Pediatric Metabolic and Bariatric Surgery

Vertical sleeve gastrectomy: VSG has become the most used and most recommended operation in adolescents with severe obesity for several reasons, near-equivalent weight loss to the RYGB in adolescents, fewer reoperations, better iron absorption, and near-equivalent effect on co-morbidities as RYGB in adolescents. However, given the more extensive long-term data available for RYGB, we can recommend the use of either RYGB or VSG in adolescents. Long-term outcomes of GERD after VSG are still not well understood.

Preoperative attempts at diet and exercise: there are no data that the number of weight loss attempts correlates with success after MBS. Compliance with a multi-disciplinary preoperative program may improve outcomes after MBS but prior attempts at weight loss should be removed as a barrier to definitive treatment for obesity.

The use of the most up to date definitions of childhood obesity are as follows: (1) BMI cut offs of 35 kg/m² or 120% of the 95th percentile with a co-morbidity, or (2) BMI >40 kg/m² or 140% of the 95th percentile without a co-morbidity (whichever is less). Requiring adolescents with a BMI >40 to have a co-morbidity (as in the old guidelines) puts children at a significant disadvantage to attaining a healthy weight. Earlier surgical intervention (at a BMI <45 kg/m²) can allow adolescents to reach a normal weight and avoid lifelong medication therapy and end organ damage from comorbidities.

Certain co-morbidities should be considered in adolescents, specifically the psychosocial burden of obesity, the orthopedic diseases specific to children, GERD, and cardiac risk factors. Given the poor outcomes of medical therapies for T2D in children, these co-morbidities may be considered an indication for MBS in younger adolescents or those with lower obesity percentiles.

Vitamin B deficiencies, especially B1 appear to be more common in adolescents both preoperatively and postoperatively; they should be screened for and treated. Prophylactic B1 for the first 6 months postoperatively is recommended as is education of patients and primary care providers on the signs and symptoms of common deficiencies.

The use of emerging technologies in adolescents should be considered when standard procedures are unavailable or anatomically inappropriate, but when done in adolescents they must be used in the setting of an age appropriate multidisciplinary team that treats obesity and under an institutional review board–approved trial. Companies should be encouraged to fund trials of new devices in adolescents at least as soon as a device is FDA approved in adults.

Developmental delay, autism spectrum, or syndromic obesity should not be a contraindication to MBS. Each patient and caregiver team will need to be assessed for ability to make dietary and lifestyle changes required for surgery. Multidisciplinary teams should agree on the specific needs and abilities of the given patient and caregiver and these should be considered on a case-by-case basis with the assistance of the hospital ethics committee where appropriate.

Because MBS results in better weight loss and resolution of co-morbidities in adolescents at lower BMI’s with fewer co-morbidities, referrals should occur early, as soon as a child is recognized to suffer from severe obesity disease (BMI >120% of the 95th percentile or BMI of 35). Prior weight loss attempts, Tanner stage, and bone age should not be considered when referring patients to a MBS program.

Unstable family environments, eating disorders, mental illness, or prior trauma should not be considered contra-indications for MBS in adolescents; however, these should be optimized and treated where possible before and surrounding any surgical intervention for obesity.

Routine screening of alcohol use is imperative across all procedures. Conservative clinical care guidelines, which strongly advocate abstinence, while appropriate, must also include information for this age group on harm reduction (i.e., lower consumption levels, how to avoid or manage situations related to alcohol-related harm) to mitigate clinical and safety risks. Risks of nicotine should be discussed and smoking or vaping nicotine should be discouraged.

The recognition of obesity as a chronic disease that requires multimodal therapies justifies the treatment of such a disease in a multidisciplinary team that can provide surgical, pharmacologic, behavioral, nutritional, and activity interventions. Pharmacologic therapies as adjuncts to surgical therapies may provide improved outcomes long term in the pediatric population; more studies are needed.