OBES SURG (2017) 27:3110–3117 DOI 10.1007/s11695-017-2738-y ORIGINAL CONTRIBUTIONS Long-Term Outcome of Bariatric Surgery in Morbidly Obese Adolescents: a Systematic Review and Meta-Analysis of 950 Patients with a Minimum of 3 years Follow-Up Saeed Shoar 1,2 & Habibollah Mahmoudzadeh 2 & Mohammad Naderan 2 & Shahram Bagheri-Hariri 3 & Catherine Wong 4 & Ahmad Shahabeddin Parizi 5 & Nasrin Shoar 6 Published online: 2 June 2017 # Springer Science+Business Media New York 2017 Abstract Background Obesity in pediatric and adolescent population has reached a universal pandemic. This study aimed to summarize the literature on the longest available outcome of bariatric surgery in morbidly obese adolescents. Methods A systematic review was conducted to pool available data on the longest available (>3 years) weight loss and comorbidity resolution outcome in adolescent bariatric surgery. Results A total of 14 studies reporting the result of bariatric surgery after 3 years in 950 morbidly obese adolescents were included. Preoperative age and BMI ranged from 12 to 19 years and from 26 to 91 kg/m2, respectively. Females were the predominant gender (72.8%). Laparoscopic roux-en-Y gastric bypass (n = 453) and adjustable gastric banding (n = 265) were the most common bariatric procedure performed. The number of patients at the latest follow-up was 677 (range from 2 to 23 years). On average, patients lost * Saeed Shoar saeedshoar@gmail.com 1 Department of Medicine and Surgery, Tehran University of Medical Sciences, No17, Isar 2 Alley, Khandaee street, Kashan, Tehran 8719757161, Iran 2 Department of Surgery, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran 3 Department of Emergency Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran 4 Weight Loss Center, The Brooklyn Hospital, Brooklyn, NY, USA 5 Department of Epidemiology and Statistics, University of Groningen, Groningen, Netherlands 6 Department of Medicine, Shahid Beheshti Hospital, Kashan University of Medical Sciences, Kashan, Iran 13.3 kg/m2 of their BMI. Among comorbidities, only diabetes mellitus resolved or improved dramatically. Of 108 readmissions, 91 led to reoperation. There was a weight regain < 5 kg/m2 between 5 and 6 years of follow-up. Removal, exchange, or conversion of the previous band constituted the majority of the revisional procedures. Three deaths were reported. No long-term data was obtainable on nutritional deficiency or growth status of adolescents who underwent a bariatric procedure. Conclusion Although bariatric surgery is a safe and effective procedure in the treatment of adolescent morbid obesity, longterm data is scarce regarding its nutritional and developmental complication in this growing population of patients. Keywords Adolescent . Pediatric . Obesity . Morbidly obese . Bariatric surgery . Mid-term . Systematic review . Meta-analysis Introduction In parallel with the global pandemic of morbid obesity in adult population, pediatric and adolescent obesity has also reached a warning level [1, 2]. Despite the global increase in the prevalence of obesity in childhood and adolescence [3, 4], the national utilization of bariatric surgery has reached a plateau in this population [5]. One reason for this underutilization of adolescent bariatric surgery (ABS) can be the heterogeneous analysis of obesity prevalence among adolescents within different socioeconomic status (SES). A recent systematic review of 30 studies revealed that over half of the studies are indicative of an increasing obesity prevalence in low SES compared to only one third of the studies on adolescents of high SES [4]. OBES SURG (2017) 27:3110–3117 Another explanation for the underutilization of ABS includes poor access to the health care resources [6]. Regardless of the underlying reason for such an inadequate surgical treatment, adolescent morbid obesity can turn into the adulthood comorbid conditions such as established hypertension (HTN), limited mobility, diabetes mellitus, renal failure, adult-onset asthma, and obstructive sleep apnea (OSA) [7]. To prevent the transmission of adolescent obesity into an adulthood compromised health status and to encourage