HEN synthesis report

June 2012

Do surgical interventions to treat obesity

in children and adolescents have
long- versus short-term advantages and
are they cost-effective?

Andrea Aikenhead
Cécile Knai
Tim Lobstein
Abstract
The prevalence of childhood and adolescent obesity in the WHO European Region has risen in
recent decades. Obesity in this population is linked to increased risk factors for cardiovascular
diseases, type 2 diabetes, sleep apnoea and psychological distress. While bariatric surgery is
seen as an effective intervention under clear conditions for obese adults, the indications for
medical and surgical treatment of overweight and obese children are still not well defined.
Moreover, children and adolescents have distinctive metabolic, developmental and psychological
needs, which must be carefully considered to avoid the inappropriate use of weight-loss surgery.
This review looks at the effectiveness and cost–effectiveness of surgical interventions for
overweight and obese children and adolescents, and finds that the majority of relevant studies
are methodologically limited and long-term data remain largely unavailable. Some evidence
suggests that bariatric surgery in severely obese adolescents can result in significant weight
loss, and improvement in co-morbidities and quality of life. A conservative approach to child
and adolescent bariatric surgery is warranted until further long-term prospective studies on the
subject are conducted, so there remains an urgent need to develop alternatives to surgery, such
as lifestyle programmes that are even modestly effective.

Keywords

ADOLESCENT CHILD
BARIATRIC SURGERY – ECONOMICS EUROPE
BARIATRIC SURGERY – METHODS OBESITY – SURGERY

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ISSN 2227-4316
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 Contents

Summary i
The issue i
Findings i
Policy considerations ii

Introduction 1
Indications and patient assessment 2
Surgical interventions for obesity 4
Sources for this review 5

Findings 7
Effectiveness of surgical options in children and adolescents 7
Cost–effectiveness of surgical options in children and adolescents 9
Summary of recommendations from existing reviews on child and
adolescent weight loss surgery 10

Discussion 13
Unique challenges of children and adolescents 14
Issues requiring further investigation 17

Conclusions 18

Annex 1. Search strategy 21

Annex 2. Results tables 23

References 28
Contributors

Authors

Andrea Aikenhead
Education Manager
International Association for the Study of Obesity (IASO), England

Cécile Knai
Lecturer, European Centre on Health of Societies in Transition (ECOHOST)
London School of Hygiene & Tropical Medicine, England

Tim Lobstein
Director of Policy and Programmes
International Association for the Study of Obesity (IASO), England

External peer reviewers

David Haslam
Professor and Chair
National Obesity Forum, England

Thomas J Hoerger
Senior Fellow
RTI International, USA

HEN editorial team

Govin Permanand, Series Editor

Kate Frantzen, Managing Editor
Claudia Stein, Director, Division of Information, Evidence, Research and Innovation

HEN evidence reports are commissioned works which are subjected to international
peer review, and the contents are the responsibility of the authors. They do not
necessarily reflect the official policies of WHO/Europe.
 Summary

The issue
i
During the last decades the prevalence of childhood and adolescent obesity in
Europe has grown. Although it is possibly levelling off in some areas of Europe
(1–3), the scale of childhood obesity and its associated morbidities and costs
remains considerable (4,5). Obese children and adolescents are more likely than
others to have risk factors for cardiovascular diseases, experience other health
conditions associated with increased weight, such as type 2 diabetes and sleep
apnoea, perform poorly at school and suffer psychological distress (6,7). Clear
evidence for successful and cost-effective non-surgical strategies for treating
childhood obesity is lacking, leading the medical profession to turn increasingly
to surgical treatment options. While bariatric surgery is established as a safe and
effective alternative with well-defined risks for severely obese adults (8–12), little
of quality has been published on its use in children, with their unique metabolic,
developmental and physiological needs (13). Evidence is needed on the
effectiveness and cost–effectiveness of surgical treatment in order to support policy-
makers and guide future research.

Findings

In the context of a general lack of effective tools for primary prevention or behavioural
treatment of obesity (14), surgical treatment may be advocated as a preferred and
cost-effective solution for certain children and adolescents (15). However, the role
of bariatric surgery in the treatment of obese children or adolescents is controversial.
The concerns about surgery to treat obesity in young populations include:

l obtaining informed consent from minors;

l timing of intervention;
l whether or not surgery is cost-effective;
l how to ensure healthy growth through to adulthood; and
l what support services are needed after surgery: compliance with the postoperative
nutrition regimen, and attendance at appointments for long-term follow-up
and care.

These concerns underscore the importance of well-designed and well-evaluated

research studies on the effectiveness of treatment options for obesity in child
 populations (6). As demonstrated in the current evidence review, the few studies
that exist are primarily retrospective or observational, and underpowered (16). The
indications for medical and surgical treatment in overweight and obese children are
still not well defined (7). There is no clear indication of the cost–effectiveness of
surgical interventions for paediatric obesity. There is very limited evidence available
to adequately estimate long-term safety, effectiveness, cost–effectiveness or
durability of bariatric surgery in growing children.

ii
Policy considerations

l Although based on methodologically limited and underpowered studies, the

existing evidence suggests that bariatric surgery in severely obese adolescents
results in significant weight loss and improvements in comorbidities and quality
of life.
l Postoperative complications, (both physical and psychological), compliance and
follow-up may be more problematic in adolescents than adults, and long-term data
on safety, effectiveness and cost remain largely unavailable.
l Simple adoption of adult bariatric surgery guidelines for use in younger age groups
would overlook the contrasting metabolic, developmental and psychological
needs of children and adolescents and could result in the inappropriate use and/
or overuse of weight loss surgery. Conversely, delaying treatment and allowing
comorbid conditions to progress could be equally or more disadvantageous.
l An academic approach to child and adolescent bariatric surgery is warranted until
further long-term prospective studies on the subject are conducted.
l Controlled clinical trials to test the safety and efficiency of surgical approaches
to address obesity in young people are required, as well as renewed efforts at
developing effective approaches to preventing and treating excess weight gain in
children in order to inhibit progression to greater degrees of obesity.
 Introduction

Since the early 1990s, the prevalence of childhood and adolescent obesity in Europe
has grown rapidly. Despite reports of levelling off in some countries (1–3), childhood 1
obesity and its associated morbidities and costs are considerable and increasing
in scale in many European countries (4,5), particularly among socioeconomically
disadvantaged population segments (17). Obese children and adolescents are more
likely than their normal weight peers to suffer endocrine, cardiovascular, pulmonary,
orthopaedic, psychosocial and other complications associated with excessive weight,
many of which persist into adulthood (6,7,18). While prevention of obesity must
continue to be a policy goal, the treatment of those that are already obese is an issue
requiring urgent attention.

The treatment options for children and adolescents include changes in dietary and
physical activity behaviour as well as pharmacotherapy and bariatric surgery (19).
A recent Cochrane review of childhood obesity treatments (20) concluded that
combined behavioural lifestyle interventions, compared with standard care or self-
help, can produce a significant and clinically meaningful reduction in overweight in
children and adolescents. For severe paediatric obesity, however, there is evidence
to suggest that non-surgical approaches are of limited effectiveness (14). Moreover,
strong evidence for successful and cost-effective strategies is still generally lacking,
in large part because of methodological shortcomings in the majority of prevention
trials (18).

