Study validates metabolic and bariatric surgery for adolescents

A new paper co-authored by Steven E. Lipshultz, A. Conger Goodyear Professor and Chair of Pediatrics, validates the long-term efficacy and safety of metabolic and bariatric surgery (MBS) for treatment of adolescent obesity.

“Long-Term Outcomes after Adolescent Bariatric Surgery,” published online Sept. 15 in the Journal of American College of Surgeons, is the longest follow-up on the procedure published thus far.

MBS is a safe and effective treatment option for adolescents with severe obesity, but no long-term studies with more than 10 years of follow-up data to document sustained improved outcomes had previously been available, according to Lipshultz, pediatric chief-of-service at Kaleida Health, medical director of Pediatric Services Business Development at Oishei Children’s Hospital, and president and CEO of UBMD Pediatrics.

In the new study, a total of 96 patients who completed MBS at 21 years of age or younger in a tertiary academic center from 2002-10 were contacted for a telehealth visit.

Body weight, comorbidity status, social/physical function status, and long-term complications were evaluated 10-18 years after surgery.

“Our findings show that among 96 severely obese adolescents there is a sustained decrease in morbid conditions and risk for future clinically significant diseases,” Lipshultz says. “This is the longest follow-up of these patients we are aware of. Our study also focused on a high-risk, ethnically underrepresented population, Hispanic adolescents. A relatively normal lifestyle is present in these patients on long-term follow-up.”

Lipshultz notes the obesity epidemic in the adolescent population continues to worsen, despite increased awareness.

“Similar to adults, excess adipose tissue triggers multiple immunological and metabolic pathways leading to serious co-morbidities, such as impaired glucose tolerance or even Type 2 diabetes, dyslipidemia, arterial hypertension, non-alcoholic fatty liver disease, and hyperuricemia,” he says.

The management of severe childhood obesity requires a lifelong, multidisciplinary approach with a combination of lifestyle changes, nutrition and medications.

Standardized lifestyle intervention programs remain the first-line treatment for morbidly obese children and adolescents, but unfortunately, they reveal limited long-term success, Lipshultz notes.

“In such cases, metabolic bariatric surgery has evolved from being a controversial issue to being included in distinct recommendations,” he says.

“Although there is an improved understanding of the role of metabolic bariatric surgery in the treatment of obesity in adolescents, a number of barriers still prevent its widespread utilization,” Lipshultz adds.

“The lack of formal obesity-focused education in the continuing medical education of primary care and specialty providers, coupled with variable distribution of comprehensive resources, creates an inhospitable environment for effective anti-obesity treatment in adolescents and hesitation to refer for surgery.”

Racial disparities and variability in insurance coverage also contribute to the complexity of the problem, Lipshultz notes.

“These newly published findings show that adolescent metabolic bariatric surgery is effective and sustainable with long-term follow-up,” he says. “Further, we directly address the issues of the safety and efficacy of adolescent metabolic and bariatric surgery related to racial disparities.”

The study showed patients with elevated cholesterol levels, asthma and diabetes/hyperglycemia before surgery reported 100% remission at follow-up (these were statistically significant with p<0.05 for all).

Decreases following surgery in hypertension, sleep apnea, gastroesophageal reflux disease, anxiety and depression were also found to be statistically significant, according to Lipshultz. 

“This study has taken more than 20 years to conduct, but should provide necessary evidence to guide providers, patients and their families, and insurers in the decisions to offer severely obese adolescents metabolic and bariatric surgery, since significant sustained reductions in weight and co-morbidities, and low rates of long-term complications a decade or more after completing metabolic bariatric surgery as an adolescent were found,” he says.

Lipshultz notes that Oishei Children’s Hospital has a comprehensive program for children who are overweight, obese or morbidly obese called Healthy Weigh.

The program is surgically led by Carroll M. Harmon, the John E. Fisher Chair in Pediatric Surgery, chief of the Division of Pediatric Surgery in the Jacobs School of Medicine and Biomedical Sciences, and chief of pediatric surgery at Oishei Children’s Hospital and chief of surgery at Kaleida Health.

“This program provides multidisciplinary care for these patients,” Lipshultz says. “This new publication suggests that the surgical management for these patients in Western New York is safe, effective and available in our community.”

The study was led by first author Nestor de la Cruz-Munoz, chief of the Division of Laparoendoscopic and Bariatric Surgery at the University of Miami Miller School of Medicine.

Sarah E. Messiah, professor of epidemiology, human genetics and environmental sciences in the School of Public Health, University of Texas Health Science Center, and a voluntary professor of pediatrics at the Miami medical school, was senior author.

Lipshultz was chair of the Department of Pediatrics at Miami when the study began.

The researchers had organized a comprehensive childhood obesity program that continues to be the subject of papers and a published book on pediatric metabolic syndrome.

In 2021, de la Cruz Munoz and Lipshultz published an invited comprehensive narrative review on the short- and long-term safety and efficacy of bariatric surgery for severely obese adolescents, which was followed by publications by the American Academy of Pediatrics calling for better access for pediatric metabolic and bariatric surgery for teens with severe obesity based on the growing evidence and best practices.