appropriate utilization of bariatric surgery among adolescent population, a long-term assessment of the successfulness of ABS is warranted. Although there is four systematic reviews regarding bariatric surgery in adolescents [8–11], there is no study to exclusively pool available data in the literature on the long-term outcome of weight loss surgery in this young group of morbidly obese patients. Our systematic review aimed to investigate the outcome of bariatric surgery in morbidly obese adolescents after a minimum of 3 years follow-up. The result of this meta-analysis can encourage proportional utilization of ABS in selected candidates. 3111 Eligibility Criteria Original studies in English language with a minimum followup of 3 years after bariatric surgery in adolescent or pediatric population (age at surgery <18 years) were eligible. Only studies regarding primary bariatric surgery for adolescents’ idiopathic morbid obesity including at least 10 patients were eligible. Review articles, case reports, editorials, and commentaries were excluded. Outcome Definition According to the executive summary of the American Society for Metabolic and Bariatric Surgery (ASMBS) on the outcome reporting standards [13], the mid-term and long-term followup are defined as >3 and <5 years and >5 years, respectively. At each follow-up, weight loss outcome and comorbidity resolution were investigated as the primary endpoint of this review article. The second endpoints were any postoperative complication, nutritional deficiency, or other adverse events attributable to the weight loss procedure. Data Extraction and Analysis Methods and Materials Study Design A comprehensive literature review was conducted through January 2017 to identify studies reporting the longest outcome of bariatric surgery in morbidly obese adolescents. Our systematic review strictly followed the instructions provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [12]. Search Strategy We performed an electronic database search on PubMed/ Medline, ISI Web of Science, and Scopus. The following search terms were used: (Blong term^ OR Blong-term^ OR Bmid-term^ OR Bmid term^ OR Byears^ OR Byear^) AND (Badolescents^ OR Badolescent^ OR Bpediatrics^ OR Bpediatric^ OR Bchildren^ OR Bchildhood^ OR Bteenagers^ OR Bteens^ OR Byoung^ OR Byouth^) AND (Bbariatric surgery^ OR Bsleeve gastrectomy^ OR Bgastric bypass^ OR BRoux-en-Y^ OR BRYGB^ OR BLSG^ OR Bbiliopancreatic diversion^ OR Bduodeno-ileal switch^ OR Bduodenoileal switch^ OR Bduodeno-ileal bypass^ OR Bduodenoileal bypass^ OR Bileal bypass^ OR Badjustable gastric band^ OR Bgastric banding^ OR BLAGB^ OR BAGB^). For each included article, primary characteristics of the study, demographics and preoperative features of the participants, and perioperative variables were extracted. Data were pooled according to the availability of the variables of interest. The pooled estimations are expressed as mean ± SD, minimum and maximum range, or the number (%) whenever appropriate. No other quantitative synthesis was sought in this systematic review. Results A total of 3193 records were identified through the initial database search. After exclusion of the duplicates, title/ abstract of the remaining 1832 papers were screened of which 45 articles were relevant. Reviewing the full text of the relevant papers yielded 16 eligible articles for quality assessment. Finally, 2 articles were excluded during data extraction and 14 papers were included into qualitative synthesis (Fig. 1). Primary Characteristics of the Included Studies Fourteen studies encompassed 950 morbidly obese adolescents who were followed at least 3 years after their bariatric surgery [7, 14–25]. Publication timeframe of the included studies ranged from 2003 [26] to 2016 [7, 15–17]. Of these, 8 studies were retrospective chart review (301 patients, 31.7%) [14, 16, 17, 19, 21, 23, 25, 26], 4 were prospective observational studies (621 patients, 65.4%), and 2 were case 3112 OBES SURG (2017) 27:3110–3117 Fig. 1 PRISMA flowchart describing our strategy for electronic database searching series (28 patients, 2.9%) [22, 24]. Follow-up after bariatric surgery ranged from 2 