In this context, the medical profession is increasingly turning to surgical options

(see below) to treat obesity in children and adolescents (21). While established
as a safe and effective alternative with well-defined risks for severely obese
adults (8–12), little has been published on bariatric surgery in children and their
distinctive metabolic, developmental and physiological needs (13). In the
above-mentioned Cochrane review of childhood obesity treatments the maximum
follow-up of studies was two years and no surgical intervention studies met the
inclusion criteria (20). To date there has only been one randomized controlled trial
(published one year after the Cochrane review) comparing bariatric surgery with a
lifestyle intervention in adolescents (22).

The concerns about bariatric surgery for children and adolescents include questions
about obtaining informed consent from minors, timing of intervention, whether or not
 surgery is cost-effective, maintenance of weight loss, how to ensure healthy growth
through to adulthood, what support services are needed after surgery, compliance
with the postoperative nutrition regimen and ensuring participation in lifelong medical
surveillance. Therefore, bariatric surgery for the treatment of child and adolescent
obesity remains controversial. Many researchers are calling for caution and a critical
appraisal of surgical interventions to treat obesity in children and adolescents (7,23–
25), as well as an economic analysis of these procedures to provide evidence in
support of policy-making.
2
This report reports on the evidence of whether surgical interventions to treat children
and adolescents have long- versus short-term advantages and whether they are cost-
effective.

This report was challenging because of a number of limitations within the existing
literature:

l Apart from one randomized controlled trial, the studies assessing the effectiveness
of surgical options for obesity in children and adolescents were either
retrospective or observational, and underpowered.
l Sample sizes were generally small, with the largest sample containing only 68
patients and the majority of studies reporting data on fewer than 40 patients.
l Results are not broadly comparable given a lack of consistency across surgeons,
procedures and reported outcomes.
l Accurate information for low-frequency outcomes like mortality and complications
is sparse.
l No studies on clinical effectiveness reported on costs, and only one publication
addressed bariatric surgery cost in children.
l It is difficult to assess the degree of weight regain in adolescents from the
literature, partially because of the bias introduced by patients lost to follow-up.
In the current review, weight regain was reported in four studies for a minority
of patients and ranged from 50 to over 100% of weight lost (26–29). Common
reasons for weight regain include postoperative complications, such as pouch
dilation and staple disruption, and poor postoperative dietary habits, underscoring
the need for continued focused research on effective behavioural lifestyle
interventions.

Indications and patient assessment

A review of 15 guidelines for bariatric surgery in adolescents (30) reported on

inclusion and exclusion criteria for surgery as detailed below.
Inclusion criteria

There appears to be very little consensus on an appropriate age for using surgical
interventions; guidance is more likely to be offered on developmental stage rather
than chronological age. Recommendations include Tanner stage 3 (31) or 4 or 5
(32,33), final or near final adult height (32–34), post-pubertal (35), physical maturity
(assumed to be > 13 years for girls and > 15 years for boys) (36), complete or near
complete skeletal and developmental maturity (31,37,38), minimum bone age of
13 years for girls and 15 years for boys (32) and bone age > 13 years for girls and
3
> 15 years for boys (39).

Body mass index (BMI, in kg/m2) is the most often cited inclusion criteria, although
there is much variation in the guidance. Nine guideline documents set minimum
thresholds > 35 (31–34,36–40) while five suggest > 40 (36–38) and one uses BMI
standard deviation scores (35).

Nine publications include comorbidities in addition to the BMI criteria (31–34,36–

40). Severe comorbidities (i.e. type 2 diabetes, hypertension, non-alcoholic
steatohepatitis, benign intracranial hypertension, obstructive sleep apnoea) are
mentioned in three publications as mandatory criteria for eligibility for surgical
intervention in addition to a minimum BMI threshold (32,35,38).

Ten guidelines require previous attempts at weight loss prior to bariatric surgery
(31–34,36–41). Details mentioned include minimum of six month’s duration
(32,33,36,38–41), lifestyle modification component (32,33,36,40), formal
supervision or organized weight loss (32,34) and family involvement (39).

The issue of consent is addressed only by four sets of guidelines. These specify the
conditions required as assent from the adolescent (34,39), informed consent from
the adolescent (37), informed consent from the adolescent and full consent from
parent/legal guardian (32) and informed permission from caregivers (34).

Patient and family knowledge and attitudes is given as an indication for surgery in
some guidelines: these include a requirement that patients be motivated and well-
informed (31,32,34,38,40), aware of the risks of surgery (31,34,41), in a supportive
family environment (32,33,39,41) or psychologically stable (31,33,37,40,41).
Preoperative psychiatric or psychological patient (34,39) and family (33,39)
evaluations are also suggested. Capability and willingness to adhere to
postoperative guidelines and prolonged surveillance (32–34,37) are referred to in
inclusion criteria.
 Exclusion criteria/major contraindications

In the same review (30), six guidelines were found that describe exclusion criteria
or major contraindications for bariatric surgery in the paediatric population. These
include pregnancy or breastfeeding (31–33), alcohol or substance abuse (31,37,40)
and Prader-Willi syndrome or other hyperphagic conditions (32,33). Further
cautions are given that recommend against bariatric surgery for adolescents with
life-threatening multisystem organ failure, uncontrolled or metastatic malignancy,
uncontrolled HIV infection, hypercarbic respiratory failure, active systemic infection
4
or untreated endocrine dysfunction (31), plans to conceive or unresolved eating
disorders (33), diseases threatening in the short term or lack of care (self-care or
access to family or social support) (37) and medically correctable causes of
obesity (34).

Surgical interventions for obesity

Bariatric surgery refers to a number of different procedures designed to restrict food

intake and/or reduce nutrient absorption (Table 1). The procedures are now usually
performed laparoscopically for adults and adolescents (42). The most common
operations for adolescents are laparoscopic adjustable gastric banding (LAGB) and
Roux-en-Y gastric bypass (RYGB).

Table 1 Bariatric surgical interventions

Restrictive Malabsorptive Combination

Banding: adjustable gastric Biliopancreatic diversion Bypass: gastric bypass (GBP);

band (AGB); laparoscopic (BPD) usually with duodenal laparoscopic GBP (LGBP);
AGB (LAGB) switch (DS or BPD-DS) Roux-en-Y GBP (RYGB);
Gastroplasty: vertical laparoscopic RYGB (LRYGB);
banded (VBG), horizontal open RYGB (ORYGB); distal
(HG), and silicone band GBP (DGBP); long-limb GBP
(SBG) gastroplasty (LLGBP)

Gastrectomy: laparoscopic Other: vagotomy (VAG);

sleeve gastrectomy (LSG); sleeve gastrectomy with
sleeve resection (SR) entero-omentectomy (SGE)

Other: intragastric balloon

(IGB)

