Bariatric Surgery in Adolescents

By Hyman, Bill Kooi, Kari; Ficklen, David

Bariatric surgery is the term used for any surgical procedure intended to promote weight loss. Many health professionals view this procedure as a viable avenue to addressing a serious health condition in obese adults who have struggled to lose large amounts of body weight. Though the surgery is not without risks, it does reduce the comorbidities of obesity. Some severe comorbidities of obesity include type 2 diabetes mellitus, heart disease, obstructive sleep apnea, osteoarthritis, and psychosocial issues.1 Bariatric surgical procedures are on the rise, with the number of surgeries increasing from about 16,000 in the early 1990s to over 100,000 in 2003,2 and it is also becoming more prevalent among adolescents.3 The comorbidities of obesity are also present in many young adolescents, and although they often remain silent during this age, they can become life threatening in time. However, a recent controversy has emerged concerning the appropriateness of bariatric surgical procedures for young adolescents.4 Bariatric surgery is not cosmetic surgery, and the increase in this major gastrointestinal surgical procedure among adolescents has raised some important social and health issues.3 It is critical that school nurses, counselors, health educators, and other school personnel who work with adolescents have an understanding of this controversial procedure and the issues involved. The prevalence of obesity among the pediatric population has almost tripled in the past 30 years, and the associated increase in comorbidities has produced a need for aggressive weight management interventions.5 Reasons for this obesity epidemic include decreased physical activity; excessive use of the television, video games, and the computer; and excessive caloric intake. Genetic, environmental, and biologic factors have an impact on excessive weight gain. Current estimates show that 15.5% of children and adolescents are obese, and if just 1 of the youth’s parents is obese, the risk of carrying obesity into adulthood is increased by 80%. An estimated 50%-77% of children and adolescents who are obese carry their obesity into adulthood.6

Treatment of obesity among adolescents poses a challenge to health care professionals and is often unsuccessful. Though behavior modification, diet, and exercise are the keys, only 1 in 5 obese children succeed in achieving the desired weight loss.4 The consideration of comorbidities causes a dilemma for physicians who must decide on the most appropriate treatment strategy for morbid obesity among adolescents.6 One approach has been the prescription of weight loss drugs. Sibutramine and Orlistat are medications that have been used to try to help obese adolescents lose weight, but these drugs often result in only modest weight loss and can have significant side effects. Possible side effects of Sibutramine, an appetite suppressant, include headache, constipation, heartburn, back pain, flu-like symptoms, and painful menstrual periods. Less common but more serious side effects could include chest pain and shortness of breath, anxiety, depression, and seizures.7 Possible side effects of Orlistat, a lipase inhibitor which works by blocking the absorption of some of the fat in the food eaten, include oily spotting on underwear or clothing, gas, urgent need for a bowel movement, stomach pain, headache, and irregular menstrual periods. Other, less common yet serious, side effects could include hives, rash and itching, difficulty breathing or swallowing, and severe or continuous abdominal pain.8 In addition to the risks of any side effects, many health care professionals become frustrated with the noncompliance that is seen with overweight adolescents who have life- threatening comorbidities. For this reason, health care professionals are exploring bariatric surgery for obese adolescents with life-threatening or life-altering comorbidities.5

There have been no long-term studies on bariatric surgery in adolescents and many question whether teen obesity is serious enough to warrant the surgery. Opponents claim that these young patients are seeking a quick fix and are not ready to take on the responsibility of the lifetime adjustments of the surgery, which include drastic dietary changes along with regular exercise.9 However, for morbidly obese adolescents who have exhausted all other methods of weight loss without success or who are suffering serious conditions associated with their obesity, bariatric surgery may be the only effective alternative for attaining a healthy body weight. Ethical concerns are a major part of the debate on bariatric surgery in adolescents. Some health professionals claim that obtaining assent from adolescents for bariatric surgery is questionable because these adolescents do not have the psychological maturity to give full consideration to this major, lifealtering decision.4

