Surgical aspects of pediatric obesity.

The prevalence of pediatric obesity in the United States has increased dramatically in recent years. It will likely continue to be a major drain on healthcare resources as well as a significant source of morbidity and mortality. In some areas of the United States with a substantial minority population, up to a quarter of the pediatric population may be considered obese. While several societal, cultural and familial influences contributing to this obesity epidemic have been identified, no easy solution to address these issues has emerged. Medical management has proved frustrating for both physicians and patients with only limited success and a high rate of recidivism. Moreover, increased media attention has raised public awareness of the dramatic weight loss potential of bariatric surgery.

Surgical approaches to pediatric and adolescent obesity have been elegantly reviewed by Pohl et al. (1) While it is tempting for both physicians and patients to seek the rapid weight loss induced by bariatric surgery with its promise of associated health benefits, it is important to recognize that widespread adoption of bariatric surgery for pediatric and adolescent obesity without further studies and discussion may be premature. The long-term adverse sequelae may prove significant. It is worrisome that the increased rate of bariatric surgery in the pediatric and adolescent population preceded the publication of expert recommendations for such surgery. (2) Have all salient points been considered and adequately discussed before embarking on bariatric surgery in this age group? There is some evidence that this is perhaps not the case, with the increasing rate of bariatric surgery in youth reflecting the willingness on the part of the surgeon and the patient to readily proceed with this type of surgery. (2)

As indicated by Pohl et al, (1) bariatric surgery may be appropriate for selected cases of pediatric and adolescent obesity. However, the guidelines for surgical referral (1) must be regarded as preliminary on account of the lack of long-term studies in this population. In addition, there needs to be greater dialogue between surgeons and other health professionals providing a variety of multidisciplinary medical services to these patients to determine the optimum candidates for bariatric procedures. Further discussion is needed on the age appropriateness and the role of informed consent in this population before a broader national consensus can be reached.

We can, however, learn some lessons from the issues which have emerged from bariatric surgery in adults. Flum and colleagues (3) indicate that among Medicare beneficiaries the risk of early death is much greater than initially surmised. Surgeons with a lower volume of bariatric procedures may also have a greater rate of adverse outcomes. Studies also suggest that the mortality rate may decline substantially after approximately 100 bariatric procedures. (4)

While bariatric surgery has a long track record in adults, its role in the pediatric population is relatively new. Preliminary information indicates that many benefits seen with weight loss in adults may also be observed in the younger population. However, the risks of long-term complications are not known and these risks should not be minimized. More information is clearly needed in the pediatric population to judge the appropriate time for surgical intervention and if delays in implementing bariatric procedures will have a profound impact on outcome.

Adjustable gastric banding if approved may provide a promising technology given the potential for substantial benefit with the possibility of reduced complications. However, until additional data emerges with long-term follow up, bariatric surgery should be considered only in highly selected individuals in the pediatric and adolescent age group with immediate and life threatening health risks linked to obesity after failure of intensive medical management. Ideally, bariatric procedures in this age group should be scheduled only after deliberation within a bariatric multidisciplinary review board. Recognizing that surgery is just one facet in the ongoing management for this serious problem, bariatric procedures should be done in centers with access to special resources which are needed for both immediate and long-term care and follow-up. Pending advances in our knowledge of pediatric obesity, prevention is the key to addressing this epidemic. Active public education at an early age emphasizing physical activity and informed nutrient intake to establish a lifestyle conducive to optimal health needs emphasis at both home and school.

References

1. Pohl JF, Stephen M, Wilson DP. Pediatric Obesity: The Newest National Epidemic. South Med J 2006;99:833-844.

2. Davis MM. Slish K, Chao C, et al. National trends in bariatric surgery, 1996-2002. Arch Surg 2006;141:71-74.

3. Flum DR, Salem L, Elrod JA, et al. Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures. JAMA 2005;294:1903-1908.

4. Flum DR, Dellinger EP. Impact of gastric bypass operation on survival: a population-based analysis. J Am Coll Surg 2004;199:543-551.

Alan N. Peiris, MD, PhD, MRCP (UK)

From East Tennessee State University, Chief of Endocrinology. Mountain Home VAMC, Johnson City, TN.

Reprint requests to Alan N. Peiris, MD, PhD, MRCP (UK), Professor of Medicine, East Tennessee State University, Chief of Endocrinology, Mountain Home VAMC, Johnson City, TN 37614. Email: [e-mail]

Accepted June 2, 2006.