Bedah Bariatrik

International Journal of Obesity (2007) 31, 114 & 2007 Nature Publishing Group All rights reserved 0307-0565/07
$30.00 www.nature.com/ijo
PEDIATRIC REVIEW
Bariatric surgery for pediatric extreme obesity: now or later?
TH Inge1, SA Xanthakos2 and MH Zeller3
1 Division of Pediatric and Thoracic Surgery, Comprehensive Weight Management Program, Cincinnati Childrens Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA; 2Division of Gastroenterology, Hepatology and Nutrition, Comprehensive Weight Management Center, Cincinnati Childrens Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA and 3Division of Behavioral Medicine and Clinical Psychology, Cincinnati Childrens Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
Obesity is a multifactorial disease of epidemic and global proportions that poses the most significant threat to the health of our younger generations. Those who are the most extremely affected bear the largest burden of health problems. In the US, extreme obesity affects approximately 9 million adults and 2 million children, and is associated with both immediate health problems and later health risk, including premature mortality. Present medical and behavioral interventions for extreme obesity in adults and children rarely result in the significant, durable weight loss necessary to improve health outcomes, prompting a search for more aggressive measures. Weight loss (bariatric) surgery has been advocated as an intervention for those with extreme obesity. In adults, bariatric surgery results in prolonged weight control and improvement in serious obesity comorbidities, namely type 2 diabetes, dyslipidemias, hypertension and obstructive sleep apnea syndrome. A surge in weight loss operations for adolescents has been observed recently, with a threefold increase in case volumes nationwide from 2000 to 2003. Current evidence suggests that after bariatric surgery, adolescents lose significant weight and serious obesity-related medical conditions and psychosocial status are improved. Thus it is reasonable to propose that bariatric surgery performed in the adolescent period may be more effective treatment for childhood-onset extreme obesity than delaying surgery for extremely obese youth until adulthood. This position has been echoed by a number of groups and an independent systematic review. Finally, it is conceivable that bariatric surgery performed in adulthood for childhood onset extreme obesity may not be as effective for comorbidity treatment as surgery performed earlier during adolescence. The purpose of this review is to examine the evidence, which supports early rather than later use of bariatric surgery in the treatment of extreme obesity, and to present this information in light of the medical and surgical risks of bariatric surgery. International Journal of Obesity (2007) 31, 114. doi:10.1038/sj.ijo.0803525 Keywords: pediatric obesity; bariatric surgery; diabetes; sleep apnea; quality of life; NASH
Introduction
Obesity, defined in adults as body mass index (BMI)X30 kg/m2 or in children as BMIX95th percentile for age, is increasing in epidemic proportions, with a disproportionately greater increase in the prevalence of those with extreme obesity.1,2 To distinguish levels of obesity with adverse health consequences or mortality implications, a number of terms have been used in the literature including extreme obesity, very severe obesity, clinically severe obesity
Correspondence: Dr TH Inge, Division of Pediatric and Thoracic Surgery, ML 2023 Cincinnati Childrens Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229-3039, USA. E-mail: thomas.inge@cchmc.org Received 22 September 2006; revised 1 November 2006; accepted 2 November 2006
or class 3 obesity, and morbid obesity. These terms generally are used to characterize adults with a BMIX40 kg/m2, whereas the terms super obesity and super, super obesity have been used in the bariatric literature to describe individuals with BMI values X50, and X60 kg/m2, respectively. Ambiguity in this lexicon clearly presents problems when attempting to summarize or compare published clinical or research outcomes. Furthermore, only recently have we begun to define extreme obesity in pediatric populations. It would be useful to adopt common definitions for varying levels of obesity and to synchronize terminology between adult and pediatric age groups, especially as greater attention is focused on research and treatment efforts in extremely obese youth. As described by Freedman et al.,3 a definition of extreme obesity in pediatrics should not only correlate anthropometrically with a recognized definition of extreme adult obesity
Bariatric surgery for pediatric extreme obesity TH Inge et al
2
such as a BMI of 40 kg/m2, but should also identify a group of children with a high likelihood of being obese, with significantly elevated obesity-related health risks, and should define those who are highly likely to remain extremely obese into adulthood. In this regard, an attempt was recently made to describe the current prevalence of extreme pediatric obesity (99th percentile of BMI for age) based on a historic US reference population. Using this metric, approximately 4% of US children are currently affected with extreme obesity, outnumbering those affected by childhood cancer, cystic fibrosis, HIV and juvenile diabetes combined.3 Extreme obesity, particularly when coupled with medical comorbidities, place youth at high risk for premature mortality and morbidity in adulthood.4,5 When considering the mounting prevalence and deleterious effects of obesity on individuals and society, it is also important to factor in duration of obesity, which will cumulatively impact the health of young people over time.5 Although metabolic disorders (particularly insulin resistance and dyslipidemia), obstructive sleep apnea syndrome (OSAS), and psychosocial impairments are highly prevalent in extremely obese adolescents, currently little research effort focuses specifically on interventions which could realistically treat and reverse extreme obesity for young people. Behavioral weight management, which has been appropriately advocated for less extreme levels of obesity, results in poor rates of attendance and suboptimal weight reduction for youth with extreme obesity.6 Indeed, for adolescents with BMI values more than 40 kg/m2, some have reported only 3% BMI reduction after 1 year for those adolescents participating in well-designed, age-appropriate weight management program.7 Poor weight loss results have also been reported for pre-adolescents with extreme obesity.8 Bariatric surgery is an effective treatment option that significantly reduces adiposity and improves obesity-related comorbidities in adults. The purpose of this review is to discuss the rationale for early bariatric intervention for extremely obese youth, and to review currently available outcomes of for bariatric interventions in adolescents.
History of adolescent bariatric surgery

In the late 1960s, the early experiences with surgical treatment for adult obesity were first published.9,10 It was not until the 1970s and 1980s that bariatric procedures for adolescents with severe obesity were first reported. Jejuno ileal bypass (Figure 1) was performed in at least 20 adolescents (age range 1120 years) with preoperative weight in the range 120150 kg.11,12 The expected macronutrient malabsorption resulted in 3436% weight reduction for these patients. Significant improvement in hypertriglyceridemia, type 2 diabetes (T2DM) and quality of life were also reported, although at the expense of fat-soluble vitamin loss,
Figure 1 Operations for weight loss.
International Journal of Obesity
3
electrolyte abnormalities and diarrhea in some. Indeed, numerous patients required reversal of their jejunoileal bypass to manage nutritional complications.13,12 Owing to the documented risks of electrolyte disturbances, vitamin malabsorption, and liver and renal damage,1416 this operation has been abandoned17 and has no role in the modern treatment of adolescent or adult obesity. A small number of adolescents have also undergone biliopancreatic diversion, during which a partial gastrectomy is performed, with bypass of a majority of the small bowel absorptive area (Figure 1). The major advantage of this operation is that there is little restriction of food ingestion, but owing to poor nutrient absorption, ingested nutrients are minimally absorbed. There was typically a short (50 cm) common channel where biliopancreatic secretions and nutrients from the alimentary limb could admix and thus be absorbed. This procedure is associated with a high risk for postoperative protein and micronutrient deficiency.18 In particular, complications have included included hypoalbuminemia, hypovitaminosis A and D and folic acid deficiencies. However, the related duodenal switch procedure, which preserves a small cuff of duodenal mucosa for micronutrient absorption, and extends the distal common channel for macronutrient absorption, represents an refinement in this operation (Figure 1). Duodenal switch has been most widely recommended for adults with BMIX60 kg/m2 for whom other less malabsorptive operations have been deemed ineffective in reliably reversing this degree of obesity. This operation is commonly performed today as a two-stage procedure, by first performing a vertical gastrectomy using a 1216 mm diameter internal bougie, which results in a narrow, lesser curve gastric tube. This procedure is followed months later by a completion of the duodenal switch procedure (see Figure 1). The potential for micronutrient malabsorption, requirement for rigorous compliance with vitamin and mineral supplements, combined with the higher frequency of loose stools and excess flatulence associated with such diversionary operations suggests that such malabsorptive procedures should not be the first choice of operation for adolescents. Alternatively, some reports indicate that adults who have undergone vertical gastrectomy alone have lost significant weight (25%) over a 6-month period of time.19 Although few nutritional side effects would be predicted, longer-term follow-up will be needed to determine the durability of vertical gastrectomy alone. Following early experiences with malabsorptive procedures, adolescents were treated with a less complex, restrictive vertical-banded gastroplasty between the early 1980s and mid 1990s (Figure 1).2022 Mean BMI reduction at 5 and 10 years was 25 and 22%, respectively,20 consistent with the adult experience.23 In addition to this modest weight loss (compared to other operations), numerous reoperations were required for disrupted staple lines and resultant failure of the restrictive operation, limiting overall enthusiasm for this approach in the surgical community.
The modern era of bariatric surgical procedures for adolescents

