To date, no study has indicated long-term data on whether LAGB had consequent nutritional deficiencies, growth impact, or development impact.
Long-term weight loss outcomes also are still lacking. In 1 study, at least 80% of adolescents had sustained weight loss 5 years after LAGB but the total number of treated patients was small and the number lost to follow-up was not provided (55). Precise descriptions of changes in comorbidities after LAGB in adolescents are still lacking, although initial reports appear to be encouraging (53,54). LAGB is more effective than behavioral interventions alone, and results in significant weight loss when used as part of a comprehensive weight loss program for adolescents. It is considered investigational if done in an institutional review board–approved study.
LSG is a new, alternative, and effective weight loss surgical procedure used with increasing frequency (56). This surgical procedure was originally performed as the first step in a staged weight loss procedure for severely obese adults (57). It was initially introduced in 1990 as an alternative to distal gastrectomy with the duodenal switch procedure to reduce the rate of complications (58,59). Sleeve gastrectomy was first performed laparoscopically by Ren et al (60). In this restrictive procedure, the stomach is reduced to approximately 20% of its original size by the surgical removal of a large portion. The open edges are then stapled together to form a sleeve or narrow banana-shaped tube. As a result, the size of the stomach is permanently reduced and cannot be reversed (61). Although LSG functions as a restrictive procedure, it may also cause early satiety by removing the ghrelin-producing portion of the stomach (57). Early postoperative complications, following LSG surgery, that need to be identified urgently, include bleeding (intra- or extraluminal), staple line leak, and any development of an abscess. Delayed complications include strictures, nutritional deficiencies, and gastroesophageal reflux disease (57,62). Short-term data suggest that LSG may be a safe alternative, with fewer nutritional risks than other laparoscopic surgical procedures such as RYGB, but its irreversibility and the present lack of longitudinal data on outcome are drawbacks to this procedure (63). The benefits of this procedure include the lack of a foreign body, no need for frequent adjustments necessary with LAGB, fewer nutritional deficiencies than those seen in malabsorptive procedures, and a decreased risk of dumping syndrome because the vagus nerve is preserved (63).
The majority of studies on outcomes after sleeve gastrectomy involve adult patients. A small case study (n = 4, girls) of adolescent patients (mean age 14.5 years, mean BMI 48.4 kg/m2) demonstrated weight loss after a mean follow-up of 12 months (mean BMI 37.2 kg/m2). No patients had operative complications, and no patients had postoperative malnutrition or vitamin deficiency (Table 3 , (64)).
Another small study (n = 7) of pediatric patients (mean age 16.2 years) demonstrated a weight loss in 85.7% of patients (n = 6). No operative complication was described and comorbid conditions improved (Table 3 , (65)).
LSG in the pediatric age group is of a similar safety and effectiveness when compared with adults. Pediatric patients had fewer major complications and were more compliant with follow-up than adults; however, its applicability in the adolescent age group remains controversial (69). Nevertheless, long-term results are required to further clarify the safety and effectiveness of LSG in pediatric patients.
IB is an endoscopic device for the temporary nonpharmaceutical and nonsurgical treatment for morbid obesity (70,71). In past years, devices such as those of Ballobes and Garren had no significant effects on weight reduction, offered a large number of complications (gastric erosion 26%, gastric ulcer 14%, Mallory-Weiss tears 11%) and a small volume of the balloon (220 mL for Garren-Edwards and 400 mL for Ballobes) (71–73). The BioEnterics intragastric balloon (BIB) (74) has a spherical shape, a high volume capacity (500–700 mL) and is designed to remain in the gastric cavity for a period of 6 months (74,75). The insertion of a BIB is usually easy and safe. Its use is totally reversible and repeatable. Although an endoscopic treatment for morbid obesity with an IB has been tested in adults with simple obesity (76), there are limited data in the literature about the use of BIB in adolescents with morbid obesity. In a large multicenter study, Genco et al (76) showed that the use of BIB induced a significant reduction of BMI and an improvement of comorbidities. Indications for BIB usage in lower degrees of obesity have been increasingly accepted (74,77), and the improvement in metabolic profile after the BIB placement has been reported in several studies (75,78–83).
The long-term effect of BIB, combined with pharmacotherapy, was superior to the combination with lifestyle modification only (84,85). Some patients were reported to continue losing weight for up to 22 months of follow-up after balloon extraction (86). Long-term maintenance of weight loss is controversial. Some studies confirm it (87), whereas others report that weight regain after BIB was universal and that almost all of the patients needed surgery after balloon removal (88).
Complication rates (eg, stapling complications) are low as suggested by several studies (58,89). Therefore, the balloon can be a preoperative treatment for patients with morbid obesity, before undergoing elective surgeries (bariatric, etc) in selected cases. So although this reversible device appears to be attractive for use in children, to date there are no published data regarding the use of this technique in children and adolescents with obesity, and it is not yet fully established whether BIB is of long-term benefit in patients with morbid obesity.
