Indications and Limitations of Bariatric Intervention in Severely Obese Children and Adolescents With and Without Nonalcoholic Steatohepatitis

Abstract

Morbid obesity is strongly associated with nonalcoholic fatty liver disease (NAFLD), which is one of the most common causes of chronic liver disease worldwide. The present best treatment for NAFLD and nonalcoholic steatohepatitis (NASH) is weight reduction through lifestyle modification. Because of frustrating inefficiency of such a therapeutic approach, bariatric surgery is increasingly performed in adolescents as an alternative option for weight reduction. Standards of care and consensus for indications are, however, scarce. We explore the indications and limitations of bariatric surgery in children with severe obesity with and without NASH and aim to provide guidance for the exceptional indications for adolescents with extreme obesity with major comorbidity that may benefit from these controversial interventions. Present evidence suggests that bariatric surgery can decrease the grade of steatosis, hepatic inflammation, and fibrosis in NASH. Uncomplicated NAFLD is not an indication for bariatric surgery. Roux-en-Y gastric bypass is considered a safe and effective option for adolescents with extreme obesity, as long as an appropriate long-term follow-up is provided. Laparoscopic adjustable gastric banding has not been approved by the Food and Drug Administration for use in adolescents and therefore should be considered investigational. Finally, sleeve gastrectomy and other types of weight loss surgery that have grown increasingly common in adults, still need to be considered investigational. Temporary devices may be increasingly being used in pediatrics; however, future studies, including a long-term risk analysis of patients who undergo surgery, are much needed to clarify the exact indications for bariatric surgery in adolescents.

Metabolic syndrome in children and adolescents

“…Extreme comorbidities include T2DM, moderate to severe sleep apnea, pseudotumor cerebri, debilitating orthopedic problems, and NASH with advanced fibrosis (47). Mild comorbidities include hypertension, dyslipidemia, moderate orthopedic problems, mild sleep apnea, NASH, and obesity related extreme psychological distress (73). Surgical options may be considered without a preceding pharmacological intervention trial, only if a formal life style modification program with documented compliance has failed.…”

The management of childhood liver diseases in adulthood

“…-Bariatric surgery. ESPGHAN (European society for paediatric gastroenterology, hepatology and nutrition) have recently published a position statement on the role of bariatric surgery in young adults [131]. The benefits of bariatric surgery are plentiful and include the obvious; reduction in weight and BMI, to the more subtle improvement in systemic inflammation, glucose tolerance and dyslipidaemia.…”

“…The benefits of bariatric surgery are plentiful and include the obvious; reduction in weight and BMI, to the more subtle improvement in systemic inflammation, glucose tolerance and dyslipidaemia. ESPGHAN conclude that bariatric surgery should be considered in patients without cirrhosis and with the support of a specialized multi-disciplinary team [131].…”

Non-alcoholic fatty liver disease: a new epidemic in children

“…In the pediatric field, its indication should consider the patient's physical and emotional maturity, his/her personal desire to have the procedure, prior weight loss attempts, and his/her ability to comply with the necessary follow-up care. 24,25 …”