Bariatric Surgery in Severely Obese Adolescents
Background Increasing numbers of severely obese young people undergo bariatric surgery in the USA with reports of substantial weight loss after 1 year. National Institute for Clinical Excellence 2006 suggests considering surgery for young people in 'exceptional circumstances'. We present six patients operated upon 2004–2012 at our centre in the UK.
Case series Six patients (4 male) aged 14–16 years (mean age 15.10) underwent surgery. Mean preoperative body mass index (BMI) was 62.7 kg/m and BMI SDS +4.4. Comorbidities included hypertension, insulin resistance, obstructive sleep apnoea, limited mobility, benign intracranial hypertension and psychosocial issues. All six patients had prior involvement with local lifestyle weight management services and had pharmacological intervention. Four laparoscopic gastric bypass procedures, one laparoscopic gastric banding (patient had a gastric balloon prior to band) and one laparoscopic sleeve gastrectomy were performed.
Results There were no major postoperative procedural complications (one patient had a port rotation). Mean percentage of weight loss, as a percentage of total body weight at 6 and 12 months, was 22 and 27%, respectively. Average absolute weight loss at current follow-up is 54 kg. Mean BMI at 12 months postprocedure was 46.5 kg/m—a mean fall of 16.2 kg/m. Mean BMI SDS fell from +4.4 to +3.8 at 12 months and +3.1 at 2 years. Resolution of hypertension, improved school attendance and no progression to T2DM were the benefits noted.
Conclusions Recent systematic reviews and meta-analyses suggest that bariatric surgery results in sustained and clinically significant weight loss in paediatric populations. The surgical option should continue to be exercised with extreme caution only in severely obese adolescents and done so in appropriate case results in positive outcomes.
Currently, 30% of children in England aged 2–15 years are overweight or obese. Most school-age obese young people will become obese adults with a consequent decrease in life expectancy of anywhere between 5 and 20 years.
Overweight and obesity also contribute to significant physical, mental and emotional morbidities. Direct National Health Service (NHS) costs of treating the overweight and obese, and their related morbidity in England ranged from 480 million in 1998 to £4.2 billion in 2007 with a projected cost of £6.3 billion for 2015.
A very small proportion of young people are very severely obese with a body mass index (BMI) greater than 3.5 SDs above the mean of the UK reference chart for age and sex, which is roughly equivalent to an adult BMI of 40 kg/m or class III obesity. This puts them at greater risk of obesity-related health problems, including significant psychosocial problems like poor self-esteem, depression and poor school attendance.
UK obesity services are patchy with significant regional variation. Bariatric surgery has been used successfully in the management of severe obesity in adults resulting in long-term weight loss and improvement in comorbidities. However, a review of the bariatric services offered by the Primary Care Trust's across England for adults showed that about 60% were effectively rationing surgery with some raising the threshold above that in the National Institute for Clinical Excellence (NICE) guidance. The first report from the UK national bariatric surgery register (April 2011) has called upon the government to improve access to bariatric surgery given that the cost of the procedure is recouped within 3 years and could save the NHS £56 million a year.
There is understandable reluctance to consider bariatric surgery in young people. Some of the concerns relate to obtaining informed consent in minors, timing of surgery, its cost-effectiveness and impact on growth. However, for young people at the extreme end of the spectrum, non-surgical approaches are of only limited value. The NICE guidance in 2006 made provision for surgery in exceptional circumstances in young people, which are described in Box 1.
Advocates of bariatric surgery point out that it is generally well tolerated and provides significant and sustained weight loss. Important strides have been made in providing guidance and universally applicable international recommendations for the employment of bariatric surgery in obese adolescents. However, public and media perception of bariatric surgery in adolescents is still largely negative. We present the results of bariatric surgery performed at Sheffield Children's Hospital NHS Trust, one of three UK centres currently offering this service for adolescents.
Abstract and Introduction
Abstract
Background Increasing numbers of severely obese young people undergo bariatric surgery in the USA with reports of substantial weight loss after 1 year. National Institute for Clinical Excellence 2006 suggests considering surgery for young people in 'exceptional circumstances'. We present six patients operated upon 2004–2012 at our centre in the UK.
Case series Six patients (4 male) aged 14–16 years (mean age 15.10) underwent surgery. Mean preoperative body mass index (BMI) was 62.7 kg/m and BMI SDS +4.4. Comorbidities included hypertension, insulin resistance, obstructive sleep apnoea, limited mobility, benign intracranial hypertension and psychosocial issues. All six patients had prior involvement with local lifestyle weight management services and had pharmacological intervention. Four laparoscopic gastric bypass procedures, one laparoscopic gastric banding (patient had a gastric balloon prior to band) and one laparoscopic sleeve gastrectomy were performed.
Results There were no major postoperative procedural complications (one patient had a port rotation). Mean percentage of weight loss, as a percentage of total body weight at 6 and 12 months, was 22 and 27%, respectively. Average absolute weight loss at current follow-up is 54 kg. Mean BMI at 12 months postprocedure was 46.5 kg/m—a mean fall of 16.2 kg/m. Mean BMI SDS fell from +4.4 to +3.8 at 12 months and +3.1 at 2 years. Resolution of hypertension, improved school attendance and no progression to T2DM were the benefits noted.
Conclusions Recent systematic reviews and meta-analyses suggest that bariatric surgery results in sustained and clinically significant weight loss in paediatric populations. The surgical option should continue to be exercised with extreme caution only in severely obese adolescents and done so in appropriate case results in positive outcomes.
Introduction
Currently, 30% of children in England aged 2–15 years are overweight or obese. Most school-age obese young people will become obese adults with a consequent decrease in life expectancy of anywhere between 5 and 20 years.
Overweight and obesity also contribute to significant physical, mental and emotional morbidities. Direct National Health Service (NHS) costs of treating the overweight and obese, and their related morbidity in England ranged from 480 million in 1998 to £4.2 billion in 2007 with a projected cost of £6.3 billion for 2015.
A very small proportion of young people are very severely obese with a body mass index (BMI) greater than 3.5 SDs above the mean of the UK reference chart for age and sex, which is roughly equivalent to an adult BMI of 40 kg/m or class III obesity. This puts them at greater risk of obesity-related health problems, including significant psychosocial problems like poor self-esteem, depression and poor school attendance.
UK obesity services are patchy with significant regional variation. Bariatric surgery has been used successfully in the management of severe obesity in adults resulting in long-term weight loss and improvement in comorbidities. However, a review of the bariatric services offered by the Primary Care Trust's across England for adults showed that about 60% were effectively rationing surgery with some raising the threshold above that in the National Institute for Clinical Excellence (NICE) guidance. The first report from the UK national bariatric surgery register (April 2011) has called upon the government to improve access to bariatric surgery given that the cost of the procedure is recouped within 3 years and could save the NHS £56 million a year.
There is understandable reluctance to consider bariatric surgery in young people. Some of the concerns relate to obtaining informed consent in minors, timing of surgery, its cost-effectiveness and impact on growth. However, for young people at the extreme end of the spectrum, non-surgical approaches are of only limited value. The NICE guidance in 2006 made provision for surgery in exceptional circumstances in young people, which are described in Box 1.
Advocates of bariatric surgery point out that it is generally well tolerated and provides significant and sustained weight loss. Important strides have been made in providing guidance and universally applicable international recommendations for the employment of bariatric surgery in obese adolescents. However, public and media perception of bariatric surgery in adolescents is still largely negative. We present the results of bariatric surgery performed at Sheffield Children's Hospital NHS Trust, one of three UK centres currently offering this service for adolescents.
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