Reports describing the outcomes related to biliopancreatic diversion and duodenal switch exist, but presently the reports are not robust. Concerns regarding associated fat-soluble vitamin deficiencies and long-term protein malnutrition limit the ability to offer specific recommendations at present (91,92), especially in pediatrics.
Protein malnutrition is usually seen after malabsorptive procedures and occurs more often in patients who do not follow dietary recommendations. Vitamin B12 deficiency results from a decrease in intrinsic factors, decreased protein intake, and decreased uptake in an often defunctionalized ileum, and can lead to anemia, glossitis, and peripheral neuropathy if unrecognized (93). Fat-soluble vitamin deficiencies are commonly seen in these procedures, with up to a 60% prevalence (94). Calcium deficiency is of particular concern in adolescent patients, given the potential for additional bone mineralization (95). Kaulfers et al (96) found significant bone density loss in patients after bariatric surgery.
The multitude and complexity of nutritional deficiencies after these procedures underscore the need for consultation with an experienced dietician both before and after the surgery and largely limit the choice of this surgical technique in adolescents.
The duodenal switch with biliopancreatic diversion is primarily a malabsorptive operation that involves a subtotal gastrectomy (sleeve gastrectomy) with the preservation of the pylorus and the transaction of the duodenum to 3 to 4 cm from the pylorus with anastomosis to a Roux limb. This leads to a bypass of the distal 250 cm of ileum. Malabsorption is achieved by this bypass, which results in only approximately 100 cm of bowel exposed to both digestive enzymes and food (97). Although the procedure has been determined to be highly effective for weight loss, it is the least common (5% of bariatric procedures) and has fallen out of favor owing to increased nutritional deficiencies and greater operative complexity.
RYGB is still one of the most commonly used bariatric procedures for adolescents (99). For the restrictive portion of the procedure, the proximal stomach is divided, creating a small 15 to 20 cm3 gastric pouch. The mid-jejunum is transected approximately 40 cm from the ligament of the Treitz, and a Roux limb is brought up to the new gastric pouch. The biliopancreatic limb is attached to the distal jejunum, 100 to 125 cm from the gastric pouch (97). The benefits of an RYGB include a proven ability to induce long-term weight loss and to decrease comorbid disease (92,93). The procedure is, however, irreversible, causes significant change to the normal gut orientation, and carries a risk of malnutrition if proper attention is not paid to diet and the supplementation of essential nutrients (100).
The efficacy of an RYGB for weight loss is well documented in both adults and adolescents. In the meta-analysis of RYGB procedures among adolescents by Treadwell et al (Table 3 , (51)) BMI decreased anywhere from 17.8 to 22.3. A resolution of hypertension occurred in more than half of the patients, and sleep apnea was resolved in all of the patients (51).
Perioperative complications from an RYGB include pneumonia; deep venous thrombosis; pulmonary embolus; gastrointestinal hemorrhage, anastomotic obstruction leading to a rupture of the gastric pouch, obstruction of the jejunojejunal anastomosis, leakage from the staple lines or anastomoses, incisional hernias; and wound infections. Long-term complications include stomal stenosis, gastric staple line breakdown with gastrogastric fistula formation, symptomatic cholelithiasis, and internal herniation (99). In a meta-analysis (Table 3 , (51)) of 131 adolescents who underwent an RYGB, there were 4 reported postoperative deaths, with only 1 of those deaths potentially related to the procedure (Clostridium difficile colitis 9 months after surgery). The most commonly encountered complication was protein malnutrition. In 6 studies of adolescents undergoing RYGB, complication rates ranged from 0% (n = 34) to 39% (n = 36) (51,101–103). Despite the potential for significant complications from an RYGB, data have so far indicated that this procedure is effective with a good risk-to-benefit ratio in the adolescent population, making it the presently preferred surgical therapy for adolescents (103).
At present, to our knowledge there have been no trials directly comparing LAGB to RYGB in the adolescent population. With respect to the previously described LAGB, RYGB presents a combination of restrictive and malabsorptive surgical procedures. Although it is an irreversible procedure with a risk of malabsorption of essential nutrients, RYGB includes a proven ability to induce long-term weight loss and to decrease comorbid diseases reported in various studies (104–106).
The treatment for metabolic disease provides another important factor in considering this type of bariatric surgery in adolescents with obese. Lawson et al (104) found a 37% decrease in BMI of the surgical group compared with a 3% decrease in BMI of the behavioral therapy group at 1 year. In addition, RYGB was found to be associated with remission of type 2 diabetes mellitus while improving cardiovascular risk factors. Also, Lee et al (105) found that RYGB achieves superior weight loss in adolescents when compared with LAGB in a short-term 24-month follow-up. Randomized studies with longer-term follow-ups will be needed before definitive recommendations can be made on the appropriate operation for this age group (106).
