The prevalence of childhood and adolescent obesity is rapidly increasing, causes are difficult to pinpoint, and the disease leads to other conditions/diseases. Evidence shows the high tendency of severely obese adolescents to become severely obese adults (Michalsky, Reichard, Inge, Pratt, & Lenders, 2012). Adolescents not able to lose weight through lifestyle modifications/behavioral therapy (e.g., diet changes and increased physical activity) or are experiencing severe weight-related complications may benefit from weight loss surgery. Tsamis et al. (2015) suggest that “bariatric surgery is currently the most effective evidence-based method to obtain long term-term weight loss in severely obese patients.” Below is a case study of a patient who was seen in our adolescent bariatric surgery clinic.
B. L. is a 15-year-old male adolescent who was referred to the weight clinic with a body mass index (BMI) of 50. He was referred based on his history of severe obesity and nonalcoholic fatty liver disease for a discussion of weight loss surgery.
B. L. has experienced obesity since childhood. B. L. had tried a low-carbohydrate and low-fat diet, reducing his portion sizes, working with a nutritionist, and increasing his level of physical activity, but could not achieve or maintain a healthy body weight. His obesity increased because of a poor selection of foods (e.g., high-caloric fast food) and not attaining enough physical activity, as he spent many hours watching television and playing video games, spending up to 15 hours per day on electronic devices or television. He also had numerous obesity-related comorbidities including fatty liver disease, obstructive sleep apnea requiring Continuous positive airway pressure (CPAP), dyslipidemia, and Vitamin D deficiency. Not only was his weight affecting his physical health, but it also contributed to his depression, low self-esteem, and teasing/bullying episodes.
At his initial appointment in the weight clinic, B. L. weighed 387 pounds (176 kg) with a BMI of 50 (greater than the 99th BMI percentile). In addition to being seen in the weight clinic by a pediatrician who specializes in child and adolescent obesity, he also underwent evaluation by a dietician, a psychologist, a social worker, a surgery nurse practitioner, and a pediatric general surgeon. “No empirical evidence is available supporting the establishment and use of a multidisciplinary team for adults or adolescents undergoing bariatric surgery,” but the recommendations to maximize a multidisciplinary approach include the following team members: a surgeon, a pediatric specialist, a dietician, a mental health specialist, a coordinator, and an exercise specialist (Michalsky et al., 2012).
The preoperative bariatric surgical workup requires fasting laboratory studies (e.g., metabolic profile, lipid panel, C-reactive protein, lipoprotein, homocysteine, ferritin, Hemoglobin A1c, iron, transferrin, thyroid stimulating hormone, Vitamin B12, complete blood count with differential, insulin, folate, thiamin, zinc, Vitamin D, magnesium, Vitamin B3, and Vitamin B6); a sleep study to rule out obstructive sleep apnea; an upper endoscopy with biopsies to rule out gastric ulcers, Helicobacter pylori infections, or other inflammation in the esophagus and stomach; chest x-ray; and electrocardiogram. In addition, the patient is asked to complete a minimum of 4–6 months of consecutive monthly clinic appointments with the entire bariatric team showing that a patient is able to lose and/or maintain his or her weight for a minimum of 3 months while following diet and physical activity recommendations. All patients are also required to receive anesthesia clearance.
During the preoperative process, B. L.’s highest weight was 417 pounds (189.5 kg). He showed regular attendance to his clinic appointments, modified his diet to include healthier foods and regular meals, and engaged in more regular exercise.
All of his obesity-related comorbidities, along with his severe obesity as evidenced by a BMI of 51, put B. L. at an extreme risk for early mortality, development of other severe medical comorbidities related to his obesity, and a poor quality of life (Bacha & Gidding, 2016; Reiter-Purtill et al., 2017).
Lifestyle modifications in children/adolescents with severe obesity “have demonstrated modest improvement in BMI,” and the “participants have generally remained severely obese and often regained weight after the conclusion of the treatment programs. Bariatric surgery has generally been effective in reducing BMI and improving cardiovascular and metabolic risk factors” (Kelly et al., 2013).
The most recent national consensus article published in 2012 by Michalsky et al. on best practice guidelines in pediatric/adolescent weight loss recommended weight loss surgery for adolescents with BMI ≥ 35 and specific obesity-related comorbidities (e.g., Type 2 diabetes, moderate or severe Obstructive Sleep Apnea (OSA), idiopathic intracranial hypertension, severe nonalcoholic steatohepatitis, or a BMI of ≥40 with other comorbidities [e.g., hypertension, insulin resistance, glucose intolerance, impaired quality of life, or dyslipidemia]). B. L. met these criteria, as mentioned above (Table 1).
Our bariatric team discussed B. L.’s case at our multidisciplinary bariatric board meeting, and it was the unanimous consensus of the entire multidisciplinary team that bariatric surgery, specifically a laparoscopic sleeve gastrectomy (LSG), was B. L.’s best option to treat his severe obesity.
The LSG is a procedure that is effective in achieving sustained weight loss and is increasingly used as an alternative to the Roux-en-Y gastric bypass procedure. With the LSG procedure, the fundus of the stomach is resected to achieve a smaller gastric volume while not affecting the absorption of critical nutrients. Although the LSG is a restrictive procedure, resection of the gastric fundus alters the hormonal milieu in a way that is favorable to patients with Type 2 diabetes or insulin resistance. It also affects the appetite center in the hypothalamus, much like the gastric bypass procedure. This is a very attractive operation for adolescents because it does not permanently alter the intestinal tract anatomy, as is done using the gastric bypass procedure (Styne et al., 2017).
B. L. was aware of the risks of the surgery, which included bleeding, blood clots, leaking at the staple line, infection, pneumonia, and reflux postoperatively. He was also aware that the surgery is most successful when used in combination with healthy eating and exercise habits. At his preoperative appointment, he weighed 403 pounds (183 kg) with a BMI of 51. He completed a 2-week preoperative full liquid diet to help reduce the size of his liver. B. L. underwent an LSG and a liver biopsy. He had a 3-night/4-day hospital stay. He was discharged home on a full liquid diet for an additional 4 weeks and then was advanced to a pureed, soft, and, eventually, regular diet 6 weeks after surgery.
B. L. responded well to surgery, and 18 months postoperatively, he had lost 143 pounds (65.2 kg) or 64% of his excess body weight, with a BMI of 33. In addition to his excellent weight loss and reduction in his BMI, B. L.’s obesity-related comorbidities (OSA, dyslipidemia, and fatty liver) have resolved. He no longer requires CPAP. He will take a multivitamin, Vitamin B12, and calcium supplementation for life.
In terms of changes in his quality of life, B. L. attends school and is employed. He exercises on a daily basis. He continues on a low-calorie diet with a goal of 60–80 grams of protein per day, eating small frequent meals and drinking at least 60 ounces of water per day.
B. L. will continue to be monitored by our adolescent bariatric surgery team on an annual basis with fasting laboratories that include checking his vitamin levels. When he reaches the age of 25 years, he will then be transitioned to our adult colleagues for continued annual evaluation.
CONCLUSIONS AND RECOMMENDATIONS
If you have an adolescent patient who has a BMI ≥ 35 with specific obesity-related comorbidities or a BMI of ≥40 with other comorbidities who has tried to lose weight through diet and physical activity but has been unsuccessful, consider a referral to an adolescent bariatric program.
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