The least invasive of the purely restrictive bariatric surgery procedures is LAGB,
which does not permanently alter gastrointestinal continuity (43). An adjustable band
is placed around the uppermost part of the stomach, creating a small gastric pouch
that will restrict food intake. Band adjustments are made with saline injections via a
subcutaneous access port and are usually done at regular intervals postoperatively
until target weight is reached. Although LAGB is not currently approved by the
American Food and Drug Administration for implantation in adolescent patients, it is
considered to be the safest operation (25) and the most regularly used procedure in
Europe (44). Complications with LAGB include those associated with the operative
procedure, splenic injury, oesophageal injury, wound infection, micronutrient
deficiency, port or tube dysfunction, hiatus hernia, pouch dilation, band slippage,
band erosion (or migration), reservoir deflation/leak, persistent vomiting and acid
reflux (9,45). Revisional or band-removal surgery may be expected in up to 20% of
adult patients after follow-up periods averaging five years (46,47).
5
The RYGB method involves complex alteration of gastrointestinal anatomy, although
reversal is technically possible. To restrict gastric capacity, a small proximal stomach
pouch is created at the gastro-oesophageal junction, to which a Roux limb of the
small bowel is anastomosed. The majority of the gastric and duodenal alimentary
system is bypassed (44), preventing normal absorption of calories and nutrients
and necessitating long-term vitamin and mineral supplementation. The beneficial
metabolic effects of the RYGB have not yet accurately been defined, but it appears
to cause rapid remission of diabetes postoperatively (48). Although complications
appear to be higher than for LAGB, occurring at a rate of 20–30% (42), weight
loss is typically higher than that achieved with purely restrictive procedures, and it
is the only approved procedure for adolescents in the USA (44,49). Associated
complications include postoperative bleeding, severe malnutrition (particularly iron,
vitamin B12 and calcium deficiency), shock, failure of or leak in the staple partition,
acute gastric dilatation, delayed gastric emptying, vomiting, wound hernias, bowel
obstruction, anaemia, stomal stenosis, gallstone formation, marginal ulceration and
dumping syndrome (caused by eating refined sugar, symptoms of which include
rapid heart rate, nausea, tremor, faint feeling and diarrhoea) (9,44,50).

Sources for this review

This report is based on a detailed search of the medical and scientific literature using
PubMed and the Cochrane Library databases, supplemented by specific searches
for additional papers cited in research studies and review articles. The searches
were designed to identify evidence on whether surgical interventions to treat obesity
in children and adolescents have long- versus short-term advantages and whether
they are cost-effective. The searches followed validated methods for systematic
reviews (51) and included studies with the following designs: case studies,
longitudinal studies, prospective cohorts, prospective longitudinal trials, prospective
randomized controlled trials, retrospective analyses, cohorts and multicentre studies.
Kin relationships, where multiple publications described overlapping series of
patients, were identified and only data from one study were included to avoid
double counting cases. The authors defined adolescents as aged 10–19 years
 according to the World Health Organization (WHO) definition, and children as < 10
years of age.

The search strategy identified 1410 citations of which 233 articles were included
as potentially relevant. Examination of the full text of these articles revealed 46 of
sufficient quality for detailed review and inclusion in the assessment, of which 13
were kin studies. Reasons for excluding potentially relevant articles included no
original data (n = 78), no paediatric data (n = 42) and unobtainable papers (n = 24).
The search strategy is described in more detail in Annex 1.
6
 Findings

Effectiveness of surgical options in children and adolescents

7
Thirty-three relevant papers on bariatric surgery in children or adolescents were
included. These spanned 36 years, but 12 (36%) were published after the
December 2007 cut-off used by Treadwell et al. in the only existing systematic
review on the topic (45). The majority of studies (26) looked exclusively at
adolescents, together covering 604 subjects. Six studies in 199 patients examined
both children and adolescents (8 years was the youngest age in the ranges studied),
and a single case study was the only research to focus solely on children. The
results according to surgery type are described in the following section and in Annex
2 in Tables 2–4. Formal meta-analysis and comparisons between surgery types were
not attempted because of the marked heterogeneity of study designs and outcome
measures among the included studies.

Gastric banding

Eleven studies examined gastric banding, including four retrospective studies

(52–55), four cohort studies (56–59), two prospective longitudinal trials (60,61)
and a prospective randomized controlled trial (22), together covering 427 patients
aged 9–19 years. Eight studies looked at adolescents (n = 266), while three also
examined children (n = 161). Mean baseline BMI in patients studied ranged from
42.4 to 50. All but two papers (54,56) described baseline comorbid conditions,
which included amenorrhoea, depression, dyslipidaemia, hypertension, metabolic
syndrome, orthopaedic problems, osteoarthritis, sleep apnoea and type 2 diabetes.

Follow-up time varied greatly, ranging from 3 to 85 months. Ten studies reported
preoperative and postoperative BMI measures, with mean BMI reductions
ranging from 8.5 to 16.4. One study (22) compared BMI reduction in 25 surgical
patients with a mean age of 16.5 years with that in patients treated with a lifestyle
intervention; it found that mean BMI in patients receiving gastric banding decreased
by 12.7 (30%) after two years compared with 1.3 (3%) in the control group. Two
studies (57,59) did not report on percentage of excess weight loss, while the other
nine studies reported an average excess weight loss at 12 months ranging from
34 to 60%. Changes in comorbid conditions were reported in seven studies, with
resolution of specific comorbidities reported in 11–100% of cases. Only two studies
examined quality of life measures (58,60). Six out of eleven studies did not report
 on mortality; five studies reported that there were no surgery-related mortalities (52–
54,56,59). All papers reported on surgical complications, with only one reporting
no complications (57). The others reported a range of complications including band
slippage in 2–13% of cases in five studies (53,55,56,59,61); band removal because
of psychological intolerance in 10% of patients in one study (53); repeated vomiting
in 18% of cases and band readjustment in 10% of cases in one study (52). No
weight regain was reported.

8 Gastric bypass

Of eight papers examining RYGB (26,62,65–70), three were retrospective studies

(26,62,68), two were longitudinal (67,70) and three were case studies (65,66,69),
covering a total of 135 adolescent patients aged 13–21 years. Mean baseline BMI
in patients studied ranged from 48 to 60. All but two studies (26,66) described
baseline comorbidities, including hypertriglyceridaemia, hypercholesterolaemia,
degenerative joint disease, diabetes, osteoarthritis, sleep apnoea, asthma and
gastroesophageal reflux.

Follow-up time ranged from 4 to 156 months, with two studies presenting more
than one year of follow-up data in 40 patients. All studies reported preoperative and
postoperative BMI measures, with mean BMI reductions ranging from 9 to 25. Three
studies (62,65,68) reported on the resolution of comorbid conditions: in one study
(68), three of the four patients reported 100% resolution of hypertriglyceridaemia,
hypercholesterolaemia, degenerative joint disease, asthma and gastroesophageal
reflux. Improvements such as a decrease in triglycerides, total cholesterol, fasting
blood glucose, fasting insulin and blood pressure were also reported (26,67,70).
One surgery-related death was reported (26). All studies but one (67) reported
on postoperative complications, with only two studies reporting none (65,68);
the others reported a range of complications including dehydration, peristomal
ulcer, intestinal leakage, wound infection, anastomotic stricture (62,70), nutritional
deficiencies (70) and bowel obstruction (62,66). Weight regain was reported in two
patients in one study (26). One study (67) examined quality of life measures, citing
postoperative improvement.

