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IFSO 2018

Which procedure is best for children with obesity?

(Credit: Obesity Action Coalition)
Sleeve gastrectomy is the preferred operation for children and adolescents, although adolescents are a special population with complex ethical challenges

The 23rd World Congress of the International Federation for the Surgery of Obesity and Metabolic Disorders was held in Dubai, United Arab Emirates, from September 26-29, 2018. Attended by over 2,500 bariatric specialist and allied healthcare professionals, participants were witness to a superb scientific programme focusing on the widest array of topics in the field of adiposity based chronic diseases, through postgraduate courses, symposia, expert talks and video and pre-recorded operations. Here are some of the highlights from the meeting.

The rise in the number of children and adolescents who are overweight and have obesity presents will create a health care crisis in the near future, according to Dr Samer G Mattar, Medical Director at Swedish Weight Loss Services and President of the American Society for Metabolic and Bariatric Surgery (ASMBS). In his presentation, ‘Which procedure is best for children with obesity?’, he noted that although bariatric surgery is the most effective and durable in adults, except for TEEN-LABS 5 year data, long-term data is lacking for adolescents, and surgery in this group of patients comes with complex ethical challenges.

He began his presentation by outlining the severity of the overweight/obesity problem in this population. For example, Skinner et al (Prevalence and trends in obesity and severe obesity among children in the United States, 1999-2012. JAMA Pediatr. 2014 Jun;168(6):561-6), reported that in 2011-2012, 17% of children were obese, 6% had Class 2 obesity, 2.3% had Class 3 obesity with significant increases in Class 2 and 3 obesity in females of all ages and in adolescent boys.

Samer Mattar

“The prevalence of overweight in US children and adolescents has reached alarming levels. In 1997, Whitaker et al (NEJM: 1997;337:869-873) reported that the proportion of children and adolescents who are overweight, defined as a BMI exceeding the 95th percentile for age and sex based on norms from the 1960’s has tripled in the past three decades (5%-15.5%). In addition, children at the upper percentiles of BMI for age are now heavier than were the children in these same percentile of BMI in earlier studies. The children with excess fat seem to be gaining more fat and this is not explained by a genetic shift in such a short time or immigration of susceptible populations. Obese children are now 30% heavier than in 1990 with approximately 250,000 with BMI>40. From this study, it is clear that an overweight child is more likely to be obese as an adult. Other studies have shown this same trend of tracking occurring from childhood to adulthood.”

The latest studies show that 30% of US children are overweight, 17% of US children have obesity and 80% of these children will become obese adults and more paediatricians are managing ‘adult’ comorbidities, Dr Mattar noted. However, this problem is not unique to the US as data from the World Health Organisation1 shows worldwide obesity has nearly tripled since 1975 and in 2016, more than 1.9 billion adults (18 years and older), were overweight, and of these over 650 million were obese. The same data reported that in 2016, 41 million children under age five were overweight or had obesity and over 340 million children and adolescents aged 5-19 were overweight or had obesity.

Which surgical solution?

Although Roux-en-Y gastric bypass (RYGB) has a 60-year track record, Dr Mattar added that it is a more complex operation, with the potential for leaks and nutrient supplements is also required. Miyano G et al (Perioperative outcome of laparoscopic Roux-en-Y gastric bypass: a children's hospital experience. J Pediatr Surg 2013;48(10):2092-8) reported their outcomes from 77 adolescent patients (mean age: 16.8 years; 68% female) and found that 22% had a 30 day complication rate and 13% a 31-90 day complication rate and re-operations were required in nine patients (11.6%).

"There remains however, several ethical and moral challenges and therefore, important questions must be asked: When is the right time for surgery? Who are the right patients for surgery? How should they be globally prepared for surgery and how should they be followed up?”

Nevertheless, RYGB is effective as reported by Göthberg et al (Laparoscopic Roux-en-Y gastric bypass in adolescents with morbid obesity--surgical aspects and clinical outcome. Semin Pediatr Surg. 2014 Feb;23(1):11-6) who performed gastric bypass surgery in 81 adolescents with morbid obesity (13-18 years) and matched the outcomes with adolescent patients who received conventional care and with a group of gastric bypass adult patients. They revealed that at two-years, those in the adolescent surgery group had 76% excess weight loss (%EWL>50% in 95% of RYGB adolescents). Weight loss was similar in the adult gastric bypass patients (-31%) while weight gain (+3%) was seen in the conventionally treated obese adolescents. Significant improvement in cardiovascular and metabolic risk factors and inflammation was seen after surgery, as well as substantial improvements in risk factors and quality of life.

Additional studies on sleeve gastrectomy in this patient group have noted the procedure may be advantageous for this age group, as it is a simpler operation involves no lifelong malabsorption, foreign body (as in LAGB) no marginal ulcers and less morbidity compared to gastric bypass.

