Adolescent bariatric surgery

2013/2014 Ana Rita Mateus Magalhães Adolescent bariatric surgery Março, 2014 Mestrado Integrado em Medicina Área: Cirurgia Geral Trabalho efetuado sob a Orientação de: Mestre Hugo Santos Sousa E sob a Coorientação de: Mestre John Rodrigues Preto Trabalho organizado de acordo com as normas da revista: Acta Médica Portuguesa Ana Rita Mateus Magalhães Adolescent bariatric surgery Março, 2014 Dedicatória Aos meus pais pelo apoio incondicional sem o qual este trabalho não seria possível. 1" " Adolescent bariatric surgery Cirurgia bariátrica em adolescentes Ana Magalhães Student of 6th grade of Faculty of Medicine of Porto, Porto, Portugal, corresponding author Hugo Sousa Assistant Professor of Surgery, Department of Surgery, Faculty of Medicine of Porto, Porto, Portugal John Preto Assistant Professor of Surgery, Department of Surgery, Faculty of Medicine of Porto, Porto, Portugal Ana Rita Mateus Magalhães Department of Surgery, Faculty of Medicine of Porto Alameda Prof. Hernâni Monteiro 4200-319 Porto-Portugal E-mail: [email protected] 2" " Adolescent bariatric surgery Abstract Introduction: Pediatric obesity has become a public health problem of most concern in the 21st century. Common diseases in adulthood such as type 2 diabetes mellitus, hypertension and dyslipidemia began to be increasingly prevalent in young ages. The early presentation of these comorbidities has significant impact on their future since they will require earlier medical care and will have a decreased life expectancy. Bariatric surgery has been gradually accepted as a hypothesis of treatment for obese adolescents with comorbidities and whose conservative treatment had no effect. This review will address the current indications for bariatric surgery in adolescents, surgical procedures used for weight loss, outcomes and the importance of multidisciplinary management. Materials and methods: We searched Pubmed, MEDLINE, HighWire and Scielo for free full text available systematic reviews, clinical trials and journal articles published after 2008. More than 139 papers were identified and 54 of the most relevant ones were reviewed in detail. Results: Short-term results for bariatric procedures in adolescents are similar to those observed in adults, although there is still a lack of long-term data to conclude about the outcomes of bariatric surgery in these individuals. Discussion and Conclusion: Bariatric surgery in adolescents has specific risks and benefits that must be balanced before proceeding to this approach. Adolescence is an unique period requiring special psychological and emotional care that makes patient selection process and perioperative management different from that used in adults. The available data point to a clear improvement of comorbidities and quality of life. Keywords: Obesity, Bariatric surgery, Adolescents, Quality of life, Outcomes 3" " Cirurgia bariátrica em adolescentes Resumo Introdução: A obesidade pediátrica tornou-se num dos problemas de saúde pública mais preocupantes no século XXI. Doenças típicas dos adultos como Diabetes Mellitus tipo 2, hipertensão arterial e dislipidemia começaram a ser mais prevalentes em idades jovens. A apresentação dessas co-morbilidades nos jovens tem um impacto significativo sobre o seu futuro uma vez que exigirá cuidados médicos precoces e trará uma menor esperança média de vida. A cirurgia bariátrica tem sido gradualmente aceite como hipótese de tratamento para adolescentes obesos com co-morbilidades e cujo tratamento conservador não surtiu efeito. Esta revisão bibliográfica abordará as indicações atuais para cirurgia bariátrica em adolescentes, procedimentos cirúrgicos utilizados, resultados e a importância da abordagem multidisciplinar. Materiais e métodos: A pesquisa foi realizada na Pubmed, MEDLINE, HighWire e Scielo, por revisões sistemáticas, ensaios clínicos, e artigos completos gratuitos publicados após 2008. Mais de 139 trabalhos foram identificados e 54 dos mais relevantes foram analisados em detalhe. Resultados: Os resultados a curto prazo dos procedimentos bariátricos em adolescentes são semelhantes aos dos adultos, todavia há ainda uma falta de dados que permitam concluir sobre os seus efeitos a longo prazo. Discussão e conclusão: A cirurgia bariátrica em adolescentes tem riscos e benefícios específicos que devem ser ponderados antes de prosseguir com esta abordagem. A adolescência é um período que requer um cuidado especial a nível psicoemocional, tornando o processo de seleção de pacientes e a abordagem perioperatória distintos dos utilizados em adultos. Os dados disponíveis apontam para uma clara melhoria das co-morbilidades e qualidade de vida. Palavras-chave: Obesidade, Cirurgia bariátrica, Adolescentes, Qualidade de vida, Resultados 4" " Introduction Obesity is currently classified by the