weekly_question 25/6/2023

[Admin]

A 15 yo boy is being considered for surgical treatment of his severe obesity and its comorbidities. The bariatric procedure with the least adverse impact on adolescent bone health is:

A Adjustable gastric band

B Sleeve gastrectomy

C Roux-en-Y gastric bypass

D Biliopancreatic Diversion with duodenal switch

[Admin]

correct answer
A Adjustable gastric band

The benefits of bariatric surgery in adolescents in achieving lasting and meaningful weight loss and in reversing secondary complications of obesity are well established. Less well understood are the effects of bariatric surgery on bone health. Bone health (which correlates with fracture risk) is the result of a complex interaction of nutritional, hormonal, compositional, bone turnover and mechanical loading factors. There is a significant body of adult bariatric surgery literature that characterizes postoperative fracture risk by procedure. This literature suggests that restrictive procedures like the adjustable gastric band (AGB), which generally achieve lower excess weight loss than the malabsorptive procedures, are associated with the lowest fracture risk. Studies comparing malabsorptive procedures suggest that Roux-en-Y gastric bypass (RYGB) is associated with a higher fracture risk than sleeve gastrectomy (SG). Biliopancreatic diversion with duodenal switch is performed infrequently but induces severe malabsorption with nutritional deficiencies and appears to be the operation associated with the highest fracture risk. With all procedures, the fracture risk increases over time, with several studies suggesting that first fractures usually occur at about 3 years after surgery, with a peak between 3 and 5 years.

Currently, there are no outcome studies which report fracture rates in adolescent patients following bariatric surgery. There are several studies looking at bone health (micronutrients, vitamin D, parathyroid hormone, bone density and biochemical markers of bone turnover) before and after bariatric surgery in adolescents that seem to follow similar patterns to those observed in adults. A recent adolescent study which looked at bone turnover markers at 6 and 12 months following either AGB or SG, demonstrated a marked increase in bone turnover following SG. Micronutrient comparisons of adolescent versus adult cohorts undergoing RYGB suggest a greater vulnerability to mineral (calcium, phosphate) and vitamin D deficiencies and acquired secondary hyperparathyroidism in adolescents at baseline and after surgery. Studies of bone mineral density (BMD) using dual energy X-ray absorptiometry (DXA) demonstrate reduction of BMD Z-scores at 12 months in adolescents undergoing SG versus obese controls.

The potential for adverse effects of bariatric surgery performed in adolescence on adult bone health is real and tracking bone density during aging to determine lifelong risk of fracture is an important ongoing research objective.

[Ismailmohamed]

B

[Javier Escalante]

C

[Admin]

correct answer
A Adjustable gastric band

The benefits of bariatric surgery in adolescents in achieving lasting and meaningful weight loss and in reversing secondary complications of obesity are well established. Less well understood are the effects of bariatric surgery on bone health. Bone health (which correlates with fracture risk) is the result of a complex interaction of nutritional, hormonal, compositional, bone turnover and mechanical loading factors. There is a significant body of adult bariatric surgery literature that characterizes postoperative fracture risk by procedure. This literature suggests that restrictive procedures like the adjustable gastric band (AGB), which generally achieve lower excess weight loss than the malabsorptive procedures, are associated with the lowest fracture risk. Studies comparing malabsorptive procedures suggest that Roux-en-Y gastric bypass (RYGB) is associated with a higher fracture risk than sleeve gastrectomy (SG). Biliopancreatic diversion with duodenal switch is performed infrequently but induces severe malabsorption with nutritional deficiencies and appears to be the operation associated with the highest fracture risk. With all procedures, the fracture risk increases over time, with several studies suggesting that first fractures usually occur at about 3 years after surgery, with a peak between 3 and 5 years.

Currently, there are no outcome studies which report fracture rates in adolescent patients following bariatric surgery. There are several studies looking at bone health (micronutrients, vitamin D, parathyroid hormone, bone density and biochemical markers of bone turnover) before and after bariatric surgery in adolescents that seem to follow similar patterns to those observed in adults. A recent adolescent study which looked at bone turnover markers at 6 and 12 months following either AGB or SG, demonstrated a marked increase in bone turnover following SG. Micronutrient comparisons of adolescent versus adult cohorts undergoing RYGB suggest a greater vulnerability to mineral (calcium, phosphate) and vitamin D deficiencies and acquired secondary hyperparathyroidism in adolescents at baseline and after surgery. Studies of bone mineral density (BMD) using dual energy X-ray absorptiometry (DXA) demonstrate reduction of BMD Z-scores at 12 months in adolescents undergoing SG versus obese controls.

The potential for adverse effects of bariatric surgery performed in adolescence on adult bone health is real and tracking bone density during aging to determine lifelong risk of fracture is an important ongoing research objective.