ESPE Yearbook of Paediatric Endocrinology

To read the full abstract: The New England journal of medicine. 2019;380(22):2136–45.

Here, Inge et al. explored whether the outcomes of Roux-en-Y gastric bypass (RYGB) differ according to the age of the patient at the time of surgery. They analysed retrospective data on the 5-year outcomes of RYGB in 161 adolescents from the Teen-LABS-study (1) and in 396 adults with a history of obesity dating back to age 18 years, enrolled in the LABS-study (2), regarding weight, coexisting conditions, as well as mortality, abdominal reoperations and selected micronutrition levels.

Most importantly, there was no significant difference between adolescents and adults in the percent weight change (-26% vs. -29%, P =0.08) and mortality (1.9% vs. 1.8%) 5 years after RYGB surgery. However, the rates of remission of type 2 diabetes and hypertension were significantly higher in adolescents vs. adults (86% and 68% vs. 53% and 41%, respectively), whereas the rate of abdominal reoperations (mainly cholecystectomies) was significantly higher in adolescents (19 vs. 10) during 5 years after surgery. The proportion with low ferritin and low vitamin D levels markedly increased among adolescents (48% and 38%), whereas low ferritin levels slightly increase and low vitamin D levels decrease in adults (29% and 24%) 2 years after surgery, most probable because of a decrease in adherence to supplementation after surgery among adolescents. Improvements in cholesterol and triglyceride levels were observed in both cohorts.

Although accumulating evidence supports bariatric surgery as an efficacious and safe intervention also for severe obese adolescents (3–6), providers still are reluctant to refer them for bariatric surgery (7). Thus, the present findings are an important contribution to an early intervention and in line with other publications, showing better results at an earlier timepoint of surgery (8–10).

However, due to the paucity of long-term data on bariatric surgery in adolescents, it is still not impossible to determine a definitive risk-benefit analysis of bariatric surgery in this population. It is indispensable that all adolescents are cared for by multidisciplinary teams in centers with expertise in adolescent extreme obesity and bariatric surgery. Measures to improve patient understanding of the procedure and lifestyle changes, as well as compliance, need to be implemented in a preoperative treatment program. Risk-benefit ratios must be assessed on a case-by-case basis, keeping in mind that full information on long-term risks is not yet available.

References:

1. Inge TH, Zeller MH, Jenkins TM, et al. Perioperative outcomes of adolescents undergoing bariatric surgery: the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study. JAMA Pediatr 2014;168:47–53.

2. Courcoulas AP, King WC, Belle SH, et al. Seven-year weight trajectories and health outcomes in the Longitudinal Assessment of Bariatric Surgery (LABS) study. JAMA Surg 2018;153:427–34.

3. Armstrong SC, Bolling CF, Michalsky MP, et al. Pediatric metabolic and bariatric surgery: evidence, barriers, and best practices.Pediatrics, 2019;144 (6):e20193223.

4. Sarno LA, Lipshultz SE, Harmon C, et al. Short-and long-term safety and efficancy of bariatric surgery for severely obese adolscents: a narrative review. Pediatric Research 2020;87 (2):202–9. https://doi.org/10.1038/s41390-019-0532-3.

5. Olbers T, Beamish AJ, Gronowitz E, et al. Laparoscopic Roux-en-Y gastric bypass in adolescents with severe obesity (AMOS): a prospective, 5-year, Swedish nationwide study. Lancet Diabeste Endocrinol. 2017;5 (3):174–183.

6. Flum DR, belle SH; Longitudinal Assessment of Bariatric surgery (LABS) Consortium. Perioperative safety in the longitudinal asssessment of bariatric surgery. N Engl J Med 2009;361 (5):445–454.

7. Woodford SJ, Clark SJ, Gebremariam A, et al. To cut or not to cut: physicians’ perspectives on referring adolecscents for bariatric surgery. Obes Surg 2010;20 (7):937–42.

8. Inge TH, Jenkins TM, Xanthakos SA, et al. Long-term outcomes of bariatric surgery in adolescents with severe obestiy (FABS5+): a prospective follow-up analysis. Lancet Diabestes Endocrinol. 2017;5 (3):165–173.

9. Michalsky MP et al. Cardiocascular risk factors after adolscent bariatric surgery. Pediatrics 2018;141 (2):e20172485.

10. IngeTH, Jenkins TM, Zeller M, et al. Baseline BMI is a strong predictor of nadir BMI after adolescent gastric bypass. J Pediatr. 2010;156 (1):103–108.