World Health Organization (WHO) as one of the most serious public health challenges of the 21st century. It is defined as an excessive body fat accumulation that may impair health. According to the World Health Statistics report of 2012, obesity is the cause of death of 2.8 million people per year. Currently 12% of the world´s population is considered obese and the United States of America has the highest prevalence of this problem with 34.9% of obese adults1. Among children and adolescents the prevalence of obesity is dramatically increasing, especially in developed countries. Pediatric obesity has more than doubled in children and tripled in adolescents over the last 30 years2,3. By 2020 nearly 60 million children will be overweight or obese4. In the U.S., according to data from the National Health and Nutrition Examination Survey (NHANES) 2010, 19% of girls and 20% of boys aged 5 to 17 years were overweight and 14.2% of girls and 15.1% of boys were obese. In Portugal, a 2008 study5 concluded that the values for girls and boys with ages between 10 and 18 years were 17% and 17.7% for overweight and 4.6% and 5.8% for obesity, respectively. Cyprus, Greece, Spain, and England have some of the highest adolescent obesity rates among European countries6. Immediate health impairments are noticed in obese youth. They are more likely to have risk factors for cardiovascular disease, such as dyslipidemia or high blood pressure7. In a population-based sample of 5 to 17 year-old, 70% of obese youth had at least one risk factor for cardiovascular disease7. These teens also have an increased risk for the development of type 2 diabetes (T2DM)8, bone and joint problems and sleep apnea. Social and psychological problems such as stigmatization and poor self-esteem can also affect their daily life9,10. Obese children and adolescents are likely to become obese adults11 and are consequently more at risk to develop adult health problems such as cardiovascular disease, non-alcoholic fatty liver disease, several types of cancer (breast, colon, endometrium, esophagus, kidney, pancreas, gall bladder, thyroid, ovary, cervix, and prostate, as well as multiple myeloma and Hodgkin’s lymphoma12), and osteoarthritis. Today it is known that obesity is a chronic disease that results from the action of exogenous factors on genetically predisposed individuals. In 95% of the cases, obesity´s etiology is related to environmental factors dictated by a sedentary lifestyle and nutritional imbalances. The remaining 5% have genetic, tumor or endocrine etiology13. Because it is a multifactorial disease and so difficult to treat, the fight against obesity should begin with preventive intervention14. Educational institutions and family should promote raising awareness of healthy lifestyles in an attempt to encourage young people to a more active lifestyle through sport and balanced diet15. When prevention fails, the conservative treatments should always be considered firstline treatment. Information available suggests that changes in lifestyle and eating habits are 11" " was documented in 38% of adults after bariatric surgery and is a point of particular importance in women of child-bearing age due to the risk of fetal neural tube defects24. Kaulfers et al40 conducted a study in which they reported a significant bone density loss after WLS. This underlines the problem of calcium and vitamin D deficiency in adolescents, since they are vital for optimal bone mineralization in the developing skeleton27. Currently the recommended supplementation includes a high potency chewable multivitamin, calcium citrate with vitamin D, vitamin B12, iron in menstruating females and vitamin B1 if low intake or post-operative nausea and vomiting16. However, adherence to these plans is not always accomplished, especially in this particular group of patients. In fact, one study found that only 13% of teenagers joined the prescribed supplementation50. Compliance strategies, careful monitoring of vitamin and mineral intake and periodic laboratory surveillance to detect deficiencies are crucial during these patients follow-up23. Pregnancy risks There is a lack of studies about the outcomes of teenage pregnancy after WLS, however, recent surveys reported a twofold increase in pregnancy in this population61. This suggests that there may be a higher risk of pregnancy in adolescents undergoing bariatric surgery61. Therefore, it is recommended that before performing WLS all young adolescents are informed about the increased fertility following weight loss and about the risks associated with pregnancy during the first 18 months after the procedure (quick weight loss and potential micronutrient shortcomings may have adverse effects on the mother and the fetus)23. This highlights the importance of addressing contraception and pregnancy