Abstract and Introduction
Abstract
Severe obesity in adolescence negatively impacts upon health and wellbeing. Lifestyle modifications do not usually achieve a sufficient degree or durability of weight loss to mitigate the risk of medical complications. In recent years, metabolic and bariatric surgery (MBS), already a well-established treatment for adults with severe obesity, has emerged as an option in adolescents. Controlled studies in this age group have demonstrated substantial and sustained weight loss, improvements in associated health parameters, and a safety profile surpassing that observed in adult patients. This review aims to present published data on the results of MBS in adolescents with a focus on long-term outcomes. Indications for bariatric surgery and aspects of timing in the young person's life are also presented, along with safety considerations and factors influencing patient selection for surgery. We conclude, predominantly from short- to medium-term outcomes data, that MBS is a safe and valuable therapeutic option for adolescents with severe obesity. Considering the poor health and social wellbeing prognosis in this group, MBS appears to be underutilized. The need for continued research, multiprofessional specialist provision, coherent contemporary clinical guidelines, and routine long-term follow-up in adolescents undergoing MBS is highlighted.
Introduction
The prevalence of obesity in adolescents continues to increase globally.[1] Adolescents with severe obesity have a greater risk of cardiometabolic disease, impaired quality of life, and shorter life expectancy than peers with normal weight.[2,3] As severe obesity has become more prevalent, extreme disease profiles have emerged. Type 2 diabetes mellitus is increasingly being identified in adolescents and worryingly appears to take a substantially more aggressive form in the young,[4] with an earlier need for escalation of pharmacological treatments than in adults,[5] and frequent end-stage complications in early adulthood.[6] Hypertension, dyslipidemia, and obstructive sleep apnea are all commonplace in adolescents with severe obesity.[7,8]
Bariatric surgery, frequently referred to as metabolic and bariatric surgery (MBS), is now an accepted standard treatment for severe obesity and obesity-associated diseases in adults. Randomized trials[9,10] and large observational cohort studies, including the controlled Swedish Obese Subjects study,[11,12] have unanimously demonstrated long-term weight loss, improvement in cardiometabolic risk factors, and reduced incidence of cardiovascular disease, cancer, and mortality after MBS in adults.
Initial interventions in children and adolescents with obesity focus on lifestyle modifications.[13,14] However, the effectiveness of such programs is modest, less pronounced than in adults,[15] and generally insufficient either as a treatment for obesity or to prevent obesity-related comorbidities, especially in adolescents with severe obesity.[16–19] Novel and promising pharmacological treatments are emerging. Their associated weight loss has, thus far, been less than after MBS and achieved by a smaller proportion of patients than MBS. Furthermore, weight gain occurs after treatment discontinuation.[20–22] Current usage has also been limited by a reluctance to use medications off license.[15]
The weight loss effect and safety profile of MBS in adolescents have been similar to adults in observational studies.[7,8,23–26] The single existing randomized trial involving MBS in adolescents completed recruitment in 2008 and compared weight outcomes over 2 years after laparoscopic gastric banding or intensive nonsurgical treatment.[25] Since that trial completed, the field of adolescent MBS has progressed, and alternative procedures are typically favored today. Although an important milestone in the field, the trial's generalizability to adolescents in secondary and tertiary care has been questioned as participants were recruited through advertising.[27,28] A Swedish study comparing adolescents randomized to gastric bypass or intensive nonsurgical treatment, Adolescent Morbid Obesity Study 2 (AMOS2), is ongoing.[29]
A number of concerns exist surrounding the use of MBS in the adolescent population. Recognizing the increased risk of nutritional deficiencies[30] and bone health impairment,[31] along with heightened psychosocial vulnerability[28,31,32] and more risk-taking behaviours,[33,34] it is crucial to consider the mental and social aspects of health and wellbeing, in addition to the physical aspects that are more frequently reported.[35] The potential requirement for additional surgical intervention should also be recognized.[8,23,26]
For this mini-review, we identified published original data in adolescent MBS outcomes from PubMed. We focus on data beyond 2 years postoperative follow-up.
J Clin Endocrinol Metab. 2023;108(9):2184-2192. © 2023 Endocrine Society
