Patient Evaluation
Body mass index (BMI [weight in kilograms divided by height in meters, squared]) is a useful screening tool for assessing and tracking the degree of obesity among adolescents. Medical evaluations should include investigation into possible endogenous causes of obesity that may be amenable to treatment and identification of any obesity-related health complications. Likely candidates for bariatric surgery should be referred to centers with multidisciplinary weight management teams experienced in meeting the distinct physical and psychologic needs of adolescents. These teams should include specialists with expertise in adolescent obesity evaluation and management, psychology, nutrition, physical activity instruction, and bariatric surgery. Surgeons participating in multidisciplinary adolescent bariatric teams should undergo subspecialty training in bariatric medical and surgical care, as detailed by the American College of Surgeons and the American Society for Bariatric Surgery. The importance of proper training and experience in bariatric surgery to ensure safe and effective application of this intervention in the adolescent population cannot be understated.
Additional expertise in adolescent medicine, endocrinology, pulmonology, gastroenterology, cardiology, orthopedics, and ethics should be readily available. The team approach should include a review process (patient review board) similar to that used in multidisciplinary oncology and transplant programs. This review should result in specific treatment recommendations for individual patients, including the appropriateness and timing of possible surgical intervention.
In addition to undergoing medical assessments, potential candidates should undergo comprehensive psychologic evaluations involving both patient and parent interviews, to facilitate assessment of the family unit, determination of the coping skills of the adolescent, and assessment of the severity of psychosocial comorbidities. These evaluations may inform the team of family strengths or family dysfunction that could have significant effects on the overall success of bariatric surgery, because of the influence of the family environment on postoperative regimen adherence.
The most important ethical issues when considering an adolescent for a bariatric procedure are whether the patient’s health is being compromised by severe obesity, whether the patient has failed more conservative options to meet that health need, and whether the patient has decisional capacity. Decisional capacity is not determined strictly by chronologic age, but many would agree that children <13 years of age usually do not have the capacity to make decisions regarding such a complicated serious intervention. At >13 years of age, adolescent patients, if developmentally normal, may be able to make informed decisions. The responsibility then falls on health care professionals to make the argument for or against that capacity for any given patient. When there are questions about decisional capacity, specialists in pediatric psychiatry or psychology can assist in determining decisional capacity or competency (the legal term). Patients with decisional capacity should be allowed to participate in self-determining decisions. However, the younger the patient, the more compelling and serious the comorbidity of obesity should be to prompt surgical intervention (refer to Table 1 in the original guideline for a list of obesity-related conditions that may be improved with bariatric surgery).
In the presence of certain circumstances or medical conditions, bariatric surgery is not a realistic treatment option. These conditions include a medically correctable cause of obesity; a substance abuse problem within the preceding year; a medical, psychiatric, or cognitive condition that would significantly impair the patient’s ability to adhere to postoperative dietary or medication regimens; current lactation, pregnancy, or planned pregnancy within 2 years after surgery; and inability or unwillingness of either the patient or the parents to fully comprehend the surgical procedure and its medical consequences, including the need for lifelong medical surveillance.
Patient Selection
Criteria for Bariatric Surgery
Adolescents being considered for bariatric surgery should:
- Have failed >6 months of available, organized attempts at weight management, as determined with the assistance of their primary care provider
- Have attained or nearly attained physiologic maturity
- Be very severely obese (BMI >40 kg/m2) with serious obesity-related comorbidities or have a BMI of >50 kg/m2 with less severe comorbidities
- Demonstrate commitment to comprehensive medical and psychologic evaluations both before and after surgery
- Agree to avoid pregnancy for at least 1 year postoperatively
- Be capable of and willing to adhere to nutritional guidelines postoperatively
- Provide informed assent to surgical treatment
- Demonstrate decisional capacity
- Have a supportive family environment
Surgical Treatment
Optimal Timing
The timing of surgical treatment of clinically severe obesity among adolescents is controversial and often depends on the severity of obesity-related comorbidities for individual patients. Neuroendocrine, skeletal, and psychosocial maturation are accelerated during adolescence, and it is not yet known how these processes are affected by restrictive or malabsorptive surgical procedures. The rapid somatic growth observed in early adolescence requires adequate nutrition; therefore, bariatric procedures performed before the growth spurt could potentially compromise linear growth. Physical examinations should include evaluations of sexual maturation, because the linear growth spurt generally occurs before Tanner stage IV for both boys and girls. The majority of skeletal maturity is attained for girls by >13 years and for boys by >15 years of age.
