Metabolic Bariatric Surgery: History
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Subjects: Surgery
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Oliver Mann

Despite worldwide public attention and intense medical efforts, the prevalence of severe morbid obesity in children and adolescents is still rising. Similar to adults, excess adipose tissue triggers multiple immunological and metabolic pathways leading to serious co-morbidities such as impaired glucose tolerance or even type 2 diabetes (T2D), dyslipidemia, arterial hypertension, non-alcoholic fatty liver disease, and hyperuricemia. The management of severe childhood obesity requires a life-long multidisciplinary approach with a combination of lifestyle changes, nutrition, and medications. Standardized life-style intervention programs remain the first-line treatment for morbid obese children and adolescents, but unfortunately reveal limited long-term success. In such cases, metabolic bariatric surgery (MBS) has evolved from being a controversial issue to being included in distinct recommendations. 

  • adolescence
  • childhood
  • obesity
  • metabolic and bariatric surgery
  • guidelines

1. Introduction

Despite worldwide public attention and intense medical efforts, the pandemic of severely morbid obesity in children and adolescents has continued over the last decades [1]. Similar to adults, excess adipose tissue triggers multiple immunological and metabolic pathways resulting in serious comorbidities including disturbed glucose metabolism leading to prediabetes or type 2 diabetes, non-alcoholic fatty liver disease, renal disease, hyperlipidemia, and hyperuricemia [2][3][4]. In addition, adolescents with severe obesity seem to present a pronounced risk for developing major cardiovascular morbidities in early adulthood [5]. Furthermore, orthopedic problems as well as obstructive sleep apnea syndrome often already exist in these children [6]. Obese children and adolescents also suffer from psychological and social sequelae such as depression, stigmatization, bullying, social isolation, and poor self-esteem [7].
If left untreated, obesity in childhood and adolescence has serious long-term medical and socioeconomic consequences, as it often persists into adulthood, including an increased risk to develop malignant diseases [8][9].
The management of severe childhood obesity requires a life-long multidisciplinary approach with a combination of lifestyle changes, nutrition, medications, and metabolic bariatric surgery (MBS) in selected cases. In children, overweight is classified as having a BMI ≥ 90th and < 97th percentile, obesity as having a BMI ≥ 97th and < 99.5th percentile, and extreme (morbid) obesity as having s BMI ≥ 99.5th percentile. Conservative lifestyle intervention programs remain the first-line treatment, but unfortunately reveal limited long-term success [10]. On the other hand, similarly to adults, surgical procedures represent an effective option for morbidly obese adolescents to lose weight and treat their obesity-related co-morbidities [3][11][12].

