752 M.C.P. VELHOTE ET AL.
As in adults, however, these children are prone to In children, due to the variability of BMI with
develop metabolic consequences, as well as regard to sex and age, we have to evaluate the
physical and social constraints which imply a poor degree of obesity by comparing the BMI using
quality of life and low survival. population charts14 (Fig. 1). The definition of over-
Obese children, like adults, may have insulin weight is BMI between the 85th and 95th per-
resistance and type 2 diabetes mellitus, high blood centiles, while obesity is defined as BMI above the
pressure, dyslipidemia, orthopedic problems, sleep 95th percentile. In these charts, there is no recog-
apnea, hepatic steatosis, cholecystopathy, poly- nition of extreme obesity and super-obesity.
cystic ovary syndrome with hyperandrogenism, From a practical point of view, we can say that
menstrual irregularities and even infertility, cere- for an adolescent who has completed at least 80%
bral pseudo-tumor, alveolar hypoventilation, skin of his/her bone maturation, it is adequate to use the
problems, besides low self-esteem and social same parameters as in adults. However, when we
isolation9. pay attention to the distribution of the population
Due to refractoriness to clinical treatment and BMI curves, we can see that in adolescents younger
the severity of the associated co-morbidities, the than 18 years of age the BMIs that define obesity
surgical approach in obese adolescents has gained and overweight are lower than in adults. Especially
more and more adepts10. This attitude makes sense in 4-6 year-old children, a BMI of 18 is the limit
in view of the poor results even in very well for obesity and not a BMI of 30 as used for adults.
structured clinical groups in which patient
compliance is high11 as opposed to the initial good
results of bariatric surgery12. INDICATIONS FOR BARIATRIC SURGERY
In adults, there has been a consensus for more
EVALUATION OF THE DEGREE OF OBESITY than 15 years that whenever BMI is greater than 35
WITH THE AIM OF SURGERY with co-morbidities and above 40 even without co-
morbidities this is an indication for surgery3.
Body mass index (BMI) calculated by the In children, cure of extreme exogenous obesity
quotient of the weight by the height squared has is extremely difficult, if not impossible, employing
been extensively used in adults to evaluate the conventional clinical strategies. The best results
degree of obesity. As shown in Table 1, it is with behavioral, dietetic, and clinical approaches in
possible to classify individuals according to BMI13. the long run (5-10 years) show that only 30% reach
stability or some degree of improvement15. Those
children who do not improve with clinical therapy
may, with time, develop co-morbidities that shorten
TABLE 1 life expectancy and compromise physical and
Classification of individuals based on psychological status16, and will be obese adults.
body mass index (BMI) The American Pediatric Surgical Association
(APSA) accepted the recommendation for surgery
BMI (kg/m2) Classification in girls older than 13 years and boys older than 15
18-25 Normal years when BMI is greater than 40 with co-
morbidities and above 50 as an isolated index17.
25-30 Overweight Many authors state that, due to the failure of
30 -35 Moderately obese behavioral therapy in these highly obese patients,
the benefit of surgery must be offered to children,
35-40 Intensely obese
using at least the same parameters as in adults12,18-24.
40-50 Extremely obese Since good results have been obtained in
50-60 Super-obese adolescents submitted to bariatric surgery, there is
no point in being more stringent in terms of
Above 60 Super-super-obese indications for surgery or even postponing surgery
JOURNAL OF PEDIATRIC ENDOCRINOLOGY & METABOLISM
BARIATRIC SURGERY IN PEDIATRICS 753
VOLUME 20, NO. 7, 2007
754 M.C.P. VELHOTE ET AL.
to an age greater than 18 years, since BMI will (LAGB) and gastric bypass with Roux-en-Y
have increased even more. The risk of waiting for reconstruction, devised by Fobi-Capella (RYGBP)
surgery till adult age is probably small, but the In the USA, LAGB was only approved by the
natural history of obesity indicates that it keeps on FDA in 2001, and this is the reason why the longer
deteriorating9. This increases the surgical risks, and follow-up studies are European. It consists of
worsens self-esteem and social behavior, which laparoscopic placement of a silicon band, which is
may leave permanent psychological scars4. On the adjusted in the region of the cardia, keeping the
other hand, the sooner the orthopedic lesions, gastric capacity above the band, at around 20 ml.
