FROM THE JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION

Bariatric surgery be considered in adolescents with a body mass index of 35 kg/m2 or higher with certain severe comorbidities and for those with BMI of 40 kg/m2 or higher with milder comorbidities, according to recommendations in a new position paper from the European Society of Paediatric Gastroenterology, Hepatology, and Nutrition.

The paper, released jointly this month by the ESPGHAN and its North American counterpart, NASPGHAN, aligns criteria for bariatric surgery in adolescents more closely to those used in adults, clinicians say.

The new guidelines “are still more conservative than what is currently recommended for adults, which begin with severe comorbidities at a BMI of 30 or higher, but this is a great paper to move things in the right direction for adolescents,” said Dr. Elizabeth P. Prout , medical director of the adolescent bariatrics program at the Children’s Hospital of Philadelphia.

Recommendations on bariatric surgery in this patient group are far from standardized, though they have become less conservative over time. Guidelines issued be the American Society for Metabolic and Bariatric Surgery in 2012 and the International Pediatric Endosurgery Group in 2009 both say surgery can be considered in adolescent patients with a BMI of 35 and severe comorbidities, while those published in 2004 by the advise that bariatric surgery be considered only for adolescents with BMI of 40 or higher.

Dr. Valerio Nobili of Bambino Gesù Children’s Hospital in Rome led the 12-author team in developing the new recommendations, which were published online Jan. 19 in the Journal of Pediatric Gastroenterology and Nutrition (doi:10.1097/MPG.0000000000000715). Dr. Nobili and his colleagues wrote that “the exact indications and the role of bariatric surgery in the pediatric patient are still controversial,” citing ethical considerations along with limited information on long-term outcomes in younger patients.

Dr. Nobili and his colleagues noted that there is still disagreement as to whether nonalcoholic steatohepatitis (NASH) should be a considered a major or minor criterion for bariatric intervention in adolescents. The guidelines state that NASH with significant fibrosis can be considered an indication along with BMI of 35 kg/m2 or higher.

Additional serious comorbidities to consider include diabetes, moderate to severe sleep apnea, and pseudotumor cerebri. Milder comorbidities include hypertension, insulin resistance, glucose intolerance, impaired quality of life, psychological distress, and mild sleep apnea.

Adolescents who are candidates for bariatric surgery should have a documented failure to lose weight by other means, a Tanner stage of 4 or greater, indicating advanced puberty, 95% skeletal maturity, a “demonstrated commitment” to lifestyle change, and a stable psychosocial environment, the guidelines say. No specific minimum age is described.

The guidelines do not exclude adolescents who have mental retardation from being considered for surgery; however, these should be considered on a case-by-case basis, and an ethicist should be part of any evaluating team.

Multidisciplinary patient management before and after surgery is stressed in the guidelines, particularly nutritional and psychological counseling.

This approach has “the potential to facilitate optimal weight loss following bariatric surgery but also to reduce the risk of psychological consequences indicated by a recent systematic review,” Dr. Nobili and his colleagues wrote.

Dr. Raquel G. Hernandez , director of Healthy Steps/Fit4AllKids at All Children’s Hospital Johns Hopkins Medicine, St. Petersburg, FL, commented that a trained multidisciplinary team is “essential” to consider an adolescent patient’s overall fit for bariatric surgery.

The guidelines support Roux-en-Y gastric bypass with long-term follow-up care. Other procedures, including adjustable gastric banding and sleeve gastrectomy, should be considered investigational in this patient group, the guidelines caution, while temporary devices, which have the advantage of reversibility and appear promising for pediatric patients, are yet too little studied to recommend.

Dr. Dennis P. Lund , professor of child health and surgery at the University of Arizona, Phoenix, commented that while that while the guideline authors are correct to emphasize that newer procedures do not have enough of a track record in adolescent patients to recommend, “the Roux-en-Y seems a very aggressive option for an adolescent and can be fraught with metabolic complications long term.”

Dr. Lund said that in adults, adjustable gastric banding has been “somewhat disappointing in durability and in ultimate weight loss,” while sleeve gastrectomy has shown more promise.

“What is required is a good matched, controlled study comparing medical treatment vs. sleeve gastrectomy for adolescent patients with BMI > 35 and 40 with the associated comorbidities outlined in the guidelines,” Dr. Lund said. “Given the ability of children’s hospitals to perform good multicentered trials, I would suggest that this would be a valuable study for those interested in treating obesity surgically to pursue.”

The guidelines were funded by ESPGHAN and NASPGHAN. Neither Dr. Nobili nor any of his 11 coauthors declared conflicts of interest.

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