Published online March 1, 2005
PEDIATRICS Vol. 115 No. 3 March 2005, pp. 822-823 (doi:10.1542/peds.2004-1692)
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Adolescent Bariatric Surgery: Treatment Delayed May Be Treatment Denied

Victor F. Garcia, MD
Department of Pediatric Surgery,
School of Medicine,
University of Cincinnati,
Cincinnati, OH 45229

As a senior member of the panel and a coauthor of "Bariatric Surgery for Severely Overweight Adolescents: Concerns and Recommendations,"1 I am acutely aware of the palpable need for these guidelines given the absence of any data to guide the selection of adolescents for bariatric surgery and the role that pediatric and adult surgeons will have in fielding the plethora of inquiries for bariatric surgery. In that respect, these guidelines provide practical information about physiologic and sexual maturation when considering the timing of bariatric surgery, the value of a multidisciplinary panel in patient selection, and the importance of psychological assessment of the patient and the family and the use of that assessment to develop a compliance program that meets the unique cognitive and developmental needs of the adolescent. However, in respect to the proposed BMI criteria for bariatric surgery, I now submit that the guidelines are flawed. Clinically severe obesity is an intractable and chronic disease,2 not amenable to extant drug or behavioral therapies. Currently, surgery offers the only effective long-term weight-loss therapy for morbidly obese patients.3

Four points warrant specific emphasis:

  1. Given that a higher BMI is clearly a predictor of operative mortality and morbidity and longer duration of operation and conversion rate,4–6 the stipulation of a higher BMI as a criterion for adolescent bariatric surgery actually (and I believe unnecessarily) exposes the adolescent to a higher degree of risk for death and operative complications. The only approach demonstrated to result in sustained weight loss is bariatric surgery. Severely obese adolescents who are unable to lose weight with nonsurgical means may not only be motivated to gain weight to meet the arbitrary BMI threshold for adolescent bariatric surgery but, in doing so, place themselves at higher risk for death and complications related to bariatric surgery. Thus, it is ironic that the panel's intent, by limiting the application of bariatric surgery to only those at highest risk, will in fact increase the risk for complications and death.
  2. The heavier the patient is, the less the degree of weight loss,7,8 the higher the complication rate, and the lower the likelihood that conditions amenable to surgical weight loss will be ameliorated or resolve.9–13 Diabetes and metabolic syndrome are increasing in incidence and prevalence among children,14–20 and the clustering of risk factors of the metabolic syndrome at younger ages implies a longer duration of disease. When one considers that the severity and duration of diabetes influences the ability of surgical weight loss to ameliorate or "cure," it argues against a higher BMI threshold. This is especially cogent when one looks at minorities,14,16 a population not only at increased risk but less likely, in general, to have access to or receive effective weight-loss treatment and thus more likely to suffer the complications and premature death associated with intractable obesity.21 In some respects, treatment delayed may be treatment denied. It is more appropriate under the rubric of "conservative," at a minimum, to apply the BMI criteria currently used for adults or preferably either an algorithm based on risk-factor analysis22 (as is used in determining the appropriateness of lipid therapy) or the presence of a weight-responsive major comorbidity.
  3. The setting for adolescent bariatric surgery merits stronger emphasis. Adolescent bariatric surgery should be performed in a setting that can identify and address the unique but often underappreciated psychosocial and cognitive needs of the adolescent that, if unmet, impair immediate and perhaps long-term compliance with a salutary lifestyle and eating pattern.
  4. The final point is that most if not all adolescents undergoing bariatric surgery should be entered into a robust national database. The outstanding questions that prompted the conservative approach of the pediatric panel cannot and will in no way be met by stipulating a higher BMI threshold. They will only be addressed by having a large enough cohort of adolescents who undergo bariatric surgery entered into such a database and have their outcomes evaluated prospectively. Only then can we accelerate our understanding of the effect that surgical weight loss has in this population, increasingly vulnerable to the metabolic consequences of severe obesity.

