An Ongoing Dilemma Amid Obesity Pandemic: Is Obesity Surgery Feasible in Turkish Adolescents? A Multicenter Study

Introduction

Obesity is the global pandemic of the 21st century. Nearly 50% of the world’s population is overweight, and approximately 15% is considered morbidly obese. ¹ Many genetic and environmental factors contribute to the development of this devastating condition, which affects adolescents as well as adults. The prevalence of obesity among patients aged 12–19 (adolescents) exceeds 20%. ² In contrast to global statistics, the prevalence of morbid obesity among adolescents in our country is estimated to be less than 10%. ³ Current literature suggests that obesity in adolescents has quadrupled overall.^4,5 Similar to adult obesity, adolescent obesity is associated with preventable chronic health conditions such as noninsulin-dependent diabetes mellitus (NIDDM), hypertension (HTN), obstructive sleep apnea syndrome (OSAS), dyslipidemia, nonalcoholic steatohepatitis (NASH), polycystic ovary syndrome, and various musculoskeletal diseases.^6,7

To address these comorbidities earlier in life, an obese adolescent with any of the aforementioned diseases might be considered a candidate for bariatric and metabolic surgery (BMS), although obesity surgery remains controversial during adolescence. ⁶ Nevertheless, the American College of Surgeons Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program encourages BMS in this age group to some extent, either at an Adolescent Obesity Center or, more commonly, at a Comprehensive Center with Adolescent Qualifications. ⁸ Given the controversy due to the early alteration of anatomy and the lack of data regarding the safety and efficacy of this delicate matter, we aim to present our short-term surgical results of 170 consecutive obese adolescent patients.

Materials and Methods

A total of 170 adolescent patients from six different Turkish obesity and metabolic surgery centers, whose BMI was either greater than 40 kg/m² or between 35 and 40 kg/m² with accompanying obesity-related comorbidity, underwent bariatric surgery between March 2012 and January 2020, and were enrolled in this study. Ethical approval was obtained from the Local Ethics Committee of Istinye University Faculty of Medicine (2/2020.K-071). Informed consent was obtained from every participant. A thorough evaluation by a multidisciplinary team consisting of a general surgeon, a psychologist, a dietitian, and an anesthesiologist preceded the surgical intervention. All patients’ preoperative and follow-up data were recorded prospectively. A retrospective analysis of this database was then carried out for this particular study population, including demographics, pre- and postoperative 6-month BMI, excess weight loss (EWL), total weight loss (TWL), comorbidities, pre- and postoperative medications, length of hospital stay (LoHS), and postoperative complications.

NIDDM was defined as fasting blood glucose (FBG) ≥125 mg/dL and/or HbA1c ≥ 6.4%. Remission of diabetes was defined as maintaining FBG levels under 100 mg/dL and HbA1c levels under 6.0% without the use of antidiabetic medications. No improvement in the aforementioned parameters was defined as a failure in comorbidity treatment, while any conditions in between were defined as clinical improvement. HTN was defined as blood pressure levels greater than 120/80 mmHg. Remission of HTN was defined as maintaining blood pressure levels under 120/80 mmHg without medical treatment. Improvement in blood pressure levels while on the same antihypertensive medication, or a decrease in the dosage or number of antihypertensive medications, was defined as clinical improvement. Arthropathy was defined based on the patient’s individual complaints, with the disappearance of symptoms defined as remission, and improvement in symptoms defined as clinical improvement. NASH was diagnosed radiologically, with a normal liver appearance during clinical follow-up defined as remission, and a decrease in the grade of NASH defined as clinical improvement.

Statistical analysis was conducted using SPSS version 25.0. The distribution of variables was assessed with the Kolmogorov–Smirnov test. Data that were normally distributed were analyzed using ANOVA, and post hoc comparisons were made using the Tukey test. Results were evaluated within a 95% confidence interval, and P values less than .05 were considered statistically significant.

Results

Female patients comprised the majority of cases (74.1%). The mean age was 17 years (Table 1), and the mean BMI was 43.9. HTN, NIDDM, arthropathy, NASH, and hypothyroidism were the comorbidities present in 21.2% of patients, with HTN being the most common (Table 2). Table 3 demonstrates the preferred surgical techniques. Most patients underwent laparoscopic sleeve gastrectomy (LSG) (94.1%), while laparoscopic adjustable gastric banding (LAGB) was the least preferred technique (1.2%).

For LAGB, the youngest patient was 17 years old, and the highest BMI recorded was 34.2 kg/m². Regarding mini gastric bypass, the youngest patient was 16 years old, and the highest BMI recorded was 56.4 kg/m². For Roux-en-Y gastric bypass, the youngest patient was 16 years old, and the highest recorded BMI was 52.3 kg/m². The youngest patient in the entire study population was 12 years old and underwent LSG, with the highest recorded BMI in the LSG group being 67 kg/m². All procedures were performed by metabolic and bariatric surgeons, with one case involving a pediatric surgeon as well.