2. Indication for Metabolic Bariatric Surgery in Adolescents

The American Society for Metabolic and Bariatric Surgery (ASMBS) Pediatric Committee has recently updated their guidelines [3]. Adolescents with class II obesity and a diagnosed co-morbidity or with class III obesity should be considered for MBS [13].
Pratt et al. recently recommended treatment teams to conduct a thorough pre-operative evaluation including metabolic profiling but also to provide sufficient education about the surgical interventions and the postoperative lifestyle changes that will be necessary [13].
In Europe, indications for MBS in morbidly obese adolescents vary between countries. Nevertheless, the European Association for the Study of Obesity and the European Chapter of the International Federation for the Surgery of Obesity have agreed upon interdisciplinary European guidelines on MBS in adolescents in 2013 [14]. According to these guidelines, bariatric surgery can be considered in patients
  • with a BMI > 40 kg/m2 and at least one confirmed comorbidity;
  • following at least 6 months of organized weight-reducing attempts in a specialized center;
  • showing skeletal and developmental maturity;
  • capable to commit to comprehensive medical and psychological evaluation before and after surgery;
  • willing to participate in a post-operative multidisciplinary treatment program;
  • with the possibility to access surgery in a unit with specialist pediatric support (nursing, anesthesia, psychology, post-operative care).
Moreover, bariatric surgery can even be considered in patients with genetic syndromes such as Prader–Willi syndrome, but only after careful consideration by an expert medical, pediatric, and surgical team [14].
The German guideline published by the German Society for General and Visceral Surgery describe a BMI ≥ 35 kg/m2 and at least one diagnosed somatic and/or psychosocial comorbidity as indication for bariatric surgery in children and adolescents. In patients with a BMI ≥ 50 kg/m2, surgery can be considered even without any comorbidity. The patient, however, should have reached 95% of the predicted final height or Tanner stage IV. Before surgery, the adolescents should have undergone at least 6 months of unsuccessful conservative interdisciplinary lifestyle intervention programs [15].
Exclusion criteria for bariatric surgery in adolescents include:
  • Severe psychiatric disorders (unstable psychosis, borderline personality, severe depression and personality disorders, active suicidality) and diagnosed eating disorders;
  • Alcohol and/or drug abuse;
  • Pregnancy (present or planned within 18 months after surgery);
  • Inability of the patient to participate in a long-term interdisciplinary follow-up at the obesity center.
Immediately preoperatively, most multidisciplinary bariatric surgery programs nowadays recommend a protein-rich liquid diet to induce weight loss and decrease the mass of the liver size. Such conditioning improves surgical safety, operative times, and intraoperative blood loss [12].
Moreover, psychologists should examine the adolescents’ readiness and suitability for bariatric surgery. Amongst others, motivation, adherence, and the ability to understand pre- and postoperative requirements should be assessed [16].
When dealing with obese adolescents who may qualify for bariatric surgery, the role of the parents should not be underestimated because parental attitudes towards the weight status of their children may pose significant barriers to their consideration of treatment options [17]. It has been shown that most parents of overweight children fail to recognize that their child has a weight problem [18][19]. Moreover, in their telephone survey, Singh and Chernoguz found that only half of the parents with obese children concerned for their child’s future health would consider metabolic surgery, and most parents who would consider metabolic surgery would wait until their child was over age 18. However, provider counseling seems to significantly increase parents’ likelihood to consider bariatric surgery [17]. The authors concluded that “more detailed provider education on the current state of bariatric surgery in the treatment of severe adolescent obesity is necessary.” [17].

3. Surgical Principles and Methods

Despite a recent increase in the number of these surgeries, adolescents still constitute only a very small proportion of patients undergoing bariatric procedures. In the United States, adolescents constitute only 0.1% of all patients subjected to metabolic and bariatric procedures [20]. As a consequence, and according to the present guidelines, MBS should be performed in high-volume centers specialized in the medical and surgical treatment of morbid obesity at any age. Thus, it seems highly advisable for pediatric surgeons to join a high-volume center for adult bariatric surgery. In the US, the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) requires for adolescent bariatric surgery that a children’s hospital conducting fewer than 25 stapling cases per year invites an MBSAQIP-verified bariatric surgeon on each case [13].
Pathophysiologically, a fundamental distinction is made between the so-called restrictive versus the malabsorptive procedures. Restrictive procedures “simply” tighten the stomach, for example, by placing an adjustable band around the fundus (laparoscopic adjustable gastric banding, LAGB). This maneuver creates a pouch and a small channel into the remaining stomach. The volume of food passing through the band may be adjusted by changing the diameter of the band. The continuity of the gastrointestinal tract remains intact.
The Roux-Y gastric bypass (RYGB) remains the “gold standard” of all malabsorptive procedures. Technically, the stomach is resected close to the gastroesophageal junction, leaving only a small pouch of approximately 20 mL. A loop of the small bowel is anastomosed to this gastric pouch (alimentary loop), while the rest of the stomach, duodenum, and the adjoining proximal small intestinal loops are initially excluded from the food route (biliodigestive loop). Further distally (100–170 cm), both loops are joined (common channel), allowing the absorption of food.
Sleeve gastrectomy (LSG, Laparoscopic Sleeve Gastrectomy) may serve both principles. Basically, the stomach is resected longitudinally, leaving a “restricted” volume of approx. 50–100 mL. This procedure was first recommended by the authors as a “stand-alone” technique for young adolescents in 2008 [21]. Metabolically, it is assumed that resection of the gastric fundus also extensively removes ghrelin production. Since ghrelin induces feelings of hunger in the central nervous system (arcuate nucleus), the removal of ghrelin-producing cells induces changes in the eating behavior [22][23][24]. Valid studies have shown that it is almost as effective as RYGB in inducing weight loss and improving co-morbidities [25]. Thus, LSG has gained general acceptance and has become the most commonly performed MBS procedure in adolescents [3].
 

