Bariatric Surgery for Obese Adolescents – ‘Make Assurance Doubly Sure’

Obesity among children and adolescents is becoming a significant health problem across the world. The emergence of a greater number of severely obese individuals in this age group, rarely encountered in previous decades, has led to an increased incidence of obesity related co-morbidities appearing at an earlier age. Such co-morbidities includes type 2 diabetes (T2DM), non-alcoholic fatty liver disease (NAFLD), sleep apnea, and other conditions previously considered ‘non-pediatric’ diseases. Standard interventions against obesity in children and adolescents that involve elements of nutritional guidance and increased physical activity are usually labor-intensive, rather expensive and not covered by health insurance in many countries, and unfortunately result in poor compliance as well as in limited success. Similarly, pharmacological treatment of obese adolescents (by agents approved for use in the adolescent age range) may result in a modest degree of weight loss; yet it is not clear whether this is effect is sufficient to reverse significant metabolic derangements in obese youth [1]. Bariatric surgery procedures are gaining acceptance as an effective treatment for obesity in adults. The long-term effects of some of these procedures have been studied, and the results, particularly with regard to metabolic complications of obesity, are very promising, especially when compared to conservative lifestyle modification interventions [2]. The positive impact of bariatric surgery on glucose metabolism in patients with T2DM has received the greatest attention, and the postulated hormonal mechanisms of such effects have led to the concept of ‘metabolic surgery’ that aims not only to achieve weight reduction per se but also to positively alter the hormonal profile of the patient. Recently, there is increasing interest in the performance of bariatric procedures in younger obese patients, specifically in adolescents. Indeed, preliminary results of non-controlled studies on the impact of bariatric surgery in adolescents show promising outcomes [3]. One can argue that the expected morbidity associated with severe obesity during adolescence, especially in cases where significant complications are already present, justifies the performance of bariatric surgery early, even if long-term outcome studies are not available yet and unforeseen future complications are potentially possible. Several guidelines regarding patient selection for bariatric surgery in adolescence have been published and highlight criteria of eligibility [4, 5]. These obviously include severe obesity with presence of significant obesity-related co-morbidity and near complete physical maturity (defined by bone age). Additional criteria include failure of adequate response to a standard weight reduction program, while demonstrating compliance, motivation to participate adherence to nutritional recommendations, and commitment to a comprehensive medical and psychological evaluation before and mainly after surgery. An additional criterion includes the presence of a supporting family environment. While criteria such as anthropometric measures and presence of disease are straightforward, the criteria of compliance, adherence, presence of a supporting environment, and mental capacity to understand the implications of bariatric surgery are more difficult to define and quantify. As most caregivers know and as it has been demonstrated by the vast majority of interventional studies, compliance and adherence are not exactly the forte of this unique population of patients, and familial support is commonly not present. Despite the qualitative nature of these eligibility criteria and the lack of comparative long-term studies of ‘compliant versus non-compliant’ patients, one can reasonably assume that the initial degree of adherence and compliance is the key to the long-term success of the procedure. Thus, operating on obese adolescents who a priori have poor compliance should not be performed, unless an immediate life-threatening condition that may be reversed by the procedure is present (a condition rarely encountered).