prevention in all female adolescents undergoing bariatric surgery61. On the other hand, data show that patients who become pregnant a few years after bariatric surgery have reduced risk of eclampsia and gestational diabetes when compared with this risk before WLS62. These adolescent females will need further vitamin and mineral supplementation in the prenatal period63. Psychossocial risks Psychosocial outcomes in adolescents after bariatric surgery have not been adequately studied23. These patients are in a vulnerable psychological state and are at a high risk of having mental health complications postoperatively27. However, some data refers short-term improvements in depression, eating disturbances and quality of life after the procedure64. 12" " Conclusion The epidemic rise in pediatric obesity and the immediate and long-term consequences associated with it has led to an increasing recognition and acceptance of bariatric surgery as a safe and effective tool for weight loss in selected extremely obese adolescents. Although there are currently no clear guidelines to choose a specific bariatric procedure for a specific adolescent patient, the RYGB remains the gold standard procedure. Strict criteria for surgery and the adolescent’s understanding of the process are key points for successful surgical shortterm results and long-term improvement in comorbidities. While conducting studies to determine the effects of bariatric surgery in adolescents are needed in the long-term, the available data point to a clear improvement of comorbidities associated with extreme obesity and improved quality of life of young people65. Conflicts of interest The authors declare no conflicts of interest regarding to this Article. Sources of funding The work was carried out without the support of any scholarship or other financial support " " " 13" " References 1. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of Obesity Among Adults: United States, 2011– 2012. NCHS Data Brief, No.131. Hyattsville, MD: National Center for Health Statistics. 2013. 2. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010. Journal of the American Medical Association 2012; 307(5):483-490. 3. National Center for Health Statistics. 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General Hospital Psychiatry 35 (2013) 259–264 17" " Figure 1 – Percentile table of BMI for age (2 to 20 years) and sex (male) Figure 2 - Percentile table of BMI for age (2 to 20 years) and sex (female) Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000) 18" " Table 1 – Selection criteria for WLS in adolescents (adapted from Obesity 2009; 17(5): 901–910) BMI Comorbidities ≥35 Serious: Type 2 diabetes mellitus, moderate or severe obstructive sleep apnea (AHI >15 events/h), pseudotumor cerebri, and severe steatohepatitis ≥40 Other: Mild obstructive sleep apnea (AHI ≥5 events/h), hypertension, insulin resistance, glucose intolerance, dyslipidemia, impaired quality of life or activities of daily living, among others Eligibility criteriaa Tanner stage IV or V (unless severe comorbidities indicate WLS earlier) Skeletal Completed at least 95% of estimated growth (only if planning a diversional or malabsorptive operation, including RYGB) Lifestyle Demonstrates ability to understand what dietary and physical activity changes will be required for optimal postoperative outcomes Psychosocial Evidence for mature decision making, with appropriate understanding of potential risks and benefits of surgery Evidence for appropriate social support without evidence of abuse or neglect If psychiatric condition (e.g., depression, anxiety, or binge eating disorder) is present, it is under treatment Evidence that family and patient have the ability and motivation to comply with recommended treatments preand postoperatively, including consistent use of micronutrient supplements. Evidence may include a history of reliable attendance at office visits for weight management and compliance with other medical needs AHI, apnea–hypopnea index; RYGB, Roux-en-Y gastric bypass; WLS, weight loss surgery aAll of the eligibility criteria must be fulfilled. Agradecimentos Ao meu orientador, Mestre Hugo Santos Sousa e co-orientador, Mestre John Rodrigues Preto pela disponibilidade e apoio fundamentais para o desenvolvimento desta monografia. Revista Científica da Or dem dos Médicos ww w.actamedicap ortugues a.com 1 Normas de Publicação da Acta Médica Portuguesa Acta Médica Portuguesa’s Publishing Guidelines Conselho Editorial ACtA MédiCA PORtuguEsA Acta Med Port 2013, 5 de Novembro de 2013 NORMAS PUBLICAÇÃO 1. MISSÃO Publicar trabalhos científicos originais e de revisão na área biomédica da mais elevada qualidade, abrangendo várias áreas do conhecimento médico, e ajudar os médicos a tomar melhores decisões. 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