Find best premium and Free Joomla templates at GetJoomlaTemplatesFree.com

Establishing a Bariatric Surgery Service for Obese Adolescents

¹Jones NM, ²Viner RM, Kiely EM, Curry JI

¹Department of General Surgery, St. George’s Hospital, London, UK

²Department of Adolescent Medicine, University College London Hospitals, UK

Department of Surgery, Great Ormond Street Hospital, London, UK

 

Abstract

Obesity among teenagers in the United Kingdom is a serious clinical concern. Bariatric surgery effects sustained and significant weight loss in adults and adolescents. Recent guidelines from the National Institute of Health and Clinical Excellence advocate this intervention in teenagers and so more of these procedures will now be performed on this age-group in the UK. The authors outline the history and basic concepts of Bariatric surgery, the types of patients likely to be appropriate for this intervention and the steps necessary in the development of an adolescent Bariatric service.

Key words: obesity, teenager, adolescent, Bariatric, surgery

 

Correspondence:

Niall Jones

Department of General Surgery, St Georges Healthcare NHS Trust

e-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

Telephone: 02086721255

 

Introduction

The recently published National Institute of Health and Clinical Excellence (NICE) guidelines on the treatment of obesity (December 2006) identify a place for bariatric surgery in obese adolescents in “exceptional circumstances” (1). In the UK until now, bariatric surgery in teenagers has been limited to a handful of extremely obese older teenagers. Given that NICE has defined criteria to identify potential adolescent candidates for bariatric surgery, this now appears set to change.

Here we outline the history and basic concepts of bariatric surgery, the types of patients likely to be appropriate for this intervention, and the steps necessary in the development of an adolescent bariatric service.

There is a new and growing clinical population of obese teenagers/adolescents in the developed world. The prevalence of adolescent obesity (defined as BMI above the International Obesity Taskforce thresholds) has more than doubled over the last 3 decades (2), with the most recent estimates suggesting that 7-10% of early adolescents are obese by this conservative definition (3). Around 60-70% of obese adolescents will become obese adults (4) with higher risk of associated physical co-morbidities (obstructive sleep apnea, type II diabetes, metabolic syndrome, pseudotumour cerebri, psychosocial dysfunction, hypertension, nonalcoholic steatohepatitis, venous stasis disease, gastro-oesophageal reflux disease, weight-related arthropathies etc.) and psychological co-morbidity (5, 6).

The term bariatric derives from the Greek words bari, meaning weight and iatros, meaning physician. Bariatric surgery is the most effective means to achieve durable weight loss with amelioration, if not resolution, of most obesity-related comorbidities in adolescents (7). Bariatric surgery in adults is safe and effective (8). Approximately 100,000 bariatric operations are performed in the US every year (9). The commonest procedures are the Roux-en-Y gastric bypass (RYGB, restrictive and malabsorptive) and the laparoscopic adjusted gastric band (LAGB, restrictive). The RYGB was originally described by Mason in 1969 (10). It involves the creation of a small gastric pouch, which is drained by a Roux-en-Y jejunal limb. This operation combines gastric restriction with a minimal degree of malabsorption. Simple sugars must be limited to avoid the undesirable effects of the dumping syndrome. It is currently the most commonly performed bariatric procedure worldwide (11), and is now adapted to the laparoscopic approach (12). In terms of results, DeMaria reported a cohort of 281 patients with a mean age of 41.6 years (range 15 to 71 years). The average pre-operative BMI was 48. The mean operating time was 162 minutes and 3% of cases were converted to open. There were 7% early complications and 17% late complications with a mean hospital stay of 4 days. There was no mortality and the average BMI at one year follow-up was 30 kg/m2 (13). Lawson et al reported their experience with RYGB in morbidly obese adolescents (14). They achieved a mean fall in BMI of 37% from 56.5 pre-operatively to 35.8 kg/m2. A review of the literature reveals seven publications reporting results from bypass procedures in a total of 157 obese adolescents (14-20). The average BMI reduction was 19.4 units with an 18% morbidity rate and 1.9% mortality.