to 23 years [25] with an average greater than 3 years (Table 1). Preoperative Characteristics of Adolescents Undergoing Bariatric Surgery Gender distribution was reported in 12 studies (875 patients, 92.1%) [7, 14–20, 22–26]. Of these, most patients were female (637 patients, 72.8%) and 224 were male (27.2%). Patients’ age and preoperative BMI ranged from 12 to 19 years and from 26 to 91 kg/m2, respectively. Preoperative comorbidity was reported by 11 studies (844 patients, 88.8%) [7, 14–21, 25, 26]. Of these, dyslipidemia was the most prevalent comorbidity (497 patients, 58.8%), followed by hypertension (305 patients, 36.1%), dyspnea (134 patients, 15.9%), and insulin resistance (93 patients, 11%). The majority of patients underwent Roux-en-Y gastric bypass (453 patients, 47.7%), adjustable gastric banding (265 patients, 27.9%), and then sleeve gastrectomy (148 patients, 15.6%). Only one study (68 patients, 7.1%) reported their patients to undergo biliopancreatic diversion [25]. Moreover, one study (33 patients, 3.5%) had their patients undergo standard RYGB, distal gastric bypass (D-GBP), long-limb gastric bypass (LL-GBP), horizontal gastroplasty, and vertical gastroplasty [26]. Outcome of Morbidly Obese Adolescents after Bariatric Surgery After a minimum follow-up of 3 years, data of 677 patients (71.3%) was available for analysis (attrition rate of 28.7%) (Table 2). The weight loss outcome based on BMI ranged from 11.3 to 33 kg/m2. Two studies (43 patients) reported weight regain at the last follow-up for 6 patient (13.9%) [9, 26]. Additionally, comorbidities at the last follow-up were reported by 11 studies (645 patients, 67.9%) [7, 14–21, 25, 26]. Of these, dyslipidemia (213 patients, 33%) was the most common persistent comorbidity followed by hypertension (118 patients, 18.3%), dyspnea (63 patients, 9.8%), and diabetes/insulin resistance (28 patients, 4.3%). On the other hand, comorbidity resolution rate was 57.1% for dyslipidemia (284 resolved out of 497), 61.6% for hypertension (188 resolved out of 305), 53% for dyspnea (71 resolved out of 134), and 69.9% for diabetes mellitus/ insulin resistance (65 resolved out of 93). During the postoperative follow-up, there were 108 readmissions (11.4%) and 91 reoperations (9.6%). Three deaths were reported (0.3%), 1 due to a hypoglycemic event after gastric bypass [7] and 2 unrelated to the bariatric procedure [26]. In a meta-analysis of 8 studies (746 patients, 78.5%) for which the mean ± SD weight loss was obtainable [7, 9, 15, 17, 18, 21, 22, 26], adolescents demonstrated a pooled BMI loss of 13.3 kg/m2 (95% confidence interval [95%CI], 11.9– 14.7) at the last available follow-up (Fig. 2). A small amount of weight gain was observed between 5 and 6 years after bariatric surgery (Fig. 3). Moreover, the fate of bariatric surgery after a minimum of 3 years follow-up was reported in 7 studies (224 patients, 23.6%) [16, 18, 21, 22, 24–26]. Of a total of 53 revisional surgeries performed in adolescents, conversion of LAG to RYGB (31 patients, 58.5%), band removal (15 patients, 28.3%), band exchange or band to BPD (each in 2 patients, 3.8%), LSG to RYGB (1 patient, 1.9%), and DGBP to GBP and GBP to a LL-GBP (each in 1 patient, 1.9%) constituted the fate of the failed primary bariatric procedures (Fig. 4). Discussion Bariatric surgery has been established as an effective treatment for severe adolescent obesity [11, 19]. Initially, most morbidly obese adolescents were conservatively selected for OBES SURG (2017) 27:3110–3117 Table 1 3113 Primary characteristics of the studies on primary bariatric surgery in adolescents Author/year Study type Sample size Mean ± SD age (years) Gender (M:F) Preop BMI (kg/m2) Preop comorbidity Type of BS DM/ HTN Dyslip OSA/ Other RYGB SG InsI Dysp AGB 50.5 30 104 179 N/A 39 161 67 14 53 (51–54) 43 (37–51) 29 0 96 2 171 0 N/A 7 36 0 161 0 67 0 0 10 Nehus/2016 [15] POS 242 17.1 Inge/2016 [7] Paulus/2016 [16] POS ROS 228 10 Vilallonga/2016 [17] Zitsman/2015 [18] ROS 19 17 ± 1.6 57:171 16.5 4:6 (14.9–18.5) 15.5 (13–17) 4:15 38.9 (35–44) 3 1 5 1 N/A 0 0 19 POS ROS ROS POS 137 18 25 14 16 ± 1.2 17.5 14–18 16 42:95 5:13 N/A 4:10 48.3 ± 8.2 