Weight Loss Surgery and Kids - Part 3

Laparoscopic Roux-en-Y gastric bypass in adolescents with morbid obesity--surgical aspects and clinical outcome by Göthberg et al.

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This series is part of the work I did with WIND (Weight Inclusive Nutrition and Dietetics) to create a comprehensive response to the disastrous American Academy of Pediatrician (AAP) guidelines for higher-weight children. I was part of the team that analyzed the research that, the AAP claims, supports their recommendations, and I’ll be publishing my breakdowns here as well.

You can find the other studies here:
Part 1
Part 2
Part 4

Today I’m looking at Laparoscopic Roux-en-Y gastric bypass in adolescents with morbid ob*sity--surgical aspects and clinical outcome by Gunnar Göthberg MD, PhD, Eva Gronowitz PhD, Carl-Erik Flodmark MD, PhD, Jovanna Dahlgren MD, PhD, Kerstin Ekbom PhD, Staffan Mårild MD, PhD, Claude Marcus MD, PhD, Torsten Olbers MD, PhD

First, I noted that in this study’s discussion of behavioral “treatments” for “ob*sity” (which the AAP guidelines recommend,) these authors write “Among ob*se adolescents, the effect [weight loss] seems to be absent and undoubtedly insufficient for long-term risk reduction.” So while the AAP Guideline authors cite this paper to support their surgery recommendations, it directly contravenes their recommendations about behavior-based weight loss programs.

Issues with sample

This study analyzes the findings of a study on gastric bypass surgeries performed on adolescents. The study included:

·         only 81 subjects

·         all Swedish

·         operated on in one hospital

·         operated on by one of two surgeons

·         using an original technique

All of this severely limits the exptrapolatability of the findings.

Issues with follow-up

They offer only two years of clinical outcome follow-up and only five-year surgical adverse event rate follow-up.

This is not nearly enough follow-up for a surgery that creates a lifelong disease state in the digestive system of an adolescent, forcing both restriction and malabsorption with high potential for nutritional deficiencies. Also, surgical adverse event rate follow-up fails to account for many bio/psycho/social adverse events.

Short-term complications

Post-surgery, two patients required blood transfusions for postoperative bleeding, and another was re-hospitalized with fever 3 days after being discharged and received intravenous antibiotics due to an intra-abdominal infection. Also, the median post-operative hospital stay was four days, but the maximum was 11 days of hospitalization.

Longer-term surgical complications and re-surgeries

In just two years of follow-up, 15% of the subjects required additional surgeries: 6.2% for internal hernia, 7.4% for cholecystectomy due to symptomatic gallstone, one patient for adhesions. Four patients visited an emergency intake for non-specific abdominal pain.

In five years (and with incomplete follow-up due to attrition) four more subjects required surgery for ileus, two more for internal hernias, and two more had cholecystectomies.

Two of the subjects required two additional surgeries.

43% of subjects regained weight in year 2, with no further follow-up.

Nutritional Issues

These surgeries create a malabsorptive state, meaning that they leave their survivors without the ability to get the nutrition they need from food alone and post-surgery supplements are required for the rest of the patient’s life in order to avoid nutritional deficiencies.

All subjects were prescribed daily multivitamin and mineral supplements, vitamin B12, and calcium–vitamin D combination tablets. The cis girls were prescribed iron tablets.

The authors note “We identified poor compliance in the intake of prescribed vitamin and mineral supplements in two-thirds of patients.”

It should be noted that “poor compliance” means “nutritional deficiencies” since it is impossible for surgery survivors to get enough nutrition if they fail to take their supplements. This can be an ongoing issue for adolescent populations, both because they can be psychologically immature and may not be able to fully grasp the consequences of failing (or refusing) to take supplements and/or they may not be in a position to ensure the availability of the supplements for themselves. Relatedly, the supplements are expensive and, at least in the US, are often not covered by insurance creating greater of risk of “non-compliance” for children in lower-income families or those who have financial difficulties at any point in their lives.

Loose Skin

They note that “Most adolescents having undergone surgery experienced problems with excessive skin following weight loss; this aspect was not formally addressed in the current study.”

There is, then, no discussion of how this impacts quality of life, participation in sports or other activities where excessive skin might prevent a physical or psychological barrier etc. Nor is there discussion of what surgical options to correct loose skin are available to children who are still growing. Remember that the AAP recommends this surgery to kids as young as 13.

Conclusion

They conclude that “we have demonstrated that Roux-en-Y gastric bypass surgery results in similar weight loss in adolescents as in adults over 2 years. We found substantial improvements in risk factors for co-morbidities and improvements in quality of life. Nonetheless, the surgical and psychiatric adverse events that appeared in this psychosocially vulnerable cohort require careful attention. It appears so far that gastric bypass is a viable option for future interventional studies in severely ob*se adolescents.”

Note that they do not conclude that it is a viable option for widespread recommendations (although the AAP Guidelines are citing it for that exact purpose,) only that they believe that it should be studied further. I would suggest that the relatively high complication rates and the extremely high failure to take supplements even in their short follow-up suggest otherwise. They also fail to mention where health-supporting behaviors can create those same risk-factor improvements with massively less risk and/or if the post-surgery improvements even last more than two years. I do not find that this study supports the idea of surgically creating a disease state in the perfectly healthy digestive system of an adolescent.

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More research and resources:
https://haeshealthsheets.com/resources/

*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.