The mean LoHS was 4 days (range: 3–12 days). No patient required admission to the intensive care unit (ICU). The mean BMI, EWL, and TWL at 6 months postoperatively were 30.17 kg/m², 77.7% (range: 17.5%−139.1%), and 31.32% (range: 7.6%−55.8%), respectively (Table 4). The temporal decrease in BMI values was found to be statistically significant (P < .05). At the 6-month follow-up, 75% of patients experienced either remission or clinical improvement in associated comorbidities.

Three complications (1.8%) were encountered in this study population. Liver injury due to trocar placement occurred in 1 patient and was treated conservatively. A staple-line leak occurred in another patient and was treated endoscopically. In addition, 1 patient developed peripheral neuropathy 18 months postsurgery due to poor dietary adherence.

Discussion

Although it is proven that current dietary and lifestyle interventions generally fail to achieve desirable long-term results in patients with obesity, surgical treatment for obesity in adolescents remains a controversial topic. ⁹ The ongoing debate is primarily due to concerns about its necessity and safety. When performing bariatric surgery, surgeons expect the benefits to outweigh the risks. However, before initiating surgical treatment, a physician must first ensure its safety. Second, long-term outcomes should not negatively impact the daily life of patients.

Given that adolescents typically have a higher life expectancy compared with adults, altering their anatomy may jeopardize their current and future health. Contemporary guidelines suggest that bariatric surgery should only be considered for adolescents with obesity whose BMI exceeds 35 kg/m² and who have an accompanying comorbidity, such as NIDDM, HTN, NASH, dyslipidemia, pseudotumor cerebri, or OSAS.^10–12 However, the evidence in the literature is scarce. Therefore, objective data regarding the safety, efficacy, and long-term outcomes of these procedures are of paramount importance.

In our study, the mean BMI of patients was 43.9 kg/m². The study population exhibited a clear female predominance, consistent with the literature. ¹³ Approximately 20% of our study group had an accompanying obesity-related comorbidity, which is less than the reported rates of 40%–50% in contemporary literature. ¹⁴ This discrepancy might be due to the smaller size of our study group and the exclusion of dyslipidemia, one of the most prominent obesity-related comorbidities, due to poor structuring.

The percentage of patients undergoing LSG in our study exceeds 90%, which is higher than the pooled analysis reported by the American Society for Metabolic and Bariatric Surgery. ¹⁵ We believe this is due to the younger age of our study population, leading to a preference for less anatomy-altering procedures. The mean LoHS in our study group is consistent with the literature. ¹⁶ The absence of ICU admissions following surgery further supports the safety of these procedures.

The EWL outcomes at the 6-month follow-up are consistent with the literature and demonstrate the efficacy of surgery in promoting weight loss. ¹⁷ Our complication rates are also similar to those reported in the literature. ¹⁸ It is known that obesity-related comorbidities often resolve in the majority of cases following bariatric surgery during long-term follow-up.^19–23 Our short-term remission rates are comparable with the literature, indicating that these procedures are effective in the adolescent population.

An emerging debate regarding bariatric surgery practices in adolescents is whether these procedures should be carried out by bariatric and metabolic surgeons or pediatric surgeons. Obesity management is not unique in this regard, as pediatric inguinal hernias, appendicitis, and circumcision are also areas of debate. For example, pediatric appendicitis cases are managed by both pediatric and general surgeons, with no proven clear advantage of one specialty over the other.^24,25 The controversy arises from the limited number of available and specialized pediatric surgeons, resulting in less scientific evidence.

Although in some developed European countries the percentage of pediatric surgeons specializing in adolescent treatment reaches up to 15%, in the United States, this percentage is limited to 2%, and in our country, no pediatric surgeon practices obesity surgery in the adolescent population to date.^26,27 Nevertheless, the available scarce data suggest that these surgeries can be performed by pediatric surgeons as well. However, it remains unclear whether a pediatric subspecialty offers a significant benefit. ²⁶ Consequently, based on our results and the available data in the literature, we suggest that bariatric surgery can be carried out safely by adult bariatric and metabolic surgeons.

This study has several limitations. First, although the data were recorded prospectively, the analysis was carried out retrospectively, making the study susceptible to selection bias. Second, this study lacks long-term outcomes, which are crucial for this topic. Third, our study lacks a distinctive assessment of comorbidity remission, as dyslipidemia was not included and NIDDM patients were not grouped according to their duration of symptoms and medications.

In conclusion, we suggest that bariatric surgery in the adolescent population is a safe and efficacious approach in the short term. We plan to publish our midterm and long-term results in the future and encourage our fellow bariatric and metabolic surgeons to do the same to demonstrate the clear importance of these surgeries in addressing obesity in adolescents.