Use of roux en Y gastric bypass (RYGB) (Figure 1) for weight loss in the US dates back to the 1960s for adults and the 1980s for adolescents.18,22,24 Currently, gastric bypass remains the most common operation for obesity in the US, consisting of a very small, 2030 ml gastric pouch created at the gastroesophageal junction, typically excluding the ghrelin-rich fundus from the alimentary stream. The roux limb typically measures 75150 cm in length and is surgically anastomosed to the gastric pouch.25 The result is a restrictive reconstruction owing to the small size of both the gastric pouch and the gastrojejunal anastomosis. In addition, the procedure is considered (mildly) malabsorptive as the gastroduodenal mucosal is not present in the alimentary stream. Although this fact certainly impairs absorption of vitamin B12, iron and calcium, no significant impairment of macronutrient absorption is seen as three-fourths of the small intestinal mucosa (all except the roux limb) is represented in the common channel where absorption can occur. In adults, this operation results in the sustained (414 years) loss of approximately 30% of body weight.23,26 Since the 1990s minimally invasive laparoscopic techniques have increasingly been used for this operation, but before that time cases were performed using open laparotomy. Strauss retrospectively evaluated results of gastric bypass performed using an open, laparotomy technique in 10 adolescents (age range: 1517).27 Mean preoperative weight was 148 kg (mean BMI 52.4 kg/m2) and seven of 10 had severe obesity-related morbidities which included OSAS, hypertension, vertebral compression fracture and school avoidance owing to teasing. No early complications were recorded during a mean weight loss was 40%. Maximal weight loss was achieved at 1215 months postoperatively and was accompanied by significantly improved OSAS and hypertension. Reoperations for cholelithiasis, small bowel obstruction and incisional hernia were required in four patients. Sugerman et al.28 have provided us with the largest retrospective study of adolescent bariatric surgery with the longest follow-up to date. Over a 21-year period between 1981 and 2002, 33 adolescents underwent a variety of procedures including 30 with RYGB or a variation thereof and three with horizontal or vertical gastroplasty. Mean preoperative BMI was 52 kg/m2 and mean age was 16 years. Major complications observed within 30 days of operation included one major wound infection, one pulmonary embolism, three stomal stenoses requiring endoscopic dilation and four ulcers within the roux limb-treated medically. Late (beyond 30 days) complications included one small bowel obstruction and six incisional hernias. Two late deaths occurred, one at 1 year and one at 6 years; although autopsy was not performed after either of these sudden deaths, no relationship between these deaths and the surgical procedure was suspected. All preoperative comorbidities had resolved at
4
1 year except gastroesophageal reflux and hypertension in two patients, respectively. Mean BMI measured at 1, 5, 10 and 14 years after surgery was 36, 33, 34 and 38 kg/m2, respectively. Importantly however data for only 12 of 18 subjects eligible for 10 year follow-up were available and at 14 years, data from only six of nine eligible were available despite attempts to maintain contact with this cohort. Five patients (15%) regained all or most of their lost weight at 510 years after surgery. In 2005, weight loss and complications data were compiled from several pediatric centers participating in the Pediatric Bariatric Study Group. It should be recognized that in this consortium, conservative indications for operation have been used.29 In addition, adolescent patients are evaluated by an adolescent bariatric team consisting of bariatric surgeons, pediatricians with a subspecialty focus on obesity and psychologists with expertise in pediatrics, in addition to other allied health-care workers.30 A more detailed review of patient selection criteria can be found elsewhere29,31,32 but in general, in those adolescents who have completed linear growth, a BMI of X40 kg/m2 with obesity-related comorbidities can be used to justify surgical intervention. Among three pediatric centers using similar operative criteria, 41 adolescents undergoing laparoscopic gastric bypass were followed for at least 1 year.7 BMI at baseline was 57 kg/m2, decreasing by 37% to 36 kg/m2 by 1 year after surgery. There were no perioperative deaths. No complications were seen in 61%. Of the remaining 15 patients with some complication, nine were deemed minor with no long-term sequelae, four were scored as moderate with sequelae lasting 7 days or more and two had at least one severe complication with long-term consequences (30 or more days duration) including one death at 9 months owing to severe infectious colitis. Indeed several cases of Clostridium difficile colitis requiring intraluminal antibiotics have occurred now in our series of over 70 patients. In addition, two patients began regaining lost weight within the first year, one of whom regained over 50% of the initial weight lost. The precise frequency of weight regain after adolescent gastric bypass is not clear but may be as high as 10 20%.7,27,28 Adjustable gastric banding (Figure 1) is the most recent procedure introduced for surgical weight management, and is gaining worldwide acceptance.33 During this procedure, a device consisting of a synthetic band with a small inflatable inner balloon is placed around the proximal stomach, just beyond the gastroesophageal junction. The inner balloon is inflated by injection of saline into a subcutaneous port to adjust the degree of gastric restriction. The band procedure is completely reversible and does not transect the gastrointestinal tract. A large Australian experience with adjustable gastric banding in adults has been enormously beneficial to our knowledge about the use of this surgical technique and the consequences of significant weight loss on adult obesity and comorbidities.3442 The largest adolescent series to date is
also Australian, consisting of 41 adolescents (age range 12 19 years) with a mean weight of 125 kg, and a mean BMI 42 kg/m2.43 These patients generally presented without any major physical health problem associated with obesity, with the exception of five patients with either T2DM, OSAS or hypertension. Weight loss in the range of 30% was reported 3 years postoperatively in 18 patients in this series for whom 3-year data was available. All patients with comorbidities experienced improvement in these conditions. Few complications were reported for this period of follow-up, but included one patient with gastric prolapse (band slippage) requiring band repositioning, and one with a leak from the tubing requiring revision. When gastric bypass and adjustable gastric banding have been compared, reports have cited greater weight loss and comorbidity resolution with gastric bypass at early time intervals (13 years),44,45 but similar weight loss efficacy at later (5 year) time intervals.33 Despite difficulties in comparison of studies which report results from cohorts differing in weight and comorbidity status, adjustable gastric banding seems to be a technically safer operation with lower mortality risk than other procedures,33 principally related to the lack of risk of intestinal leakage and subsequent sepsis early after operation. Systematically collected information about both efficacy and potentially worrisome later (510 year) complications including band obstruction, gastric prolapse, pouch dilatation, port/tubing problems, severe esophageal dilatation/dysmotility and frequency of band explantation will be critical for clinical decision making for adolescents who have perhaps five or six decades to live with the device. Although this device holds a great deal of promise for treatment of adolescents with extreme obesity, more information about long-term efficacy and durability is needed. Tsai et al.46 have also recently used the National Inpatient Sample, a large US administrative database, to examine temporal trends in utilization of bariatric surgery in youth. This analysis spanning the years 19962003 estimated that over 3000 bariatric procedures were carried out for adolescents during this time period. Constant adolescent procedure volumes of approximately 200 cases per year were found between 1996 and 2000. From 2000 to 2003 however, a threefold increase in utilization of weight loss procedures (90% gastric bypass) occurred in adolescents. No inpatient mortality was seen for adolescents whereas a mortality rate of 0.2% was estimated for adults. Although adolescents presented with fewer comorbid conditions, adolescents and adults demonstrated similar rates of inpatient postoperative complications in this analysis.
Nutritional risks of weight loss surgery

