PUSHING THE
AGE ENVELOPE:
         
How Young is Too Young for Bariatric Surgery?


Published in May 2014 Issue             


A new study (in press) in Surgery for Obesity and Related Diseases (SOARD) is raising questions about when bariatric surgery should be considered in children. Researchers from King Saud University in Riyadh, Saudi Arabia report on changes in obesity related diseases and select clinical safety outcomes after sleeve gastrectomy in pre-adolescent children (ages 5 to 12), 155 adolescents (ages 13-17) and 37 young adults (ages 18 to 21). The questions are not as much about the 13 to 21-year-olds, but rather about whether children as young as five should have surgery.

According to an accompanying editorial (in press) by Thomas Inge, MD, PhD, surgical director of the Surgical Weight Loss Program for Teens at Cincinnati Children's Hospital Medical Center, “pre-adolescent children have only rarely been represented in the bariatric surgical literature and since this experience is the largest available, it is pushing the ‘age envelope.’”


Thomas Inge, MD, PhD

“We know surgery is effective, but there are real questions about the appropriateness of performing it in the pre-adolescent population,” said Dr. Inge. “Surgery is the treatment of last resort, but why is the last resort needed in this very young group of children who are not in position to make unhealthy food and lifestyle decisions independent of their parents or caregivers? There must be justification for this and this is what’s missing from the studies that report on surgery in pre-adolescents.”

 In his editorial Dr. Inge writes, “It is implausible that caregivers are helpless to change the factors that are driving the dramatic weight gain in most pre-adolescents.”

Amongst the study group of 226 patients, it was reported that within the first three months after sleeve gastrectomy, nearly 60 percent of all comorbid conditions showed improvement or remission. That number grew to 90 percent within two years. The operations were performed between 2008 and 2013 in Saudi Arabia. Less than 4 percent developed minor complications and no major complications were reported, except for one patient who experienced a drop in hemoglobin postoperatively, which was managed conservatively.

The mean age of the patients was 14.4, the mean preoperative body mass index (BMI) was 48.2 and patients had on average two co-morbidities, with diabetes, hypertension, prehypertension, dyslipidemia, obstructive sleep apnea and non-alcoholic fatty liver disease (NAFLD), being among the most common.

Some say extreme measures are needed for a growing population of children suffering from type 2 diabetes, high blood pressure and sleep apnea, diseases and conditions once the sole domain of adults. An obesity epidemic among children is most often cited as the source for these all too common problems. In 2012, more than one third of children and adolescents were overweight or obese, according to the latest estimates from Centers for Disease Control and Prevention (CDC).

The American Heart Association (AHA) published a statement in the journal Circulation, estimating about 5 percent of children in the U.S. have severe obesity, which includes children over age 2 who have BMI that is at least 20 percent higher than the 95th percentile for their age and gender. The AHA puts children with severe obesity at higher risk of developing diabetes, heart disease and stroke. To treat these diseases and conditions, more young children are taking medications for longer periods of time, which may lead to health and quality of life consequences in adulthood. A lesser number are turning to bariatric surgery, mostly after other interventions have failed, to produce results.


Kirk Reichard, MD

Kirk Reichard, MD, ASMBS Pediatric Surgery Committee Chair in a Q&A with connect last October said, “In adolescents, bariatric surgery is a safe and effective treatment for morbid obesity and co-morbid conditions, for whom other treatment options have failed.” However, Dr. Reichard and Best Practice Guidelines published in SOARD in January 2012, drew a clear line in saying that bariatric surgery should not be performed on children before adolescence.

“Pre-adolescents with obesity have a substantially greater chance of getting to a healthy weight without surgery than adolescents,” said Dr. Inge. “Parents, caregivers and health care providers need to get out in front of this issue of early obesity to save their children from a life of disease and perhaps even a lower lifespan than their parents.”


Dustin Holston Before Bariatric Surgery

However, for adolescents and young adults who have developed severe obesity, bariatric surgery can be a lifesaver. Dustin Holston, 24, was 18-years-old when he had a sleeve gastrectomy. He was 366 pounds at his heaviest before surgery, suffering cardiac and respiratory issues, obstructive sleep apnea, pre-diabetes, joint problems and depression. He tried to lose weight with diet and exercise but it wasn’t enough and whatever he lost, he soon regained. At the age of 16, bariatric surgery appeared his only option to help him
regain his health.

“I knew people who had bariatric surgery were mostly older adults, but I was against a wall. I couldn’t exercise and I was sick all the time,” Dustin says.

Dustin and his mom spent two years trying to get their insurer to cover bariatric surgery. He was denied more than a half dozen times. When he turned 18, he filed for disability and applied for bariatric surgery under Medicaid. He was approved.

Dr. Inge performed the surgery on the teenager who within six months lost 75 pounds, resolved his sleep apnea and no longer had pre-diabetes. Within a year he dropped more than seven pants sizes and more than 100 pounds. More importantly, he used the surgery as a tool to a healthier, more active life.

Today, Dustin is a support group coordinator at Cincinnati Children’s Hospital where he leads twice a month meetings for new patients and adolescents who have undergone surgery. His struggle with weight and experience as a bariatric surgery patient has even influenced his career path. Dustin will graduate from the University of Cincinnati next year with a bachelor’s degree in social work and hopes to work in a hospital helping patients navigate the health care system.