Should severely obese teens postpone weight-loss surgery to adulthood?
Teens with severe obesity need not wait until they are adults to undergo Roux-en-Y gastric bypass, with 5-year follow-up data from a recent study showing that the bariatric procedure leads to substantial weight loss that is similar in magnitude in adolescents and adults.
However, there are important differences in specific health outcomes between the patient groups, the authors said. Particularly, adolescents are more likely to achieve remission of both type 2 diabetes (T2D) and hypertension, as well as to undergo abdominal reoperations and develop short-term nutritional deficiencies.
The analysis included 161 adolescents (mean age, 17 years; mean body mass index [BMI], 50 kg/m2) from the Teen-LABS* study and 396 adults (mean age, 37.9 years; mean BMI, 50 kg/m2) from the LABS study who reported having had obesity since they were about 18 years of age. The two studies were independent but related.
Five years after gastric bypass surgery, the percentage of weight lost was not significantly different between adolescents (−26 percent, 95 percent CI, −29 to −23) and adults (−29 percent, −31 to −27; p=0.08). [N Engl J Med 2019;380:2136-2145]
As pointed out earlier, significantly more adolescents than adults attained remission of T2D (86 percent vs 53 percent; risk ratio, 1.27, 1.03–1.57) and hypertension (68 percent vs 41 percent; risk ratio, 1.51, 1.21–1.88). However, the teen cohort had a markedly higher abdominal reoperation rate (19 vs 10 reoperations per 500 person-years; p=0.003) as well as lower ferritin levels (72 of 132 patients [48 percent] vs 54 of 179 patients [29 percent]; p=0.004).
Death rate over 5 years after surgery was similar: three in the adolescent cohort and seven in the adult cohort (1.9 percent vs 1.8 percent). Two of the cases in the adolescent cohort were related to polysubstance use, a finding the authors described as worrying.
“[D]espite the small number of [individuals] thus far affected by overdose after gastric bypass surgery, these findings may indicate a need for more focused research efforts, patient education and anticipatory guidance,” in light of the overall increasing trend of drug overdose deaths in the US and the heightened risk of substance- and alcohol-use disorders reported in adults after gastric bypass surgery, they said. [NCHS Data Brief 2017;294:1-8; Surg Obes Relat Dis 2017;13:1337-1346,1392-1402]
In a linked editorial piece, Dr Ted Adams from the University of Utah pointed out that “the decision whether to recommend bariatric surgery treatment for adolescents with severe obesity or to postpone the surgery to adulthood,” like most clinical care decisions, is made only after careful consideration of associated harms and benefits. [N Engl J Med 2019;380:2175-2177]
“Adolescent patients may not have fully developed the capacity for decision making, especially about a procedure that will have lifetime consequences. The current data are incomplete, though long-term data on bariatric surgery in adolescents are beginning to emerge. However, more complete data will be required to fully inform clinicians, parents and adolescents whether to embark on surgical intervention or to postpone it,” Adams wrote.
“For now, while we hope to identify new, effective and less-invasive therapies and effective adjuncts to bariatric surgery in adolescents (ie, pharmacotherapy and multispecialty lifestyle integration), decisions should be made on a case-by-case basis, with the knowledge that the 5-year data look promising but that the lifetime outcome is unknown,” he added.
*The Teen–Longitudinal Assessment of Bariatric Surgery