Although there is good rationale to consider bariatric surgery in adolescents, the potential benefits of intervention cannot
5
be evaluated without parallel consideration of attendant nutritional risks.47 In the absence of micronutrient supplementation, inadequate absorption of calcium, vitamin D, iron, vitamin B1, B6, B12, A and folate can occur following bariatric procedures.4851 Both restrictive and malabsorptive factors can contribute to an increased risk of nutritional deficiencies after gastric bypass. Even purely restrictive procedures may too result in decreased intake of macro and micronutrients with potential risks for youth, although this risk should predictably be less than with other procedures. Peripheral neuropathy is one of the more common manifestations of vitamin deficiencies after bariatric surgery, occurring in 516% of gastric bypass patients who receive inadequate B vitamin supplementation.52,53 In particular, vitamin B1 deficiency (beriberi) has been well-described after bariatric surgery in adults54 as well as several of our adolescent patients.55 In our adolescent cases, the predominant symptoms were similar to those in adults and occurred within 6 months of surgery. Painful paresthesias, weakness and difficulty walking were key features. In contrast with adult series, postoperative emesis was not always an associated feature, which suggests that perhaps poor compliance with routine vitamin supplementation may have been an underlying factor. Further, the prevalence of beriberi in the larger cohort (four out of 55 patients) was higher than would be anticipated based on adult case series. We have recommended specific nutritional interventions, including (1) initiation of preoperative multivitamin supplementation to correct possible pre-existing micronutrient deficiencies and (2) addition of a separate thiamine supplement for the initial 6 months postoperatively in an empiric effort to reduce the risk of micronutrient depletion following bariatric surgery in adolescents.55 Menstruating young women who undergo gastric bypass are also at increased risk of iron deficiency anemia primarily resulting from poor absorption of ingested iron. With specific iron supplementation, iron deficiency anemia may be prevented (as assessed by adequacy of ferritin levels) but mild anemia can still result, despite normal vitamin levels.51 This finding highlights the concern that some nutritional risks of gastric bypass may be usual and expected, whereas others may not necessarily fit with expected physiologic paradigms. Concern for osteoporosis and osteopenia has recently come to the forefront after some adult recipients of bariatric surgery, primarily those who have undergone more malabsorptive procedures, have developed osteopenia and osteoporosis, secondary hyperparathyroidism and low serum vitamin D, a decade or more after surgery.56 In 15 adults undergoing gastric bypass surgery, decreased bone mineral density at 9 months was evident, despite normal parathyroid hormone (PTH), calcium and vitamin D levels.57 Extremely obese adults may be at increased risk of postoperative deficiencies in calcium and vitamin D, as up to 20% of severely obese adults were found to have low vitamin D and elevated PTH levels before surgery. Potential factors behind these pre-existing deficiencies include reduced physical activity, less sunlight exposure and increased storage in body fat with reduced bioavailability.58 Obese children and adolescents also may have lower levels of some fat soluble vitamins (A, D and E),59,60 and dietary calcium intake has been decreasing among children and adolescents over the past few decades.61,62 Specific data on pre-existing calcium and vitamin D deficiencies in obese adolescents are lacking. Short-term preliminary assessment of a series of adolescents in our program is reassuring, as we have found that bone mineral content and density is typically 2 to 3 s.d. above normal preoperatively and minimal loss of bone mineral density and content occurs 1 year postoperatively as measured by dual-energy X-ray absorptiometry (unpublished observations). However, long-term data in these adolescents is not yet available. Chronic deficiency of vitamin D may also result in important secondary effects on other metabolic processes other than bone health, as vitamin D deficiency has been linked to cancer, hypertension, rheumatoid arthritis, diabetes and peripheral vascular disease.63,64 In the short term, however, a preliminary assessment of nutritional status 1 year after gastric bypass surgery in a cohort of 28 of our adolescent gastric bypass patients has not revealed significant nutritional concerns, with the notable exception of the reported beriberi cases. Measurements of albumin, total lymphocyte counts, hemoglobin, ferritin, water and fat soluble vitamins were preserved or increased. During this period, the adolescents had been prescribed routine multivitamin, calcium and B12 supplementation (additional iron only if female). However, adherence was not measured. Current supplementation practices are often based on standards established in adults, in whom regimens frequently vary by surgical center. Further, evidence from randomized controlled trials is often lacking to justify supplementation amounts or choices. Adolescents present a unique population and optimum needs for supplementation and time points for monitoring must be determined, both in consideration of the increased length of time they will live with altered physiology and in light of lower rates of adherence during this critical developmental period. In other pediatric disease models, such as kidney transplant, adolescents with chronic disease often have been reported to have lower compliance with medication regimens.65 Early data in adolescents undergoing bariatric surgery appear to confirm this risk of low compliance: a small study of adolescents after RYGB revealed that only 14% took recommended supplements.66 Factors that impede or promote compliance in this age group require further study to enhance the long-term safety of bariatric surgery in adolescents.
Pregnancy prevention and counseling Any bariatric program that includes adolescents must include counseling to prevent pregnancy in the first 1218
6
months after surgery and nutritional counseling to ensure safe pregnancy outcomes as young adults. Chance of pregnancy after bariatric surgery is increased by weight loss, which improves the ovulatory dysfunction often associated with obesity, thus increasing the risk of unplanned pregnancy if contraception is not used.67 Nationally, approximately 50% of adolescents have engaged in sexual intercourse by age 17, however it is not clear to what extent this is true for extremely obese youth, as weight-related stigma may affect rates of sexual activity.68 Though the weight loss associated with gastric bypass has been shown to reduce weight-related complications of subsequent pregnancies in adults, it is important to counsel adolescent females to avoid pregnancy during the period of rapid weight loss and up to 1218 months after surgery.69 Further, adolescent pregnancy in general is associated with a higher incidence of complications, such as prematurity and low birth weight, though outcomes of pregnancy in adolescent females after bariatric surgery have not yet been systematically studied.68 Higher rates of specific nutritional deficiencies after bariatric surgery can place the mother and infant at greater risk. In particular, deficiencies in iron, folate, vitamin B12, calcium and vitamin D can result in poor fetal growth or even malformation.70 Before pregnancy, compliance with multivitamin supplementation should be specifically addressed, screening for anemia, vitamin deficiency should be performed and any deficiencies corrected. During pregnancy, prenatal vitamins, oral iron and calcium are required and higher levels of folate and iron supplementation may be necessary. After pregnancy, the malabsorptive and/or restrictive component of the bariatric surgery may result in suboptimal breastmilk quality and the maternal diet should be adjusted to promote adequate caloric intake for the infant, but avoid excess weight gain for the mother.71 Vitamin supplementation should continue during breastfeeding to avoid development of hypovitaminosis in the infant, in particular vitamin B and A deficiencies.72 extremely obese adolescents currently meet diagnostic criteria for the metabolic syndrome.83,84 Thus, available evidence suggests a strong association between features of the metabolic syndrome, elevated BMI and subsequent cardiovascular disease (CVD) in adulthood. Bariatric surgery results in sustained and significant weight reduction and a reduction in CVD risk factors for extremely obese adults.85 We have also demonstrated that bariatric surgery in adolescence results in correction of nascent features of the metabolic syndrome.7 Particularly significant were a 70% decline in fasting insulin levels, a 13% decline in fasting glucose concentrations and a 30% decrease in triglyceride levels following adolescent surgical weight loss. Extremely obese adolescents also demonstrate increased eccentric and concentric ventricular hypertrophy compared to less obese and lean adolescents.86 This elevated ventricular mass is an important risk factor for subsequent myocardial failure. Early outcomes also suggest that extremely obese adolescents undergoing bariatric surgery experience significant decreases in ventricular wall thickness and left ventricular mass index (H Ippisch, personal communication). Thus, the cardiac hypertrophy associated with extreme adolescent obesity does not appear to represent fixed end organ damage, but rather suggests a plasticity and possible anatomic change following surgical weight loss in youth. Improvement in cardiac structural changes have less commonly been documented after surgical weight loss in adults, with one study finding only a modest 15% loss of left ventricular mass after surgical weight loss.87 These metabolic and early echocardiographic data support the hypothesis that surgical weight loss in extremely obese adolescents may improve cardiac health to a greater extent than surgical weight loss used in adulthood. Whether normalization of these risk factors in adolescents will ultimately reduce the incidence of life-threatening CVD after they become adults is unclear and will require careful and long-term study.
Can comorbidities justify earlier rather than later intervention?