diabetes mellitus, and hypertension are stabilized or The degree of compression of the band is adjusted
cured, the better the surgical results. in the post-operative period through the injection of
Recent reports have been more liberal in the saline into the subcutaneous reservoir, under radio-
indications for surgery (younger patients, with scopic control (Fig. 2B). This method has many
smaller BMIs) using the same parameters as in advantages, being easily and quickly placed, keeps
adults (BMI >40 or BMI >35 with co-morbi- the patient in the hospital for a short time, has low
dities)18,20,25. Even in adults, there has been a indices of complications, and is totally reversible.
tendency of being more flexible in individual cases, The first reports used vertical-banded gastrec-
accepting for surgery patients with smaller BMIs26. tomy (VBG) (Fig. 2A), later replaced by the
This strategy takes into account the fact that higher RYGBP, today the most often performed surgery
risks of surgical complications are associated with for obesity all over the world, including the USA.
late surgical indication, high BMI, and longer time From 1993, RYGBP began to be performed
suffering from diabetes mellitus or hypertension27. laparoscopically, with transection of the stomach
As new data in adolescents have demonstrated close to the cardia, creating a gastric chamber with
good results in the long run, low complication capacity around 25 ml. The remaining part of the
indices, and low morbidity and mortality, the stomach is left in the abdominal cavity. A Roux-en-
acceptance of bariatric surgery has increased for Y loop in the jejunum is created, just after the
extremely obese adolescents and even in the not- Treitz angle, whose length goes from 100 to 150
so-obese. cm, anastomosed to the gastric remnant (Fig. 2D).
Disabsorptive techniques decrease the intestinal
RATIONALE OF THE SURGICAL TECHNIQUES absorptive area, preventing the meal running
through the whole digestive tract, since there is an
The first trials to treat obesity with surgery date internal bypass. The pattern of this surgery is the
back to the 1950s. To create malabsorption, an bilio-pancreatic bypass (BPD) by Scopinaro with
internal jejuno-ileal bypass was performed by or without duodenal switch. It consists of
Kremen et al. in 195428. Although the weight loss transverse gastrectomy with reconstruction in
was considerable, the maintenance of a normal Roux-en-Y which keeps 50-100 cm of ileal loop
gastric reservoir, profuse diarrhea with intense with digestive enzymes (Fig. 2C). This technique
undernutrition, deficient calcium, vitamins B12, A, has not usually been performed in children due to
and D absorption, cholelithiasis and renal stones, severe long-term complications (proteic-caloric
precluded carrying on with this form of surgery. malabsorption, bacterial overgrowth in the blind
Observing the weight loss in patients submitted loop, the need to supplement vitamins, and the need
to gastrectomy, Mason and Ito in 1967 proposed for close medical follow-up for life)13.
gastric septation as a surgical procedure to treat Recently, a new protocol has been proposed for
obesity29. This pioneer technique branched into modulated surgery which may also be used in
different approaches with the aim of creating a tiny pediatric patients. It is neither disabsorptive nor
gastric reservoir. The restrictive approach leads to does it use obstructive devices, and aims at
difficulty in ingestion through the creation of a reactivating entero-hormones in the postprandial
small gastric camera with a slow emptying outlet. period, leading to early satiety. It has been named
The most used are adjustable gastric banding ‘digestive adaptation with intestinal reserve’
JOURNAL OF PEDIATRIC ENDOCRINOLOGY & METABOLISM
BARIATRIC SURGERY IN PEDIATRICS 755
satiety sensation is also obtained quickly after full
(DAIR), and consists of vertical gastrectomy,
omentectomy and reduction of the small intestine
to 3 meters (40 cm of jejunum and 260 cm of
ileum). At its simplest it consists only of vertical
gastrectomy (sleeve gastrectomy), a procedure
suggested for super-obese or pre-adolescents. At
the other extreme the reconstruction of the bowel is
in Roux-en-Y gastroileal anastomosis, depicted in
Figure 2E, keeping the pylorus and leaving the
duodenum and 120 cm of small bowel in
The modern diet, processed and easy to obtain,
hypercaloric, and easy digestible in the proximal
intestine, does not stimulate the terminal ileum to
produce the entero-hormones (glucagon-like peptide
1 [GLP-1], PYY, and oxyntomodulin) implicated,
among many different and interesting actions, in
satiety and in the activation of an adequate insulin
response to ingestion of food. In addition, the
VOLUME 20, NO. 7, 2007
756 M.C.P. VELHOTE ET AL.
BARIATRIC SURGERY IN CHILDREN
Bariatric surgery is far from being a cosmetic
procedure. It is an extensive surgery, performed in
patients with high surgical risk and with mortality7.