The LAGB is a restrictive procedure. An inflatable band was first described in 1986 by Kuzmak (21) and in 1993 Belachew (22) and Forsell (23) were the first to perform the procedure laparoscopically. The adjustable band is wrapped around the proximal stomach creating a 20ml gastric pouch. A subcutaneous port allows adjustment of the band. The primary advantage of LAGB is the ease of insertion with most patients staying in hospital for just one day. It has been proven to be safer than LRYGB with a peri-operative complication rate of 1-2%. Late complications are more frequent however, with prolapse of the stomach through the band (15%) and erosion of the band into the stomach (3.2%). Both complications can be managed laparoscopically and have become less common with modifications of the technique (24). The literature reveals a total of 213 adolescents who have undergone laparoscopic banding (24-28). No mortality has been reported and patients sustain median 56% excess weight loss at 5 year follow-up.

Selection criteria

Which adolescents should be selected for bariatric surgery? A consensus conference of paediatricians and paediatric surgeons concerned with the epidemic of childhood obesity in the US identified the following evaluation and selection criteria (29):

  1. medical evaluation should include investigation of possible endogenous causes of obesity that may be amenable to treatment and identification of any obesity-related co-morbidities;
  2. likely candidates should be referred to centres with multidisciplinary weight management teams experienced in meeting the distinct physical and psychological needs of adolescents. These teams should include specialists in adolescent obesity evaluation and management, psychiatry and/or psychology, nutrition, physical activity and, of course, bariatric surgery;
  3. surgeons undertaking adolescent bariatric surgery should follow subspecialty training in line with that detailed by the American College of Surgeons and the American Society for Bariatric Surgery. Preceptorship with an established bariatric surgeon is vital and at least 100 cases should be performed with supervision;
  4. additional services should be available: adolescent medicine or endocrinology, respiratory, gastroenterology, cardiology physicians, anaesthetists, orthopaedic surgeons, ethicists;
  5. the team approach should include a review process (patient review board) similar to that used in multidisciplinary oncology and transplant programmes. The review should result in specific treatment recommendations for individual patients including the appropriateness and timing of possible surgical intervention;
  6. candidates should undergo comprehensive psychological assessment including both patient and parent interviews;
  7. bariatric surgery should not be a treatment option if:

 

    1. there is a medically-treatable cause of obesity,
    2. there is substance abuse,
    3. there is a medical, psychiatric or cognitive condition that would impair the patient’s ability to adhere to postoperative dietary or medication regimens,
    4. the patient is lactating, pregnant or considering pregnancy within 2 years after surgery
    5. or if there is inability or unwillingness of either patient or parent to fully comprehend the surgical procedure and its medical consequences, including the need for lifelong medical surveillance.

 

The US consensus statement suggested that adolescents being considered for bariatric surgery should:

  1. have failed at least 6 months of medically-supervised attempts to lose weight;
  2. have attained or nearly attained physiologic maturity;
  3. be severely obese – BMI >40 with serious obesity-related co-morbidity or BMI >50 with less severe co-morbidities;
  4. demonstrate commitment to comprehensive medical and psychological evaluations both before and after surgery;
  5. agree to avoid pregnancy for at least 1 year post-operatively;
  6. be capable of and willing to adhere to nutritional guidelines post-operatively;
  7. provide informed assent to surgical treatment;
  8. demonstrate capacity to make informed decisions;
  9. have a supportive family environment.

The NICE criteria on the use of bariatric surgery in adolescents are largely similar to the above (see Table 1), identifying key patient selection criteria as adolescents with a BMI ≥ 40kg/m2 (≥35kg/m2 with significant co-morbidities) who are largely physiologically mature, and in whom “all appropriate” life-style modification and anti-obesity drug treatments have failed. The NICE guidance also clearly restricts the procedure to specialist teams with experienced bariatric surgeons and paediatric multi-disciplinary teams with significant expertise in child and adolescent obesity management who are able to provide expert psychological assessment and support pre- and post-surgery.