This entry is adapted from the peer-reviewed paper 10.3390/children8050372

References

  1. World Health Organization. Fact Sheet on Obesity and Overweight. Available online: (accessed on 28 March 2021).
  2. Oberbach, A.; Neuhaus, J.; Inge, T.; Kirsch, K.; Schlichting, N.; Bluher, S.; Kullnick, Y.; Kugler, J.; Baumann, S.; Till, H. Bariatric surgery in severely obese adolescents improves major comorbidities including hyperuricemia. Metabolism 2014, 63, 242–249.
  3. Pratt, J.S.A.; Browne, A.; Browne, N.T.; Bruzoni, M.; Cohen, M.; Desai, A.; Inge, T.; Linden, B.C.; Mattar, S.G.; Michalsky, M.; et al. ASMBS pediatric metabolic and bariatric surgery guidelines, 2018. Surg. Obes. Relat. Dis. 2018, 14, 882–901.
  4. Lautenbach, A.; Wienecke, J.W.; Stoll, F.; Riedel, N.; Mann, O.; Huber, T.B.; Busch, P.; Aberle, J. Bariatric Surgery Is Protective Against Renal Function Decline in Severely Obese Patients in the Long-Term. Obes. Surg. 2021, 31, 1038–1045.
  5. Ryder, J.R.; Xu, P.; Inge, T.H.; Xie, C.; Jenkins, T.M.; Hur, C.; Lee, M.; Choi, J.; Michalsky, M.P.; Kelly, A.S.; et al. Thirty-Year Risk of Cardiovascular Disease Events in Adolescents with Severe Obesity. Obesity 2020, 28, 616–623.
  6. May, A.L.; Kuklina, E.V.; Yoon, P.W. Prevalence of cardiovascular disease risk factors among US adolescents, 1999–2008. Pediatrics 2012, 129, 1035–1041.
  7. Rankin, J.; Matthews, L.; Cobley, S.; Han, A.; Sanders, R.; Wiltshire, H.D.; Baker, J.S. Psychological consequences of childhood obesity: Psychiatric comorbidity and prevention. Adolesc. Health Med. Ther. 2016, 7, 125–146.
  8. Llewellyn, A.; Simmonds, M.; Owen, C.G.; Woolacott, N. Childhood obesity as a predictor of morbidity in adulthood: A systematic review and meta-analysis. Obes. Rev. 2016, 17, 56–67.
  9. Weihrauch-Bluher, S.; Schwarz, P.; Klusmann, J.H. Childhood obesity: Increased risk for cardiometabolic disease and cancer in adulthood. Metabolism 2019, 92, 147–152.
  10. Lee, E.Y.; Yoon, K.H. Epidemic obesity in children and adolescents: Risk factors and prevention. Front. Med. 2018, 12, 658–666.
  11. Pedroso, F.E.; Angriman, F.; Endo, A.; Dasenbrock, H.; Storino, A.; Castillo, R.; Watkins, A.A.; Castillo-Angeles, M.; Goodman, J.E.; Zitsman, J.L. Weight loss after bariatric surgery in obese adolescents: A systematic review and meta-analysis. Surg. Obes. Relat. Dis. 2018, 14, 413–422.
  12. Thenappan, A.; Nadler, E. Bariatric Surgery in Children: Indications, Types, and Outcomes. Curr. Gastroenterol. Rep. 2019, 21, 24.