The option of the surgical approach in adoles-
cents has always faced strong opposition2,6 but the
data are accumulating on the procedure and new
techniques have been devised to try to solve or
attenuate a very serious health problem with less
risk to the patients.
The first reports on adolescents submitted to
bariatric surgery date back to 1985 by Silber,
employing the gastric-ileal bypass technique. Although
the weight loss is still significant after 10 years of
follow-up, this technique has been abandoned due
to high indices of severe complications (encephalo-
pathy, nephrolithiasis, hypoproteinemia, cortical
nephropathy, hepatopathy, etc.) and the need for
frequent revisions. Since then, different modalities
of surgery have revolutionized obesity surgery in
adults due to much fewer complications and
At the end of the 1990s, although recognizing
the risks of infantile obesity, bariatric surgery for
adolescents was not recommended, except in
extreme cases, due to the risks of the procedure11,33.
These restrictions have not been endorsed by other
repletion of the stomach with small amounts of groups working with children who, although
food. This technique takes into consideration all utilizing low number of patients, had low indices of
these factors. Vertical gastrectomy and entero- complications and good results with regard to
omentectomy are performed, and promising results weight loss and patient satisfaction21-23,34,35. More
have been shown, although the time of follow-up is recent data from adolescents confirm the good
up to 4 years in the oldest patient. The gastrectomy results with RYGBP18,25,37-39, placing this modality
reduces the gastric capacity to around 200 ml, of surgery as an acceptable tool to deal with
adapting the chamber size to the high caloric extreme obesity in adolescents.
density of modern food, and diminishing ghrelin In 2005, a review of members of the ASBS
production, involved in the hunger sensation in revealed that 53% had already performed some
fasting periods. The enterectomy allows the surgical procedure in obese adolescents, 70%
nutrients to reach the ileum, increasing the planned to start a regular program of surgery in
secretion of GLP-1 and PYY (leading to early adolescents, and 84% were interested in partici-
satiety and higher and faster insulin secretion - the pating in multicenter studies in this area. This
incretin effect). The removal of the epiplon reduces demonstrates an increasing interest in bariatric
the dangerous visceral fat, an important factor in surgery in pediatrics and forecasts its more
triggering metabolic syndrome, decreasing a source disseminated utilization in the future40.
of IL-6, IL-8, TNF-α, and resistin, with reduction Apovian et al. in 200541, in a study on evidence-
of insulin resistance in the liver32. based medicine, emphasizes the need for more
research with regard to indications and long-term
JOURNAL OF PEDIATRIC ENDOCRINOLOGY & METABOLISM
BARIATRIC SURGERY IN PEDIATRICS 757
results of bariatric surgery, and recognizes that the emphasize the importance of referral centers that
techniques applicable to adolescents are RYGBP follow well-designed protocols to allow for com-
and LAGB. parisons, since the total number of patients is
small13. Analyzing the existing data, the initial
Laparoscopic adjustable gastric banding (Fig. 2B) results are uniformly good with 33% of weight loss
up to the 6th month, 47% up to one year, and 53%
Adjustable silicon banding (LAGB), created in up to 2 years of follow-up37. There was a good
1990, has been extensively used in Europe18-20,39. resolution of co-morbidities, such as diabetes
This procedure was only approved in the USA in mellitus, hypertension, and sleep apnea12,22,37, as
2001, which makes the European experience more well as improvement in self-esteem and social
extensive. In adults, the long-term European and life36,38. On the other hand, some patients deve-
Australian results have been very good: decrease in loped cholelithiasis12,22,23,25 and needed surgery
co-morbidities, absence of malabsorption, persis- (laparoscopic in the majority of cases).