With insufficient data to assess the long-term effects of bariatric surgery on adolescents, several points of concern emerge. One unknown outcome of specific concern is how the surgery will affect reproductive ability and pregnancy. Reliable contraception is recommended for the first year after surgery because the rapid weight loss could potentially cause harm to a developing fetus.6 Another concern is the potential for large weight loss to interfere with linear growth in the adolescent. Decreased nutrient absorption also poses a concern. While inevitable in adults who undergo bariatric surgery, the decrease in nutrient absorption is even greater for adolescents because they are still growing.4 Strict adherence to a low-calorie, low-carbohydrate diet and vitamin/ mineral supplementation is crucial to preventing nutritional complications. Patients must pay close attention to ensuring that they receive adequate protein in the diet to maintain lean body mass. Calcium, vitamin B12, folate, multivitamins, thiamine, and iron for menstruating females must be supplemented after bariatric surgery. 10

Dietitians who specialize in barratries can offer dietary guidance on the progressive addition of foods with more complex compositions. The postoperative diet for the first 2 weeks is clear liquids, advancing to a full liquid diet for 4 weeks. The goal is to have the adolescent on a liquid diet for 6 weeks before progressing to a soft diet, which consists of a regular diet using food that is soft or pureed to allow continued healing of the anastomotic site.11

Nutritional complications are most often the result of the patient not complying with the postoperative dietary rules. This supports the argument that adolescents may not be ready to accept the responsibility of major dietary changes. Some of the postoperative dietary rules include: consuming the protein first when eating a meal or snack, drinking adequate fluid before and after a meal but not during the meal, scheduled meals to avoid meal skipping, and taking a daily multivitamin/multimineral and calcium supplement.12 Complications of noncompliance include dehydration, dumping syndrome (symptoms including abdominal cramps and nausea resulting when the undigested contents of the stomach are transported into the small intestine too rapidly), protein-calorie malnutrition, nutrient deficiencies, and weight gain.6

The American Pediatric Surgical Association Clinic Task Force on Bariatric Surgery has selected guidelines for patient selection for bariatric surgery in adolescents. Bariatric surgery should be limited to children with a body mass index over 40 with major comorbidities or a body mass index over 50 with minor but life- altering comorbidities. Indications for surgery include the following: failure to lose weight after at least 6 months of organized attempts at weight loss, near-mature physiologic status as determined by Tanner stage III or above, commitment to medical and psychological evaluation before and after surgery, commitment to avoid pregnancy for 1 year after the surgery, ability and intent to adhere to postoperative nutritional guidelines, living in a supportive family environment, and ability to provide informed assent from the patient and consent from the family.4

A complete work-up is performed on adolescents who are candidates for bariatric surgery. A thorough health history as well as a family health history are taken, and a complete physical exam is performed. Serum analysis is conducted, and a polysomnogram is indicated in patients who have symptoms of sleep apnea. Psychological testing is also performed to assess eating behavior, personality traits, cognitive maturity, depression, and quality of life that may have an influence on the surgical candidate.4 Selection of patients for surgical treatment involves the careful consideration of numerous factors and clinical judgment by the bariatric team.6

A variety of bariatric surgical procedures exist, but the Roux- en-Y gastric bypass and adjustable gastric banding are the most popular procedures among adolescents.6 The Roux-en-Y gastric bypass creates a small gastric pouch, with the jejunum being attached to the pouch. This procedure is both restrictive and malabsorptive and because secretions bypass a segment of the jejunum before going into the small bowel, there is a decrease in the efficiency of digestion and a higher risk of malnutrition. The adjustable gastric band is very restrictive in that it creates a small gastric pouch that induces early satiety and decreased oral intake. Of these 2 options, the Roux-en-Y gastric bypass is considered to be the “gold standard” by many health professionals.4 Common postoperative complications of the gastric bypass include acute gastric distension and anastomotic leak. Postoperative complications that commonly occur later include anastomotic stricture, internal hernia, and thiamin deficiency. If a thiamin deficiency is not detected early, then the patient is at risk of cardiac and neurologic complications that are associated with a thiamin deficiency.4

