Seminars in Pediatric Surgery 23 (2014) 11–16

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Seminars in Pediatric Surgery

journal homepage: www.elsevier.com/locate/sempedsurg

Laparoscopic Roux-en-Y gastric bypass in adolescents with morbid

obesity—Surgical aspects and clinical outcome
Gunnar Göthberg, MD, PhDa, Eva Gronowitz, PhDa, Carl-Erik Flodmark, MD, PhDb,
Jovanna Dahlgren, MD, PhDa, Kerstin Ekbom, PhDc, Staffan Mårild, MD, PhDa,
Claude Marcus, MD, PhDc, Torsten Olbers, MD, PhDa,n
a
Department of Surgery, Medicine and Pediatrics, Sahlgrenska Academy at University of Gothenburg, Institute of Clinical Sciences, and Centre of Obesity at
the Queen Silvia Children's Hospital, Gothenburg, Sweden
b
Childhood Obesity Unit, Skåne University Hospital, Malmö, Sweden
c
Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Division of Paediatrics, and National Childhood Obesity
Centre, Children's Hospital, Karolinska University Hospital, Stockholm, Sweden

a r t i c l e in fo a b s t r a c t

In this paper, we address surgical aspects on bariatric surgery in adolescents from a nationwide Swedish study.
Keywords: Laparoscopic gastric bypass surgery was performed for 81 adolescents with morbid obesity (13–18 years),
Adolescent while 81 adolescents with obesity-matched by age, sex, and BMI received conventional care. Another
Bariatric comparison group was adults undergoing gastric bypass at the same institution during the same time period.
Surgery This report addresses the 2-year clinical outcome and five-year surgical adverse event rate. Body weight
Gastric bypass decreased from 133 kg (SD ¼ 22) at inclusion to 92 kg (SD ¼ 17) after 1 year and was 89 (SD ¼ 18) after
2 years (p o 0  001) representing a 32% ( 35 to  30) weight loss after 2 years, corresponding to 76% ( 81 to
 71) excess weight loss. Weight loss was similar in the adult gastric bypass patients ( 31%) while weight gain
(þ 3%) was seen in the conventionally treated obese adolescents. Significant improvement in cardiovascular
and metabolic risk factors and inflammation was seen after surgery. The treatment was generally well tolerated
and quality of life improved significantly. The surgical adverse events included cholecystectomies (10%) and
operations for internal hernia (9%) but no postoperative mortality. Adolescents undergoing laparoscopic gastric
bypass surgery achieve similar weight loss to adults. Improvements in risk factors and quality of life were
substantial. There were surgical complications similar to the adult group, which may be preventable.
& 2014 Elsevier Inc. All rights reserved.

Introduction Few reports on bariatric surgery in adolescents exist in the

literature, and surgery is not generally endorsed under the age of 18
An increased risk of cardiovascular and endocrine disorders, years except in extreme cases.10 O'Brien et al.11 published the only
metabolic syndrome, various cancers, and psychological problems randomized trial between lifestyle intervention and laparoscopic
in adolescents with severe obesity1–3 collectively results in an gastric banding surgery for morbid obesity demonstrating favorable
increased risk of reduced quality of life and shorter life expectancy.4 weight loss and improvements in cardiovascular risk factors as well
Yet behavioral intervention constitutes the cornerstone of childhood as improved quality of life in the surgically treated group.
and adolescent obesity treatment,3 the results for adolescents are This paper, based on a Swedish nationwide study (AMOS),12
modest.5 Among obese adolescents, the effect seems to be absent addresses the safety and efficacy of using laparoscopic Roux-en-Y
and undoubtedly insufficient for long-term risk reduction.6 gastric bypass surgery in severely obese adolescents who were
The most successful long-term treatment strategy for severely followed up for up to 5 years postoperatively regarding adverse
obese adults is bariatric surgery, where long-term weight loss is events. We are also reporting previously published data regarding
associated with a decrease in mortality and morbidity and weight changes up to 2 years, in comparison to a conventionally
improvements in quality of life.7–9 treated adolescents group and an adult group undergoing the
same surgery, as well as changes in metabolic risk factors and
quality of life.
Primary funding source: Research council, Västra Götalandsregionen, Sweden,
http://www.vgregion.se/sv/Vastra-Gotalandsregionen/startsida/. Additional fund-
ing source: Fru Mary von Sydow's foundation, Gothenburg, Sweden. Material and methods
Clinicaltrials.gov identifier: NCT00289705.
n
Correspondence to: Department of Gastrosurgical Research and Education,
Sahlgrenska University Hospital, 41345 Gothenburg, Sweden. Baseline characteristics and 1- and 2-year outcomes have
E-mail address: [email protected] (T. Olbers). previously been reported for three groups of patients recruited