tent weight loss, with decreased mortality and low This modality of surgery, to be effective in the
complication indices. However, the weight loss is long run, needs the maintenance of a small gastric
slower and less intense than with RYGBP13. chamber, with slow emptying (calibrated
Compared to RYGBP, LAGB has five-fold less anastomosis). Vomiting is frequent when the
mortality and much fewer complications, which ingested volume surpasses the gastric capacity, or
make this procedure preferred over gastric when there is stenosis in the anastomosis. The com-
bypass13. It has the advantage of being reversible plications directly related to the procedure are less
and preserves the gastrointestinal physiology and than 5%, including deficiencies of vitamins D,
anatomy39, and does not lead to malabsorption. The B1, B12 and A22,25,43, as well as micronutrients,
weight loss of 33% of the excess in the first
especially iron and calcium22,36. Other complica-
6 months, and 58% in the first year, caused BMI to tions include dehiscent stitches in the remaining
fall from 44.7 kg/m2 in the pre-operative period to stomach37, suppuration of the abdominal wall38,
30.2 kg/m2 in 2 years19. Therapeutic failures incisional hernia22,38, stenosis of the anastomosis,
occurred in 2-3% of cases18,39. deep venous thrombosis37,38, and occlusive scars22,38.
The indices of satisfaction and self-esteem in Four patients died some time after surgery and
the post-operative period are improved, although these deaths were not directly related to the
the resolution of co-morbidities is lower than with surgical procedure23,38. After 5 years, however,
RYGBP (67%)39. Surgical complications are some patients started gaining weight38, and some of
few24,39, including gastric erosion with migration of them were submitted to another surgery to further
the band18, wrong positioning of the band which reduce the gastric chamber25.
requires re-operation18,20, no weight loss18 and Many patients got pregnant after the bariatric
secondary megaesophagus. It has been shown surgery and the pregnancy ran normally22.
recently that gastric banding negatively interferes The main criticisms of the procedure are: it
with esophagic motility42. creates an intestinal bypass, leading to malabsorp-
The biggest criticism of this procedure is that tion of nutrients that have exclusive proximal
the weight loss comes from an iatrogenic sub- absorption. It does not allow gastric digestion, and
esophagical gastric stenosis, caused by a foreign potentially, changes the intestinal flora, due to the
body. The patient may cheat weight loss by lack of gastric acid. The stomach itself stays
imbibing caloric fluids since the procedure does not isolated and is not accessible to endoscopic
lead to dumping. examination, in case this should be a necessary
procedure. The ingestion of hyperosmolar meals
Roux-en-Y gastric bypass (Fig. 2D) leads to dumping.
Until 2004, there were 171 adolescent patients
reported in the medical literature submitted to this
modality of bariatric surgery12,21-25,34-38. The reports
VOLUME 20, NO. 7, 2007
758 M.C.P. VELHOTE ET AL.
Digestive adaptation with intestinal reserve (Fig. 2E) to a second procedure (DPB or RYGBP). We think
that in children, LSG could have two indications: in
This technique consists of vertical laparoscopic prepubertal children with BMI >50 refractory to
gastrectomy, preserving the antrum, followed by a clinical therapy, and in Prader-Willi syndrome.
small abdominal incision to complete the procedure Since it does not affect nutrition and meal
with a resection of the greater epiplon and part of absorption at all, it is presumed not to impair
the small intestine, leaving 40 cm of jejunum and children’s growth, while it provokes consistent
260 cm of ileum30, as illustrated in Figure 2E. weight reduction. A 12 year-old child of 164 kg
The advantages of this procedure are many: it (BMI 58), obese from 3 years of age, with
does not use a prosthesis, and there are no areas progressive increase in weight, underwent LSG.
excluded from the intestinal transit. The duodenum After 1.5 year, he lost 52 kg and had a BMI of 42.
is kept on transit. There are no detectable signals of His growth during this year has been unimpaired
malabsorption, no diarrhea, no vomiting, and it and he is asymptomatic (personal communication).
allows the digestion of vitamins and oligonutrients. There are few reports on performing bariatric
It gives early satiety and an outstanding improve- surgery with success in Prader-Willi syndrome.
ment in insulin resistance, blood pressure and RYGBP and BPD have been used in children with
dyslipidimia31. Prader-Willi syndrome with variable results47-49.