Other forms of bariatric surgery

Of the thirteen studies reporting other forms of bariatric surgery, three were case
studies (71–73), five were retrospective reviews (27,28,64,74,75) and five were
prospective cohort studies (29,76–79). Nine studies looked at adolescents
(n = 203); three examined both children and adolescents (n = 38), and one case
study considered a child. Mean baseline BMI in patients studied ranged from 42 to
62. Sleeve gastrectomies, a relatively new procedure, were performed in 19 patients
(71–73,78,79). Vertical banded gastroplasty was performed in 61 patients in four
studies (27–29,64). Five papers reported on more than one surgical procedure,
in 91 patients, and presented combined results (27,28,74,79,80). One Italian
retrospective study on biliopancreatic diversion reported two or more years of
follow-up data in 68 patients, with mean excess weight loss of 78% (75). With the
exception of those with a RYGB component, the procedures reported on below are
not commonly used. Jejunoileal bypass and biliopancreatic diversion have both been
largely abandoned because of the high risk of nutritional complications, morbidity
and mortality resulting from bypassing the majority of the small intestine (81,82), and
vertical banded gastroplasty results in modest weight lost and a higher postsurgical 9
complication rate (83). Vertical sleeve gastroplasty is reported to be gaining in
popularity because of a predictably lower risk of nutritional complications and a
weight loss performance that is potentially comparable to other procedures (84).

Studies described a wide range of baseline comorbidities, including depression

(27,72,73,79), hypertension (27,28,75,76,79) and diabetes (28,74,78). Follow-up
time ranged from 0 to 276 months, with two studies presenting five-year follow-
up data in 45 patients. All studies reported preoperative and postoperative BMI
measures, with mean BMI reductions ranging from 9 to 24. Changes in comorbid
conditions were reported in all but two studies. There were generally high rates of
resolution or improvement in physical (e.g. hypertension) (27,28,75,77) and mental
(73) health. Eleven papers reported on surgical complications, four of which reported
no complications (65,71,74,77), and the others reporting a range of complications
including pulmonary embolism (28); nutritional deficiencies (27,28,76,78) such as
anaemia, thiamine deficiency, electrolyte imbalance and early protein malnutrition;
infections and ulcers (28,75,78); and mechanical problems such as enlarged pouch
and disrupted staple lines (29). Three surgery-related mortalities were reported in
one study, resulting from protein energy malnutrition, pulmonary oedema and acute
necrotizing pancreatitis (75). Weight regain was reported in seven patients in two
studies (27,28).

Cost–effectiveness of surgical options in children and adolescents

The only systematic review of the literature on the effectiveness of child and
adolescent bariatric surgery (in 2007) concluded that there was insufficient
evidence on which to base a comprehensive cost profile of surgical options for
paediatric obesity management (45). Since then, only one study examining the cost
of bariatric surgery in children has been identified (85). This paper was concerned
with modelling the costs of paediatric obesity interventions in comparison with other
forms of treatment and prevention of obesity in childhood. It took cost data from a
series of 28 patients who had LAGB and gave an average estimated cost of
AU$ 31 553 per child (approximately US$ 24 330 or €18 000), exclusive of future
cost savings.
 These findings are comparable with those reported for adults, although most cost
analyses of bariatric surgery appear to have been performed in an American setting,
and thus may have limited relevance to European countries with universal health care
coverage. One study based in Wisconsin analysed the inpatient hospital discharge
data from 1990 to 2003 and concluded that rate and costs of weight loss surgeries
had increased dramatically and the incidence of postoperative complications was
high (86). In a more recent study, a large employer claims database was analysed
for bariatric surgery patients and related costs from 1999 to 2005; the authors
10 found that third-party payers could expect bariatric surgery to pay for itself through
decreased comorbidities within two to four years (87).

A recent systematic review and economic evaluation of the clinical effectiveness and
cost–effectiveness of bariatric surgery for obesity modelled economic evaluations of
bariatric surgery. Based on these, the authors concluded that bariatric surgery was
cost-effective compared with non-surgical treatment, but noted that the variability in
estimates of costs and outcomes is large and the methodological shortcomings of
such models are numerous, making it difficult to provide generalizable estimates of
cost–effectiveness of bariatric surgery in comparison with non-surgical treatment (9).

While children and adolescents might benefit from a longer lifetime with associated
lower medical costs, lack of data does not permit accurate quantification of lifetime
costs and thus calculation of cost–effectiveness ratios.

Summary of recommendations from existing reviews on child and

adolescent weight loss surgery

Several papers (9,15,23,24,44,45,83,88–93) have made recommendations and

clinical guidelines for child and adolescent weight loss surgery, although these
are based to a great extent on the data sources presented in the current evidence
review, which are underpowered and generally of poor quality. A cross-comparison
of recommended BMI thresholds for bariatric surgery in young people demonstrates
the great variability across recommendations. They range from “extreme obesity”
(15,23,83,90) to “morbid obesity” (45,89), “a BMI ≥ 40 or ≥ 35 with significant
comorbidity” (44,88), “severe obesity” (93), “a BMI > 40 and one or more
comorbidities” (92), “a BMI > 50 or > 40 with significant comorbidity” (91), to “a
BMI > 95th percentile with significant comorbidity or a BMI > 99th percentile” (94).

Several reviews concluded that bariatric surgery results in effective or clinically

significant weight loss: one 2005 review concluded that weight loss surgery can be
a safe and effective treatment option for carefully selected adolescents with severe
obesity and serious related comorbidities (93). Another review conducted by the
Ontario Medical Advisory Secretariat in 2005 referred to LAGB as safe and effective
(89). A more recent review (2009) concluded that RYGB is a safe and effective
option for extremely obese adolescents as long as there is appropriate long-term
follow-up provided, and that adjustable gastric banding and sleeve gastrectomy
should be considered investigational. Other surgical interventions such as
biliopancreatic diversion and duodenal switch procedures cannot be recommended
in adolescents because of the substantial risks of protein malnutrition, bone loss
and micronutrient deficiencies (23). These recommendations may reflect the
varying levels of expertise with specific types of bariatric surgical procedure across
countries.
11
The only systematic review of the literature on the effectiveness of child and
adolescent bariatric surgery (45) concluded that LAGB and RYGB for morbidly
obese patients (aged 21 or younger) can result in sustained and clinically significant
weight loss compared with non-operative approaches, however, the evidence is
insufficient to conclude on quantitative estimates of the precise amount of weight
loss. Moreover, compared with non-surgical approaches, LAGB and RYGB can
help to resolve comorbid conditions such as diabetes and hypertension, although
there is not enough evidence to conclude on quantitative estimates of the likelihood
of comorbidity resolution, quality of life improvement and survival, or on potential
impacts of bariatric surgery on growth and development (45).

Many reviews recommend a cautious approach, however, citing lack of sufficient

evidence on adverse effects and a potential for raised risk of postoperative morbidity,
weight regain and mortality as a basis for limiting the use of paediatric bariatric
surgery to clinical trials only. Guidance from the American Society for Bariatric
Surgery in 2004 suggested that, after a thorough medical and psychological
assessment, adolescents must have decisional capacity, participate in the decision
process and have parental support. In particular, the need for lifelong care must be
emphasized to the patient and their family. The authors stressed the importance
of collecting and analysing long-term and non-traditional paediatric bariatric
surgical data (88). A recent (2009) review of the clinical effectiveness and cost–
effectiveness of bariatric surgery for obesity (9) found no published studies on
clinical effectiveness of surgical intervention for obesity in young people that met the
inclusion criteria of the review.