A strict reading of the NICE guidelines would potentially allow bariatric surgery in adolescents with a BMI ≥40kg/m2 with no significant co-morbidities. We note that 0.3% of contemporary 11-16 year olds in an epidemiological sample had BMI ≥40kg/m2 (3) and our clinic data indicates around 25% of 12-17 year olds greater than this BMI threshold had no identified co-morbidities (30). Given that BMI is a poor measure of fat mass, and a poor measure of harmful fat deposits such as visceral fat (31), we would argue that to meet NICE’s case for “exceptional circumstances”, bariatric surgery only be considered in young people of extreme BMI (e.g. 40kg/m2) with multiple significant obesity co-morbidities.

Furthermore, we believe that NICE’s criteria that subjects should have failed to control or reduce weight with appropriate non-surgical measures for ≥6 months, based largely on previous overseas guidance, is inadequate for adolescents, as our experience is that undertaking adequate trials of a range of non-surgical treatments takes far longer than 6 months.

Table 1

NICE guidance on the use of bariatric surgery in adolescents (1)

A. General recommendations for all ages:

Bariatric surgery is recommended as a treatment option for people with obesity if all of the following criteria are fulfilled:

  1. they have a BMI of 40 kg/m2 or more, or between 35 kg/m2 and 40 kg/m2 and other significant disease (for example, type 2 diabetes or high blood pressure) that could be improved if they lost weight
  2. all appropriate non-surgical measures have been tried but have failed to achieve or maintain adequate, clinically beneficial weight loss for at least 6 months
  3. the person has been receiving or will receive intensive management in a specialist obesity service
  4. the person is generally fit for anaesthesia and surgery
  5. the person commits to the need for long-term follow-up

B. Additional recommendations for children and adolescents:

  1. Bariatric surgery may be considered for young people only in exceptional circumstances, and if they have achieved or nearly achieved physiological maturity.
  2. Surgery for obesity should be undertaken only by a multidisciplinary team that can provide paediatric expertise in:

- preoperative assessment, including a risk–benefit analysis that includes preventing complications of obesity, and specialist assessment for eating disorders

- providing information on the different procedures, including potential weight loss and associated risks

- regular postoperative assessment, including specialist dietetic and surgical follow-up

- management of co-morbidities

- psychological support before and after surgery

- providing information on or access to plastic surgery (such as apronectomy) where appropriate

- access to suitable equipment, including scales, theatre tables, Zimmer frames, commodes, hoists, bed frames, pressure-relieving mattresses and seating suitable for patients undergoing bariatric surgery, and staff trained to use them.

c.  Surgical care and follow-up should be coordinated around the young person and their family’s needs and should comply with national core standards as defined in the Children’s NSFs for England and Wales.

d.  All young people should have had a comprehensive psychological, education, family and social assessment before undergoing bariatric surgery.

e.  A full medical evaluation including genetic screening or assessment should be made before surgery to exclude rare, treatable causes of the obesity.

 

We suggest that to meet the criteria of “exceptional circumstances”, previous treatment efforts should have included (1) a dedicated obesity life-style modification programme with adequate parental support for at least 6 months; and (2) adequate 3-6 month trials of at least two anti-obesity drugs (currently Orlistat and Sibutramine) within a specialist paediatric weight management clinic.

Setting up an adolescent bariatric service

Important elements in developing an adolescent bariatric surgery service have been described by Haynes (32) as follows:

1. Team and Assessment: patients would be referred following intensive medical and psychological assessment in a multidisciplinary clinic with specialist experience in paediatric obesity. The work-up would include history, clinical examination, screening for obesity-related comorbidities, radiological investigations where indicated, and psychological and social assessments of the patient and family. NICE also requires specialist assessment for eating disorders. We would add that consideration of child protection issues will be essential.

