FEATURE OBESITY 021
INTRODUCTION Obesity is a serious health concern for children and adolescents worldwide and is increasing at an alarming rate. According to the World Health Organization, the number of overweight children globally under the age of five is estimated to be more than 42 million. While prevention of childhood obesity must remain a priority,
effective treatment options must equally be considered for highly selected adolescents. Bariatric surgical intervention has proven, in appropriately
selected adolescents, to be effective at both adequate weight loss and curbing obesity-related health ailments in the shor t and medium term. Long-term results are being conducted currently to assess durability of bariatric surgical interventions. While adolescents have unique health needs that should be considered when making bariatric evaluation, there are a few options for bariatric surgery that can provide effective relief for obesity-related issues.
CONSEQUENCES OF CHILDHOOD OBESITY Childhood obesity can lead to serious ailments that affect a person for the rest of their life, including type 2 diabetes mellitus, hyper tension, dyslipidemia, sleep apnoea and non-alcoholic liver disease. Additional risks of obesity among adolescents include musculoskeletal problems, asthma, gastroesophageal reflux disease (GERD), pseudotumor cerebri, gallstones, and menstrual abnormalities. Obese patients also experience reduced quality of
agree more stringent criteria should be applied to adolescents. Additional suggested criteria prior to adolescent bariatric surgery include: The failure of > 6 months of organized attempts at weight management, as determined by the primary care provider Attainment of physical maturity as reflected by Tanner stage IV puber tal development or a bone age of > 13 years in girls or > 15 years in boys. Additionally, the adolescents should be able to par ticipate in
the decision making process and also demonstrate commitment to comprehensive medical and psychological evaluations both before and after surgery. A suppor tive family environment is extremely crucial and necessitates a complete evaluation of the home environment by trained personnel. Currently, bariatric surgery should not be performed for preadolescent children, for any patient who has not mastered the principles of healthy dietary and activity habits, and for those with an unresolved eating disorder, untreated psychiatric disorder, or Prader-Willi syndrome although this may change as more evidence is collected. Pregnant, breast-feeding adolescents and those planning to become pregnant within two years of surgery should cer tainly not be considered candidates for bariatric surgery. The family should be evaluated to determine if adequate social and emotional, suppor t would be available for the adolescent before and after surgery. Each adolescent and family should be extensively
"risks of obesity among adolescents include musculoskeletal problems, asthma, gastroesophageal reflux disease (GERD), pseudotumor cerebri, gallstones, and menstrual abnormalities"
life and social marginalization. Some adolescents are completely debilitated by their medical disease related to their obesity. The mainstay of treatment for obesity in adolescents has
been non-surgical interventions aimed at creating a negative energy balance by dietary modifications, increasing physical activity and decreasing sedentary behavior. Weight loss in obese individuals has been shown to lead to reversal or improvement of obesity-related comorbidities and improvement in quality of life. Behavioral modifications have shown to be modestly effective in achieving weight loss but results are influenced by high drop out rates. The overall effects have been rather modest with small changes in weight and BMI compared with controls. Studies using pharmacotherapeutic agents such as orlistat and sibutramine have demonstrated very modest effects on weight loss in adolescents. While many of these interventions are appropriate, there are a few patients that may benefit from more definitive and effective therapy.
MEDICAL CRITERIA FOR BARIATRIC SURGERY Bariatric surgery is a safe and effective means of treatment for severe obesity in adults. Currently, adults with BMI > 35 with medical comorbidities and for those with BMI >40 even without comorbidities are considered candidates for bariatric surgery. However, there is limited information on the long-term efficacy and safety of bariatric surgery in children and adolescents. There is currently no uniformly accepted consensus on the BMI criteria that would make adolescents candidates for bariatric surgery, and many
evaluated by a multidisciplinary team with experience in pediatric weight management. The team should consist, at a minimum, of an experienced bariatric surgeon, paediatrician with exper tise in obesity, behavioral clinician (i.e., paediatric psychiatrist or psychiatrist), and a registered dietitian.
RELIABLE OPTIONS FOR BARIATRIC PROCEDURES Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic adjustable gastric banding (LAGB) are the two most common adolescent bariatric procedures offered. Recently a third procedure, laparoscopic sleeve gastrectomy (LSG), has been increasingly offered as a safe option.
Roux-en-Y gastric bypass Roux-en-Y gastric bypass involves stapling and excluding almost all of the stomach (see figure 1). This creates a small (approx. 30 ml) gastric pouch that is directly attached to the jejunum (small bowel), bypassing almost all of the stomach, and mush of the small bowel. LRYGB is both a restrictive procedure, since the new proximal stomach pouch is small, and also a minimal mal-absorptive procedure by bypassing some of the small intestines. There are numerous studies with shor t and medium term follow-up in adolescents that have demonstrated that LRYGB offers significant reduction in weight and comorbidities fairly quickly. Although, we do not have decades of long-term follow
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