Adolescents who have undergone bariatric surgery must be put under meticulous, lifelong medical supervision. Regular visits to the surgeon and subspecialists (dietitian, psychologist, and exercise physiologist) must be made during the first preoperative year so that complications can be detected early and compliance with eating behavior, nutritional supplements, medications, and exercise regimens can be reinforced. Monitoring adolescents who have undergone bariatric surgery is especially important because of the absence of data on the long-term effects.6

It is critical to remember that bariatric surgery is not a cure for obesity in adolescents but is a tool for successful management of this serious health condition. The success of bariatric surgery in adolescents depends upon the individual’s ability to be dedicated to making lifestyle changes that include drastically modifying eating behavior and daily physical activity. School personnel including nurses, health educators, counselors, and dietitians must be prepared to support and guide adolescents through this critical medical procedure.

REFERENCES

1. National Institute of Diabetes and Digestive and Kidney Diseases: Weight Control Information Network. Understanding Adult Obesity. Available at: http://win.niddk.nih.gov/publications/ understanding.htm. Accessed October 31, 2007.

2. Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA 2005;294(15):1909-1911.

3. Steinbrook R. Surgery for severe obesity. N Engl J Med. 2004;350(11):1075-1079.

4. Klish WJ. Obesity surgery in pediatrics. J Pediatr Gastroenterol Nutr. 2004;39(1):2-4.

5 . Kirk S, Scott BJ, Daniels SR. Pediatric obesity epidemic: treatment options. J Am Diet Assoc. 2005;105:44-51.

6. Inge TH, Krebs NF, Garcia VF, et al. Bariatric surgery for severely overweight adolescents: concerns and recommendations. Pediatrics. 2004;114(1):216-223.

7. United States National Library of Medicine and the National Institutes of Health. Sibutramine. Available at: www.nlm.nih.gov/ medlineplus/druginfo/medmaster/a601110.htm. Accessed October 27, 2007.

8. United States National Library of Medicine and the National Institutes of Health. Orlistat. Available at: www.nlm.nih.gov/ medlineplus/druginfo/medmaster/a601244.htm. Accessed October 27, 2007.

9. Barlow SE. Bariatric surgery in adolescents: for treatment failures or health care failures? Pediatrics. 2004;114(1):252-253.

10. Escott-Stump S. Nutrition and Diagnosis Related Care. 5th ed. Baltimore, Md: Lippincot Williams & Wilkins; 2002.

11. Mahan LK, Escott-Stump S. Krause’s Food, Nutrition, and Diet Therapy. 11th ed. Philadelphia, Pa: Elsevier; 2004.

12. American Dietetic Association. American Dietetic Assotiation Nutrition Care Manual. Chicago, Ill: American Dietetic Association. 2006.

BILL HYMAN, PhD(a)

KARI KOOI, MS, RD(b)

DAVID FICKLEN, MD(c)

a Professor of Health Education, (bhyman@shsu.edu), Department of Health and Kinesiology, Sam Houston State University, PO Box 2176, Huntsville, TX 77341.

b Clinical Dietitian Specialist, The Methodist Hospital, (dstdklk13@shsu.edu), Department of Health and Kinesiology, Sam Houston State University, PO Box 2176, Huntsville, TX 77341.

c Assistant Professor of Health Education, (drf005@shsu.edu), Department of Health and Kinesiology, Sam Houston State University, PO Box 21 76, Huntsville, TX 77341 .

Address correspondence to: Bill Hyman, Professor of Health Education, (bhyman@shsu.edu), Department of Health and Kinesiology, PO Box 2176, Sam Houston State University, Huntsville, TX 77341.

Copyright Blackwell Publishing Ltd. Aug 2008

(c) 2008 Journal of School Health, The. Provided by ProQuest LLC. All rights Reserved.