2. Setting: Furniture, beds, door width, toilets should be appropriate and weight limits and widths confirmed. An appropriate bed and wheelchair should be wheeled throughout the building (day care, operating theatre, x-ray, in-patient ward, intensive care unit, lifts) to check fit. Toilets may have to be changed from wall-mounted to floor. An architect/engineer should participate in the walk-through;

3. Mentoring from established professionals: learning from the experience of established bariatric surgical and nursing colleagues is vital. The operating theatre staff should attend bariatric procedures in established centres to become familiar with techniques and instruments. A lead nurse should join colleagues at these hospitals in clinics and on the wards. The surgical staff should observe and assist at the procedures. It is generally accepted that the beginner should assist with and perform with supervision at least 100 cases before embarking on the procedures alone. Similar issues pertain to mentoring of medical, dietetic and psychological professionals as well.

4. Cost: Inge et al reported the experience of establishing such a centre in Cincinnati Children’s Hospital (33). The cost to the institution was difficult to summarize because the programme was developed over 18 months. However the most notable expenses were (a) the cost of proctored training – including modules for surgeons, nurses and business managers, and new instrumentation (US$278,000); (b) new full-time personnel to support the programme (nurse practitioner and administrator – salary and benefits $108,000 per year); (c) assorted office, medical, surgical supplies $180,000 per year. The authors argued that these considerable start-up costs are offset by reduced medical costs of the patients’ co-morbidities and that the return on investment can be realised in as few as 3 to 5 years.

Conclusions

Obese children and teenagers in the UK deserve optimal medical and surgical management. There is emerging evidence that bariatric surgery performed on an appropriately prepared adolescent is safe and effective. It is essential that such preparation and surgery would take place within the confines of a multidisciplinary, structured programme. Collaboration between paediatric surgeons and ‘adult’ surgeons must be developed so that these children get the benefit of best practice.

 

 

REFERENCES

1. National Institute for Health and Clinical Excellence. Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. NICE Clinical Guideline December 2006;43: www.nice.org.uk/CG043

2. ÂChinn S, Rona RJ. Prevalence and trends in overweight and obesity in three cross sectional studies of British Children, 1974-1994. BMJ 2001; 322:24-6.

3. Taylor SJ, Viner R, Booy R, Head J, Tate H, Brentnall SL, et al. Ethnicity, socio-economic status, overweight and underweight in East London. Ethn Health 2005; 10:113-28.

4. Viner RM, Cole TJ. Who changes body mass between adolescence and adulthood? Factors predicting change in BMI between 16 years and 30 years in the 1970 British Birth Cohort. Int J Obes (Lond) 2006; 30:1368-74.

5. Viner RM, Cole TJ. Adult socioeconomic, educational, social, and psychological outcomes of childhood obesity: a national birth cohort study. BMJ 2005; 330:1354.

6. Reilly JJ, Methven E, McDowell ZC, Hacking B, Alexander D, Stewart L, et al. Health consequences of obesity. Arch Dis Child 2003; 88:748-752.

7. Garcia VF, DeMaria EJ. Adolescent bariatric surgery: treatment delayed, treatment denied, a crisis invited. Obesity Surgery 2006; 16:1-4.

8. Miyazwa Y, Ochiai T, Kawamura I. Indications for surgery for morbid obesity and effectiveness of bariatric surgery. Japanese Journal of Clinical Medicine 2001; 59:613-19.

9. Mitka M. Surgery for obesity: demand soars amid scientific, ethical questions. JAMA 2003; 289:1761-62.

10. Mason EE, Ito C. Gastric bypass. Ann Surg 1969;170:329.

11. Buchwald H, Williams SE. Bariatric surgery worldwide 2003. Obes Surg 2004; 14:1157-64.

12. Wittgrove AC, Clark GW, Schubert KR. Laparoscopic gastric bypass, Roux-en-Y: technique and results in 75 patients with 3-30 months follow-up. Obes Surg 1997;6:500-04.

13. DeMaria EJ, Sugerman HJ, Kellum JM, Meador JG, Wolfe LG. Results of 281 consecutive total laparoscopic roux en y gastric bypasses to treat morbid obesity. Ann Surg 2002; 235:640-7.