There are several reviews with particular relevance to European countries. In 2005,
a European Expert panel, the “Bariatric Scientific Collaborative Group”, was created
with representation from the major European scientific societies active in the field of
obesity management. The panel published clinical guidelines on surgery for severe
obesity, recommending that surgery in children and adolescents (including those with
genetic syndromes) could be considered in centres with a multidisciplinary approach
and extensive experience with adult bariatric surgery. The recommended criteria for
eligibility for surgery included BMI > 40 (or 99.5th percentile for respective age)
and at least one comorbidity; more than six months of organized weight-reducing
 attempts in a specialized centre; skeletal and developmental maturity; capability to
commit to comprehensive medical and psychological evaluation before and after
surgery; willingness to participate in a postoperative multidisciplinary treatment
programme; and access to a hospital unit with specialist paediatric support (nursing,
anaesthesia, psychology, postoperative care) (37). In 2006, the National Institute
for Health and Clinical Excellence (NICE) in the United Kingdom produced clinical
guidelines on obesity prevention and treatment (41), which suggested consideration
of bariatric surgery for young people only in exceptional circumstances, and if they
12 have achieved or nearly achieved physiological maturity.

Recent guidance published in 2010 in Australia and New Zealand (32) and in Israel
(39) in 2009 cited a minimum age of 15 and 13, respectively, for bariatric surgery
eligibility. Recommended criteria for eligibility included comprehensive preoperative
psychological, social, educational and family assessment; multidisciplinary surgical
team with paediatric expertise; regular postoperative dietetic monitoring; and a
postoperative audit to collect data on outcomes, complications, quality of life,
nutritional status and comorbidities in both the short and long term.
 Discussion

The results clearly indicate a much more limited evidence base for bariatric surgery
in children compared with adolescents, and in obese adolescents compared with 13
their morbidly obese counterparts. Distinguishing between these groups is further
justified by the fact that childhood BMI is associated with adiposity in adulthood,
and the magnitude of this correlation increases with the age at which the childhood
measurement is obtained (95). Furthermore, the accuracy of childhood BMI as an
indicator of body fatness increases with the degree of adiposity (95). This suggests
that perhaps age and degree of obesity should be considered on a continuum when
making recommendations for bariatric surgery use.

Bariatric surgery is promoted as a treatment option for children and adolescents

for several reasons, as outlined above, but these also generate some controversy.
Proponents in the surgical community suggest that the procedure is justified by
weight loss results from clinical trials in adults and that surgery should form part of a
multidisciplinary paediatric weight management strategy to address life-threatening
comorbidities seen in morbidly obese children. They add that, in practice, most adult
bariatric centres already perform adolescent surgery (96). In principle, treatment
risks are accepted when the benefits of treatment outweigh the risks of inaction. So
the use of bariatric surgery in paediatric weight management is needs-related not
age-related: that is, when the risks of chronic comorbidities outweigh the risks of
surgery at any age.

However, most children do not exhibit severe weight-related comorbidities that are
associated with significant mortality and morbidity in the short term. For the majority
of morbidly obese children, therefore, the risk–benefit ratio of bariatric surgery is
extremely difficult to assess. The question arises whether we can be confident that
the profound weight loss outweighs the long-term risk of iatrogenic endocrine injury,
particularly when the obesity-related health risks for a child do not force immediate
surgical intervention? (63,97) In contrast, it is claimed that behavioural therapy
approaches to weight management have been demonstrated to be more effective for
children and adolescents than for adults (98).
 Unique challenges of children and adolescents

Children and adolescents have distinctive metabolic, developmental and

psychological needs, which must be carefully considered to avoid the inappropriate
use of weight loss surgery. In particular, there are several areas of concern, as
outlined below.

Complications
14 Researchers and practitioners point to the high risk of serious operative and
postoperative complications and mortality (18). Comparatively higher morbidity and
mortality associated with gastric bypass have led to increased use of gastric banding
in the United States, particularly for morbidly obese adolescents (98). Clinical
evidence demonstrates that complications are directly related to the experience
of the surgical team (99). A 2006 study that assessed insurance claims for 2522
adult bariatric surgeries at more than 300 hospitals in the United States identified
a significant high complication rate during the six months after surgery (data not
typically reported in the literature), resulting in costly readmissions and emergency
department visits in nearly 40% of patients (100).

Nutrition

Bariatric procedures increase the risk of malnutrition, through either malabsorption

or decreased nutrient intake, although the risk is lower with restrictive procedures
(101). With LAGB, these are related to reduced intake of food, and with RYGB
are related to both reduced intake and mild malabsorption as a result of bypassing
the stomach (diminishing gastric digestion) and the duodenum (a main site for
calcium and iron absorption) (83,102). Nutritional complications are particularly
important considerations for young patients because of their long life expectancy
and reproductive capacity. Patients who have had gastric bypass are at risk of
vitamin deficiencies because excess weight loss is rapid during the first year after
surgery, and the altered gastrointestinal anatomy reduces absorption of several
micronutrients, including iron, calcium and vitamin B12 (103). Even patients with
restrictive surgeries may suffer from malnutrition because of reduced food intake and
lack of improvement in diet quality. The consumption of calorifically dense liquids in
obese adolescents raises a concern that restriction alone may not be sufficient for
the extremely obese adolescent (99).

Compliance

The ultimate success of all bariatric procedures depends on a patient’s ability to

adhere to a markedly changed and reduced diet. Given the propensity for some
adolescents to rebel against strict regimens, continued support must be available to
all of these patients. Postoperative vitamin and mineral supplementation is critical.
All non-steroidal anti-inflammatory medications should be avoided (104). After
surgery, patients are typically prescribed a multivitamin and monitored periodically
for nutrient deficiencies; in younger patients, ability to cooperate with postoperative
dietary restrictions and comply with medical requirements may be reduced (96).
Adolescents have a variable but low rate of adherence to supplementation and,
therefore, may potentially be at higher risk for development of nutritional deficiencies
(105).
15
Family

Given the close association of excess weight in children with excess weight in
their parents, it is important to recruit parents into any weight management plan.
Bariatric surgery requires the active participation, understanding and consent of the
patient and relevant caregivers. However, there are ethical concerns with obtaining
paediatric consent. While adolescents are increasingly seeking bariatric surgery
for justifiable health reasons, most children are not fully capable of participating in
weight loss surgery treatment decisions, nor of comprehending and adhering to
the critically important dietary and activity plan needed postoperatively for lifelong
success (13). Patient follow-up is important to success for maximal weight loss with
the LAGB (106), and parental involvement may be essential to ensure attendance
(107).

Growth and development

Surgical timing is controversial for a number of reasons: pubertal development

and growth, neuroendocrine and skeletal maturation, sexual development and
psychological maturity. There is potential for as-yet-unknown chronic complications
(93), although it is assumed that controlled weight loss would not lead to any
change in normal growth or maturation (108). Normal growth and development may
be affected by rapid weight loss or nutrient deficiencies induced by surgery, but may
also be affected by severe excess weight. More evidence is needed in this area.
Developmental stage dictates children’s control over food choices and involvement
in physical activity. Weight management that requires strict, unpalatable activities or
schedules may be harder to maintain during changing developmental stages (109).

