Bariatric Surgery for Adolescents: A View From the American Pediatric Surgical Association

In this issue of Pediatrics, Inge et al1 report the conclusions of a consensus conference of pediatricians and pediatric surgeons concerned with the epidemic of childhood obesity in this country. The intent of the conference was to outline an approach for the evaluation of the morbidly obese adolescent and define candidates for bariatric surgical procedures. The magnitude of this “epidemic” is well defined, with 15% to 20% of children and adolescents in the United States now meeting criteria for obesity, with enormous consequences to their own personal health and quality of life and our health care system itself. An estimated 75% of these obese adolescents will continue to be so categorized in adulthood. This problem is simply too great for physicians for children to fail to respond with suggestions for the appropriate evaluation and therapy of these unfortunate youngsters. The results of bariatric surgery in adult patients would suggest that surgery will play a significant role in the treatment of some of these adolescents.Inge et al proposed what I believe to be an appropriate approach to the evaluation of these patients and focused on the therapy for these individuals, with particular emphasis on the surgical techniques that may prove useful in a highly select group of adolescents. There is much to be learned from the adult experience in this arena, because bariatric surgery has become one of the most commonly used operative procedures in the United States today. A great deal has been learned by bariatric surgeons with regard to the technical aspects of a successful operation and avoidance of the many potential complications of these procedures. Nonetheless, Inge et al correctly emphasize that obese adolescents are different; they are not just large adults. The obese adolescent presents a unique array of issues, many of which may be impacted by these surgical procedures in ways we do not understand yet: What will be the psychosocial impact of significant weight loss, the metabolic consequences, and the long-term efficacy of these operations? One of the principal conclusions of this conference was that these patients should be cared for in a multidisciplinary program, comprising individuals with special expertise in dealing with adolescents. These programs will include pediatric endocrinologists, nephrologists, psychiatrists, and psychologists, as well as dietitians and exercise therapists. In this sense, these programs will be quite similar to the multidisciplinary groups with which pediatricians and pediatric surgeons are familiar for treatment of pediatric neoplasms and transplantation. Pediatric surgeons who wish to participate in the surgical management of these individuals will have to take the time to learn to perform these procedures safely and care for these patients postoperatively. These are not easy operations to perform in this population, and here again, there is much to be learned from the adult experience. In some communities, the surgical members of these multidisciplinary teams may be pediatric surgeons who have been willing to acquire this knowledge, whereas in other communities, bariatric surgeons with a special interest in the care of adolescents may assume this role.Inge et al attempted to suggest criteria for selecting obese adolescents for surgical therapy. In this regard, I believe that they have been appropriately conservative, because there are many unknown consequences of these operative procedures in this population. Inge et al suggest that the candidate must have failed at least 6 months of aggressive dietary and exercise therapy and must have demonstrated appropriate compliance with therapy during that interval. Because of concerns regarding calcium absorption after many of these procedures, the authors suggested that candidates initially be limited to those who have achieved skeletal maturity, ∼13 years of age for females and 15 years of age for males. Finally, they suggested that candidates have a body mass index of ≥40 with serious comorbidities or ≥50 with somewhat less serious comorbidities. These criteria are considerably more conservative than those proposed for adult patients in 1991 by the National Institutes of Health consensus panel.2 One could argue with the authors’ delineation of “serious” and “less serious” comorbidities, but they emphasize throughout the article that selection of appropriate adolescent candidates for surgical treatment of obesity must be individualized in this heterogenous population and that we must be conservative as we move forward.The Board of Governors of the American Pediatric Surgical Association had an opportunity to review and discuss this article before it was submitted to Pediatrics. There is currently a great deal of interest within the pediatric surgical community in participation in these multidisciplinary teams. We feel that Inge et al presented a reasoned approach to begin to define the appropriate management of these difficult patients. We applaud the group for defining appropriately conservative criteria for selecting surgical candidates, because there are many questions to be answered with regard to the safety and efficacy of this treatment strategy in adolescence. We agree very strongly with the authors’ conclusion that we must establish a system for ongoing clinical data collection and long-term follow-up as we enter this arena. The fact that there is so little experience with these procedures in the adolescent population offers a particularly propitious opportunity for significant clinical research and outcomes analysis. Randomized, clinical trials should be designed to compare the gastric bypass to the adjustable band in this population. Appropriate quality-of-life instruments will need to be designed to compare outcomes of medically and surgically treated patients. The American Pediatric Surgical Association salutes the authors for attempting to provide useful criteria for the introduction of bariatric surgery to this population, and we look to this group to provide ongoing recommendations as we proceed.