14. Lawson ML, Shelley K, Mitchell T, Chen MK, Luox TJ, Daniels SR, et al. One-year outcomes of Roux-en-Y gastric bypass for morbidly obese adolescents: a multicenter study from the Pediatric Bariatric Study Group. J Pediatr Surg 2006; 41:137-43.

15. Barnett SJ, Stanley C, Hanlon CM, Acton R, Saltzman DA, Ikramuddin S, et al. Long-term follow-up and the role of surgery in adolescents with morbid obesity. Surg Obes Relat Dis 2005; 1:394-8.

16. Rand CS, Macgregor AM. Adolescents having obesity surgery: a 6-year follow-up. South Med J Dec 1994; 87:1208-13.

17. Stanford A, Glascock JM, Eid GM, Kane T, Ford HR, Ikramuddin S, et al. Laparoscopic Roux-en-Y gastric bypass in morbidly obese adolescents. J Pediatr Surg 2003; 38:430-3.

18. Capella JF, Capella RF. Bariatric surgery in adolescence: is this the best age to operate? Obes Surg 2003; 13:826-32.

19. Mason EE, Scott DH, Doherty C, Cullen JJ, Rodriguez EM, Maher JW, et al. Vertical banded gastroplasty in the severely obese under twenty-one. Obes Surg 1995; 5:23-33.

20. Breaux CW. Obesity surgery in children. Obes Surg 1995; 5:279-84.

21. Kuzmak LI, Yap IS, McGuire L, Dixon JS, Young MP. Surgery for morbid obesity. Using an inflatable gastric band. AORN J 1990;51:1573.

22. Belachew M, Legrand MJ, Defrechereux TH, Burtheret MP, Jacquet N. Laparoscopic adjustable silicone gastric banding in the treatment of morbid obesity. A preliminary report. Surg Endosc 1994; 8:1354-6.

23. Forsell P, Hellers G. The Swedish Adjustable Gastric Banding (SAGB) for morbid obesity: 9 year experience and a 4-year follow-up of patients operated with a new adjustable band. Obes Surg 1997; 7:345-51.

24. Nadler EP, Youn A, Ginsburg HB, Ren CJ, Fielding GA. Short-term results in 53 US obese pediatric patients treated with laparoscopic adjustable gastric banding. J Pediatr Surg 2007; 42:137-41.

25. Angrisani L, Favretti F, Furbetta F, Paganelli M, Basso N, Doldi SB, et al. Obese teenagers treated by Lap-Band system: the Italian experience. Surgery 2005; 138:877-81.

26. Fielding GA, Duncombe JE. Laparoscopic adjustable gastric banding in severely obese adolescents. Surg Obes Relat Dis 2005; 1:399-405.

27. Silberhumer GR, Miller K, Kriwanek S, Widhalm K, Pump A, Prager G. Laparoscopic adjustable gastric banding in adolescents: the Austrian experience. Obes Surg Aug 2006; 16:1062-7.

28. Abu-Abeid S, Gavert N, Klausner JM, Szold A. Bariatric surgery in adolescence. J Pediat Surg 2003;38:1379-82.

29. Inge TH, Krebs NF, Garcia VF, Skelton JA, Guice KS, Strauss RS, et al. Bariatric surgery for severely overweight adolescents: concerns and recommendations. Pediatr 2004; 114:217-223.

30. Viner RM, Segal TY, Lichtarowicz-Krynska E, Hindmarsh P. Prevalence of the insulin resistance syndrome in obesity. Arch Dis Child 2005; 90:10-4.

31. Wells JC, Fewtrell MS. Measuring body composition. Arch Dis Child 2006; 91:612-7.

32. Haynes B. Creation of a bariatric surgery program for adolescents at a major teaching hospital. Ped Nursing 2005; 31:21-3.

33. Inge TH, Garcia V, Daniels S, Langford L, Kirk S, Roehrig H, et al. A multidisciplinary approach to the adolescent bariatric surgical patient. J Pediat Surg 2004; 39:442-7

 

Correspondence:

Niall Jones

Department of General Surgery, St Georges Healthcare NHS Trust

e-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

Telephone: 02086721255