Cardiovascular risks It has become clear that obesity, especially visceral adiposity, may be the engine which drives the development of both insulin resistance and the features of the metabolic syndrome.73 Longitudinal studies have demonstrated that obesity in childhood and adolescence significantly increases the likelihood of hypertension,74 hypercholesterolemia,75 hypertriglyceridemia76,77 and atherosclerotic disease78,79 in young adulthood. Insulin resistance may be the important common denominator in multiple obesity-related comorbidities including T2DM, ischemic heart disease,80 OSAS,81 polycystic ovary syndrome, fatty liver disease82 and even depression. An alarming one third to one half of all
OSAS OSAS refers to the occurrence of repetitive episodes of complete or partial obstruction of the airway during sleep, usually in association with loud snoring and daytime somnolence. Immediate consequences of OSAS are sleep fragmentation, arousal, poor school/job performance, irritability, intermittent hypercapnia and hypoxemia, nocturnal hypertension and marked changes in autonomic control of the cardiovascular system.88 The long-term consequences of OSAS include sustained daytime and nocturnal hypertension,89,90 cor pulmonale, left ventricular hypertrophy91 and increased cardiovascular and cerebrovascular morbidity and mortality.92 Indeed, cross-sectional results from the Sleep Heart Health Study showed a strong association between OSAS, heart failure and stroke.93 OSAS is highly prevalent and debilitating in extremely obese adolescents and adults.94 OSAS is a compelling indication for bariatric surgery because of the reliable improvement seen in adults after
7
weight loss. To determine the effect of surgical weight loss on OSAS adolescents, polysomnograms have been performed before and after surgical weight loss.95 OSAS (apnea hypopnea index (AHI)X5 events/h) was diagnosed in 55% of 34 patients studied preoperatively, and a marked increase in OSA prevalence with increasing BMI was observed. Preoperatively, the mean AHI for adolescent bariatric patients with OSAS was 9.1 events/h (mean BMI of this group was 61 kg/m2). Ten patients had follow-up polysomnograms after weight loss, and mean AHI in this group was 0.6 events/h, a nearly 20-fold improvement; OSAS had resolved completely in nine of these 10 subjects. This finding is especially significant in light of the fact that in studies utilizing overnight polysomnography in adults before and after bariatric surgery, weight loss was associated with improvement in AHI values by only five-fold (e.g., preoperative AHI of 60 events/h vs postoperative AHI of 12 events/h).96,97 Indeed, complete OSAS resolution was seen in only half of adults following surgical weight loss.98 The likelihood of resolution of OSAS after surgical weight reduction may be greater in those with less severe OSAS preoperatively. Thus, from available evidence it is reasonable to hypothesize that effective weight loss interventions applied before OSAS progression may result in more complete and perhaps more durable resolution of OSAS. Earlier improvement in OSAS could have manifold benefits, given the wide range of neurocognitive and cardiopulmonary consequences of OSAS. As more than half of all adolescents presenting for treatment of extreme obesity have OSAS, it is important to begin to understand the effects of surgical weight loss on this disorder in adolescents. Direct comparisons of the effects of bariatric surgery on OSAS in individuals who vary in their duration of severe obesity will help elucidate factors important in the pathogenesis of OSAS over time. only incomplete normalization of parameters of insulin secretion and insulin resistance.106111 Adolescents undergoing bariatric surgery also demonstrate significant fasting hyperinsulinemia and insulin resistance as estimated by homeostasis model assessment (HOMA-IR) was abnormal in 64% of patients preoperatively.7 However, in contrast to adult outcomes, surgical weight loss in adolescents resulted in complete resolution of fasting hyperinsulinemia.7 HOMA-IR decreased by 78% overall (Po0.01) and completely normalized in all but one patient (Po0.01). One explanation for lack of complete correction of carbohydrate metabolism in adults is that in adulthood (and particularly for diabetics), some may have already experienced functional b-cell exhaustion that cannot be recovered even after surgical weight loss. Indeed, the duration of T2DM significantly predicts poorer resolution after weight loss surgery,26,112 and may well be related to the incomplete resolution of diabetes after weight loss surgery in adults.26,36,39 Thus, it is possible that greater benefit may be achieved by intervention earlier rather than later in the continuum of disordered carbohydrate metabolism associated with extreme obesity before metabolic and pancreatic abnormalities have escalated and are less likely to completely resolve.
Endocrine changes Abnormalities in carbohydrate metabolism are strongly associated with both adult and childhood obesity.73,99 A 10-fold increased incidence of T2DM in pediatric age groups was first reported from Cincinnati in 1996.100 Up to 25% of obese individuals in both pediatric101,102 and adult26,103 age groups have impaired glucose tolerance, whereas the prevalence of T2DM is only 46% in obese youth and 25% for adults. In adults, RYGB results in remission and prevention of T2DM,104,105 with normalization of fasting hyperglycemia in 6483% of type 2 diabetic patients and 99% of those with impaired glucose tolerance.26,36 Improvements in insulin resistance and b-cell function have been documented following surgical weight loss.36,106109 Interestingly, although significant improvements in carbohydrate metabolism occur after surgical weight loss in adults, studies also demonstrate that in response to a glucose challenge there is
NAFLD and steatohepatitis Nonalcoholic fatty liver disease (NAFLD) is strongly associated with obesity, in particular with visceral adiposity and insulin resistance, and with the rising prevalence of obesity, is rapidly becoming one of the most common liver diseases in the United States and worldwide.113,114 The spectrum of NAFLD ranges from simple steatosis, believed to be benign and nonprogressive, to more severe, potentially progressive steatohepatitis (NASH), which is marked by hepatic inflammation, hepatocellular injury and fibrosis. The population prevalence of NAFLD and NASH in adults has been estimated to be 1532% and 24%, respectively,115 whereas in children, the prevalence of NAFLD is estimated to be 9.6%, and NASH 3%.116 Although NASH is less common than NAFLD, up to a quarter of individuals with NASH may go on to develop extensive fibrosis and cirrhosis.117,118 The specific genetic and environmental risk factors that drive development of NASH in only a subset of patients with NAFLD are not clearly defined, nor is the time course over which NASH develops in susceptible individuals known. Older age, obesity and T2DM however have been identified as predictors of NASH in adults,119,120 whereas race and ethnicity, male gender, obesity and insulin resistance may be predictors of NASH in children.116 Consistent with a larger burden of obesity-related comorbidities in extremely obese adults, liver disease in such patients is more prevalent and advanced.121126 Therefore, to define the spectrum and determinants of NAFLD in extremely obese adolescents, we correlated liver histology with clinical features and compared findings to reported adult
8
data.127 In our cross-sectional study of 41 adolescent subjects undergoing gastric bypass, 83% had NAFLD. Despite severe obesity (mean BMI 59 kg/m2), 24% percent had steatosis alone, whereas 7% demonstrated isolated fibrosis with steatosis, 32% nonspecific inflammation and steatosis and 20% had NASH. Overall, 29% percent had fibrosis; none had bridging fibrosis or cirrhosis. As we had anticipated, NAFLD and NASH were more prevalent in these extremely obese adolescents than in less obese children, in whom the prevalence of fatty liver has been reported as 3850%.116 Further, abnormal serum aminotransferases were more prevalent in those adolescents with NASH (Pp0.05). but could not distinguish between steatosis and more severe forms of NAFLD. Not surprisingly, given the degree of severe obesity, 73% of the cohort met criteria for the metabolic syndrome. Strikingly, the prevalence of the metabolic syndrome did not differ significantly between the histologic subgroups and nearly 60% of those with histologically normal liver biopsies also had the metabolic syndrome. Of individual components of the metabolic syndrome, only mean fasting glucose was significantly higher in those with NASH (P 0.05). Impaired fasting glucose, hypertension and abnormal high-density lipoprotein were highly prevalent in the entire cohort, but not significantly different between histologic subtypes. This indicates that additional biologic processes and genetic susceptibility factors may be driving the onset of hepatic inflammation and fibrosis in response to obesity and insulin resistance at this younger age. Elucidating these biological factors which drive development of inflammation and fibrosis in severely obese adolescents will be critical for risk-stratification in the future when contemplating aggressive obesity treatment approaches, by helping predict which patients are destined to undergo rapid progression of obesityrelated NASH. Studies of NASH outcome after gastric bypass in adolescents are currently lacking. Several studies in adults have reported improvement in NAFLD and NASH after surgery, though some studies have highlighted a transient increase in inflammation after surgery.34,121 Two recent studies of outcome of NASH after bariatric surgery in adults have demonstrated significant decreases in steatosis, but variable or no changes in inflammation and fibrosis.128,129 Although both of these recent studies in adults suggest a clear beneficial effect of gastric bypass surgery on NAFLD and NASH, the persistence of fibrosis and inflammation in a subset of patients indicate the need for longer-term followup. A significant unanswered question is whether earlier intervention in adolescents will not only prevent progression from simple steatosis to NASH in susceptible individuals, but will also result in greater normalization of inflammation and fibrosis in those adolescents who already have NASH at time of bariatric surgery. Further, it is not known whether severely obese adolescents with hepatic steatosis and insulin resistance who do not actually normalize their weight and remain obese may still be at risk for
subsequent development of NASH, owing to ongoing exposure to the proinflammatory and profibrotic milieu of obesity. To answer these questions, longitudinal outcome studies of liver histology are needed in severely obese adolescents, from both surgical and nonsurgical cohorts.
Psychosocial implications of obesity in children and adolescents There is a substantial gap in our understanding of the psychosocial comorbidities that characterize youth whose obesity progresses to extreme levels before adulthood, and in particular, those who seek surgical intervention. Just as adolescents with BMI values at extreme levels (e.g., X40 kg/m2) are poorly represented in the National Health and Nutrition Examination Survey so too have they been poorly represented in studies seeking to explore psychosocial status in obese children. However, it is clear from a number of focused studies that adolescents with extreme obesity are at considerable psychosocial risk. Briefly, compared to leaner peers, obese adolescents report more stigmatizing experiences (e.g., name-calling and teasing),130 victimization,131 have fewer friendships and are more socially marginalized.132 To date, no prospective longitudinal studies have tracked the consequences of the poor peer relations of obese youth over time. However, in the general population, poor peer relations have been empirically linked to greater psychopathology and poorer life adaptation (e.g., school/ job performance, interpersonal relations) in adulthood.133 Adolescent obesity has also been associated with poor selfconcept, with persistent obesity from middle childhood to adolescence associated with decreasing self-esteem.134 Recent research examining the health-related quality of life (HRQOL) of obese youth has documented significant impairments in daily functioning across physical, social, emotional and school domains.135,136 Further, when HRQOL was examined across the weight spectrum, results suggested that HRQOL decreased with increasing weight.137,138 We recently reported baseline psychosocial status of a small but unique population of extremely obese adolescents referred by their physician for consideration of bariatric surgery.139 We documented significant and global impairments in HRQOL (e.g., PedsQL140), with an effect size greater than previously reported for any other adolescent population in the pediatric obesity literature (Figure 2). There is a considerable controversy regarding the association between depressive symptomatology and adolescent obesity.139,141144 Obese adolescents typically exhibit subclinical or average range depressive symptomatology, with only a small subset having a clinically significant range of symptoms or meeting diagnostic criteria for a depressive disorder. Noteworthy however, is the growing and compelling evidence regarding important correlations between depressive symptomatology, obesity development and obesity persistence in adolescence and adulthood.145 When we examined depressive symptomatology in extremely obese adolescents presenting for bariatric surgery,139 30% of
Generic HRQOL scales for adolescents with extreme obesity and healthy youth
100 90 Scaled Scores (0-100) 80 70 60 50 40 30 20 10 0 Psychosocial Physical Emotional Social School Total
Healthy Children Youth SelfReport Healthy Children Parent Proxy Report Bariatric Youth Self-Report Bariatric Parent Proxy Report
PedsQL Scales
Figure 2 Self-reported and parent-proxy HRQOL scores for adolescents with extreme obesity and healthy youth. Adapted from published data on norms for healthy children.140 This figure used with permission of publisher.139
adolescents endorsed symptoms in the clinical range on the Beck Depression Inventory.146 This rate of clinical-range depressive symptomatology is higher than published rates of obese children and adolescents enrolling in behavioral treatment (11%)147 and population base rates (10%).148 Our initial data suggest that adolescents who are at extreme levels of obesity and choosing an aggressive surgical intervention have accumulated greater distress as their obesity has progressed. Equally noteworthy is that our data document that the majority (e.g., two-thirds) of adolescents presenting for surgical evaluation self-report depressive symptoms in a mild or subclinical range. Finally, overweight adolescents report more binge eating behavior than their non-overweight peers.149 However, when binge eating symptomatology was assessed using structured diagnostic interviews such as the Eating Disorder Examination,150 only a very small percentage (between 0.04 and 2.80%) of obese adolescents in population-based studies meet Diagnostic and Statistical Manual-IV criteria for Binge Eating Disorder (BED).151 Similarly, only 1% of youth (ages 1016) enrolled in a behavioral weight management program met full diagnostic criteria for BED, with 9% engaging in objective binge eating episodes (overeating with loss of control).152 To date, there have been no investigations of binge eating behaviors in extremely obese adolescents or in adolescents seeking bariatric surgery. In the absence of longitudinal studies which track the psychosocial trajectories of adolescents with extreme obesity, some clues about the extremely obese adolescents psychosocial future may be discovered by examining the adult experience. For instance, it is well documented that obese adults, and extremely obese adults in particular, experience considerable psychosocial impairment. Obesity in the emer-
ging adulthood years (ages 1823) has been strongly associated with completing fewer years of advanced education, lower family income, lower rates of marriage,153 and lower life satisfaction in the areas of work and close interpersonal relations.154 Extreme obesity in adulthood is associated with a lifetime history of mood and anxiety disorders155 and impaired HRQOL.156 HRQOL becomes more impaired as both BMI and treatment intensity increase,157 with those seeking bariatric surgery having the poorest quality of life.158,159 The prevalence of BED in severely obese adults reportedly ranges from 13160 to 49%,161 and is comparatively higher than BED rates in obese adolescents. Adults with BED seeking bariatric surgery report poorer quality of life159 and greater psychological distress162 than those without BED. When such data from adolescent and adult cohorts are placed on a hypothetical continuum, a reasonable extrapolation would be that adolescents who are extremely obese are at considerable risk of continued and mounting psychosocial impairment and poor developmental adaptation. Indeed, one could reasonably hypothesize that these psychosocial comorbidities may well be irreversible if adolescent extreme obesity is not effectively treated during formative adolescent years. Based on adult outcomes, it is known that postsurgery adult patients report improved HRQOL,37,163165 less stigmatization and discrimination,166 an improved social life,167,168 and improved educational and occupational status.168,169 Further, there is evidence suggesting that pre-existing psychosocial impairment influences adult surgical outcomes.170 For example, binge eating behavior, depression, or active-untreated problems with alcohol or drug abuse have resulted in higher rates of surgical postoperative
10
medical complications, less weight loss,171,172 and less relative improvement in social functioning, quality of life, depression and overall psychological status. Our early observations in a sample of 16 adolescents (mean age 15.6 years; 63% females, mean BMI 59.9 kg/m2) revealed that at 12-months postsurgery adolescents experience significant improvement in HRQOL and depressive symptomatology (e.g., within more normative ranges) despite continued obesity (mean BMI 36.9 kg/m2; Zeller, M, unpublished data). These psychosocial changes may substantively alter the psychological health and socioeconomic trajectory of the adolescent to a greater extent than if surgery is performed later in adulthood. Further follow-up into adulthood is crucial to document weight and psychosocial trajectories and their interrelations. The identification of psychosocial predictors of positive short- and long-term surgical outcomes will be critical to the development of more informed adolescent patient selection criteria and more efficacious adolescent treatment paradigms. emotional development when considering their candidacy. Adolescents must also be active participants in the decisionmaking process (e.g., assent/consent, knowledge of risks/ benefits) to assure that the decision to have surgery is voluntary, well informed and rational.175 Critically needed are well-designed, prospective studies, which evaluate the efficacy and safety of weight loss interventions using comparable clinical management protocols, uniform data definitions, and standardized research methodology to minimize bias and maximize usefulness of this information. To accomplish these aims, a federally funded multicenter research initiative in the US known as the Longitudinal Assessment of Bariatric Surgery (LABS) was recently begun. Teen-LABS, a parallel project to carefully phenotype and follow adolescents undergoing bariatric surgery was also recently funded. Similar federally funded adolescent bariatric research initiatives are also underway in Australia. Thus, there is good reason to believe that many of the hypotheses outlined above will be testable and in the future and more evidence will be available on which to base treatment decisions for youth and adults worldwide who suffer with extreme obesity and health consequences.
Conclusions and perspective

