DALLAS — With obesity in children and adolescents growing at an alarming rate, patients seeking bariatric surgery are younger than ever, Dr. Scott A. Shikora said at a conference sponsored by the American Society for Parenteral and Enteral Nutrition.
The incidence of severe obesity has doubled among children over the past 20 years. “Obese adults are producing obese children,” he said, noting that the problem has given rise to an epidemic of type 2 diabetes in children.
With obesity medications no more successful in children than in adults, there has been a dramatic increase in gastric bypass surgery in adolescents. According to Dr. Shikora, outcomes in adolescents are similar to those of adults: In adolescents who have gastric bypass, 75%–80% lose at least 50% of excess weight and successfully sustain weight loss over time with proper patient selection and follow-up. The surgery has been shown to improve health, prevent comorbidities and adult obesity, and improve self-esteem.
Retrospective studies indicate that the surgery can lower the risk of death an average of 33% in severely obese adolescents, with the largest reduction in mortality in cardiovascular deaths among obese diabetic adolescents.
Performing this procedure on children, however, raises safety and ethical questions; there are few studies on the safety and efficacy of gastric bypass in patients under age 18, and the maturity level of such patients brings up concerns about informed consent. The maturity and comprehension levels of young patients regarding nutritional compliance after surgery present a high risk for severe complications and long-term health problems, said Dr. Shikora of the bariatric surgery division at Tufts University, Boston.
Patients undergoing this procedure need lifelong nutritional supplementation to prevent osteoporosis, anemia, and other problems. He stressed the importance of a rigorous patient selection process and warned that gastric bypass surgery in this age group presents a much greater risk for lawsuits than does surgery in adults.
“It's one thing to be sued for medical complications of a 50-year-old,” he said, “but much more serious in a 16-year-old.”
Standards for adolescent surgical candidates should at least meet the American Society for Bariatric Surgery (ASBS) standard for adults, he said. He also suggested a social assessment by a behavioral therapist to determine if the patient is mature enough to comprehend the life changes that will be necessary after surgery and to determine parental involvement, to ensure that a good support system is in place.
The ASBS standard for selecting patients for gastric bypass surgery is 35 kg/m
He also offered alternative procedures physicians should consider.
Banding, which has been around for 30 years, can be effective for weight loss when the obesity is related to overeating because it creates a smaller stomach chamber without staples or rerouting. A new version of the procedure, called lap-band, uses an adjustable band that can be tightened or loosened to change the size of the stomach chamber and is easily removed.
This laparoscopic procedure may be a better choice for adolescents than gastric bypass, which carries a risk of life-threatening or long-term complications, Dr. Shikora said. But he noted, “This isn't perfect. The weight loss is not as good.”
A new implantable gastric stimulator device, or weight-loss pacemaker, could be an alternative to bariatric surgery if it is approved by the Food and Drug Administration. The device doesn't change the size of the stomach but instead creates a feeling of satiety, so the patient eats less. It is in use in Europe but is in clinical trials in the United States. The results so far are promising, with some patients reporting 100% loss of excess weight.