1055-8586/$ - see front matter & 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1053/j.sempedsurg.2013.10.015

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12 G. Göthberg et al. / Seminars in Pediatric Surgery 23 (2014) 11–16

between February 2006 and June 2009.12 The study is called Table 1
Adolescent Morbid Obesity Surgery (AMOS). In this paper, we Baseline anthropometric characteristics.
summarize results and expand the presentation regarding surgical
Adolescents— Adolescents— Adults—
adverse events until September 2013. undergoing controls with undergoing
surgery obesity surgery

Obese adolescents treated with gastric bypass Number

Total 81 81 81
All adolescents referred to three specialist pediatric units in Male/female 28/53 35/46 28/53
Sweden (Stockholm, Gothenburg, and Malmö) were offered Age (yr)
assessment for gastric bypass surgery if they had been in a Total 16.5 (1.2) 15.8 (1.2) 39.7 (2.9)
comprehensive weight program and fulfilled the inclusion criteria Male 16.6 (1.3) 15.9 (1.2) 40.2 (3.5)
Female 16.5 (1.1) 15.7 (1.3) 39.5 (2.6)
of the study.
Height (m)
Total 1.71 (9.3) 1.71 (9.3) 1.71 (0.1)
Inclusion criteria Male 1.78 (10.4) 1.78 (7.9) 1.82 (0.1)
Female 1.67 (6.4) 1.66 (7.7) 1.66 (0.1)
- Consent to undergo surgical treatment Weight (kg)
- Aged 13–18 years Total 133 (22) 124 (21) 127 (20)
- BMI Z 40 or Z35 kg/m2 with comorbidity (type 2 diabetes, Male 147 (23) 135 (20) 142 (17)
Female 125 (17) 115 (17) 120 (17)
sleep apnea, joint pain, and high blood lipids)
- Pubertal Tanner stage 4III and passed peak height growth BMI (kg/m2)
velocity Total 45.5 (6) 42.0 (5) 43.5 (5)
Male 47.0 (6) 43.0 (5) 43.0 (6)
Female 45.0 (6) 42.0 (5) 44.0 (5)

BMI (SDS)
Exclusion criteria Total 4.1 (0.45) 3.9 (0.39) nd
Male 4.4 (0.45) 4.0 (0.39) nd
Female 4.1 (0.43) 3.9 (0.39) nd
- Severe or insufficiently treated psychiatric disorder
- Ongoing drug abuse BMI values were related to Swedish standards for age and gender with standard
- Obesity due to syndromes, monogenic disease, or brain injury deviation score (BMI SDS). Mean (SD).
- Reluctance to undergo long-term follow-up

Surgery
A total of 82 adolescents were recruited. They had been in a
comprehensive conventional treatment program for at least 1 year
Surgical patients were instructed to remain on a low-calorie diet
and had passed the assessment for the inclusion and exclusion
(LCD) for the 3 weeks leading to surgery. The laparoscopic Roux-en-Y
criteria after meeting a pediatrician, a psychologist, and a dietician.
gastric bypass consisted of a small ( o20 ml) gastric pouch and an
Recruitment took place between February 2006 and April 2009.
ante-colic, ante-gastric Roux-en-Y construction with an 80-cm
One of the patients refused surgery on the day of the operation;
long Roux limb as described in detail elsewhere (Figure 1).13
thus, 81 individuals (35% boys) underwent surgery (Table 1).
The technique is an original technique using a “double-loop
technique,” which subsequently is reconstructed to a true Roux-
Controls en-Y construction. The gastro–entero anastomosis and entero–
entero anastomoses are created using a combined technique of
Obese adolescent receiving conventional treatment linear stapling and hand suturing.
During the recruitment period, 81 adolescents (43% boys) were The patient is placed in a supine position with the surgeon
selected from the Childhood Obesity Register in Sweden (BORIS) as standing on the patient's right side and the assistant on the left.
conventional treatment controls (Table 1). We recommend the use of four 12-mm ports along with a
Nathanson liver retractor.
The Gothenburg technique to perform laparoscopic Roux-en-Y
Obese adults treated with gastric bypass
gastric bypass has been established as the “gold standard” for
A total of 81 obese adults undergoing gastric bypass were
bariatric surgery in the Scandinavian countries and by many
matched by gender with the obese adolescents obtaining surgery,
surgeons all over the world. The technique was published as an
ensuring that the date of surgery coincided within 7 1 month
original technique in 2003.13
(Table 1). The inclusion age was 35–45 years at surgery; all other
We consider the main advantages to be as follows:
inclusion and exclusion criteria were the same as for the adoles-
cents (Table 1).
1. The entire construction can be inspected during the whole
procedure, thus limiting the risk of technical errors.
Anthropometry—height and weight 2. The gastro–entero anastomosis is performed in a simplified
way by using a combination of linear stapling and hand
Height was measured to the closest centimeter using a wall- suturing.
mounted standard stadiometer with the patient in standing 3. The technique is reasonably easily learnt, provided a good
position. Weight was measured with the subject in light clothing previous knowledge about advanced laparoscopic techniques.
to the nearest 0.1 kg on an electronic scale, which was calibrated at
regular intervals.
In the adult group, weight was measured at inclusion and Initially was used a seven-port technique, but over the latest
1 year postoperatively, while 2-year weights were normally from years we have reduced the number to four 12-mm ports plus using
measurement at their general practitioner (Table 1). the Nathanson liver retractor. The patient is placed in a regular