Epidemiologic data has confirmed that pediatric obesity is increasing in prevalence and severity. The magnitude of the problem of extreme obesity in youth now warrants the attention of all pediatric health-care providers, and careful study of all reasonable interventions at the societal as well as individual level in an attempt to reverse both current obesity trends and personal health consequences. In this regard, accumulating evidence suggests that adolescents who are currently choosing bariatric surgery should expect significant improvements in obesity status and related comorbidities. It is also possible that improvements in health and psychosocial well being may exceed that which would be expected if operation were delayed until later in the life course of extreme obesity after comorbidities progress and worsen. Given numerous reports of positive outcomes of bariatric surgery in adolescence in the medical literature and general acceptance in the worldwide media, it is likely that greater numbers of youth will seek surgical interventions for obesity in the future. This increased demand for surgical services will in turn influence hospital systems to develop programs for the care of these patients. Institutions providing bariatric care to youth should only provide these services if care can be offered utilizing multidisciplinary teams dedicated to pediatric patients and if processes are in place to insure safety and excellent delivery of clinical care. Realization of this goal is the basis for bariatric credentialing described by both the American Society for Bariatric Surgery173 and the American College of Surgeons.174 Further, without an empirically valid method of assessing an adolescents capacity to make an informed decision about weight loss surgery, the clinical team must consider the adolescents cognitive, social and
Acknowledgements
We express appreciation for the conceptual framework or technical assistance of the following members of the research team who contributed to the completion of this manuscript: Drs Louise Lawson, Holly Ippisch, Stephen Daniels, Maninder Kalra, Michael Helmrath, Mac Harmon, Anita Courcoulas, Avani Modi, Victor Garcia and Ms Kimberly Wilson and Kimberly Gamm.
References
1 Sturm R. Increases in clinically severe obesity in the United States, 19862000. Arch Intern Med 2003; 163: 21462148. 2 Troiano RP, Flegal KM. Overweight children and adolescents: description, epidemiology, and demographics. Pediatrics 1998; 101: 497504. 3 Freedman DS, Mei Z, Sriniavasan SR, Berenson GS, Dietz WH. Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the Bogalusa heart study. J Pediatrics 2006. In Press. 4 Must A, Jacques PF, Dallal GE, Bajema CJ, Dietz WH. Long-term morbidity and mortality of overweight adolescents. A follow-up of the Harvard Growth Study of 1922 to 1935. N Engl J Med 1992; 327: 13501355. 5 Fontaine KR, Redden DT, Wang C, Westfall AO, Allison DB. Years of life lost due to obesity. JAMA 2003; 289: 187193. 6 Zeller M, Kirk S, Claytor R, Khoury P, Grieme J, Santangelo M et al. Predictors of attrition from a pediatric weight management program. J Pediatr 2004; 144: 466470. 7 Lawson ML, Kirk S, Mitchell T, Chen MK, Loux TJ, Daniels SR et al. One-year outcomes of Roux-en-Y gastric bypass for morbidly obese adolescents: a multicenter study from the Pediatric Bariatric Study Group. J Pediatr Surg 2006; 41: 137 143; discussion 137-143.
11
8 Levine MD, Ringham RM, Kalarchian MA, Wisniewski L, Marcus MD. Is family-based behavioral weight control appropriate for severe pediatric obesity? Int J Eat Disord 2001; 30: 318328. 9 Scott Jr HW, Law DH. Clinical appraisal of jejunoileal shunt in patients with morbid obesity. Am J Surg 1969; 117: 246253. 10 Payne JH, DeWind LT. Surgical treatment of obesity. Am J Surg 1969; 118: 141147. 11 Randolph JG, Weintraub WH, Rigg A. Jejunoileal bypass for morbid obesity in adolescents. J Pediatr Surg 1974; 9: 341345. 12 Organ Jr CH, Kessler E, Lane M. Long-term results of jejunoileal bypass in the young. Am Surg 1984; 50: 589593. 13 Silber T, Randolph J, Robbins S. Long-term morbidity and mortality in morbidly obese adolescents after jejunoileal bypass. J Pediatr 1986; 108: 318322. 14 Ehlers SM, Posalaky Z, Strate RG, Quattlebaum FW. Acute reversible renal failure following jejunoileal bypass for morbid obesity: a clinical and pathological (EM) study of a case. Surgery 1977; 82: 629634. 15 McClelland RN, DeShazo CV, Heimbach DM, Eigenbrodt EH, Dowdy AB. Prevention of hepatic injury after jejuno-ileal bypass by supplemental jejunostomy feedings. Surg Forum 1970; 21: 368370. 16 Bondar GF, Pisesky W. Complications of small intestinal shortcircuiting for obesity. Arch Surg 1967; 94: 707716. 17 Hocking MP, Duerson MC, OLeary JP, Woodward ER. Jejunoileal bypass for morbid obesity. Late follow-up in 100 cases. N Engl J Med 1983; 308: 995999. 18 Breaux CW. Obesity surgery in children. Obes Surg 1995; 5: 279284. 19 Roa PE, Kaidar-Person O, Pinto D, Cho M, Szomstein S, Rosenthal RJ. Laparoscopic sleeve gastrectomy as treatment for morbid obesity: technique and short-term outcome. Obes Surg 2006; 16: 13231326. 20 Mason EE, Scott DH, Doherty C, Cullen JJ, Rodriguez EM, Maher JW et al. Vertical banded gastroplasty in the severely obese under age twenty-one. Obes Surg 1995; 5: 2333. 21 Greenstein RJ, Rabner JG. Is adolescent gastric-restrictive antiobesity surgery warranted? Obes Surg 1995; 5: 138144. 22 Rand CS, Macgregor AM. Adolescents having obesity surgery: a 6-year follow-up. South Med J 1994; 87: 12081213. 23 Sjostrom L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, Carlsson B et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004; 351: 26832693. 24 Anderson AE, Soper RT, Scott DH. Gastric bypass for morbid obesity in children and adolescents. J Pediatr Surg 1980; 15: 876881. 25 Sugerman HJ. Gastric bypass surgery for severe obesity. Semin Laparosc Surg 2002; 9: 7985. 26 Pories WJ, Swanson MS, MacDonald KG, Long SB, Morris PG, Brown BM et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 1995; 222: 339350. 27 Strauss RS, Bradley LJ, Brolin RE. Gastric bypass surgery in adolescents with morbid obesity. J Pediatrics 2001; 138: 499504. 28 Sugerman HJ, Sugerman EL, DeMaria EJ, Kellum JM, Kennedy C, Mowery Y et al. Bariatric surgery for severely obese adolescents. J Gastrointest Surg 2003; 7: 102108. 29 Inge TH, Krebs NF, Garcia VF, Skelton JA, Guice KS, Strauss RS et al. Bariatric surgery for severely overweight adolescents: concerns and recommendations. Pediatrics 2004; 114: 217223. 30 Inge TH, Garcia VF, Daniels SR, Langford L, Kirk S, Roehrig H et al. A multidisciplinary approach to the adolescent bariatric surgical patient. J Pediatr Surg 2004; 39: 442447; discussion 446447. 31 Inge TH, Zeller M, Garcia VF, Daniels SR. Surgical approach to adolescent obesity. Adolesc Med Clin 2004; 15: 429453. 32 Helmrath MA, Brandt ML, Inge TH. Adolescent obesity and bariatric surgery. Surg Clin North Am 2006; 86: 441454. 33 Chapman AE, Kiroff G, Game P, Foster B, OBrien P, Ham J et al. Laparoscopic adjustable gastric banding in the treatment of obesity: a systematic literature review. Surgery 2004; 135: 326351. 34 Dixon JB, Bhathal PS, Hughes NR, OBrien PE. Nonalcoholic fatty liver disease: improvement in liver histological analysis with weight loss. Hepatology 2004; 39: 16471654. 35 Dixon JB, Chapman L, OBrien P. Marked improvement in asthma after Lap-Band surgery for morbid obesity. Obes Surg 1999; 9: 385389. 36 Dixon JB, Dixon AF, OBrien PE. Improvements in insulin sensitivity and beta-cell function (HOMA) with weight loss in the severely obese. Homeostatic model assessment. Diabet Med 2003; 20: 127134. 37 Dixon JB, Dixon ME, OBrien PE. Quality of life after lap-band placement: influence of time, weight loss, and comorbidities. Obes Res 2001; 9: 713721. 38 Dixon JB, Dixon ME, OBrien PE. Depression in association with severe obesity: changes with weight loss. Arch Intern Med 2003; 163: 20582065. 39 Dixon JB, OBrien PE. Changes in comorbidities and improvements in quality of life after LAP-BAND placement. Am J Surg 2002; 184: S51S54. 40 Dixon JB, OBrien PE. Health outcomes of severely obese type 2 diabetic subjects 1 year after laparoscopic adjustable gastric banding. Diabetes Care 2002; 25: 358363. 41 Dixon JB, Schachter LM, OBrien PE. Sleep disturbance and obesity: changes following surgically induced weight loss. Arch Intern Med 2001; 161: 102106. 42 OBrien PE, Dixon JB, Laurie C, Skinner S, Proietto J, McNeil J et al. Treatment of mild to moderate obesity with laparoscopic adjustable gastric banding or an intensive medical program: a randomized trial. Ann Intern Med 2006; 144: 625633. 43 Fielding GA, Duncombe JE. Laparoscopic adjustable gastric banding in severely obese adolescents. Surg Obes Relat Diseases 2005; 1: 399407. 44 Cottam DR, Atkinson J, Anderson A, Grace B, Fisher B. A casecontrolled matched-pair cohort study of laparoscopic Roux-en-Y gastric bypass and Lap-Band patients in a single US center with three-year follow-up. Obes Surg 2006; 16: 534540. 45 Bowne WB, Julliard K, Castro AE, Shah P, Morgenthal CB, Ferzli GS. Laparoscopic gastric bypass is superior to adjustable gastric band in super morbidly obese patients: a prospective, comparative analysis. Arch Surg 2006; 141: 683689. 46 Tsai W, Inge T, Burd R. Adolescent bariatric surgery: recent national trends in utilization and in hosptial outcomes. Arch Pediatric Adolesc Med 2006. (in press). 47 Xanthakos SA, Inge TH. Nutritional consequences of bariatric surgery. Curr Opin Clin Nutr Metab Care 2006; 9: 489496. 48 Boylan LM, Sugerman HJ, Driskell JA. Vitamin E, vitamin B-6, vitamin B-12, and folate status of gastric bypass surgery patients. J Am Diet Assoc 1988; 88: 579585. 49 Gollobin C, Marcus WY. Bariatric beriberi. Obes Surg 2002; 12: 309311. 50 Halverson JD. Vitamin and mineral deficiencies following obesity surgery. Gastroenterol Clin North Am 1987; 16: 307315. 51 Brolin RE, Gorman JH, Gorman RC, Petschenik AJ, Bradley LB, Kenler HA et al. Prophylactic iron supplementation after Rouxen-Y gastric bypass: a prospective, double-blind, randomized study. Arch Surg 1998; 133: 740744. 52 Thaisetthawatkul P, Collazo-Clavell ML, Sarr MG, Norell JE, Dyck PJ. A controlled study of peripheral neuropathy after bariatric surgery. Neurology 2004; 63: 14621470. 53 Berger JR. The neurological complications of bariatric surgery. Arch Neurol 2004; 61: 11851189. 54 Chaves LC, Faintuch J, Kahwage S, Alencar Fde A. A cluster of polyneuropathy and WernickeKorsakoff syndrome in a bariatric unit. Obes Surg 2002; 12: 328334.
