IPEG Guidelines for Surgical Treatment of Extremely Obese Adolescents

INTRODUCTION/PREAMBLE

Extreme obesity has become a significant health problem for the pediatric population (1), and has prompted considerable discussion about optimal management (2)  In some, the health effects are serious enough to provide compelling reasons to consider bariatric surgery (3).  This document represents a clinical practice guideline, based on review of the evidence, issued by the International Pediatric Endosurgery Group (IPEG).  This document is not intended to summarize the published evidence relevant to adolescent bariatric surgery, as a health technology assessment (systematic review) has been done in 2007 and is available on the world-wide web at:  (http://www.hta.hca.wa.gov/docs/pbs_executive_summary.pdf). 

The current recommendations are based largely upon the literature reviewed within the health technology assessment, and on other guidelines published in Obesity Research in 2005 (4) and updated in 2008 (5).  This guideline is therefore a synopsis, intended to guide surgeons who are contemplating the use of bariatric surgery for adolescents.  Most rrecommendations were based on data extrapolated from adult studies, descriptive studies focused on adolescents, and expert opinions.  The grading system used is shown in Table 1.

Table 1: Strength of Recommendations

• Category-A:  Based on randomized controlled trials in adolescents (no such studies exist).
• Category-B:  Based on controlled studies in adolescents or extrapolated from randomized controlled studies in adults.
• Category-C:  Based uncontrolled descriptive, comparative, or case-control studies in adolescents, or on controlled studies in adults.
• Category-D:  Based on expert opinion relevant to adolescents or on expert opinion or extrapolated evidence from adult studies.

PATIENT EVALUATION TEAM

Bariatric surgery for adolescents should be performed only in centers offering a multidisciplinary team approach capable of managing the unique challenges posed by the adolescent age group (6) Category-D.  The team should include specialists with expertise in pediatric obesity evaluation and management, psychology, nutrition, exercise physiology and bariatric surgery Category-D.  This team reviews referrals and functions much like a transplantation team or tumor board to determine the appropriateness of a surgical intervention.  The decision for bariatric surgery must be judged on an individual basis according to a patient’s obesity-related comorbid conditions, physiologic and psychological maturation, and family support structures Category-B, C, D.

PATIENT SELECTION

Proposed eligibility criteria are presented in Tables 1 and 2.  Consistent with recent recommendations of an expert panel (5), adolescents with a BMI > 35 kg/m2 with severe comorbidities may benefit from surgical weight loss.  Additionally, those with BMI ≥ 40 kg/m2 with less serious obesity-related comorbidities should also be considered for surgical intervention Category-B, C.  A comprehensive psychological evaluation, involving both patient and caregiver interviews, should occur prior to operation.  This evaluation may inform the team of family strengths or family dysfunction that could positively or negatively impact postoperative regimen adherence.  The importance of an in-depth assessment of the patient’s maturity and level of understanding and the family’s ability to care for the adolescent bariatric patient postoperatively cannot be understated Category-D.  Often, after consideration of psychosocial and family factors, the decision is made not to proceed with a surgical path but to continue non-operative weight management attempts.  If a patient is considered a good operative candidate (described in detail elsewhere (7), however, assent for surgery must be obtained from the adolescent patient while informed permission must be obtained from the parents prior to operation.

Some conditions that identify patients who are not appropriate operative candidates include: substance abuse problem(s) within the preceding year, the presence of a psychiatric diagnosis which would impair ability to adhere to postoperative dietary or medication regimen (e.g., psychosis), a medically correctable cause of obesity, inability or unwillingness of patient or parent to fully comprehend the surgical procedure and its medical consequences, and inability or refusal to participate in lifelong medical surveillance Category-D.  Surgeons should be cautious too when there is poor documentation of weight loss attempts, lack of a supportive family environment, a history of significant behavioral problems (conflict/defiance issues) present in the adolescent, lack of realistic expectations for the surgery, or a history of poor compliance with other medical regimens Category-D.