For example, Nocca et al (Laparoscopic sleeve gastrectomy for late adolescent population. Obes Surg. 2014 Jun;24(6):861-5) reported %EWL at six months, one and two years post-operatively was 48.1% (±17.9%), 66.7% (±19.5%) and 78.4% (±16.8%), respectively. Boza et al (Laparoscopic sleeve gastrectomy in obese adolescents: results in 51 patients. Surg Obes Relat Dis. 2012 Mar-Apr;8(2):133-7), found EWL% at six months, one and two years was 94.6%, 96.2%, and 92.9%, respectively, with 76% of patients with preoperative co-morbidities reporting complete resolution or an improvement in their condition. Lastly, Alqahtani et al (Laparoscopic sleeve gastrectomy in 108 obese children and adolescents aged 5 to 21 years. Ann Surg. 2012 Aug;256(2):266-73) at one-year reported a reduction in median BMI from 47 to 32. There was resolution of dyslipidaemia (21 of 30, 70.0%), hypertension, (27 of 36, 75.0%), pre-hypertension (15 of 18, 83.3%), symptoms of obstructive sleep apnoea (20 of 22, 90.9%), diabetes (15 of 16, 93.8%) and pre-diabetes (11 of 11, 100.0%).

Despite these positive data, there only remains one study that has reported on the long-term outcome of the surgical treatment of adolescents – the Teen- Longitudinal Assessment of Bariatric Surgery (LABS). In this study, Inge et al (Perioperative outcomes of adolescents undergoing bariatric surgery: the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study. JAMA Pediatr. 2014 Jan;168(1):47-53), reported 242 underwent surgery (LRYGB, vertical sleeve gastrectomy and adjustable gastric banding were performed in 66%, 28%, and 6% of patients, respectively). There were no deaths during the initial hospitalisation or within 30 days of operation; major complications (eg, reoperation) were seen in 19 patients (8%). Minor complications (eg, readmission for dehydration) were noted in 36 patients (15%). All reoperations and 85% of readmissions were related to surgery, Dr Mattar noted that the gastrojejunal anastomotic stricture (n=6, 3.7%) and abdominal pain/dehydration/diarrhea/nausea (n=9, 5,6%) were lower in the RYGB group vs sleeve gastrectomy (0%).

A more recent study by the same research group (Comparison of Surgical and Medical Therapy for Type 2 Diabetes in Severely Obese Adolescents. JAMA Pediatr. 2018 May 1;172(5):452-460) looking at two-year data from 30 participants from Teen-LABS study, found that compared with medical therapy, surgical treatment of severely obese adolescents with type 2 diabetes was associated with better glycaemic control, reduced weight, and improvement of other comorbidities. Specifically, they revealed that mean haemoglobin A1c concentration decreased from 6.8% to 5.5% in Teen-LABS and increased from 6.4% to 7.8% in Treatment Options of Type 2 Diabetes in Adolescents and Youth (TODAY), non-surgical group. Compared with baseline, the body mass index decreased by 29% (95% CI, 24%-34%) in Teen-LABS and increased by 3.7% (95% CI, 0.8%-6.7%) in TODAY group.

For endoscopic procedures in adolescents, Fittipaldi-Fernandez et al (Efficacy of Intragastric Balloon Treatment for Adolescent Obesity. Obes Surg. 2017 Oct;27(10):2546-2551) reported that intragastric balloons (IGB) implanted in 27 adolescents (14-19 years; 23 female) resulted in a BMI decrease from 37.04 to 31.18 (p<0.0001), % excess weight loss (%EWL) was 56.19 and % total weight loss (%TWL) 16.35. They noted that adherence to the multidisciplinary programme correlated directly with %EWL (p=0.0033) and %TWL (p=0.0052). However, seven patients (25.92%) did not achieve ‘success’ (TWL<10%).

“Obese patients are subject to prejudice, stigmatisation and discrimination and obesity is still wrongly interpreted by many as a personal choice and personal responsibility, causing children to feel guilt and shame,” he explained. “Although the evidence shows bariatric surgery is safe, effective and durable, health professionals are pessimistic about safety, efficacy and durability of bariatric surgery. There remains however, several ethical and moral challenges and therefore, important questions must be asked: When is the right time for surgery? Who are the right patients for surgery? How should they be globally prepared for surgery and how should they be followed up?”

Earlier this year, the ASMBS updated its paediatric metabolic and bariatric surgery guidelines (Pratt et al ASMBS pediatric metabolic and bariatric surgery guidelines, 2018. Surg Obes Relat Dis. 2018 Jul;14(7):882-901) and noted that sleeve gastrectomy is the most used and recommended operation, and vitamin deficiencies appear to be more common in adolescents. The authors also revealed that no data correlates with attempts at prior weight loss with surgical outcomes and they recommended BMI>35 should become current cut-off for eligibility (not BMI>40) and T2DM should be considered a comorbidity that mandates earlier treatment in younger patients.

The Guidelines also noted that:

  • the use of emerging technologies should be considered in the setting of multidisciplinary teams
  • obesity should be recognized as a chronic disease that requires continuous multimodal therapies
  • developmental delay, autism or syndromic obesity should not be surgical contraindications
  • referrals to metabolic surgery should occur early; and
  • routine referrals for alcohol abuse are imperative.

“Obesity is affecting almost 20% of children and adolescents, and comorbidities will create a health care crisis in the near future,” concluded Dr Mattar. “Bariatric surgery is safe, effective and durable in adults and the key to successful intervention is ‘the earlier the better’, but, except for TEEN-LABS five-year data, long-term data is lacking for adolescents. Sleeve gastrectomy is the preferred operation for children and adolescents, although adolescents are a special population with complex ethical challenges.”

Reference

1 http://www.who.int/en/news-room/fact-sheets/detail/obesity-and-overweight

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