12
55 Towbin A, Inge TH, Garcia VF, Roerig HR, Clements RH, Harmon CM et al. Beriberi after gastric bypass surgery in adolescence. J Pediatr 2004; 145: 263267. 56 De Prisco C, Levine SN. Metabolic bone disease after gastric bypass surgery for obesity. Am J Med Sci 2005; 329: 5761. 57 Coates PS, Fernstrom JD, Fernstrom MH, Schauer PR, Greenspan SL. Gastric bypass surgery for morbid obesity leads to an increase in bone turnover and a decrease in bone mass. J Clin Endocrinol Metab 2004; 89: 10611065. 58 Wortsman J, Matsuoka LY, Chen TC, Lu Z, Holick MF. Decreased bioavailability of vitamin D in obesity. Am J Clin Nutr 2000; 72: 690693. 59 Strauss RS. Comparison of serum concentrations of alphatocopherol and beta-carotene in a cross-sectional sample of obese and nonobese children (NHANES III). National Health and Nutrition Examination Survey. J Pediatr 1999; 134: 160165. 60 Harkness LS, Bonny AE. Calcium and vitamin D status in the adolescent: key roles for bone, body weight, glucose tolerance, and estrogen biosynthesis. J Pediatr Adolesc Gynecol 2005; 18: 305311. 61 Bowman SA, Spence JT. A comparison of low-carbohydrate vs high-carbohydrate diets: energy restriction, nutrient quality and correlation to body mass index. J Am Coll Nutr 2002; 21: 268274. 62 Ervin RB, Wright JD, Wang CY, Kennedy-Stephenson J. Dietary intake of selected vitamins for the United States population: 19992000. Adv Data 2004; 339: 14. 63 Holick MF. The vitamin D epidemic and its health consequences. J Nutr 2005; 135: 2739S2748S. 64 Holick MF. Vitamin D: importance in the prevention of cancers, type 1 diabetes, heart disease, and osteoporosis. Am J Clin Nutr 2004; 79: 362371. 65 Rianthavorn P, Ettenger RB. Medication non-adherence in the adolescent renal transplant recipient: a clinicians viewpoint. Pediatr Transplant 2005; 9: 398407. 66 Rand CS, Macgregor AM. Adolescents having obesity surgery: a 6-year follow-up. South Med J 1994; 87: 12081213. 67 Norman RJ, Noakes M, Wu R, Davies MJ, Moran L, Wang JX. Improving reproductive performance in overweight/obese women with effective weight management. Hum Reprod Update 2004; 10: 267280. 68 Klein JD. Adolescent pregnancy: current trends and issues. Pediatrics 2005; 116: 281286. 69 Gurewitsch ED, Smith-Levitin M, Mack J. Pregnancy following gastric bypass surgery for morbid obesity. Obstet Gynecol 1996; 88: 658661. 70 Woodard CB. Pregnancy following bariatric surgery. J Perinat Neonatal Nurs 2004; 18: 329340. 71 Martens WS, Martin LF, Berlin Jr CM. Failure of a nursing infant to thrive after the mothers gastric bypass for morbid obesity. Pediatrics 1990; 86: 777778. 72 Huerta S, Rogers LM, Li Z, Heber D, Liu C, Livingston EH. Vitamin A deficiency in a newborn resulting from maternal hypovitaminosis A after biliopancreatic diversion for the treatment of morbid obesity. Am J Clin Nutr 2002; 76: 426429. 73 Caprio S. Insulin resistance in childhood obesity. J Pediatr Endocrinol Metab 2002; 15 (Suppl 1): 487492. 74 Lauer RM, Clarke WR. Childhood risk factors for high adult blood pressure: the Muscatine Study. Pediatrics 1989; 84: 633641. 75 Lauer RM, Lee J, Clarke WR. Factors affecting the relationship between childhood and adult cholesterol levels: the Muscatine Study. Pediatrics 1988; 82: 309318. 76 Freedman DS, Burke GL, Harsha DW, Srinivasan SR, Cresanta JL, Webber LS et al. Relationship of changes in obesity to serum lipid and lipoprotein changes in childhood and adolescence. JAMA 1985; 254: 515520. 77 Srinivasan SR, Berenson GS. Childhood lipoprotein profiles and implications for adult coronary artery disease: the 78 Bogalusa Heart Study. Am J Med Sci 1995; 310 (Suppl 1): S62S67. Li S, Chen W, Srinivasan SR, Bond MG, Tang R, Urbina EM et al. Childhood cardiovascular risk factors and carotid vascular changes in adulthood: the Bogalusa Heart Study. JAMA 2003; 290: 22712276. Berenson GS, Srinivasan SR, Bao W, Newman III WP, Tracy RE, Wattigney WA. Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults. The Bogalusa Heart Study. N Engl J Med 1998; 338: 16501656. Lamarche B, Tchernof A, Mauriege P, Cantin B, Dagenais GR, Lupien PJ et al. Fasting insulin and apolipoprotein B levels and low-density lipoprotein particle size as risk factors for ischemic heart disease. JAMA 1998; 279: 19551961. de la Eva RC, Baur LA, Donaghue KC, Waters KA. Metabolic correlates with obstructive sleep apnea in obese subjects. J Pediatr 2002; 140: 654659. Choudhury J, Sanyal AJ. Insulin resistance and the pathogenesis of nonalcoholic fatty liver disease. Clin Liver Dis 2004; 8: 575594, ix. Cook S, Weitzman M, Auinger P, Nguyen M, Dietz WH. Prevalence of a metabolic syndrome phenotype in adolescents: findings from the third National Health and Nutrition Examination Survey, 1988-1994. Arch Pediatr Adolesc Med 2003; 157: 821827. Weiss R, Dziura J, Burgert TS, Tamborlane WV, Taksali SE, Yeckel CW et al. Obesity and the metabolic syndrome in children and adolescents. N Engl J Med 2004; 350: 23622374. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K et al. Bariatric surgery: a systematic review and metaanalysis. JAMA 2004; 292: 17241737. Ippisch H, Witt S, Glascock B, Inge T, Garcia V, Daniels S et al. Does gastric bypass surgery decrease cardiac risk factors in young patients? Circulation 2004; 110: 389. Karason K, Wallentin I, Larsson B, Sjostrom L. Effects of obesity and weight loss on left ventricular mass and relative wall thickness: survey and intervention study. BMJ 1997; 315: 912916. Amin RS, Carroll JL, Jeffries JL, Grone C, Bean JA, Chini B et al. Twenty-four-hour ambulatory blood pressure in children with sleep-disordered breathing. Am J Respir Crit Care Med 2004; 169: 950956. Nieto FJ, Young TB, Lind BK, Shahar E, Samet JM, Redline S et al. Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study. JAMA 2000; 283: 18291836. Young T, Peppard P, Palta M, Hla KM, Finn L, Morgan B et al. Population-based study of sleep-disordered breathing as a risk factor for hypertension. Arch Intern Med 1997; 157: 17461752. Amin RS, Kimball TR, Bean JA, Jeffries JL, Willging JP, Cotton RT et al. Left ventricular hypertrophy and abnormal ventricular geometry in children and adolescents with obstructive sleep apnea. Am J Respir Crit Care Med 2002; 165: 13951399. Harding SM. Complications and consequences of obstructive sleep apnea. Curr Opin Pulm Med 2000; 6: 485489. Shahar E, Whitney CW, Redline S, Lee ET, Newman AB, Javier Nieto F et al. Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med 2001; 163: 1925. Valencia-Flores M, Orea A, Castano VA, Resendiz M, Rosales M, Rebollar V et al. Prevalence of sleep apnea and electrocardiographic disturbances in morbidly obese patients. Obes Res 2000; 8: 262269. Kalra M, Inge T, Garcia V, Daniels S, Lawson L, Curti B et al. Obstructive sleep apnea in extremely overweight adolescents undergoing bariatric surgery. Obes Res 2005; 13: 11751179. Charuzi I, Lavie P, Peiser J, Peled R. Bariatric surgery in morbidly obese sleep-apnea patients: short- and long-term follow-up. Am J Clin Nutr 1992; 55: 594S596S.
79
80
81
82
83
84
85
86
87
88
89
90
91
92 93
94
95
96
13
97 Sugerman HJ, Fairman RP, Sood RK, Engle K, Wolfe L, Kellum JM. Long-term effects of gastric surgery for treating respiratory insufficiency of obesity. Am J Clin Nutr 1992; 55: 597S601S. 98 Valencia-Flores M, Orea A, Herrera M, Santiago V, Rebollar V, Castano VA et al. Effect of bariatric surgery on obstructive sleep apnea and hypopnea syndrome, electrocardiogram, and pulmonary arterial pressure. Obes Surg 2004; 14: 755762. 99 Goran MI. Impaired glucose tolerance in obese children and adolescents. N Engl J Med 2002; 347: 290292; (author reply 290292). 100 Pinhas-Hamiel O, Dolan LM, Daniels SR, Standiford D, Khoury PR, Zeitler P. Increased incidence of non-insulin-dependent diabetes mellitus among adolescents. J Pediatr 1996; 128: 608615. 101 Sinha R, Fisch G, Teague B, Tamborlane WV, Banyas B, Allen K et al. Prevalence of impaired glucose tolerance among children and adolescents with marked obesity. N Engl J Med 2002; 346: 802810. 102 Paulsen EP, Richenderfer L, Ginsberg-Fellner F. Plasma glucose, free fatty acids, and immunoreactive insulin in sixty-six obese children. Studies in reference to a family history of diabetes mellitus. Diabetes 1968; 17: 261269. 103 Cowan Jr GS, Buffington CK. Significant changes in blood pressure, glucose, and lipids with gastric bypass surgery. World J Surg 1998; 22: 987992. 104 Torgerson JS, Sjostrom L. The Swedish Obese Subjects (SOS) study rationale and results. Int J Obes Relat Metab Disord 2001; 25 (Suppl 1): S2S4. 105 Sjostrom CD, Peltonen M, Wedel H, Sjostrom L. Differentiated long-term effects of intentional weight loss on diabetes and hypertension. Hypertension 2000; 36: 2025. 106 Letiexhe MR, Scheen AJ, Gerard PL, Desaive C, Lefebvre PJ. Postgastroplasty recovery of ideal body weight normalizes glucose and insulin metabolism in obese women. J Clin Endocrinol Metab 1995; 80: 364369. 107 Polyzogopoulou EV, Kalfarentzos F, Vagenakis AG, Alexandrides TK. Restoration of euglycemia and normal acute insulin response to glucose in obese subjects with type 2 diabetes following bariatric surgery. Diabetes 2003; 52: 10981103. 108 Guldstrand M, Grill V, Bjorklund A, Lins PE, Adamson U. Improved beta cell function after short-term treatment with diazoxide in obese subjects with type 2 diabetes. Diabetes Metab 2002; 28: 448456. 109 Jimenez J, Zuniga-Guajardo S, Zinman B, Angel A. Effects of weight loss in massive obesity on insulin and C-peptide dynamics: sequential changes in insulin production, clearance, and sensitivity. J Clin Endocrinol Metab 1987; 64: 661668. 110 Hughes TA, Gwynne JT, Switzer BR, Herbst C, White G. Effects of caloric restriction and weight loss on glycemic control, insulin release and resistance, and atherosclerotic risk in obese patients with type II diabetes mellitus. Am J Med 1984; 77: 717. 111 Vazquez LA, Pazos F, Berrazueta JR, Fernandez-Escalante C, Garcia-Unzueta MT, Freijanes J et al. Effects of changes in body weight and insulin resistance on inflammation and endothelial function in morbid obesity after bariatric surgery. J Clin Endocrinol Metab 2005; 90: 316322. 112 Schauer PR, Burguera B, Ikramuddin S, Cottam D, Gourash W, Hamad G et al. Effect of laparoscopic Roux-en Y gastric bypass on type 2 diabetes mellitus. Ann Surg 2003; 238: 467484; (discussion 484465). 113 Younossi ZM, Diehl AM, Ong JP. Nonalcoholic fatty liver disease: an agenda for clinical research. Hepatology 2002; 35: 746752. 