Some bariatric surgeons criticize the enterec- The rationale to use LSG in Prader-Willi syndrome
tomy performed in this procedure but this is part of rests on the knowledge that it is the only situation
the adaptation of a long intestine to the kind of in obesity where basal blood levels of ghrelin are
nutrients available in the modern diet, which seem elevated. Gastrectomy, by reducing the bulk of the
to be insufficient for the proper stimulation of site of production, promotes a sustained reduction
entero-hormones which produce a feeling of of ghrelin levels50 and could be useful as an
satiety. In a series of 12 adolescents, seven have endocrine-restrictive based surgery. It has already
been followed for 2 years. The mean BMI fell from been performed in three patients (BMI 66, 65 and
54 to 30, and there was a complete reversion of co- 50) with good control of feeding compulsion and
morbidities: five patients presented insulin resis- initial weight loss (33, 80 and 21 kg 2 years, 1 year
tance which normalized, four hypertensive patients and 8 months after LSG, respectively). The blood
normalized their blood pressure, and two dys- ghrelin levels showed a significant reduction (per-
lipidemic patients normalized their serum lipids. sonal communication).
One of our patients presented transitory peripheral
polyneuropathy, which regressed with temporary
vitamin B1 supplementation. SELECTION OF PATIENTS
Laparoscopic sleeve gastrectomy (Fig. 2F) The following conditions must be taken into
account for bariatric surgery in children and
In adult surgery, performing only a vertical adolescents:
gastrectomy (also known as laparoscopic sleeve • Exogenous obesity;
gastrectomy [LSG]) in the super-super-obese • Multidisciplinary team evaluation of patients
patient is nowadays accepted as a first stage who do not show satisfactory results after a 1-
procedure to reduce weight with simpler laparo- year period of treatment;
scopic surgery44. It is not intended to completely
correct the excess weight, but it has the advantage • Age >13 years in girls and >15 years in boys;
of producing a reduction of 45 kg after 6 months, • Patients who reached 80% of his/her adult
with low surgical risk. This procedure improves stature or the equivalent bone age;
health conditions in preparation for a second • BMI >40 or BMI >35 with co-morbidities;
surgical stage45. Mognol et al.46 suggested that • Understanding and acceptance of the surgical
laparoscopic LSG can be used in bariatric surgery procedure and its consequences;
either as an isolated procedure, or as the first step
JOURNAL OF PEDIATRIC ENDOCRINOLOGY & METABOLISM
BARIATRIC SURGERY IN PEDIATRICS 759
• Psychological evaluation attesting that the be an approach that effectively leads to maintained
patient has emotional conditions to withstand weight loss with acceptable surgical risk.
the procedure; All the modalities of bariatric surgery have
• To agree in participating in follow-up visits as shown much better results, in terms of weight loss,
well as following nutritional orientation; when compared to more conservative approaches.
• The surgery has to be performed in a reference The procedures, although invasive, have demon-
center, structured to provide a comprehensive strated that they diminish co-morbidities, and carry
approach to the patient, with well trained a low risk and a low rate of complications.
surgeons and a good system of data collection; The best modality of surgery and the best time
for it to be performed still depend on studies with a
• The approach has to be individualized and has to
high number of pediatric patients and long-term
take into account all the indications and
follow-up. As the number of cases increases,
limitations of the whole process13,18;
there has been a tendency to indicate surgery at
• Informed consent given by parents or guardians. younger ages and with less severe degrees of
THE IMPROVEMENT OF CO-MORBIDITIES The initial criteria in the phase of acquisition of
LINKED TO EXTREME OBESITY experience with this procedure have to be more
rigid, but the number of patients operated upon
The association of obesity with morbidities, until now allows us to see the procedure as a useful
such as metabolic syndrome, with dyslipidimia, tool in extremely obese patients27, even at young
hyperinsulinemia, and systemic hypertension, is age.
well known51. Even before weight loss, some Once the procedure has been proven to be safe
complications associated with obesity disappear or and effective, we can have indications before the
decrease in intensity. RYGBP and DAIR tend to deleterious metabolic consequences of the obesity
correct the carbohydrate disturbances, and this take place, since they increase surgical morbidity
improvement has been attributed to the increase in and mortality. The sustained improvement of
GLP-1, secreted by the L-cells of the terminal conditions, such as insulin resistance, sleep apnea
ileum once there are nutrients in the lumen of this and hypertension, has to be taken into account in
portion of the intestine. Although this improvement the indication of the procedure.
