Mary Chris Jaklevic, MSJ. The Push for Earlier Bariatric Surgery for Adolescents With Severe Obesity. Medical News & Perspectives, May 20, 2021 JAMA. 2021;325(22):2241-2242.
In one of the most memorable lectures ever given at a Society for Pediatric Anesthesia meeting, Dr. Paul Samuels of Cincinnati Children’s Hospital discussed the epidemic (now pandemic) of childhood and adult obesity and his hospital’s experience with the perioperative management of patients presenting for bariatric surgery. For many of you who were not there, you have still benefited from his lecture because it resulted in how SPA provides food at its meetings, going from ultra-high processed foods (think sweet rolls and doughnuts) to protein (think eggs and cottage cheese) to low fat milk in addition to cream for coffee. At that time, Paul stated and I’m paraphrasing “obesity is to the current generation of Americans, what smoking was to mine”.
First, and let me get this out of the way, obesity is a medical problem and the surgical solution, namely bariatric surgery using the classic Roux-en-Y gastric bypass or the more common sleeve gastrectomy has troubled many physicians, particularly pediatricians. Although I agree that obesity is a medical problem so is atherosclerotic heart disease and CABG is well accepted as a surgical solution to that medical problem. This JAMA news report may be a bit off our PAAD beaten path but is nevertheless quite important.
Regardless of the starting weight, once bariatric surgery is performed, expected weight loss is about 25-30 percent of the starting weight or 15 BMI points. So, if the patient starts at 200 kg (440 lbs), one can expect a weight loss of around 50 kg (110 lbs). However, the patient will still be 150 kg (330 lbs) and obese. If the surgical intervention occurred earlier, say in early adolescence, the percent body weight loss would be the same but the patient’s weight would return to normal or almost normal weight. Thus, waiting for pediatric patients (or really any patient) to become a super heavy weight means the effectiveness of the treatment will be limited.
Thus, should we do and recommend this surgery at an earlier age and thereby getting our pediatric patients to a healthy weight and perhaps limit the obesity related conditions of hypertension, fatty liver, sleep disordered breathing, bone and joint dysfunction, and type 2 diabetes? This newsletter and a recent AAP policy statement emphatically say YES! In this AAP policy statement, Armstrong et al1 (PMID: 31656225) review the indications for this surgery and discuss the barriers for more widespread acceptance. “National survey data suggest that providers are reluctant to refer pediatric patients with obesity for bariatric surgery. Concerns include a lack of knowledge about the biology of obesity, surgical procedures, risks, and follow-up; a lack of awareness of surgery as an option; concern for altered growth or development; and provider weight bias manifested as a belief that weight is a personal responsibility rather than a medical problem. Existing evidence suggests that bariatric surgery does not lead to growth impairment, and among older adolescents, several studies have demonstrated that linear growth continues after surgery. Recent data from a single site outside the United States routinely performing RYGB and VSG for patients with a mean age of 11.5 years have shown no adverse impact on linear growth when compared with age-matched peers receiving medical management for obesity, though more evidence is needed to confirm this finding”.1
Finally, perhaps some good news is here and not just on the horizon. The US FDA has just approved a medical solution to obesity, namely semaglutide as an appetite suppressant which produces substantial, sustained weight loss almost equivalent to bariatric surgery! 2 (PMID: 30122305) Stay tuned!
Myron Yaster MD
References
1. Armstrong SC, Bolling CF, Michalsky MP, Reichard KW: Pediatric Metabolic and Bariatric Surgery: Evidence, Barriers, and Best Practices. Pediatrics 2019; 144
2. O'Neil PM, Birkenfeld AL, McGowan B, Mosenzon O, Pedersen SD, Wharton S, Carson CG, Jepsen CH, Kabisch M, Wilding JPH: Efficacy and safety of semaglutide compared with liraglutide and placebo for weight loss in patients with obesity: a randomised, double-blind, placebo and active controlled, dose-ranging, phase 2 trial. Lancet 2018; 392: 637-649
Interesting 🧐 good point!