Morbid obesity is strongly associated with non-alcoholic fatty liver disease (NAFLD), which is rapidly becoming the most common cause of chronic liver disease worldwide. This epidemic is not limited to adults. An increasing number of children and adolescents are being affected. In view of the significant adverse health effects of early onset obesity, aggressive intervention must be considered.
Weight loss through lifestyle change—diet and exercise—is clearly the optimal approach to childhood obesity and related diseases, including type 2 diabetes and NAFLD.
However, the potential for long-term success of this challenging strategy is limited. This has led to a growing interest in bariatric surgery, an accepted and well-established option for adults, as an alternative for weight reduction in children and adolescents. Studies suggest that in carefully selected patients, early intervention using weight-loss surgery can reduce obesity-related comorbid conditions. These studies have demonstrated that bariatric surgery in patients with nonalcoholic steatohepatitis (NASH) can reduce the grade of steatosis, hepatic inflammation, and fibrosis.
Who is elegible
The group advises consideration of bariatric surgery in “carefully selected” patients with body mass indexes of greater than 40 kg/m2 who have severe comorbidities, such as non-alcoholic fatty liver disease (NAFLD), or in those with a body mass index of greater than 50 kg/m2 who have milder comorbidities.
This is the first guideline on the use of bariatric surgery in youth since the 2012 joint document from the National Association of Children’s Hospitals and Related Institutions and the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition addressed the nutritional needs of adolescents undergoing the procedure (J Pediatr Gastroenterol Nutr. 2012; 54:125-135).
To summarize what was written in the guidelines by the Hepatology Committee of ESPGHAN, the selection criteria for consideration of a bariatric procedure should include a body mass index (BMI) > 40 kg/m2 with a comorbid condition, such as type 2 diabetes, moderate to severe sleep apnea, pseudotumor cerebri (PTC), or NASH with significant fibrosis (Ishak score ≥ 1).
Alternatively, a BMI > 50 kg/m2 with a mild comorbid condition, such as hypertension, insulin resistance, glucose intolerance, a substantially impaired quality of life or activity of daily living, dyslipidemia, or sleep apnea with an apnea/hypopnea index > 5, also meets the selection criteria.
Selection of the correct procedure for each adolescent is based on evaluation of the patient’s medical, physiologic, and social issues, as well as discussion of the risks and benefits of the surgery with the patient and family.
The bariatric surgical procedures performed on pediatric patients can be divided into two categories: restrictive and malabsorptive.
Commonly used procedures
We use the sleeve gastrectomy, which is a restrictive approach. Sleeve gastrectomy is an alternative, effective weight loss surgical procedure that is being used with increasing frequency. It is an older procedure, introduced in the 1990’s as an alternative to distal gastrectomy. This sleeve gastrectomy was first performed by Ren and colleagues in 1999.
In this procedure, the stomach is reduced about 20%, and following that, the size of the stomach is permanently reduced. It cannot be reversed. This is very important in terms of speaking to adolescents and parents about this procedure. The benefits (which are outlined in the guidelines) of this procedure include lack of a foreign body; no need for frequent adjustments; very few nutritional deficiencies, such as those seen in malabsorptive procedures; and a reduced risk for the dumping syndrome, because the vagus nerve is preserved.
In general, with respect to bariatric surgery, we know that weight loss is typically about one third of the patient’s starting BMI. Therefore, an adolescent with a BMI of 60 kg/m2 can be expected to attain a BMI of approximately 40 kg/m2 postoperatively at 1 year and will remain in the severely obese category. In contrast, an adolescent with a BMI of 40 kg/ m2 is very likely to attain a near-normal BMI status postoperatively, somewhere in the upper 20-kg/m2 range. We feel that it is important to let severely obese teens with comorbid conditions know about bariatric surgery as an option earlier rather than waiting until they reach extreme BMIs—in the 50-kg/m2 to 60-kg/m2, or even 70 kg/ m2, range.
There are fewer data on long-term weight loss outcomes and comorbid benefits for sleeve gastrectomy compared with gastric bypass, which is the gold standard, but short-term data in adults, going out 5-7 years postoperatively, appear very promising. We are also seeing very good short-term results in adolescents at 1-3 years, with very similar results in percent weight loss and comorbidity resolution.
Gastric banding, in contrast, has fallen out of favor in North America recently. It is not yet approved by the US Food and Drug Administration for adolescents, and we are finding that there is a higher rate of reoperation in adults as well as in adolescents owing to band slippage or band failure, and lower success rates with long-term weight-loss outcomes. This is the reason why banding is being eclipsed by sleeve gastrectomy.