Lifespan

Children and adolescents have an entire lifetime ahead of them, indicating the need
for careful, lifelong, medical supervision of those who undergo bariatric procedures
(13). Some procedures have a limited lifespan: in particular, use of the gastric band
creates a potential need for reoperation to replace (13). Fertility generally increases
after weight loss in adults; however, the potential effect of procedures on future
 reproductive ability and pregnancy outcome are unknown. Preliminary data suggest
that quality of life and depressive symptoms after RYGB in adolescents dramatically
improve, moving close to the level in normal controls (67,101).

Metabolic consequences

In adults, the loss of fat mass, particularly visceral fat, is associated with multiple
metabolic, adipokinetic, and inflammatory changes that include improved insulin
sensitivity and glucose disposal, reduced free fatty acid flux, increased adiponectin
16
levels, decreased interleukin 6, tumour necrosis factor-alpha and high-sensitivity
C-reactive protein levels. Metabolic effects resulting from bypassing the foregut
include altered responses of ghrelin, glucagon-like peptide-1 and peptide YY3–36,
gut hormones involved in glucose regulation and appetite control (110). In adults,
these metabolic changes may be responsible for improvements in comorbidities;
however, this has not been studied in children. There is evidence that in younger
patients metabolic complications of surgery are potentially greater (96). Surgeries
involving removal or bypass of the acid-producing portion of the stomach profoundly
decrease circulating ghrelin concentration (111,112). There is evidence to suggest
an important role for ghrelin in somatic growth and bone mineralization in childhood
that is almost certainly relevant to growing children. It is not known whether the
endocrine system of a developing child, which is dependent upon normal production
of growth hormone and numerous other hormones, has the capacity adapt to a
significant and chronic reduction in ghrelin levels following malabsorptive surgery
(63). Adolescence is a time of unusual insulin resistance as part of the normal
physiological processes associated with puberty. Obesity amplifies the situation
markedly: for a similar fatness, adolescent obese children may have more profound
degrees of metabolic abnormality than adults.

Comorbidities

Some reviews suggest that the greatest benefit may be achieved by the earliest
intervention, in order to prevent a long duration of comorbidities. The duration of
type 2 diabetes significantly predicts poor or incomplete resolution of diabetes after
weight loss surgery in adults (113–116). A delay in effective therapy means the
condition is typically more severe and the risk of complications higher (88,117).
Other reviews suggest that conservative patient selection criteria should be
considered for adolescents because, while many comorbidities of obesity can be
documented in childhood and adolescence, the severity of these complications for
the majority of obese adolescents may not justify surgical intervention for minors
(118). Distinguishing the effects of dietary changes from those of weight loss
on improvement of comorbid disease conditions is difficult. Weight loss can be
assumed to be responsible for mechanical improvements, such as reduced weight
bearing on joints, improved lung compliance and reduced bulky fatty tissue around
the neck, which relieves obstruction to breathing (90). As in adults, glycaemic
control in patients with diabetes improves almost immediately after RYGB, preceding
any significant weight loss. This suggests alterations in gastric hormones that
augment insulin secretion may be altered by gastric bypass (83).

Issues requiring further investigation

l Clear care criteria. Pre-requirements for surgeons and multidisciplinary teams 17

in centres performing bariatric procedures in adolescents, as well as pre- and
postoperative care criteria for this age group must be determined.
l Rates of weight loss associated with different bariatric procedures. Slower rates
of weight loss associated with gastric banding compared with other surgical
interventions highlight the need for long-term monitoring and data collection to
compare the efficacy of procedures and ensure the most beneficial results.
l Sensitive approaches for subpopulations. Profound metabolic and medical
disturbances present in some children despite quite modest increases in obesity.
For example, children of some ethnicities appear to have dramatically worse
adolescent type 2 diabetes, linked to evidence of higher risk of type 2 diabetes
in Asians compared with Whites for a given BMI level (119). There are also
questions concerning the value of surgery for young people with monogenic
obesities (e.g. with mutations affecting melanocortin 4 receptor or leptin receptor)
or syndromic obesity. While an individual approach in these situations is
important, it makes the standardization of procedures and selection of patients for
randomized trials very difficult.
l New clinical classifications of obesity. Reliance on BMI as a primary tool for
clinical assessment and care is problematic; the classic adult BMI cut-off points
for categorizing patients are even less reliable when used in younger adolescents,
and comorbid conditions are an important consideration. Alternative approaches
should be considered, such as the obesity staging system proposed by Sharma
and Kushner, which describes the morbidity and functional limitations associated
with excess weight (120).
 Conclusions

The existing evidence, although based primarily on small-scale retrospective or

18 observational studies, suggests that bariatric surgery in severely obese adolescents
results in the majority experiencing significant weight loss and improvements in
comorbidities and quality of life. However, surgical complications in this age group
remain a concern, and the evidence base is not sufficient to permit mortality rate
calculations and assess whether mortality for this population is more or less likely
than it is for adults. Furthermore, compliance and follow-up may be more problematic
in adolescents than adults, and evidence for the long-term safety, effectiveness and
cost–effectiveness remains largely unavailable (18). Studies involving older, severely
obese adolescents are more common than ones with children and youth at lower
BMI values, and conclusions about the former group are better supported than those
for the latter.

Long-term metabolic and psychological consequences of bariatric surgery may differ

between adolescents and adults. Effective surgical intervention earlier in the life of
a morbidly obese person may be preferable to delayed intervention after decades of
exposure to the health effects of morbid obesity. There are many other unresolved
questions emerging from the limited evidence at hand.

l Is a standard approach best or will distinct paediatric subpopulations

(characterized by age, ethnicity, degree of obesity, type of comorbidity, etc.)
benefit from specific bariatric procedures?
l To what extent can we extrapolate adult results to children and adolescents?
l Are improvements in quality of life and comorbidities derived from surgery-induced
weight loss long lasting?
l What are the predictors of success and safety with bariatric surgery?
l What is the most appropriate timing for bariatric surgery in young people?
l What is the likelihood of risk-taking behaviour after successful weight loss?
l What is the durability of weight loss?

The resolution of these issues requires long-term prospective studies to establish

safety and efficacy of surgical procedures and to clarify whether reductions in
morbidity and mortality outweigh the risks of serious surgical complications and
lifelong nutritional deficiencies (18). The relatively small number of adolescent
bariatric procedures performed suggests that multicentre research and coordination
between adult and adolescent bariatric programmes will be necessary for better
quantification of benefits and risks of early surgical intervention for adolescent
morbid obesity. Cooperation is needed to ensure better multicentre data and the
development of general guidelines (92).

While bariatric surgery may be appropriate for adolescents who are severely
obese, there is still an urgent need to develop alternatives to surgery, such as
practical lifestyle programmes that are effective, even modestly, for overweight and
obese children (121) to inhibit progression to greater degrees of obesity. Public
health experts must continue to employ the precautionary principle to convince
19
governments of the importance of implementing health-promoting public policies
to support primary prevention programmes and adequate long-term research for
treatment.
20
Annex 1. Search strategy

Scientific and biomedical literature

The present review was based upon a bibliographic search of databases, concluded
on 19 April 2010.

Databases 21
The PubMed and Cochrane Library databases were searched, using keywords (and
roots of keywords) as set out in the search terms below.

