Editorial board comment
It is now well established that bariatric surgery is the most effective treatment option for severe obesity in adults, with proven benefits in those with type 2 diabetes, evidence of reduced cardiovascular events and improvements in quality of life. However, treatment of adolescents is much more controversial due to limited data and concerns over whether benefits are maintained in the long-term and outweigh the risks of surgery in this vulnerable group.
Two papers published in The Lancet Diabetes & Endocrinology now provide some reassurance about long-term efficacy, but do raise questions about the safety and optimal timing of surgery for young people with severe obesity.
In the first paper, from the United States, Inge et al report on outcomes from 58 out of 74 patients who were originally studied when they had a Roux-en-Y gastric bypass for severe obesity aged 13–21, and show that, 6–12 years later, they have maintained most of the weight loss (although most remain significantly obese), and show improvements in blood pressure, glucose and lipids, but despite recommendations for monitoring and long term supplementation, many had developed vitamin and mineral deficiencies (mainly B12, vitamin D and Iron), some requiring transfusions or other parenteral therapy and that over 40% required some sort of upper gastrointestinal procedure including endoscopy and cholecystectomy.
In the second paper from Sweden, Olbers and colleagues report on the 5-year follow up from a study of 81 adolescents undergoing bariatric surgery, 80 controls offered standard non-surgical care and a similar number of adults also undergoing bariatric surgery. Compared to the adults the adolescents had high rates of pre-operative psychological co-morbidity prior to surgery. Similar to the US study they lost substantial amounts of weight, but remained obese. Cardiovascular risk factors and some aspects of quality of life were improved in the surgical group compared with unoperated controls, but again vitamin and mineral deficiencies were common and a quarter required further abdominal surgery. It is important to note that a quarter of the controls went on to have bariatric surgery during the follow up period.
These studies provide some reassurance over safety and do suggest net benefit in the medium term, but given the vulnerability of this group and the fact that some may have had undiagnosed inherited disorders that might have contributed to obesity and predict a poor response to surgery suggest that very careful evaluation by an expert team is essential for each individual before undertaking surgery. Where doubt exists it might be wiser to support the patient in other ways and defer the decision about surgery until adulthood; however, to provide evidence about this would require new research. Lifelong follow-up, although challenging in young people, is essential, as these individuals still have a significant amount of co-morbidity, some of which may be related to the surgical procedure.