These ages may well represent conservative estimates of skeletal maturation, because overweight children experience an early onset of puberty and are likely to achieve skeletal maturity (adult stature) earlier in adolescence, compared with age-matched, nonoverweight children. When there is uncertainty regarding whether adult stature has been attained, bone age can be objectively assessed with radiographs of the hand and wrist. If an individual has attained >95% of adult stature, according to the results of this examination, then there is little concern that a bariatric procedure may significantly impair completion of linear growth. It is unknown, however, whether and to what extent bariatric surgery may affect bone mineral density adversely and increase the risk of brittle bone fractures later in life. Finally, although many severely obese adolescents may be deemed physiologically mature, psychologic readiness for a bariatric surgical intervention is less readily assured.
Informed Permission
Assent for surgery must be obtained from the adolescent patient, whereas informed permission must be obtained from the responsible parents or guardians before surgery. Both patients and parents must be made aware of the fact that bariatric surgery is a procedure with considerable risks, including the risk of death. Although bariatric procedures can result in substantial weight loss, the long-term metabolic, nutritional, and psychologic effects among adolescents are unknown. Similarly, patients and parents must understand that the durability of surgically induced weight loss among adolescents remains to be clearly defined.
Preoperative Education
An important element of long-term health and weight loss success is the development of an integrated multidisciplinary education program. Such a program must be aimed at teaching both parents and patients about the anatomic and physiologic features of the proposed surgery and the lifelong need for strict adherence to nutritional guidelines and daily physical activity and offering behavioral strategies to meet these needs. Attendance at adolescent bariatric support group meetings before and after surgery can also be quite helpful.
Laboratory and Radiologic Investigations
Several studies should be considered when candidacy for bariatric surgery is contemplated. These studies may identify conditions that may affect perioperative decision-making or may identify obesity related comorbid conditions that may justify surgical intervention. These studies include fasting glucose and hemoglobin A1C measurements, liver function tests, lipid profile tests, complete blood counts, thyroid function tests, pregnancy tests for female patients, and screening for micronutrient deficiencies. For patients with symptoms of obstructive sleep apnea, polysomnography is suggested. Finally, bone age assessment should be considered for younger patients, to document the degree of skeletal maturity.
Choice of Surgical Procedure
There is currently a paucity of data comparing the efficacy and safety of various bariatric procedures among adolescents. However, both Roux-en-Y gastric bypass and adjustable gastric banding (AGB) have been effective in treating the medical consequences of severe obesity in adolescence.
Gastric bypass currently seems to be the most appropriate surgical option for most adolescents who are candidates for bariatric surgery; however, appropriately designed trials are needed to determine which surgical procedure is optimal for adolescents.
Postoperative Concerns
There are numerous postoperative concerns after bariatric surgery in adolescence. To avoid nutritional complications, patients must adhere to guidelines regarding diet and vitamin/mineral supplementation. Gastric bypass essentially results in surgically enforced, very low-calorie, low-carbohydrate dietary intake, thus requiring attention to adequate (>0.5 g/kg) daily protein intake. Micronutrients, including calcium, vitamin B12, folate, multivitamins, thiamine, and iron (for menstruating female subjects), must be supplemented after gastric bypass. A bariatric dietitian who is familiar with the progressive addition of food items with more complex compositions and consistencies can help with meal planning and nutritional "troubleshooting" as recovery proceeds. Finally, nonsteroidal anti-inflammatory medications should be avoided, to reduce the risk of intestinal ulceration and bleeding.
Although pregnancies can be safely supported after bariatric surgery, reliable contraception should be used for at least the first year after the operation, because of the increased risk to the fetus posed by the rapid weight loss. Iron deficiency anemia attributable to menstrual bleeding can also be minimized with oral contraception. After the period of rapid weight loss, pregnancies should be carefully planned and monitored.
Long-Term Follow Up Monitoring
Meticulous, lifelong, medical supervision of adolescent patients who undergo bariatric procedures is essential. During the first postoperative year, regular visits to the surgeon and other subspecialists with expertise in nutrition and obesity management (e.g., psychologist, dietitian, and exercise physiologist) should be provided to identify potential complications and to reinforce compliance with required eating behaviors, administration of medications and nutritional supplements, and physical activity regimens. Early hematologic or metabolic complications can be detected with periodic assessments of blood counts, blood chemistry profile, and body composition. Psychosocial adjustments during the postoperative period of rapid weight loss may present new unanticipated challenges for adolescent patients. The multidisciplinary team approach should minimize the adverse effects of these challenges as a healthier weight is achieved.
It is strongly recommended that all patients who undergo bariatric surgery be monitored throughout their lives, to ensure optimal postoperative weight loss, eventual weight maintenance, and overall health. This is particularly important for adolescents, given the fact that the long-term effects of bariatric surgery in younger, reproductively active populations have not been well characterized. Ideally, adolescents who undergo bariatric surgery should be treated consistently, at regional centers of excellence, with ongoing clinical data collection and targeted research. The ability to make useful recommendations about the appropriate timing of bariatric surgery and optimal surgical and postoperative management depends on the collection of rigorous, high quality outcome data.