Search terms

#1. obes*[TIAB] OR overweight*[TIAB] OR weight loss[TIAB] OR weight

reduc*[TIAB] OR BMI[TIAB] = 172,843

#2. child[TIAB] OR children[TIAB] OR adolescen*[TIAB] OR pediatr*[TIAB] OR

paediatr*[TIAB] = 909,583

#3. bariatric[TIAB] OR gastric surgery[TIAB] OR gastroplasty[TIAB] OR

gastrectomy[TIAB] OR gastric bypass[TIAB] OR jejunoileal bypass[TIAB] OR
gastrointestinal diversion[TIAB] OR gastrointestinal surgery[TIAB] OR biliopancreatic
diversion[TIAB] OR biliopancreatic bypass[TIAB] OR gastric band*[TIAB] OR
gastrectomy[TIAB] OR gastroenterostomy[TIAB] OR LAGB[TIAB] OR stomach
stapl*[TIAB] OR lap band*[TIAB] OR lap-band*[TIAB] OR roux-en-y[TIAB] OR
malabsorptive procedure[TIAB] OR malabsorptive surgery[TIAB] OR restrictive
surgery[TIAB] OR restrictive procedure[TIAB] OR duodenal switch[TIAB] OR
antiobesity surgery[TIAB] OR weight loss surgery[TIAB] OR weight reduction
surgery[TIAB] OR surgery[TIAB] OR surgical[TIAB] = 973,334

#4. #1 AND #2 AND #3 = 903

#5. cost[TIAB] OR cost-effective[TIAB] OR econom*[TIAB] OR financ*[TIAB] OR

ICER[TIAB] = 306,845

#6. #1 AND #3 AND #5 = 507

Selection criteria

Inclusion. Peer-reviewed research studies, meta-analyses and reviews of the

literature about the effects of surgical interventions to treat obesity in
children and adolescents; cost–effectiveness of surgical interventions to
treat obesity; Danish, English, French, Norwegian, or Spanish language.
 Exclusion. Surgical interventions to treat obesity in adults; clinical guidelines,
reviews and commentary on surgical interventions to treat adult obesity;
studies with subjects > 19 years of age; follow-up time less than one
year; reporting combined results for different procedures; no pre- and
postoperative weight measure; no postoperative weight loss measure.

Grey literature

22 A review was undertaken of major documents and web sites of governments, health
councils and advisory and expert groups.

Institutional libraries

NICE – National Institute of Clinical Excellence (www.nice.org.uk); all guidance

documents

IASO-IOTF – International Association for the Study of Obesity - International

Obesity TaskForce (internal document repository)
Annex 2 Results tables

Table 2 Results of studies employing laparoscopic adjustable gastric band

Study Study No./age Follow-up Baseline Postoperative BMIa Adverse

(country) type (years)a (months)a BMIa effectsb
Abu-Abeid CO 11/15.7 23 46.6 32.1 NR
et al. 2003 (range, (range,
(Israel) (57) 11–17) 38–56.6)
23
Al-Qahtani RR 51/16.8 16 (range, 49.9 NR Yes
2007 (range, 3–34) (range,
(Saudi 9–19) 38–63)
Arabia) (52)
Angrisani RR 58/17.96 Range, 46.1 (SD, 35.9 (SD, 8.4) at 1 Yes
et al. 2005 (SD, 0–84 6.31; year (n = 48)
(Italy) (53) 0.99; range, 37.8 (SD, 11.27) at 3
range, 34.9– years (n = 37)
15–19) 69.25)
34.9 (SD, 12.2) at 5
years (n = 25)
29.7 (SD, 5.2) at 7
years (n = 10)
Dillard et al. RR 24/18 Range, 49 (SD, 43 (SD, 10; range, Yes
2007 (USA) (SD, 2; 3–48 10; range, 28–75) at 3 months
(54) range, 38–81) (n = 24)
14–20) 42 (SD, 13; range,
25–75)at 6 months
(n = 16)
40 (SD, 13; (range,
26–75)at 12 months
(n = 14)
35 (SD, 10; range,
24–47) at 18 months
(n = 8)
37 (SD, 6; range,
30–41) at 2 years
(n = 3)
38 (SD, 9; range,
30–50) at 3 years
(n = 4)
43 (SD, 14; range,
33–53) at 4 years
(n = 20)
Dolan & CO 17/16.5 Median 43.1 30.4 (range, 22.6– Yes
Fielding (range, 25 (range, (range, 39.4)c
2004 12–19) 12–46) 30.3–
(Australia) 70.5)
(56)
 Study Study No./age Follow-up Baseline Postoperative BMIa Adverse
(country) type (years)a (months)a BMIa effectsb
Fielding & RR 41/range, 33.8 (SD 42.4 29 (SD, 6; range, Yes
Duncombe 12–19 19; range (range, 23–47)
2005 1–70) 31–71)
(Australia)
(55)
Holterman PLT 20/16 29 (SD 50 (SD, mean reduction, 8.5 Yes
et al. 2010 (SD, 1; 9; range, 10; range, (SD, 5) at 12 months
24 (USA) (60) range, 15–42) 39–74) (n = 20)
14–17) mean reduction
9.4 (SD, 5.4) at 18
months (n = 12)
Nadler et al. Trial 45 (12- Range, 48 (SD, 36.3 (SD, 7.5) at 12 Yes
2009 (USA) month 12–24 6.4) months (n = 45)
(61) data for 35.8 (SD, 7.9) at 24
41)/16.1 months (n = 41)
(SD, 1.2;
range,
14–17)
O’Brien et RCT LAGB, 24 45.2 32.6 (SD, 6.8) Yes
al. 2010 25/16.5 (SD, 7.6;
(Australia) (SD, 1.4) range,
(22) Lifestyle, 32.5–
25/16.6 76.7)
(SD, 1.2)
Silberhumer CO 50/17.1 34.7 (SD 45.2 32.6 (SD, 6.8) Yes
et al. 2006 (SD, 2.2; 17.5; (SD, 7.6;
(Austria) range, range, range,
(58) 9–19) 3.6–85.4) 32.5–
76.7)
Yitzhak et CO 60/16 39.5 42.7 30 (range, 20–39) Yes
al. 2006 (range, (range,
(Israel) (59) 9–18) 35–61)

Notes: aPresented as mean unless otherwise indicated; bComplications, reoperation, mortality; cCalculated
based on reported data; BMI: Body metabolic index (kg/m2); LAGB: Laparoscopic adjustable gastric band;
NR: Not reported; SD: Standard deviation.