114 Charlton M. Nonalcoholic fatty liver disease: a review of current understanding and future impact. Clin Gastroenterol Hepatol 2004; 2: 10481058. 115 Browning JD, Kumar KS, Saboorian MH, Thiele DL. Ethnic differences in the prevalence of cryptogenic cirrhosis. Am J Gastroenterol 2004; 99: 292298. 116 Schwimmer JB, Deutsch R, Kahen T, Lavine JE, Stanley C, Behling C. Prevalence of fatty liver in children and adolescents. Pediatrics 2006; 118: 13881393. 117 Matteoni CA, Younossi ZM, Gramlich T, Boparai N, Liu YC, McCullough AJ. Nonalcoholic fatty liver disease: a spectrum of clinical and pathological severity. Gastroenterology 1999; 116: 14131419. 118 Bacon BR, Farahvash MJ, Janney CG, Neuschwander-Tetri BA. Nonalcoholic steatohepatitis: an expanded clinical entity. (see comment) Gastroenterology 1994; 107: 11031109. 119 Neuschwander-Tetri BA, Caldwell SH. Nonalcoholic steatohepatitis: summary of an AASLD Single Topic Conference. (erratum appears in Hepatology. 2003 August; 38(2):536) Hepatology 2003; 37: 12021219. 120 Angulo P, Keach JC, Batts KP, Lindor KD. Independent predictors of liver fibrosis in patients with nonalcoholic steatohepatitis. Hepatology 1999; 30: 13561362. 121 Luyckx FH, Desaive C, Thiry A, Dewe W, Scheen AJ, Gielen JE et al. Liver abnormalities in severely obese subjects: effect of drastic weight loss after gastroplasty. Int J Obes Relat Metab Disord 1998; 22: 222226. 122 Beymer C, Kowdley KV, Larson A, Edmonson P, Dellinger EP, Flum DR. Prevalence and predictors of asymptomatic liver disease in patients undergoing gastric bypass surgery. Arch Surg 2003; 138: 12401244. 123 Moretto M, Kupski C, Mottin CC, Repetto G, Garcia Toneto M, Rizzolli J et al. Hepatic steatosis in patients undergoing bariatric surgery and its relationship to body mass index and comorbidities. Obes Surg 2003; 13: 622624. 124 Crespo J, Fernandez-Gil P, Hernandez-Guerra M, Cayon A, Mayorga M, Dominguez-Diez A et al. Are there predictive factors of severe liver fibrosis in morbidly obese patients with nonalcoholic steatohepatitis? Obes Surg 2001; 11: 254257. 125 Silverman JF, OBrien KF, Long S, Leggett N, Khazanie PG, Pories WJ et al. Liver pathology in morbidly obese patients with and without diabetes. Am J Gastroenterol 1990; 85: 13491355. 126 Spaulding L, Trainer T, Janiec D. Prevalence of non-alcoholic steatohepatitis in morbidly obese subjects undergoing gastric bypass. Obes Surg 2003; 13: 347349. 127 Xanthakos S, Miles L, Bucuvalas J, Daniels S, Garcia V, Inge T. Histologic spectrum of nonalcoholic fatty liver disease in morbidly obese adolescents. Clin Gastroenterol Hepatol 2006; 4: 226232. 128 Klein S, Mittendorfer B, Eagon JC, Patterson B, Grant L, Feirt N et al. Gastric bypass surgery improves metabolic and hepatic abnormalities associated with nonalcoholic fatty liver disease. Gastroenterology 2006; 130: 15641572. 129 Mathurin P, Gonzalez F, Kerdraon O, Leteurtre E, Arnalsteen L, Hollebecque A et al. The evolution of severe steatosis after bariatric surgery is related to insulin resistance. Gastroenterology 2006; 130: 16171624. 130 Neumark-Sztainer D, Story M, Faibisch L. Perceived stigmatization among overweight African-American and Caucasian adolescent girls. J Adolesc Health 1998; 23: 264270. 131 Janssen I, Craig WM, Boyce WF, Pickett W. Associations between overweight and obesity with bullying behaviors in school-aged children. Pediatrics 2004; 113: 11871194. 132 Strauss RS, Pollack HA. Social marginalization of overweight children. Arch Pediatr Adolesc Med 2003; 157: 746752. 133 Bagwell CL, Newcomb AF, Bukowski WM. Preadolescent friendship and peer rejection as predictors of adult adjustment. Child Dev 1998; 69: 140153. 134 Strauss RS. Childhood obesity and self-esteem. Pediatrics 2000; 105: e15. 135 Fallon EM, Tanofsky-Kraff M, Norman AC, McDuffie JR, Taylor ED, Cohen ML et al. Health-related quality of life in overweight and nonoverweight black and white adolescents. J Pediatr 2005; 147: 443450.
14
136 Schwimmer JB, Burwinkle TM, Varni JW. Health-related quality of life of severely obese children and adolescents. JAMA 2003; 289: 18131819. 137 Williams J, Wake M, Hesketh K, Maher E, Waters E. Healthrelated quality of life of overweight and obese children. JAMA 2005; 293: 7076. 138 Schwimmer JB, Burwinkle TM, Varni JW. Health-related quality of life of severely obese children and adolescents. JAMA 2003; 289: 18131819. 139 Zeller MH, Roehrig HR, Modi AC, Daniels SR, Inge TH. Healthrelated quality of life and depressive symptoms in adolescents with extreme obesity presenting for bariatric surgery. Pediatrics 2006; 117: 11551161. 140 Varni JW, Seid M, Kurtin PS. PedsQL 4.0: reliability and validity of the Pediatric Quality of Life Inventory version 4.0 generic core scales in healthy and patient populations. Med Care 2001; 39: 800812. 141 Britz B, Siegfried W, Ziegler A, Lamertz C, Herpertz-Dahlmann BM, Remschmidt H et al. Rates of psychiatric disorders in a clinical study group of asolescents with extreme obesity and in obese adolescents ascertained via a population based. Int J Obes 2000; 24: 17071714. 142 Erermis S, Cetin N, Tamar M, Bukusoglu N, Akdeniz F, Goksen D. Is obesity a risk factor for psychopathology among adolescents? Pediatr Int 2004; 46: 296301. 143 Goodman E, Whitaker RC. A prospective study of the role of depression in the development and persistence of adolescent obesity. Pediatrics 2002; 110: 497504. 144 Lamertz CM, Jacobi C, Yassouridis A, Arnold K, Henkel AW. Are obese adolescents and young adults at higher risk for mental disorders? A community survey. Obes Res 2002; 10: 11521160. 145 Mustillo S, Worthman C, Erkanli A, Keeler G, Angold A, Costello EJ. Obesity and psychiatric disorder: developmental trajectories. Pediatrics 2003; 111: 851859. 146 Beck AT, Steer RA, Brown GK. Manual for Beck Depression Inventory-II. Psychological Corp.: San Antonio, TX, 1996. 147 Zeller MH, Modi AC. Predictors of health-related quality of life in obese youth. Obesity (Silver Spring) 2006; 14: 122130. 148 Dubois F, Berthelot G, Levard H. Coelioscopic cholecystectomy: experience with 2006 cases. World J Surg 1995; 19: 748752. 149 Neumark-Sztainer D, Story M, French SA, Hannan PJ, Resnick MD, Blum RW. Psychosocial concerns and health-compromising behaviors among overweight and nonoverweight adolescents. Obes Res 1997; 5: 237249. 150 Cachelin FM, Striegel-Moore RH, Elder KA, Pike KM, Wilfley DE, Fairburn CG. Natural course of a community sample of women with binge eating disorder. Int J Eat Disord 1999; 25: 4554. 151 Johnson JG, Cohen P, Kasen S, Brook JS. Childhood adversities associated with risk for eating disorders or weight problems during adolescence or early adulthood. Am J Psychiatry 2002; 159: 394400. 152 Decaluwe V, Braet C, Fairburn CG. Binge eating in obese children and adolescents. Int J Eat Disord 2003; 33: 7884. 153 Gortmaker SL, Must A, Perrin JM, Sobol AM, Dietz WH. Social and economic consequences of overweight in adolescence and young adulthood. N Engl J Med 1993; 329: 10081012. 154 Ball K, Crawford D, Kenardy J. Longitudinal relationships among overweight, life satisfaction, and aspirations in young women. Obes Res 2004; 12: 10191030. 155 Black DW, Goldstein RB, Mason EE. Prevalence of mental disorder in 88 morbidly obese bariatric clinic patients. Am J Psychiatry 1992; 149: 227234. 156 Kolotkin RL, Meter K, Williams GR. Quality of life and obesity. Obes Rev 2001; 2: 219229. 157 Karlsson J, Sjostrom L, Sullivan M. Swedish obese subjects (SOS) an intervention study of obesity. Two-year follow-up of healthrelated quality of life (HRQL) and eating behavior after gastric surgery for severe obesity. Int J Obes Relat Metab Disord 1998; 22: 113126. 158 Kolotkin RL, Crosby RD, Williams GR. Health-related quality of life varies among obese subgroups. Obes Res 2002; 10: 748756. 159 De Zwaan M, Mitchell JE, Howell LM, Monson N, SwanKremeier L, Roerig JL et al. Two measures of health-related quality of life in morbid obesity. Obes Res 2002; 10: 11431151. 160 Busetto L, Valente P, Pisent C, Segato G, De Marchi F, Favretti F et al. Eating pattern in the first year following adjustable silicone gastric banding (ASGB) for morbid obesity. Int J Obes Relat Metab Disord 1996; 20: 539546. 161 Dymek MP, le Grange D, Neven K, Alverdy J. Quality of life and psychosocial adjustment in patients after Roux-en-Y gastric bypass: a brief report. Obes Surg 2001; 11: 3239. 162 Malone M, Alger-Mayer S. Binge status and quality of life after gastric bypass surgery: a one-year study. Obes Res 2004; 12: 473481. 163 Boan J, Kolotkin RL, Westman EC, McMahon RL, Grant JP. Binge eating, quality of life and physical activity improve after Roux-en-Y gastric bypass for morbid obesity. Obes Surg 2004; 14: 341348. 164 Dymek MP, Le Grange D, Neven K, Alverdy J. Quality of life after gastric bypass surgery: a cross-sectional study. Obes Res 2002; 10: 11351142. 165 De Zwaan M, Lancaster BA, Mitchell JE, Howell LM, Monson N, Roerig JL et al. Health-related quality of life in morbidly obese patients: effect of gastric bypass surgery. Obes Res 2002; 12: 773780. 166 Rand CS, Macgregor AM. Morbidly obese patients perceptions of social discrimination before and after surgery for obesity. South Med J 1990; 83: 13901395. 167 Kopec-Schrader EM, Gertler R, Ramsey-Stewart G, Beumont PJ. Psychosocial outcome and long-term weight loss after gastric restrictive surgery for morbid obesity. Obes Surg 1994; 4: 336339. 168 Hawke A, OBrien P, Watts JM, Hall J, Dunstan RE, Walsh JF et al. Psychosocial and physical activity changes after gastric restrictive procedures for morbid obesity. Aust NZ J Surg 1990; 60: 755758. 169 Valley V, Grace DM. Psychosocial risk factors in gastric surgery for obesity: identifying guidelines for screening. Int J Obes 1987; 11: 105113. 170 Herpertz S, Kielmann R, Wolf AM, Hebebrand J, Senf W. Do psychosocial variables predict weight loss or mental health after obesity surgery? A systematic review. Obes Res 2004; 12: 1554 1569. 171 Hsu LK, Benotti PN, Dwyer J, Roberts SB, Saltzman E, Shikora S et al. Nonsurgical factors that influence the outcome of bariatric surgery: a review. Psychosom Med 1998; 60: 338346. 172 Averbukh Y, Heshka S, El-Shoreya H, Flancbaum L, Geliebter A, Kamel S et al. Depression score predicts weight loss following Roux-en-Y gastric bypass. Obes Surg 2003; 13: 833836. 173 http://www.surgicalreview.org/pcoe/centers.html accessed September 20, 2006. 174 http://www.facs.org/cgi/bscn/index.html accessed September 20, 2006. 175 Kuther TL. Medical decision-making and minors: issues of consent and assent. Adolescence 2003; 38: 343358.