also occurs, less intensely, with LAGB, besides The acknowledgment that obesity is more than
weight loss the mechanisms involved are not yet an esthetic problem, but a disease with a very
clear. complex set of metabolic disturbances that poses
With weight loss, whatever the therapeutic serious risks to health and quality of life, induces
modality employed, surgical or not, there is us to regard surgical and more aggressive
improvement of sleep apnea, hepatic steatosis, and modalities of therapy as possible actions to be
joint problems, and in particular there is good taken to circumvent the disturbances created by
improvement in social life and self esteem. obesity. The procedure has a clear cost-benefit
relationship, since reducing obesity dramatically
decreases the later costs of complications in the
medium- and long-term. However, in future
generations, with new approaches to health care51,
Clinical treatment of obesity, always the first
we hope that surgery for obese children, that today
step in the approach to this complex metabolic
looks like being the future, will become outdated.
condition, has faced problems in solving the most
severe cases, especially in the young. In this
context, in selected cases, the possibility of
submitting the patient to a surgical procedure has to
be taken into account2, since it has been shown to 1. Rosenbaum M, Leibel RL. The physiology of body
weight regulation: the relevance to the etiology of
VOLUME 20, NO. 7, 2007
760 M.C.P. VELHOTE ET AL.
obesity in children. Pediatrics 1998; 101 (Suppl): 525- G, Capizzi FD, Giardiello C, Di Lorenzo N, Veneziani
539. A, Alkilani M, Puglisi F, Gardinazzi A, Cascardo A,
2. Barlow SE, Dietz WH. Obesity evaluation and treat- Borrelli V, Lorenzo M. Obese teenagers treated by
ment. Expert Committee recommendations. The Lap-Band system: the Italian experience. Surgery 2005;
Maternal and Child Health Bureau, Health Resources 138: 877-881.
and Services Adminstration and the Department of 19. Dolan K, Creighton L, Hopkins G, Fielding G. Laparo-
Health and Human Services. Pediatrics 1998; 102: e29. scopic gastric banding in morbidly obese adolescents.
3. National Institutes of Health Consensus Development Obes Surg 2003; 13: 101-104.
Conference. Gastrointestinal surgery for severe 20. Yitzhak A, Mizrahi S, Avinoach E. Laparoscopic
obesity: Proceedings of a National Institutes of Health gastric banding in adolescents. Obes Surg 2006; 16:
Consensus Development Conference, March 25-27, 1318-1322.
1991, Bethesda, MD. Am J Clin Nutr 1992; 55 (Suppl): 21. Greenstein RJ, Rabner JG. Is adolescent gastric-
487S-619S. restrictive antiobesity surgery warranted? Obes Surg.
4. Garcia VF, deMaria EJ. Adolescent bariatric surgery: 1995; 5: 138-144.
treatment delayed, treatment denied, a crisis invited. 22. Strauss RS, Bradley LJ, Brolin RE. Gastric bypass
Obes Surg 2006; 16: 1-4. surgery in adolescents with morbid obesity. J Pediatr
5. Troiano RP, Flegal KM. Overweight children and 2001; 138: 499-504.
adolescents: description, epidemiology and demo- 23. Breaux CW. Obesity surgery in children. Obes Surg
graphics. Pediatrics 1998; 101 (Suppl): 497-504. 1995; 5: 279-284.
6. Dietz WH. Childhood obesity: susceptibility, cause and 24. Abu-Abeid S, Gavert N, Klausner JM, Szold A.
management. J Pediatrics 1983; 103: 676-686. Bariatric surgery in adolescence. J Pediatr Surg 2003;
7. Steinbrooke R. Surgery for severe obesity. N Eng J 38: 1379-1382.
Med 2004; 350: 1075-1079. 25. Stanford A, Glascock JM, Eid GM, Kane T, Ford HR,
8. Ebbeling CB, Pawlak DB, Ludwig DS. Childhood Ikramuddin S, Schauer P. Laparoscopic Roux-en-Y
obesity: public-health crisis, common sense cure. gastric bypass in morbidly obese adolescents. J Pediatr
Lancet 2002; 360: 473-482. Surg 2003; 38: 430-433.
