Introduction

As the prevalence of obesity has increased in the pediatric population, so too have obesity related complications ⁽¹⁾. In some, the complications are serious enough to provide compelling reasons to consider bariatric surgery.

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 ⁽²⁾. The team should include specialists with expertise in pediatric obesity evaluation and management, psychology, nutrition, exercise physiology and bariatric surgery. 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.

Patient Selection

Proposed eligibility criteria are presented in Tables 1 and 2. Adolescents with a BMI (Body Mass Index) > 40 with severe comorbidities may benefit from surgical weight loss. Additionally, those with BMI ≥ 50 with less serious obesity-related comorbidities (Table 2), can also be considered operative candidates. A comprehensive psychological evaluation, involving both patient and parent 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. 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, 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 (eg, 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. 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.

Surgical Considerations

Preoperative education about appropriate postoperative nutritional and exercise programs maximizes long-term successes. Preoperative testing usually includes chest radiograph, electrocardiogram, gallbladder ultrasound, fasting comprehensive chemistries, lipid profile, urinalysis, complete blood count, hemoglobin A1C, oral glucose tolerance test, fasting insulin, transferrin, thyroid function tests, liver function tests including albumin and a beta-human chorionic gonadotropin for females. A sleep study may be needed to exclude obstructive sleep apnea. A baseline measurement of lean and fat mass, using DEXA (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.

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.asbs.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 Bariatric Surgery and American College of Surgeons ^{(3, 4)}.

Laparoscopic ^{(5, 6)} and open ^{(7, 8)} roux en Y gastric bypass and laparoscopic adjustable gastric banding ⁽⁹⁾ have been used successfully in adolescents. There are many pros and cons for each option, but in the United States, the bypass has been offered more frequently with better results. A comprehensive review of these procedures is beyond the scope of this guide, but an excellent textbook ⁽¹⁰⁾, published manuscripts ^{(3, 6)}, and web-based resources (www.asbs.org) are available comparing bariatric operations.

After the 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, then monthly, 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. Although there are numerous dietary guidelines for bariatric patients, most importantly, patients must consume 60-70g of lean protein per day following operation. Supplementation of multivitamins, calcium, vitamin B12, and iron (in menstruating females) must be provided after gastric bypass and to a lesser extent after gastric banding. Ranitidine and ursodiol are also recommended for a 6 month period postoperatively. Adequate contraception in female patients must be provided for at least the first year after operation.

Professional Liability and Risk Management

References

1. Dietz WH. Health Consequences of Obesity in Youth: Childhood Predictors of Adult Disease. Pediatrics 1998; 101:518-25.
2. Garcia VF, Langford L, Inge TH. Application of Laparoscopy for Bariatric Surgery in Adolescents. Current Opinion in Pediatrics 2003; 15:248-55.
3. Guidelines for Laparoscopic and Open Surgical Treatment of Morbid Obesity. American Society for Bariatric Surgery. Society of American Gastrointestinal Endoscopic Surgeons. Obesity Surgery 2000; 10:378-9.
4. Recommendations For Facilities Performing Bariatric Surgery. Bulletin American College of Surgery 2000; 85:20-3.
5. Stanford A, Glascock JM, Eid GM, Kane T, Ford HR, Ikramuddin S et al. Laparoscopic Roux-en-Y Gastric Bypass in Morbidly Obese Adolescents. Journal of Pediatric Surgery 2003; 38:430-3.
6. Inge TH, Garcia VF, Daniels SR, Kirk S, Langford L, Roehrig H et al. A Multidisciplinary Approach to the Adolescent Bariatric Surgical Patient. Journal of Pediatric Surgery (submitted) 2003.
7. Sugerman HJ, Sugerman EL, DeMaria EJ, Kellum JM, Kennedy C, Mowery Y et al. Bariatric Surgery for Severely Obese Adolescents. Journal of Gastrointestinal Surgery 2003; 7:102-8.
8. Strauss RS, Bradley LJ, Brolin RE. Gastric Bypass Surgery in Adolescents With Morbid Obesity. Journal of Pediatrics 2001; 138:499-504.
9. Dolan K, Creighton L, Hopkins G, Fielding G. Laparoscopic Gastric Banding in Morbidly Obese Adolescents. Obesity Surgery 03; 13:101-4.
10. Deitel, M. and Cowan, G.S.M, Eds. “Update: Surgery for the Morbidly Obese Patient.” FD-Communications, Inc. Toronto, 200

This Guideline was prepared by the IPEG Guidelines Committee and was reviewed and approved by the Executive Committee of the International Pediatric Endosurgery Group (IPEG) October, 2003.