47.2 45.7 46.1 ± 3.14 2 1 3 13 30 2 3 11 104 1 10 12 93 7 10 6 N/A N/A N/A N/A 0 8 25 0 0 10 0 0 137 0 0 14 ROS 50 17.1 ± 2.2 N/A 45.2 ± 7.6 5 12 4 3 19 0 0 50 Cozacov/2014 [19] Nijhawan/2012 [14] Osorio/2011 [20] Silberhumer/2011 [21] Widhalm/2011 [22] de la Cruz-Muñoz/ 2010 [23] Widhalm/2008 [24] Papadia/2007 [25] Sugerman/2003 [26] 59:183 CS 18 17.7 ± 2.6 12:6 51.7 ± 8.0 N/A N/A N/A N/A N/A 9 1 8 ROS 78 17.8 (12–19) 18:60 45.8 ± 5.6 N/A N/A N/A N/A N/A 71 1 6 CS ROS 10 68 17.3 ± 3 16.8 (14–18) 7:3 12:56 49.1 ± 6.8 46 (26–71) N/A N/A 5 33 N/A 11 N/A N/A N/A N/A 1 BPD 2 0 7 0 ROS 33 16 ± 1 14:19 2 11 N/A 7 22 17 950 12–19 93 305 497 134 116 453 GP: 3 LL:10 D: 3 148 265 Total 52 ± 11 (38–91) 238:637 26–91 M:F male to female ratio, Preop Preoperative, BMI body mass index, DM diabetes mellitus, InsI insulin intolerance, HTN hypertension, Dyslip dyslipidemia, OSA obstructive sleep apnea, Dysp dyspnea, AKF abnormal kidney function, N/A not available, RYGB Roux-en-Y gastric bypass, SG sleeve bypass, AGB adjustable gastric banding, BS bariatric surgery, POS prospective observational study, ROS retrospective observational study, CS case series, BPD biliopancreatic diversion, GP gastroplasty, LL long-limb gastric bypass, D distal gastric bypass Table 2 Postoperative outcome of primary bariatric surgery in adolescents Author/year Nehus/2016 [15] Inge/2016 [7] Paulus/2016 [16] Vilallonga/2016 [17] Zitsman/2015 [18] Cozacov/2014 [19] Nijhawan/2012 [14] Osorio/2011 [20] Silberhumer/2011 [21] Widhalm/2011 [22] de la Cruz-Muñoz/ 2010 [23] Widhalm/2008 [24] Papadia/2007 [25] Sugerman/2003 [26] Total No. of pts. BMI loss (kg/m2) at the last FU DM HTN Dyslip Dysp Other Admission Reoperation Death 3 yrs 3 yrs 64 (52–84) mo 7.2 yrs (2.4–10.2) 206 183 10 19 14.2 15 (13–16) 10.7 (−0.9–12.9) 11.4 1 19 0 0 29 56 0 0 54 84 0 0 N/A N/A 0 0 28 22 N/A N/A N/A 28 4 3 N/A 27 4 0 N/A 1 0 0 36 mo 55.2 mo 5–10 yrs 68 15 25 9 ± 0.2 30.1 17.1 1 0 0 21 0 0 71 0 0 62 N/A 0 N/A N/A N/A 36 N/A 4 30 N/A 1 0 0 0 45.5 ± 27.3 mo 85.9 ± 17.7 mo (63.3–138.3 42 mo 4 yrs 1 45 11.3 17 2 5 4 1 4 0 1 0 N/A 2 N/A 6 N/A 6 0 0 8 16 11.3 16.15–18.56 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 0 2 0 0 0 0 4 yrs 11 yrs (2–23) 14 yrs 8 67 6 N/A N/A 0 6 0 1 N/A 0 0 N/A N/A 0 N/A N/A 2 N/A 15 12 N/A 14 9 N/A 0 2 2–23 yrs 677 10.33 ± 6.6 78% EWL 14 kg/m2 33 ± 68% %EWL 11.3–33 28 213 63 52 108 91 3 Longest FU Comorbidity at the last FU 118 Complications FU follow-up, No. number, BMI body mass index, DM diabetes mellitus, HTN hypertension, Dyslip dyslipidemia, Dysp dyspnea, AKF abnormal kidney function, N/A not available, Yrs years, Mo months 3114 OBES SURG (2017) 27:3110–3117 Fig. 2 Meta-analysis of the adolescents’ weight loss outcome based on BMI at the last follow-up a less aggressive weight loss surgery such as adjustable gastric banding (AGB) [27]. Later on, academic centers began to consider other procedures such as sleeve gastrectomy [28] and gastric bypass (RYGB) for those who were a candidate for ABS [26]. According to an analysis of the University Health System Consortium (UHC) database between 2008 and 2011, out of 329 ABS, 136 procedures were LAGB, 47 were LSG, and 146 were LRYGB [29]. This analysis compared to a similar one for ABS data between 2002 and 2009 [27] showed a decreased use of AGB and an increased use of LSG in morbidly obese adolescents. This trend is in the same direction as the one recently reported for adult population of morbidly obese patients [28]. Nevertheless, the outcome of bariatric surgery in adolescents has been rarely described beyond 1–3 years. On the other hand, since most studies on ABS present data on AGB [27], the majority of data on the longterm outcome of ABS are related to this weight loss procedure. Weight Loss Our study demonstrated the maintenance of an average BMI loss of 13.3 kg/m2, 3 years after ABS. This pooled estimate is similar to that reported by previous meta-analyses [9, 11]. In a Fig. 3 Weigh loss pattern in adolescents after bariatric surgery systematic review of 23 studies (637 morbidly obese adolescents), Black et al. showed a significant BMI loss of 13.5 kg m2 (95%CI, −14.1 to −11.9) at 1 