Any adolescent undergoing bariatric intervention needs postinterventional long-term multidisciplinary follow-up. Morbidly obese patients often have nutritional deficiencies, particularly in fat-soluble vitamins, folic acid, and zinc (107). After bariatric surgery, these deficiencies may increase and new ones appear, especially because of the limitation of food intake in gastric reduction surgery and of malabsorption in bypass procedures. The risk of nutritional deficiencies depends on the percentage of weight loss and the type of surgical procedure performed. Purely restrictive procedures, for example, can induce digestive symptoms, food intolerance or maladaptative eating behaviors because of pre- or postsurgical eating disorders. Iron deficiency is common with almost all types of bariatric surgery, especially in menstruating women. Anemia can be secondary to iron deficiency, folic acid deficiency, and even vitamin B12 deficiency (108).
Malabsorption of fat-soluble vitamins and other nutrients, especially if diagnosed after bypass surgery, rarely cause clinical symptoms. Some complications have, however, been reported such as bone demineralization because of vitamin D deficiency (109) or hair loss secondary to zinc deficiency (107). Long-term problems such as changes in bone metabolism or neurological complications need to be carefully monitored. In addition, routine nutritional screening, recommendations for appropriate supplements, and monitoring compliance are imperative, whatever the bariatric procedure. Key elements of lifelong multidisciplinary management are virtually routine mineral and multivitamin supplementation, avoidance of alcohol intake, reduction in sugar/sucrose and reduction in soft drinks rich in fructose and prevention of gallstone formation with the use of ursodeoxycholic acid during the first 6 months. Pre- and postoperative therapeutic patient education programs, involving a new multidisciplinary approach based on patient-centered education, may be useful for increasing patients’ long-term compliance, which is often poor. The role of the general pediatrician also must be emphasized: clinical visits and follow-ups should be monitored and coordinated with the bariatric team, including the surgeon, the obesity specialist, the dietitian, and mental health professionals (110).
Patients with a greater BMI and more serious medical illness are at increased risk for complications after bariatric surgery. Earlier surgical intervention alters the natural course of many obesity-related comorbidities such as NASH that otherwise would put the patient at risk for long-term complications and early mortality. Providing access to bariatric surgery earlier in life when the disease burden and severity is lower may decrease the operative risk, morbidity, and mortality. Although present short-term data show improvement in quality of life after weight loss induced by bariatric surgery (111), the long-term results have not been well studied, particularly in adolescents (112). Present data suggest bariatric intervention induced weight reduction will also improve NASH. From a methodological point of view however, irrefutable scientific evidence that improvement in liver disease results in an actual reduction in risk of death and a real increase in the life expectancy of the patient with severe obesity presents significant technical and logistical problems. A prospective randomized controlled trial that compares the mortality rate in patients with severe obesity subjected to surgical therapy to comparable patients treated with the best available medical therapies would be the ideal tool to achieve a result of indisputable evidence. The study that comes closest to this theoretical model is the Swedish Obese Subjects Study (113), in which the mortality of a vast group of patients treated with various types of surgery was prospectively compared with the mortality of a group of patients of equal obesity and similar clinical characteristics who had chosen not to undergo the surgical procedure. Relative risk of mortality was significantly lower in the surgery group (0.76, 95% confidence interval from 0.59 to 0.99, P = 0.04), with a reduction of 24.6% of total mortality in 10 years being the effect of surgical treatment on body weight and comorbidities (113). In the specific case of adolescents one should take into consideration the long life expectancy after surgery (which could affect the type of action and the use of device, which may be suitably modified), the increase of possible reinterventions, as well as the methods and effects of alternative and integrative therapies.
Existing data are not sufficient to recommend widespread and general use of weight loss intervention in adolescents who have no other major comorbidities. The burden of obesity–associated comorbidity such as NASH in selected patients may impact intolerably on the child[Combining Acute Accent]s long-term prospects that allows us to agree with a list of exceptional indications suggested in Table 1. Future studies and a long-term risk analysis of patients with obesity associated liver disease are much needed to clarify the exact indications for bariatric surgery in adolescents, and the multitude and complexity of nutritional deficiencies after these procedures limit the choice of technique in children and adolescents. We propose the rigorous collection of experiences of any and all weight loss interventions in children until prospective and controlled trials are performed. The European Society for Pediatric Gastroenterology, Hepatology, and Nutrition provides a focus point, and on behalf of the society, the first author of this article will collect and share (anonymized) patient data from any such intervention (firstname.lastname@example.org) for future reference.
The authors are grateful for the critical review of the article by Professor Berthold Koletzko, ESPGHAN President, Munich, Germany, Dr Antje Ballauff, Krefeld, Germany, and the entire ESPGHAN Committee of Nutrition, namely Prof Mary Fewtrell, London, UK, chairperson of this group.
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