Bedah Bariatrik

Diunggah oleh

Informasi Dokumen

Deskripsi Asli:

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

Bedah Bariatrik

Diunggah oleh

Hak Cipta:

Format Tersedia

International Journal of Obesity (2007) 31, 114 & 2007 Nature Publishing Group All rights reserved 0307-0565/07

Bariatric surgery for pediatric extreme obesity TH Inge et al

History of adolescent bariatric surgery

Figure 1 Operations for weight loss.

International Journal of Obesity

Bariatric surgery for pediatric extreme obesity TH Inge et al

The modern era of bariatric surgical procedures for adolescents

Bariatric surgery for pediatric extreme obesity TH Inge et al

Nutritional risks of weight loss surgery

Bariatric surgery for pediatric extreme obesity TH Inge et al

Bariatric surgery for pediatric extreme obesity TH Inge et al

Can comorbidities justify earlier rather than later intervention?

Bariatric surgery for pediatric extreme obesity TH Inge et al

Bariatric surgery for pediatric extreme obesity TH Inge et al

Bariatric surgery for pediatric extreme obesity TH Inge et al

Bariatric surgery for pediatric extreme obesity TH Inge et al

Conclusions and perspective

Bariatric surgery for pediatric extreme obesity TH Inge et al

International Journal of Obesity

Bariatric surgery for pediatric extreme obesity TH Inge et al

International Journal of Obesity

Bariatric surgery for pediatric extreme obesity TH Inge et al

International Journal of Obesity

Bariatric surgery for pediatric extreme obesity TH Inge et al

International Journal of Obesity

Anda mungkin juga menyukai