year after bariatric surgery [11]. Furthermore, the authors showed the superiority of RYGB (−17.2 kg/m2) to LSG (−14.5 kg/m2) and AGB (−10.5 kg/m2) in terms of adolescent weight loss. Another meta-analysis of 37 studies similarly showed a BMI loss of 11.6 kg/m2 for AGB, 16.6 kg/m2 for RYGB, and 14.1 kg/m2 for LSG [9]. Interestingly, this review commented that no significant association was observed between the length of follow-up and the amount of weight loss after 1 year. This finding is in the same direction as our analysis pointing the possible plateaued weight loss of morbidly obese adolescents after 1–3 years. Moreover, while these reviews did not aim to evaluate the long-term outcome of bariatric surgery in adolescents, they demonstrated the superiority of RYGB over the other two procedures [9, 11]. Unfortunately, there were insufficient studies on the long-term weight loss of ABS to be included in a sub-analysis based on the procedure type. Nevertheless, with increasing preference of LSG and RYGB over the AGB, a changing pattern of weight loss might be expected when more studies with long-term follow-up are available on these two globally accepted weight loss procedures in adolescent population. BMI 50 45 40 35 30 25 BMI 20 15 10 5 0 Baseline 6-months 1-year 2-year 3-year 4-year 5-year 6-year 7-year OBES SURG (2017) 27:3110–3117 3115 No. 35 31 30 25 20 15 15 No. 10 5 1 1 1 1 2 0 GBP to D-GBP to LSG to LL-GBP GBP RYGB Band to Band Band Band to BPD exchange removal RYGB Fig. 4 Fate of bariatric surgery in adolescents determined at the last follow-up Resolution of Comorbidities Data on comorbidity resolution were of a very poor quality due to the inconsistency outcome measure definition, variable focus of different studies on numerous types of comorbidities, and lack of sufficient evaluation at the latest follow-up. Our meta-analysis revealed that one third of the adolescents with dyslipidemia still suffer the condition. Although the observed effect of bariatric surgery on resolution or improvement of morbidly obese associated conditions are well above that of the medical management, it is not clear if those patients would still require treatment the resolved/improved comorbidities. The meta-analysis of Black et al. has commented that the resolution rates in the studies with a larger sample size are moderate in comparison to the larger rate by smaller studies, probably due to the inflated variation of the observed effect across the studies [11]. The other meta-analysis on ABS by Paulus et al. also points out to a lower resolution rate for dyslipidemia compared to other comorbidities such as DM, HTN, and dyspnea. This provokes the concept of the possibly different metabolic responses after bariatric surgery between adolescent and adult morbidly obese individuals and potentially more strict diet modification and consideration of the medical treatment in high-risk individuals. Complications, Reoperation, and Mortality Overall there was a 11.4% readmission rate among adolescents after bariatric surgery. However, postoperative complications were poorly defined and very sparsely reported by the included studies. Previous systematic reviews have also mentioned the inadequate focus of studies on defining the cutoff and presenting of post-bariatric complications. This lack of data is mainly realized in studies reporting the long-term outcome of ABS. In case of AGB, gastrointestinal symptoms such as nausea, vomiting, gastroesopageal reflux, epigastric discomfort, port malfunction, and band slippage/erosion were reported. For RYGB and LSG, postoperative complications mostly included postoperative bleeding, leak, stenosis, infection, hernia, and vitamin deficiencies. Reoperation after the initial bariatric procedure took place for two main reasons, postoperative complication and weight loss failure. That said, 7.9% of the adolescents underwent reoperation due to a procedure-related complication. Although this rate is not far above the reoperation rate in adult bariatric surgery, which ranges from 9% [30] to more than 20% [31], considering the number of years remained ahead of the adolescents who undergo a bariatric