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 G. Göthberg et al. / Seminars in Pediatric Surgery 23 (2014) 11–16 13

scores range from 0 to 100, with higher scores indicating better

health status. Summary scores for physical and mental health are
calculated using norm-based scoring with a mean of 50.

Adverse events

Surgical adverse events have prospectively been assessed up to

5 years postoperatively in surgical subjects. Adverse events were
prospectively recorded in an e-CRF. A complementary retrospec-
tive survey of medical records was conducted to capture
missing data.

Statistical analysis

Descriptive statistics are given as means with standard devia-

tions or medians with range. Changes over time are expressed
with 95% CIs.
All p-values were two-tailed, and p o 0.05 was considered
statistically significant. Statistical analyses were carried out using
the Stata statistical package 10.1 (StataCorp. 2007. Stata Statistical
Fig. 1. Surgical construction of Roux-en-Y gastric bypass.13 Software: Release 10.1. College Station, TX; StataCorp LP).

supine position with footrest and 301 anti-Trendelenburg. The Results

surgeon stands on the patient's right side and the assistant on the
left side. Baseline characteristics
Some technical issues associated with the procedure include
the following: Conventionally treated adolescents had a somewhat lower BMI
than surgically treated adolescents at baseline (BMI 42.0 vs. 45.5,
1. The stomach pouch should be as small as technically feasible respectively), and the corresponding values for BMI standard
(o 20 cc) aiming at leaving only 1–2 cm of free stomach wall deviation score were 3.9 vs. 4.1 (Table 1). The proportion of males
below the fatty pad of cardia on the anterior wall and avoid was 35% in both surgical groups and 43% in conventionally treated
including bulging back wall of the stomach. adolescents. The mean body weight at inclusion was 133 kg (SD ¼
2. A routine vertical split of the omentum enables a relatively easy 22 kg) in adolescents undergoing surgery, 124 kg (SD ¼ 21 kg) in
pull up of the loop to the pouch in almost all cases. conventionally treated adolescents, and 127 kg (SD ¼ 20 kg) in
3. One should be aware not to kink the jejuno–jejunostomy if adults undergoing surgery. Mean ages in the surgical groups were
closure of the mesenteric defect is used. This can lead to relative 16.5 years (SD ¼ 1.2 kg) for adolescents undergoing surgery, 39.7
or total obstruction. However, mesenteric windows were not years (SD ¼ 2.9 kg) for the adults, and 15.8 years (SD ¼ 1.2 kg) for
routinely closed at the time of the study, but are today. the conventionally treated adolescents (Table 2).
In the adolescent surgical group 25 (31%) had neuropsychiatric
The technique includes no element in any way to limit the diagnoses, 13 (16%) had existing or previous self-destructive
lumen of the GE, thus leaving a fully open passage for food to pass behavior, and 33 (41%) had contacts with pediatric psychiatric
directly to the Roux limb. Our figures for postoperative weight loss units. Poor school performance (truancy or leaving school without
match international standards (84% excess weight loss after a diploma) was frequently reported ( 450%). A total of 26
2 years), indicating that a stoma size limitation is not an essential adolescents (32%) had no recorded psychosocial problems.
mechanism of action in the gastric bypass construction.
One of two experienced gastric bypass surgeons performed all Primary hospitalization and postoperative complications
procedures, assisted by a pediatric surgeon. All subjects, both
adolescents and adults, were operated at Sahlgrenska University Median surgical time was 63 min (range 38–106) in the
Hospital, using the same surgical technique. adolescent group. Median postoperative inpatient stay was 4 days
(range 2–11). None of the patients required treatment in the
Follow-up after surgery intensive care unit. Two patients required blood transfusions for
postoperative bleeding, and another was re-hospitalized with
The adolescent surgical patients were assessed one month fever 3 days after being discharged and received intravenous
before surgery and 1, 3, 6, 12, and 24 months after surgery. Body antibiotics due to an intra-abdominal infection confirmed by
weight and biochemical analyses were performed preoperatively CT scan (Table 2).
and at 12 and 24 months after surgery.
All subjects in the adolescent surgical group were prescribed Weight changes
daily multivitamin and mineral supplements, vitamin B12, and
calcium–vitamin D combination tablets. The girls were prescribed There was a 100% follow-up rate at 1 and 2 years for weight and
iron tablets in addition. height in both groups undergoing surgery. In the conventionally
treated adolescent group, there was a 100% follow-up for weight
Health-related quality of life after 1 year, but this dropped to 73% (59 individuals) after 2 years.
As demonstrated in Figure 2, there was a similar reduction in
SF-36 v2 was used to measure generic health-related quality of weight in the adolescent and adult groups undergoing surgery,
life.14 SF-36 comprises eight general health domains, and the scale while conventionally treated adolescents had increased their