  13. Pratt, J.S.A.; Roque, S.S.; Valera, R.; Czepiel, K.S.; Tsao, D.D.; Stanford, F.C. Preoperative considerations for the pediatric patient undergoing metabolic and bariatric surgery. Semin. Pediatr. Surg. 2020, 29, 150890.
  14. Fried, M.; Yumuk, V.; Oppert, J.M.; Scopinaro, N.; Torres, A.J.; Weiner, R.; Yashkov, Y.; Fruhbeck, G. Interdisciplinary European guidelines on metabolic and bariatric surgery. Obes. Facts 2013, 6, 449–468.
  15. AWMF-Leitlinie Chirurgie der Adipositas Und metabolischer Erkrankungen, Registernummer 088—001, Entwicklungsstufe S3, Version 2.3, February 2018. Available online: (accessed on 28 March 2021).
  16. Burton, E.T.; Mackey, E.R.; Reynolds, K.; Cadieux, A.; Gaffka, B.J.; Shaffer, L.A. Psychopathology and Adolescent Bariatric Surgery: A Topical Review to Support Psychologists in Assessment and Treatment Considerations. J. Clin. Psychol. Med. Settings 2020, 27, 235–246.
  17. Singh, U.D.; Chernoguz, A. Parental attitudes toward bariatric surgery in adolescents with obesity. Surg. Obes. Relat. Dis. 2020, 16, 406–413.
  18. Eckstein, K.C.; Mikhail, L.M.; Ariza, A.J.; Thomson, J.S.; Millard, S.C.; Binns, H.J.; Pediatric Practice Research, G. Parents’ perceptions of their child’s weight and health. Pediatrics 2006, 117, 681–690.
  19. Etelson, D.; Brand, D.A.; Patrick, P.A.; Shirali, A. Childhood obesity: Do parents recognize this health risk? Obes. Res. 2003, 11, 1362–1368.
  20. Grant, H.M.; Perez-Caraballo, A.; Romanelli, J.R.; Tirabassi, M.V. Metabolic and bariatric surgery is likely safe, but underutilized in adolescents aged 13–17 years. Surg. Obes. Relat. Dis. 2021.
  21. Till, H.; Bluher, S.; Hirsch, W.; Kiess, W. Efficacy of laparoscopic sleeve gastrectomy (LSG) as a stand-alone technique for children with morbid obesity. Obes. Surg. 2008, 18, 1047–1049.
  22. Kiriakopoulos, A.; Varounis, C.; Tsakayannis, D.; Linos, D. Laparoscopic sleeve gastrectomy in morbidly obese patients. Technique and short term results. Hormones 2009, 8, 138–143.
  23. Shi, X.; Karmali, S.; Sharma, A.M.; Birch, D.W. A review of laparoscopic sleeve gastrectomy for morbid obesity. Obes. Surg. 2010, 20, 1171–1177.
  24. Till, H.K.; Muensterer, O.; Keller, A.; Korner, A.; Blueher, S.; Merkle, R.; Kiess, W. Laparoscopic sleeve gastrectomy achieves substantial weight loss in an adolescent girl with morbid obesity. Eur. J. Pediatr. Surg. 2008, 18, 47–49.
  25. Inge, T.H.; Courcoulas, A.P.; Jenkins, T.M.; Michalsky, M.P.; Helmrath, M.A.; Brandt, M.L.; Harmon, C.M.; Zeller, M.H.; Chen, M.K.; Xanthakos, S.A.; et al. Weight Loss and Health Status 3 Years after Bariatric Surgery in Adolescents. N. Engl. J. Med. 2016, 374, 113–123.
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