Author: S. Bledsoe, M.D.
Weight loss surgery has been performed on adults since the 1960’s. With the exponential increase in obesity in the United States, there has been a corresponding increase in the number of weight loss procedures. Adolescent weight loss surgery is perhaps the most hotly debated topic in the field. It’s easy to see why there is some hesitation for this practice to become widespread. There is a risk to the procedure, and no one wants to see a person, much less a child, have potentially life-threatening complications from an elective surgery. While the risks are real so are the potential benefits.
A 2010 article from the Journal of the American Medical Association details the success of the adjustable gastric band (LAGB) for obese adolescents. In the study, 50 obese teenagers were randomly assigned to either receive a LAGB or significant lifestyle interventions. After following them for 2 years, the results were impressive. The teens that had the surgical intervention lost 10 times the weight that the non-surgical group lost. In addition, there was a 100% resolution for the metabolic syndrome in the surgical group. The downside to surgery in this series was a somewhat high re-operative rate of 33%.
The LAGB is not the only effective procedure in the teenage population. Surgery for Obesity and Related Diseases published an article in 2012 that demonstrated the effectiveness of the sleeve gastrectomy (LSG). The LSG resulted in 100% of co-morbid conditions being resolved or improved in 51 obese adolescents who had the procedure. These adolescents also lost an average of 93% of their excess body weight at 2 years.
The gastric bypass has also been employed in the fight against obesity in adolescents since the 1980’s. It has been shown to be as effective in teenagers as in adults. A 2008 meta-analysis in the Annals of Surgery. documented that the weight loss in adolescents was significant and sustained after gastric bypass.
The fact that weight loss surgery is beneficial should surprise no one. That’s what the surgery was designed to do. But why not wait until the adolescent is older? There are some very compelling reasons to strongly consider surgery in certain obese adolescents.
First, certain co-morbid conditions respond remarkably well to weight loss surgery and can cause havoc on the young body the longer the disease is allowed to persist. Diabetes would be the classic example. The longer diabetes continues unchecked, the more severe the damage to the body. The longer and more severe the diabetes, the less likely it is to resolve after surgery. Second, the longer the obesity is allowed to spiral out of control, the more difficult it is to return the patient to a normal weight. The end weight result is significantly influenced by the preoperative weight. The higher the preoperative weight, the less likely it is that the patient will have a normal BMI after they are finished with their weight loss. Third, weight loss surgery can result in an increased quality of life. While some may discount this, consider the emotional toll that obesity can have on an adolescent. I know many severely obese adolescents who never attended their prom, never went on a date, and even needed special accommodations. Desks were too small. PE was too vigorous. Other kids were too cruel. High school is not for the faint of heart.
Clearly, there are substantial benefits for an adolescent who has bariatric surgery, but is it worth the risk? After much thought, careful consideration, and the weighing all potential factors, in my professional opinion, the answer to that question is a resounding “Maybe.” I am not advocating for all obese teens to have surgery, but I will cautiously acknowledgement that for a select group of adolescents, surgery is the right option for them
Let me first define the specific age group I have in mind. In my practice, if you are 17 or younger, I will not operate on you. If you are 21 or older, I expect you to make decisions independent of your parents and will treat you that way. If you are 18-21, I require the presence of a VERY supportive parent or your total emancipation from them. So when I discuss adolescent weight loss surgery, I am referring to the age from roughly 13 to 17.
How do you decide which teen gets surgery and which doctor and hospital is an appropriate choice to be providing this service? These questions were addressed by the American Society for Metabolic & Bariatric Surgery (ASMBS)- the largest, most prestigious, and most effective professional society for weight loss surgery and obesity treatment in the world. In 2011, the ASMBS released a “Best Practice Guidelines” concerning bariatric surgery in adolescents. Their recommendations encompassed both patient selection and physican/hospital qualifications.
When considering a specific patient for surgery, all patients must have some type of co-morbidity. A BMI of 35 or greater with major co-morbidities or a BMI of 40 or greater with lesser co-morbidities are necessary. This is slightly more stringent than the requirements for weight loss surgery in adults, and these are reasonable recommendations. It recognizes the seriousness of obesity related diseases while considering the patient’s age and potential for complications.
The qualifications for the bariatric team are of great importance. The surgeon should be an experienced bariatric surgeon and a pediatric specialist should also be a major player in the patient’s care. In addition, the dieticians, mental health providers, and exercise specialists should all have experience working with the obese teenagers and preferably working with patients undergoing surgery as well.
All of the above is designed to bring about the safest and most effective result for the adolescent. I would also add one more thing although not found in the ASMBS guidelines. I would look for a major bariatric facility with a close relationship to a pediatric hospital. This relationship is often found with university hospitals. When a high volume of any service is provided, “institutional knowledge” builds with time and that service is offered safely and efficiently. Looking for this bariatric/pediatric relationship allows the patient to take advantage of the “institutional knowledge” from both facilities. An example of this is found at Cincinnati Children’s Hospital that founded the first surgical weight loss program in the country designed to assist obese adolescents.
When considering weight loss surgery in an adolescent, please seek the advice of a qualified bariatric surgeon. They will be able to assess the patient and assist the parents. It is also of paramount importance to consider the seriousness of the endeavor that the adolescent is about to begin. Weight loss surgery is a major procedure, and it should be approached with great caution. However, in the right candidate, it has the potential to change their life for the better.