Study type: CO: Cohort study; PLT: Prospective longitudinal trial; RCT: Randomized controlled trial; RR:
Retrospective review.
Table 3. Results of studies employing Roux-en-Y gastric bypass (laparoscopic or
open)

Study Study No./age Baseline Follow-up Postoperative Adverse

(country) type (years)a BMIa (months) BMIa effectsb
Fowler et CS 1/17 56.8 14 32; mean NR
al. 2009 reduction, 24.8
(USA) (65)
Inge et LS 61/17.2 60.2 (range, 12 37.7c; mean Yes
al. 2010 (SD, 1.88) 41.4–95.5) reduction, 37.4% 25
(USA) (70)
Lawson et RMS Surgery, 39/ Surgery, > 12 Surgery, 35.8 Yes
al. 2006 range,13– 56.5 (range, (range, 26.7–52);
(USA) (26) 21 41.9–95.5) mean reduction,
Non- 20.7 (range, 3.3–
surgical, 43.5); p < 0.001
12/range
13–21
Leslie et CS 1/12.8 48 36 25; mean Yes
al. 2008 reduction, 23
(USA) (69)
Loux et al. LS 16/18.6 54.1 (SD, 17.1 35.1 (SD, 9.3); NR
2008 (67) (SD, 1.7; 7.6) (mean; SD, mean reduction, 9
range, 12.3)
14–20)
Stanford RR 4/range 55.14 17 (mean) 34.8; mean NR
et al. 2003 17–19 (range, reduction, 20.3
(USA) (68) 45–66) (range, 22–55)
Strauss et RR 10/16 52.4 (range, 68.8 35.2c; mean Yes
al. 2001 (range, 41.4– (mean; reduction, 17.2
(USA) (62) 15–17) 70.5)c (range, (range, 26.9–52.8)
8–156)
Towbin et CS 3/15.3 59.9 (range, 5 (mean; 38.9; mean Yes
al. 2004 (range, 56.2–63.4) range, 4–6) reduction, 21
(66) 14–17) (range, 16.4–26.6)

Notes: aPresented as mean unless otherwise indicated; bComplications, reoperation, mortality; cCalculated
based on reported data; BMI: Body metabolic index (kg/m2); NR: Not reported; SD: Standard deviation.

Study type: CS: Case study; LS: Longitudinal study; RMS: Retrospective multicentre study; RR:
Retrospective review.
 26
Table 4. Results of studies employing other surgical interventions

Study (country) Study Intervention No./age Baseline Follow-up Postoperative BMIa Adverse
type (years)a BMIa (months) effectsb
Baltasar et al. CS LSG 1/10 42 9 27 NR
2008 (Spain) (71)

Barnett et al. 2005 RR VBG (n = 7), RYGB 14/15.7 55.1 (SD, 72 (mean; range, Mean reduction, 24 (SD, 13.8) Yes
(USA) (27) (n = 5), JIB (n = 3) (range, 13–17) 14.8) 9–261) (n = 9)
Breaux 1995 RR VBG (n = 5), RYGBP 22 (11 with 62 (range, 36 Initial sleep apnoea, 46.5 at mean of Yes
(USA) (64) (n = 14), BPD (n = 4) sleep apnoea, 41.3–105) 32 months (n = 11)
11 without)/ No initial sleep apnoea, 35.5 at mean
range, 8–18 of 50 months (n = 11)
Capella & Capella CO VBG–RYGB 19/range, 49 (range, 66 (mean; range, 28 (range, 23–45) Yes
2003 (USA) (76) 13–17 38–67) 12–120)
Dan et al. 2010 CS LSG 1/6 53.2 12 33.33 NR
(Trinidad &
Tobago) (72)
Fatima et al. 2006 RC Mostly RYGB, some 12/≤ 18 55 (range, 48 (mean; range, 36 (range, 27–53) None
(USA) (74) VBG 39–74) 12–96)
Leon et al. 2007 CS LSG 1/12 44.2 12 29 NR
(Ecuador) (73)
Mason et al. 1995 CO VBG 47/18.1 (SD, 48.4 (SD, 6.9) 0–120 36.2 (SD, 5.99) at 5 years (n = 25) Yes
(USA) (29) 1.84) 39.2 (SD, 7.15) at 10 years
(n = 14)
Papadia et al. RR BPD 68/16.8 46 (range, 132 (mean; NR Yes
2007 (Italy) (75) (range, 14–18) 26–71) range, 24–276)
 Study (country) Study Intervention No./age Baseline Follow-up Postoperative BMIa Adverse
type (years)a BMIa (months) effectsb
Sugerman et al. RR HG (n = 1), VBG 33/16 (SD, 1; 52 (SD, 11; 0–168 36 (SD, 10) at 1 year (n = 31) Yes
2003 (USA) (28) (n = 2), GBP (n = 17), range, 12.4– range, 38–91) 33 (SD, 11) at 5 years (n = 20) or
distal GBP (n = 3), 17.9) 29 (SD, 5) if 5 with weight regain
long-limb GBP excluded
(n = 10)
34 (SD, 8) at 10 years (n = 14), or
30 (SD, 4) if 5 with weight regain
excluded
38 (SD, 16) (n = 6) at 14 years, or
31 (SD, 2) if 1 with weight regain
excluded
Till 2008 CO LSG 4/14.5 (range, 48.4 (range, 12 (mean; range, Mean reduction, 9.2 Yes
(Germany) (77) 8–17) 40.6–56.3) 6–19)
Velhote & Damiani CS SGE 10/16.3 51.7 (range, 12 32.8 (range, 27–47); mean Yes
2008 (Brazil) (78) (range, 14–19) 44–72) reduction, 83.9%
Widhalm et al. CO LAGB (n = 7), SR 10/17.3 (SD, 49.1 (SD, LAGB, 44 (SD, Mean reduction 10.33 at 41months: Yes
2008 (Austria) (n = 2), GBP (n = 1) 30 6.8; range, 10)
(79) 40.6–63.7) SR, 32 (SD, 1)
GBP, 8
(reoperation)
(SD, 3)

Notes: aPresented as mean unless otherwise indicated; bComplications, reoperation, mortality; BMI: Body metabolic index (kg/m2); NR: Not reported; SD: Standard deviation.

Study types: CO: Cohort study; CS: Case study; RC: Retrospective cohort; RR: Retrospective review.

Surgical interventions. Banding: LAGB: Laparoscopic adjustable gastric band; Gastroplasty: VBG: Vertical banded gastroplasty; HG: Horizontal gastroplasty; Bypass: GBP:
Gastric bypass; RYGB: Roux-en-Y gastric bypass; Gastrectomy: SR: Sleeve resection; LSG: Laparoscopic sleeve gastrectomy; SGE: Sleeve gastrectomy with entero-
omentectomy; Other: BPD: Biliopancreatic diversion; JIB: Jejunoileal bypass.
27
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Abstract

The prevalence of childhood and adolescent obesity in the WHO European Region has
risen in recent decades. Obesity in this population is linked to increased risk factors
for cardiovascular diseases, type 2 diabetes, sleep apnoea and psychological distress.
While bariatric surgery is seen as an effective intervention under clear conditions for
obese adults, the indications for medical and surgical treatment of overweight and
obese children are still not well defined. Moreover, children and adolescents have
distinctive metabolic, developmental and psychological needs, which must be carefully
considered to avoid the inappropriate use of weight-loss surgery.

This review looks at the effectiveness and cost–effectiveness of surgical interventions

for overweight and obese children and adolescents, and finds that the majority of
relevant studies are methodologically limited and long-term data remain largely
unavailable. Some evidence suggests that bariatric surgery in severely obese
adolescents can result in significant weight loss, and improvement in co-morbidities
and quality of life. A conservative approach to child and adolescent bariatric surgery
is warranted until further long-term prospective studies on the subject are conducted,
so there remains an urgent need to develop alternatives to surgery, such as lifestyle
programmes that are even modestly effective.

This Health Evidence Network (HEN) evidence report is part of a series designed to
synthesize key and high quality evidence from existing reviews, in order to be used
to inform policy-making. These reports are initiated by the HEN team in response
to a policy issue or question of interest to one or more Member States in the WHO
European Region. HEN is part of the Division of Information, Evidence, Research and
Innovation’s (DIR) programme on Evidence and Information for Policy (EIP).

World Health Organization

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