Table 2: Updated (5) Indications for Adolescent Bariatric Surgery

» BMI > 35 kg/m2 with the following severe comorbidities.
» Type 2 diabetes mellitus (Category-B)
» Moderate or severe obstructive sleep apnea (AHI≥15 events/hr) (Category-C)
» Pseudotumor cerebri (Category-C)
» BMI ≥ 40 kg/m2 with the following obesity-related comorbidities (all Category-C and D unless otherwise noted):

• Hypertension
• Dyslipidemia
• Obstructive sleep apnea (AHI≥5 events/hr)
• Venous stasis disease
• Panniculitis
• Urinary incontinence
• Significant impairment in activity of daily living
• Moderate to severe non alcoholic fatty liver disease
• Gastroesophageal reflux
• Severe psychosocial distress
• Significantly impaired quality of life
• Weight related arthropathies

 

Table 3: Adolescents being considered for bariatric surgery should (Category D):

• Have attained or nearly attained (e.g., ≥ 95 %) of adult stature and;
• Have failed to attain a healthy weight with prior organized attempts at conventional weight management and;
• Demonstrate commitment to comprehensive pediatric psychological evaluation both before and after surgery and agree to avoid pregnancy for at least one year postoperatively, and;
• Be capable of and willing to adhere to nutritional guidelines postoperatively, and;
• Have decisional capacity and provide informed assent for surgical management.

SURGICAL CONSIDERATIONS

Preoperative education about appropriate postoperative nutritional and physical activity programs is important for long-term success Category-D.  Preoperative testing usually includes electrocardiogram, gallbladder ultrasound (as indicated), fasting comprehensive chemistries, lipid profile, urinary assessment, complete blood count, hemoglobin A1C (if indicated), oral glucose tolerance test (if indicated), thyroid function tests, liver function tests including albumin and a beta human chorionic gonadotropin for females.  A baseline measurement of lean and fat mass, using dual-energy x-ray absorptiometry or bioelectric impedence is useful.  At regular intervals postoperatively, these studies should be repeated to allow early detection of complications and assess treatment response Category-D.

To best care for the adolescent bariatric surgical patient, a comprehensive knowledge of and specialized training in the science and art of bariatric surgery is required.  Surgeons who plan to offer bariatric surgical procedures to adolescents should become familiar with training guidelines (see information at www.asmbs.org).  Due to the fact that this is a high-risk population and bariatric procedures are surgically complex, surgeons should plan to devote a significant portion of their practice to this effort.  If bariatric procedures are to be performed in a pediatric institution, the hospital must also be capable of meeting the care guidelines described by the American Society for Metabolic and Bariatric Surgery and American College of Surgeons.

Laparoscopic (6, 8) and open (9, 10) roux en Y gastric bypass Category-B and laparoscopic adjustable gastric banding (11-13) Category-C have been used successfully in adolescents.  Laparoscopic sleeve gastrectomy also produces significant weight loss with low operative risk in adult studies (14, 15) Category-C, D.  There are many pros and cons for each option, but in the United States, gastric bypass has been offered more frequently (16).  A comprehensive review of these procedures is beyond the scope of this guide, but an excellent textbook (17), published manuscripts (7, 18), and web-based resources (www.asmbs.org) are available comparing bariatric operations.

AFTER OPERATION

Careful, lifelong medical supervision of adolescent patients who undergo bariatric procedures will help optimize outcomes and prevent complications.  During the first postoperative year, weekly (first month), then monthly (first 3 months), then quarterly visits with the bariatrician, surgeon, dietician, psychologist and exercise physiologist should identify potential complications, and reinforce compliance with new eating behaviors, medications and supplements and exercise regimens Category-D.  Although there are numerous dietary guidelines for bariatric patients, most importantly, patients must consume at least 60-70g of lean protein per day following operation Category-D.  Supplementation of multivitamins and minerals is recommended and differs based on the procedure performed.  Multivitamins, calcium, vitamin B12, vitamin B1, and iron (in menstruating females) must be provided after gastric bypass and to a lesser extent after gastric banding Category-C.  Ranitidine and ursodiol are also recommended by some experts for a 6 month period postoperatively Category-D.  Adequate contraception in female patients must be provided for at least the first year after operation to prevent early pregnancy in a population at risk (19) Category-D.

PROFESSIONAL LIABILITY AND RISK MANAGEMENT

Bariatric surgery is a high-risk and litigious field.  As a result, bariatric surgeons have experienced steadily rising malpractice premiums.  The three most common causes for litigation are death, post-operative complications and failure of informed consent.  Patients and families must not only be told of operative risks and complications, but also of non-surgical alternatives and other alternative operations (including why you do or do not recommend them) Category-B, C.  All communications with the family and the patient should be documented(20).  Clinical research to help determine which patients are most appropriate for these procedures and in which patients the procedures are highest risk will ultimately increase knowledge of the benefit: risk ratio for this group of patients.

REFERENCES