9. Must A, Strauss RS. Risk and consequences of child- 26. Fobi M, Lee H, Igwe D, Felahy B, James E, Stanczyk
hood and adolescent obesity. Int J Obes 1999; 23 M, Fobi N. Gastric bypass in patients with BMI < 40
(Suppl 2): S2-S11. but > 32 without life-threatening co-morbidities: pre-
10. Kirk S, Scott BJ, Daniels SR. Pediatric obesity liminary report. Obes Surg 2002; 12: 52-56.
epidemic: treatment options. J Am Diet Assoc 2005; 27. Garcia VF. Adolescent bariatric surgery: treatment
105 (Suppl): S44-51. delayed may be treatment denied [Letter]. Pediatrics
11. Epstein LH, Myers MD, Raynor HA, Saelens BE. 2005; 115: 822.
Treatment of pediatric obesity. Pediatrics 1998; 101 28. Kremen AJ, Linner JH, Nelson CH. An experimental
(Suppl): 554-569. evaluation of the nutritional importance of proximal
12. Capella JF, Capella RF. Bariatric surgery in adoles- and distal small intestine. Ann Surg 1954; 140: 439-
cence. Is this the best age to operate? Obes Surg 2003; 448.
13: 826-832. 29. Mason EE, Ito C. Gastric bypass in obesity. Surg Clin
13. Inge TH, Zeller MH, Lawson L, Daniels SR. A critical North Am 1967; 47: 1345-1351.
appraisal of evidence supporting a bariatric surgical 30. Santoro S, Velhote MCP, Malzoni CE, et al. Prelimi-
approach to weight management for adolescents. nary results of digestive adaptation: a new surgical
J Pediatrics 2005; 147: 10-19. proposal to treat obesity based on physiology and
14. Growth Charts developed by the National Center for evolution. São Paulo Med J 2006; 124: 192-197.
Health Statistics in collaboration with the National 31. Santoro S, Malzoni CE, Velhote MCP, Milleo FQ,
Center for Chronic Disease Prevention and Health Santo MA, Klajner S, Damiani D, Maksoud JG.
Promotion (2000). http://www.cdc.gov/growthcharts. Digestive adaptation with intestinal reserve: a neuro-
15. Epstein LH, Valoski A, Wing R, McCurley J. Ten-year endocrine-based operation for morbid obesity. Obes
follow-up of behavioral family-based treatment for Surg 2006; 16: 1371-1379.
obese children. JAMA 1990; 264: 2519-2523. 32. Drazen DL, Woods SC. Peripheral signals in the
16. Dietz WH. Health consequences of obesity in youth: control of satiety and hunger. Curr Opin Clin Nutr
childhood predictors of adult disease. Pediatrics 1998; Metab Care 2003; 6: 621-629.
101 (Suppl): 518-525. 33. Flodmark CE. Childhood obesity. Clin Child Psychol
17. Rodgers BM. Bariatric surgery for adolescents: a view Psychiatry 1997; 2: 283-295.
from the American Pediatric Surgical Association. 34. Anderson AE, Soper RT, Scott DH. Gastric bypass for
Pediatrics 2004; 114: 255-256. morbid obesity in children and adolescents. J Pediatr
18. Angrisani L, Favretti F, Furbetta F, Paganelli M, Basso Surg 1980; 15: 876-881.
N, Doldi SB, Iuppa A, Lucchese M, Lattuada E, Lesti 35. Soper RT, Mason EE, Printen KJ, Zellweger H. Gastric
JOURNAL OF PEDIATRIC ENDOCRINOLOGY & METABOLISM
BARIATRIC SURGERY IN PEDIATRICS 761
bypass for morbid obesity in children and adolescents. 45. Regan JP, Inabnet W, Gagner M, Pomp A. Early
J Pediatr Surg 1975; 10: 51-58. experience with two-stage laparoscopic Roux-en-Y
36. Rand CS, Macgregor AM. Adolescents having obesity gastric bypass as an alternative in the super-super obese
surgery: a 6-year follow-up. South Med J 1994; 87: patient. Obes Surg 2003; 13: 861-864.