procedure, it adds to the possibility of encountering a reoperation incident. Previous reviews also reported a numerous of reinterventions including band repositioning, replacement, or removal, and port revision for AGB, endoscopic balloon dilation of anastomotic stricture, and reoperation for GI obstruction, leak, or fistula, and reoperation for leak in terms of sleeve gastrectomy [9, 11]. Our systematic review detected only 1 death after RYGB due to a hypoglycemic event [7] and 2 deaths after gastric bypass unrelated to the procedure [26]. Similarly, 2 deaths were reported after RYGB in both Paulus et al. [9] and Black et al. review article [11], which seemed unrelated to the procedure. Although the overall mortality of ABS is comparable to that of adult surgery [32], an age-specific analysis of mortality after RYGB revealed that patients younger than 35 years old especially women are at a higher risk of mortality due to external cause of death such as accident, suicide, and hypoglycemic attacks [33]. Fate of Bariatric Surgery in Adolescents Due to the relative simplicity of the laparoscopic placement of an adjustable silicon band around the stomach, 1–2 cm below the gastroesophageal junction, AGB has been widely offered to the morbidly obese pediatric and adolescent patients [11]. Furthermore, an analysis of the national trend data from the Healthcare Cost and Utilization Project Kids’ Inpatient Database 2000–2009 revealed that the predominant procedure has changed to minimally invasive techniques, such as laparoscopic AGB and RYGB [6]. Thus, it is not unexpected that after analysis of the long-term data, band removal or exchange and conversion to RYGB or BPD constitute the majority of revisional bariatric surgeries in adolescent population. Although AGB is becoming of less interest in adult population [28], it has been commonly performed initially in adolescent population. Importance of Long-Term Follow-Up in Adolescent Bariatric Surgery Although the current picture of weight loss and comorbidity resolution is still meaningful after ABS, the amount of weight gain (< 5 kg/m2) observed between 5 and 6 years after the surgery (Fig. 3), as well as the countable proportion of adolescents 3116 with persisting comorbidities may question the greater potential of the adolescents to benefit from bariatric surgery [7]. Although this diluted benefit of bariatric surgery in the long-term may result from the combined analysis of different procedures, it undoubtedly highlights the importance of a long-term follow-up to ensure the adequate adherence of the adolescents to the lifestyle modification programs and identify those who would benefit the medical treatment for residual or recurred comorbidities after bariatric surgery. Another benefit of a more robust long-term follow-up in adolescent population is the possibility of nutritional evaluation for identification of deficiencies and appropriate provision of supplements to prevent metabolic and physiologic consequences. OBES SURG (2017) 27:3110–3117 References 1. 2. 3. 4. 5. Limitations Despite the worsening childhood obesity epidemic, bariatric surgery utilization has plateaued over the last years [5, 6]. The decreasing interest in adolescent bariatric surgery might be considered a cause for inconsistency in reporting data regarding the long-term follow-up. This inherent drawback of the literature is responsible for the lack of evidence regarding the long-term sustainability of the improved metabolic status or worsening nutritional reservoir of morbidly obese adolescents who underwent bariatric surgery. Hence, although our pooled analysis of the literature data suggest the short-term safety and long-term efficacy of bariatric surgery in achieving a substantial weight loss among adolescents with morbid obesity, it was unable to comment on the ultimate safety profile of this treatment option in terms of nutritional sufficiency and appropriate thrive. 6. 7. 8. 9. 10. 11. 12. Conclusion Bariatric surgery is the only stand-alone treatment option for morbidly obese adolescents with sustainable weight loss outcome. 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