestinal leak requiring or not reintervention, suicidal ideation), respectively 11.2% for minor complications (urinary tract infection, acute pancreatitis, small bowel obstruction or ileus, gastrojejunal anastomotic stricture, wound infection, parenteral nutrition).

Another prospective study published by Göthberg et al. [13] in 2014 regarding the 2-year outcome in 81 adolescents who underwent gastric bypass, 81 controls (adolescents conventionally treated) and 81 adults who underwent bariatric procedures related a 15% complication rate during the 2-year pursue which included 6.2% of patients who underwent surgery for repairing an internal hernia, 7.4% who required cholecystectomy and one patient who underwent a laparoscopic procedure for adhesions.

A Swedish prospective non-randomized controlled study conducted by Olbers et al. [15] in 2017 on 81 adolescents who underwent gastric bypass, observed that, besides a significant decrease in the BMI in the study group, there was a remission of type 2 diabetes mellitus which occurred in all participants in the study group, there was a reduction in the disturbed glucose homeostasis in 86% of the initial affected adolescents, but with 2 new cases after 5 years. After 5 years, the prevalence of dyslipidaemia decreased from 69% to 15%, the prevalence of hypertension diminished from 15% to 3%, high level C-reactive protein decreased from 87% to 25%, also the liver function presented a significant improvement. In addition, the quality of life in the study group improved significantly. Regarding micronutrients, iron and ferritin deficiencies increased from 24% at baseline to 66% after 5 years in the study group; vitamin B deficiencies also increased from 6% to 22%. During 5 years, 25% of patients in the study group underwent 21 additional surgical procedures, primary for acute intestinal obstruction and symptomatic gallstones.

Discussion

In the specialized literature, most studies sustain the great advantages of bariatric surgery in adolescents, decreasing the prevalence of comorbidities, improving glycemic control, decreasing hypertension and reducing the whole cardiovascular risk, optimizing weight control and enhancing quality of life, with the price of micronutrient deficiencies [10,15], bone mass and mineral density [12,16], surgical major and minor complications [9,11,13,15] or the need for reintervention [9]. Interesting is the fact that the control groups described in the study did not present a statistically significant weight loss or even presented weight gain, fact that could be related to insufficient or inefficient lifestyle interventions.

We believe that, in order to achieve an important difference, you need a multidisciplinary team and a sustainable plan for the entire family. As long as these adolescents live with their parents, the habits are inherited, are learned during their infancy and adolescence, and there is a real need to change the entire family’s approach towards food, nutrition and sport. We believe that the key to avoid surgical interventions and also to improve the adolescents’ future, is to act, to help families understand the consequences of their actions, to offer solutions and support.

Conclusion

Although adolescent obesity prevention may be the best way to counteract this escalating unhealthy trend, when nutritional treatment and lifestyle intervention has lost the battle, bariatric surgery evolved into a viable treatment option for severely obese adolescents, offering substantial weight loss and improvement in obesity-related comorbidities. With the advancement in surgical techniques and perioperative care, the safety and efficacy of these procedures has improved significantly. However, careful patient selection, long-term follow-up, and comprehensive psychosocial support remain essential components of successful bariatric surgery outcomes in adolescents.