1208-1213. 46. Mognol P, Chosidow D, Marmuse JP. Laparoscopic
37. Inge TH, Garcia VF, Daniels SR, Langford L, Kirk S, sleeve gastrectomy as an initial bariatric operation for
Roehrig H, Amin R, Zeller M, Higa K. A multi- high-risk patients: initial results in 10 patients. Obes
disciplinary approach to the adolescent bariatric Surg 2005; 15: 1030-1033.
surgical patient. J Pediatr Surg 2004; 39: 442-447. 47. Papavramidis ST, Kotidis EV, Gamvros O. Prader-
38. Sugerman HJ, Sugerman EL, DeMaria EJ, Kellum JM, Willi syndrome-associated obesity treated by bilio-
Kennedy C, Mowery Y, Wolfe LG. Bariatric surgery pancreatic diversion with duodenal switch. Case report
for severely obese adolescents. J Gastrointest Surg and literature review. J Pediatr Surg 2006; 41: 1153-
2003; 7: 102-108. 1158.
39. Silberhumer GR, Miller K, Kriwanek S, Widhalm K, 48. Braghetto I, Rodriguez A, Debandi A, Brunet L,
Pump A, Prager G. Laparoscopic adjustable gastric Papapietro K, Pineda P, Pacheco MI. Prader-Willi
banding in adolescents: the Austrian experience. Obes syndrome (PWS) associated to morbid obesity: surgical
Surg 2006; 16: 1062-1067. treatment [in Spanish]. Rev Med Chil 2003; 131: 427-
40. Allen SR, Lawson L, Garcia V, Inge TH. Attitudes of 431.
bariatric surgeons concerning adolescent surgery 49. Dousei T, Miyata M, Izukura M, Harada T, Kitagawa
(ABS). Obes Surg 2005; 92-1195. T, Matsuda H. Long-term follow-up of gastroplasty in
41. Apovian CM, Baker C, Ludwig DS, Hoppin AG, Hsu a patient with Prader-Willi syndrome. Obes Surg 1992;
G, Lenders C, Pratt IS, Forse RA, O’Brien A, Tarnoff 2: 189-193.
M. Best practice guidelines in pediatric/adolescent 50. Langer FB, Reza Hoda MA, Bohdjalian A, Felberbauer
weight loss surgery. Obes Res 2005; 13: 274-280. FX, Zacherl J, Wenzl E, Schindler K, Luger A, Ludvik
42. Suter M, Dorta G, Giusti V, Calmes JM. Gastric band- B, Prager G. Sleeve gastrectomy and gastric banding:
ing interferes with esophageal motility and gastro- effects on plasma ghrelin levels. Obes Surg 2005; 15:
esophageal reflux. Arch Surg 2005; 140: 639-643. 1024-1029.
43. Towbin A, Inge TH, Garcia VF, Roehrig HR, Clements 51. Bitsori M, Kafatos A. Dysmetabolic syndrome in child-
RH, Harmon CM, Daniels SR. Beriberi after gastric hood and adolescence. Acta Paediatr 2005; 94: 995-
bypass surgery in adolescence. J Pediatrics 2004; 145: 1005.
263-267. 52. Barlow SE. Bariatric surgery in adolescents: for treat-
44. Milone L, Strong V, Gagner M. Laparoscopic sleeve ment failures or health care system failures? Pediatrics
gastrectomy is superior to endoscopic intragastric 2004; 114: 252-253.
balloon as a first stage procedure for super-obese
patients (BMI >50). Obes Surg 2005; 15: 612-617.
VOLUME 20, NO. 7, 2007
762 M.C.P. VELHOTE ET AL.
Fig. 1: Body mass index (BMI) growth charts from 2 to 20 years of age, for males and females. National Center for Health
Fig. 2: Different modalities of bariatric surgery. VGB = vertical banded gastroplasty; LAGB = laparoscopic adjustable gastric
banding; BPD = bilio-pancreatic diversion; RYGBP = Roux-en-Y gastric bypass; DAIR = digestive adaptation with
intestinal reserve; LSG = laparoscopic sleeve gastrectomy.
Fig. 1: Body mass index (BMI) growth charts from 2 to 20
years of age, for males and females. National
Center for Health Statistics14.
Fig. 2: Different modalities of bariatric surgery. VGB =
vertical banded gastroplasty; LAGB = laparoscopic
adjustable gastric banding; BPD = bilio-pancreatic
diversion; RYGBP = Roux-en-Y gastric bypass;
DAIR = digestive adaptation with intestinal
reserve; LSG = laparoscopic sleeve gastrectomy.
JOURNAL OF PEDIATRIC ENDOCRINOLOGY & METABOLISM