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14 G. Göthberg et al. / Seminars in Pediatric Surgery 23 (2014) 11–16

Table 2
Surgical adverse events up to 5 years postoperatively in 81 adolescents who have undergone laparoscopic gastric bypass.

Age at event Time after operation Primary hospitalization Surgical/physical adverse event

Girl 14 and 1st day and 15 months Postoperative hemorrhage, low hemoglobin, and Laparoscopic cholecystectomy
15 yr transfusion
Girl 16 yr 1st day Postoperative hemorrhage, low hemoglobin, and
transfusion
Girl 15 yr 2 weeks and 2.5 yr Fever and elevated CRP, hospital stay for 5 days, and Ileus operation by laparoscopy
post-operation antibiotics
Boy 17 yr 2 months Internal hernia operation by laparoscopy
Girl 16 yr 3 months Internal hernia operation by laparoscopy
Girl 16 yr 5 months Recurrent abdominal pain, laparoscopic adhesiolysis
Girl 15 yr 9 months Laparoscopic cholecystectomy
Girl 18 yr 9 months Abdominal pain
Boy 16 yr 10 months Internal hernia, operation by laparoscopy
Girl 15 yr 10 months Laparoscopic cholecystectomy
Girl 18 yr 12 months Laparoscopic cholecystectomy
Girl 18 yr 15 months Internal hernia operation by laparoscopy
Girl 17 yr 15 months Internal hernia operation by laparoscopy
Girl 18 yr 18 months Abdominal pain
Boy 17 yr 19 months Abdominal pain
Girl 18 yr 20 months Laparoscopic cholecystectomy
Girl 16 yr 20 months Laparoscopic cholecystectomy
Girl 14 yr 21 months Abdominal pain
Girl 17 and 1 and 5 yr Ileus and cholecystectomy
21 yr
Girl 20 yr 2 yr Ileus operation by laparoscopy
Boy 19 and 2 and 4.5 yr Cholecystectomy and internal hernia operation by laparoscopy
22 yr
Boy 21 yr 3 yr Internal hernia operation by laparoscopy
Boy 19 yr 4 yr Ileus operation by laparoscopy

weight slightly. Weight change after 2 years was  32% (CI  35% Changes in quality of life
to  30%) in surgically treated adolescents, as compared to weight
gain of þ 3% (CI: 0–7%) in the conventionally treated adolescents, In summary, at 1-year follow-up, significant improvements
and weight loss of  31% (CI  34% to  29%) in adults undergoing were observed in seven of the eight SF-36 health domains and in
surgery. Overall, 95% of operated adolescents achieved a weight the physical component summary score.12 After 2 years, significant
loss exceeding 50% of excess weight. improvements compared to baseline were evident in all four
There were no significant differences in the weight loss physical health domains, in the physical component summary
between genders. Of the adolescents in the surgical group, 57% score, and in two of the four mental health domains. Minor
had a continuing weight loss while 43% increase in weight during decreases in SF-36 scale scores between 1- and 2-year follow-up
the second year after surgery (range  9.7 to þ 4.2 kg). did not reach significance.

