Adolescent Bariatric Surgery: Where Kids Are More Like Adults

Photo by M Clock

When I look each week to do a blog post on a topic of interest from my current Bariatric Surgery experience, there is usually an issue or an idea that stands out and presents itself throughout the course of the preceeding week or so, and this week is no exception.

Adolescent Bariatric surgery has been in the news, my emails, and on TV all week since a study published this past week in JAMA Pediatrics.  The ASMBS  recently commented in the issue as well, and Medscape Surgery also acutely chimed in.

This JAMA Peds study was a nice foray into the highly controversial subject of adolescent weight loss surgery.  To be honest, I expect there to be a good many Providers who are still not in favor of adults having surgery for obesity, and for those, this topic will likely put them over the proverbial edge.

This highly charged debate stems from many factors, and I really do get it. (We don't do anyone less than 18 years old at our center, and have no plans to do so.)  

Although, to be honest, I am not sure I honestly have a personal stance on the issue, just that it comes up every now and then, and now this hightened increase in publicity has it again at the forefront.  

This is what I can already hear from those concerned about the issue in the health care field...

Why surgery for a "child" with a "behaviorally-induced" malady?  Why not try intensive behavior modification and stick with it instead of surgery?  Can an adolescent really comprehend the nature of their disease, its severity, or the imperative nature of doing something (NOW) to improve their condition?  Aren't there significant psychological and social aspects of morbid obesity in this age group that may not lend itself well to the 'forced' behavior modification that surgery results in?  Is the current disease state of even severe morbid obesity in this age group worth the risk of having surgery for the potential short and  long term benefit?  (These are a few questions that come to my mind as well...)

So, that now that it's out in the open, this study did a go a distance toward addressing some of those questions with it's demographic intake data, and the resultant safety as plotted from its 242 operative cases that were reviewed.  The study was limited to basically perioperative safety and outcomes in its studied adolescent weight loss surgery group.

With the benefit of intake demographic and anthropometric data, one aspect that we wonder about was accurately characterized: Just how sick are these kids?

Of the 242 studied, ranging in age from 13-19 (median age of 17.1), the rate of baseline comorbidites was in fact very similar to a preoperative adult cohort that has been studied many times in the past.  The average BMI was 50.5.

How is this for a hit list?

   *Dyslipidemia     74%   

   *OSA                  57%

   *Joint Pain           46%

   *HTN                  45%

   *Back Pain          45%

   *NASH               37%

   *PCOS                21%

   *Renal Disease    19%

   *DM 2                 14%

Furthermore, this intake data went further to shed light on this population of adolescents that was, on average, 2 fold heavier than ideal weight, in terms of cardiovascular risk factors that we more typically take note of in the adult population.

Nationally representative data demonstrates prevalence rates of HTN, high LDL, and low HDL at 3%, 8%, and 3% respectively in more normal-weighted adolescents.  In this group the numbers were 45%, 9%, and 64% respectively.  

An additional concerning factor was the measurement of C-Reactive Protein, which was abnormally elevated in more than 3/4 of those studied in the surgery group, again showing evidence of systemic inflammation, and all the malady that brings with it.

So, yes, these kids are sick, and even though adolescents are resilient, and usually show a lot of reserve, there is a limit to that physiologic fact of life, and this demonstrates that threshold can be overwhelmed.

And now to safety.  Comparative data for both the adolescents studied and what would be expected in a average adult population of weight loss surgery patients was very similar.  

A study cited by the study from JAMA showed a group of adults who had either Bypass or Sleeve Gastrectomy as experiencing a 30 day complication rate of 27% and 14% respectively.  For the adolescent group, the same surgeries had combined major / minor complication rates of 26% and 16% accordingly.  Essentially the same numbers, as far as safety goes.

So, what is the next logical part of the equation for this issue, an aspect that wasn't a component of this study (yet)?

Yes, the next logical question that will need to be answered is, "So, how did they make out as far as their weight loss and comorbidites?"

The authors write about that portion as to be published later.  But, if you are like me, you need this question answered to clarify a key component (efficacy) of this possible treatment for adolescent super morbid obesity. 

However, so far, maybe so good.  

And for better or for worse, factor this in.  There appears to be no free pass when it comes to the absolutes of some aspects of health and disease.  These kids appear to be more like their adult counterparts than not.

Going against them further is the fact that they have a (hopefully) long road ahead of them jus to get to realize the joys of "true" aging.  Another downside of our accelerated "microwave society"?