Bariatric surgery for extreme adolescent obesity: Indications, outcomes, and physiologic effects on the gut–brain axis

Abstract

Objective-This review will summarize current indications, limitations and outcomes of bariatric surgery in adolescents, as well as provide an overview of the physiologic effects of bariatric surgery on enteric hormones involved in regulating appetite, satiation and maintenance of weight.Results-Extreme obesity (BMI ≥ 99 percentile) now affects 4% of children and adolescents in the United States. Traditional dietary and behavioral weight management methods have no demonstrated efficacy for extremely obese children and adolescents, in contrast with bariatric surgery which has produced significant and sustainable weight loss and associated improvements in comorbid diseases for the extremely obese. Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB) are the most commonly performed bariatric surgical procedures in adolescents, but vertical sleeve gastrectomy may be a promising new option for selected extremely obese adolescents. A mean weight loss of 37-40% is achieved in adolescents after RYGB, with LAGB showing similar results, albeit attained at a slower rate.Conclusion-Alterations in the enteric hormones involved in the gut-brain axis that regulates appetite and energy expenditure may play a role in both the anorexigenic and weight-reducing effects of certain bariatric surgical procedures. In particular, RYGB induces a rise in both fasting and post-prandial peptide tyrosine-tyrosine which could contribute to the more rapid and greater degree of weight loss than is seen with LAGB. Limitations of bariatric surgery however include the potential for post-operative morbidity and mortality, as well as possible weight regain in a small proportion of patients.

Definitions of obesity and current indications for obesity surgery

“…Obesity is the second leading cause of preventable death in the world. [17,24] According to WHO, 1.7 billion adults, 20 years and older, were overweight or obese in 2008. 200 million men and nearly 300 million women were obese.…”

“…On the one hand, obesity surgery can be considered if the patient has a BMI >40 kg/m 2 (or 99.5 th percentile for respective age) and at least one co-morbidity or BMI ≥50 kg/m 2 with or without major co-morbidities. [17,24] On the other hand, according to the guideline of Australia and New Zealand, indications for obesity surgery among adolescents are same as adult indications comprising a BMI ≥40 kg/m 2 and BMI 35-40 kg/m 2 with the presence of severe obesity related complications. [19,44] The NIH statement noted that the surgical candidate should be evaluated by a multidisciplinary team consistingmedical, surgical, psychiatric, and nutritional specialists.…”

The Bariatric Patient: An Overview of Perioperative Care

“…15 Bariatric surgery has gained increasing acceptance as a treatment modality for adolescents with extreme obesity and significant comorbidities for whom conventional dietary and behavioral interventions have failed. 16 Currently, the two main surgical options for adolescents are the Roux-en-Y gastric bypass and adjustable gastric banding. 14 Because of the unique psychosocial, physical, behavioral, and emotional needs, surgery should take place in a pediatric multidisciplinary center.…”

“…14 Because of the unique psychosocial, physical, behavioral, and emotional needs, surgery should take place in a pediatric multidisciplinary center. 16 …”

“…Because intake capacity has been drastically reduced to as little as 15 mL to 30 mL, the nurse should explain the importance of taking small sips to reduce nausea and vomiting during this postoperative phase of care. 16 Typical dietary progression is detailed in Table 2. A radiologist may perform a gastrografin "swallow test" on postoperative day one to determine patency of the gastric pouch.…”