REFERENCES

  1. Inge TH, Krebs NF, Garcia VF, et al. Bariatric surgery for severely overweight adolescents: concerns and recommendations. Pediatrics. 2004;114 :217 –223[Abstract/Free Full Text]
  2. Friedman JM. A war on obesity, not the obese. Science. 2003;299 :856 –858[Abstract/Free Full Text]
  3. Steinbrook R. Surgery for severe obesity. N Engl J Med. 2004;350 :1075 –1079[Free Full Text]
  4. Fernandez AZ Jr, Demaria EJ, Tichansky DS, et al. Multivariate analysis of risk factors for death following gastric bypass for treatment of morbid obesity. Ann Surg. 2004;239 :698 –702, discussion 702–703[CrossRef][ISI][Medline]
  5. Livingston EH, Ko CY. Assessing the relative contribution of individual risk factors on surgical outcome for gastric bypass surgery: a baseline probability analysis. J Surg Res. 2002;105 :48 –52[CrossRef][ISI][Medline]
  6. Schwartz ML, Drew RL, Chazin-Caldie M. Laparoscopic Roux-en-Y gastric bypass: preoperative determinants of prolonged operative times, conversion to open gastric bypasses, and postoperative complications. Obes Surg. 2003;13 :734 –738[CrossRef][ISI][Medline]
  7. Bloomston M, Zervos EE, Camps MA, Goode SE, Rosemurgy AS. Outcome following bariatric surgery in super versus morbidly obese patients: does weight matter? Obes Surg. 1997;7 :414 –419[CrossRef][ISI][Medline]
  8. Brolin RE, Kenler HA, Gorman RC, Cody RP. The dilemma of outcome assessment after operations for morbid obesity. Surgery. 1989;105 :337 –346[ISI][Medline]
  9. Dixon JB, O'Brien PE. Changes in comorbidities and improvements in quality of life after LAP-BAND placement. Am J Surg. 2002;184(6B) :51S –54S[CrossRef]
  10. Long SD, O'Brien K, MacDonald KG Jr, et al. Weight loss in severely obese subjects prevents the progression of impaired glucose tolerance to type II diabetes. A longitudinal interventional study. Diabetes Care. 1994;17 :372 –375[Abstract]
  11. Polyzogopoulou EV, Kalfarentzos F, Vagenakis AG, Alexandrides TK. Restoration of euglycemia and normal acute insulin response to glucose in obese subjects with type 2 diabetes following bariatric surgery. Diabetes. 2003;52 :1098 –1103[Abstract/Free Full Text]
  12. Schauer PR, Burguera B, Ikramuddin S, et al. Effect of laparoscopic Roux-en Y gastric bypass on type 2 diabetes mellitus. Ann Surg. 2003;238 :467 –484, discussion 84–85[ISI][Medline]
  13. Schauer PR, Ikramuddin S, Gourash W, Ramanathan R, Luketich J. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg. 2000;232 :515 –529[CrossRef][ISI][Medline]
  14. Bacha F, Saad R, Gungor N, Janosky J, Arslanian SA. Obesity, regional fat distribution, and syndrome X in obese black versus white adolescents: race differential in diabetogenic and atherogenic risk factors. J Clin Endocrinol Metab. 2003;88 :2534 –2540[Abstract/Free Full Text]
  15. Berenson GS, Srinivasan SR. Emergence of obesity and cardiovascular risk for coronary artery disease: the Bogalusa Heart Study. Prev Cardiol. 2001;4 :116 –121[Medline]
  16. Chen W, Srinivasan SR, Elkasabany A, Berenson GS. Cardiovascular risk factors clustering features of insulin resistance syndrome (syndrome x) in a biracial (black-white) population of children, adolescents, and young adults: the Bogalusa Heart Study. Am J Epidemiol. 1999;150 :667 –674[Abstract/Free Full Text]
  17. Csabi G, Torok K, Jeges S, Molnar D. Presence of metabolic cardiovascular syndrome in obese children. Eur J Pediatr. 2000;159 :91 –94[CrossRef][ISI][Medline]
  18. Matthews DR, Wallace TM. Children with type 2 diabetes: the risks of complications. Horm Res. 2002;57(suppl 1) :34 –39
  19. Young-Hyman D, Schlundt DG, Herman L, De Luca F, Counts D. Evaluation of the insulin resistance syndrome in 5- to 10-year-old overweight/obese African-American children. Diabetes Care. 2001;24 :1359 –1364[Abstract/Free Full Text]
  20. Zimmet P. The burden of type 2 diabetes: are we doing enough? Diabetes Metab. 2003;29(4 pt 2) :6S9 –6S18
  21. Fontaine KR, Redden DT, Wang C, Westfall AO, Allison DB. Years of life lost due to obesity. JAMA. 2003;289 :187 –193[Abstract/Free Full Text]
  22. Kimm SY, Obarzanek E. Childhood obesity: a new pandemic of the new millennium. Pediatrics. 2002;110 :1003 –1007[Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics




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