Fig. 2. Weight change over 2 years in adolescents and adults undergoing gastric bypass surgery (n ¼ 81 þ 81) and adolescents in conventional treatment (n ¼ 81). Mean
(95% CI).

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 G. Göthberg et al. / Seminars in Pediatric Surgery 23 (2014) 11–16 15

Adverse events in surgically treated adolescents reduction and calorie malabsorption as a consequence of the
bypass of the duodenum and proximal jejunum. Other mecha-
During the 2-year follow-up, 12 adolescents (15%) underwent nisms contributing to weight loss after gastric bypass include
additional surgical interventions, five (6.2%) needed an operation reduced hunger,18 augmented satiety,19–21 increased energy
for internal hernia; six (7.4%) underwent cholecystectomy due to expenditure,22 and altered taste perception, all of which may be
symptomatic gallstone and one was laparoscopically operated at least partly mediated by alterations in gastrointestinal and
with finding of adhesions. Four patients visited an emergency central neuro-endocrine signaling.
intake due to non-specific abdominal pain. Additional incomplete We observed a substantial amelioration in cardiovascular risk
follow-up until 5 years postoperatively revealed four others factors with significantly better glucose and lipid control, as
operated for ileus, two for internal hernias, and two more were previously demonstrated in adults.12 A theoretical advantage of
cholecystectomized. All remedial surgeries were performed by early intervention would be a shorter exposure to metabolic risk
laparoscopy (Table 2). factors and thereby reduced risk for developing structural and
We identified poor compliance in the intake of prescribed functional cardiovascular impairment. Furthermore, fasting
vitamin and mineral supplements in two-thirds of patients. insulin levels decreased to one-fourth of preoperative levels.
We also found a major decrease in inflammatory activity post-
Excess skin operatively, as previously demonstrated in adults after bariatric
surgery.23
Most adolescents having undergone surgery experienced prob- A possible disadvantage of intervention in adolescents could be
lems with excessive skin following weight loss; this aspect was not their physical and psychological immaturity. Therefore, the poor
formally addressed in the current study. compliance in vitamin and mineral supplementation requires
careful attention for a long time. Another issue that needs consid-
eration in adolescents is the development of excessive skin as a
Discussion result of weight loss, which we will address in a separate paper
from this study.
In this study, we could demonstrate a substantial weight loss There were broad improvements in quality of life in adolescents
over 2 years (32%) following gastric bypass surgery for severely after surgery from a group perspective, supporting the findings of
obese adolescents, which was similar to the weight loss in an adult a previous study.24 We consciously did not exclude patients
comparison group (31%). Of the operated adolescents, 95% with psychiatric and psychosocial problems in this study possibly
achieved more than 50% excess weight loss. Minor weight gain leading to more psychosocial issues in the cohort. When
(3%) was seen in conventionally treated adolescents. Cardiovascu- treating this group of patients, the multidisciplinary team must
lar risk factors were ameliorated, mirrored by lowering of insulin offer an extended postoperative support role, as recommended
and serum lipids levels, and a reduction of inflammatory activity.12 previously.25
Furthermore, we have shown improvement in quality of life after In summary, we have demonstrated that Roux-en-Y gastric
surgery, although psychological and surgical adverse events bypass surgery results in similar weight loss in adolescents as in
occurred. adults over 2 years. We found substantial improvements in risk
Gastric bypass has been established as the “gold standard” in factors for co-morbidities and improvements in quality of life.
Scandinavian bariatric surgery and constitutes currently more than Nonetheless, the surgical and psychiatric adverse events that
90% of bariatric procedures. A previous study has demonstrated appeared in this psychosocially vulnerable cohort require careful
that laparoscopic gastric banding is feasible and effective in attention. It appears so far that gastric bypass is a viable option for
adolescents recruited directly from the community when com- future interventional studies in severely obese adolescents.
pared to the best conventional therapy.11 In contrast, other studies
have not been successful with gastric banding in adolescents.15 A
previous gastric banding study for adolescents in Sweden was References
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