ASMBS pediatric metabolic and bariatric surgery guidelines, 2018

doi:10.1016/j.soard.2018.03.019

Surgery for Obesity and Related Diseases

Volume 14, Issue 7, July 2018, Pages 882-901

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https://doi.org/10.1016/j.soard.2018.03.019 Get rights and content

Abstract

The American Society for Metabolic and Bariatric Surgery Pediatric Committee updated their evidence-based guidelines published in 2012, performing a comprehensive literature search (2009–2017) with 1387 articles and other supporting evidence through February 2018. The significant increase in data supporting the use of metabolic and bariatric surgery (MBS) in adolescents since 2012 strengthens these guidelines from prior reports. Obesity is recognized as a disease; treatment of severe obesity requires a life-long multidisciplinary approach with combinations of lifestyle changes, nutrition, medications, and MBS. We recommend using modern definitions of severe obesity in children with the Centers for Disease Control and Prevention age- and sex-matched growth charts defining class II obesity as 120% of the 95th percentile and class III obesity as 140% of the 95th percentile. Adolescents with class II obesity and a co-morbidity (listed in the guidelines), or with class III obesity should be considered for MBS. Adolescents with cognitive disabilities, a history of mental illness or eating disorders that are treated, immature bone growth, or low Tanner stage should not be denied treatment. MBS is safe and effective in adolescents; given the higher risk of adult obesity that develops in childhood, MBS should not be withheld from adolescents when severe co-morbidities, such as depressed health-related quality of life score, type 2 diabetes, obstructive sleep apnea, and nonalcoholic steatohepatitis exist. Early intervention can reduce the risk of persistent obesity as well as end organ damage from long standing co-morbidities.

Section snippets

Methods and procedures

An extensive literature search using Pubmed was performed examining publications from January 2009 thru October 2017. Search terms included: weight loss surgery (WLS) and pediatrics, adolescents, gastric bypass, sleeve gastrectomy, laparoscopic adjustable band, and extreme obesity. There were 1387 abstracts reviewed and categorized into each topic discussed below (i.e., diabetes, pregnancy, choice of surgery, etc.). These smaller libraries, which varied in size from 3 to 137 articles each, were

Cardiovascular disease

A large body of literature links the disease of obesity, and in particular severe obesity, with the associated development of numerous cardiovascular disease (CVD) risk factors, the progression of frank cardiovascular pathophysiology, and functional abnormalities leading to premature mortality in adults. There is a dose-dependent increase in mortality from CVD in adults who suffer from obesity established during childhood. When children have a BMI>95th percentile, their risk of CVD mortality is

Patient selection

While there may be children who should be considered for MBS before adolescence due to complications from obesity, we define adolescence here by the World Health Organization definition as a person who falls between the ages of 10 and 19 years of age [148].

In 2009, Flegal et al. [149] suggested the expression of severe obesity as a percentage>95th percentile; 120% of the 95th percentile of BMI for age was similar to unsmoothed 99th percentile. By 2012, Gulati et al. [150] had created new growth

Types of metabolic and bariatric surgery

In 2013, a meta-analysis was published that reviewed all case series of adolescent and pediatric patients undergoing MBS [11] and 637 adolescent patients were reported in 23 studies; by 2015, another meta-analysis only looking at studies of>10 patients found 37 studies with 2655 unique patients. These data, in addition to the recently published 3-year outcomes of Teen-LABS, a prospective observational study of 242 adolescents, and 2 long-term (>7 yr) outcome studies, provide enough data to

Mortality data from adult studies

It is important to recognize that MBS has been shown, in adults, to decrease all-cause mortality compared with weight-matched controls [190]. The Swedish obesity patients were followed for 16 years in a study that enrolled>2000 MBS patients and>2000 case-matched controls. This study showed patients who underwent MBS had a hazard ratio of .76 for mortality compared with controls. Another group from McGill looked at 1000 surgery patients and 5000 case-matched controls. They found a sustained 67%

Discussion

This update of the 2012 guidelines represents a major shift in philosophy with the significant milestones made in the current understanding of obesity. The disease of obesity has become recognized as a metabolic disease controlled by genetic factors, with clear evidence that the physiologic control of weight is through neuroendocrine pathways that regulate body mass by affecting satiety, hunger, and metabolism. The recognition that weight is largely not under volitional control leads to a

Conclusions

Children who suffer from obesity are at a significant disadvantage if they are denied MBS. MBS is clearly one of the main obesity treatment modalities with the best-sustained weight loss and control of obesity-related co-morbidities. Data support the use of MBS in adolescents with severe obesity; either the VSG or the RYGB should be considered for adolescents with a BMI>35 or>120% of the 95th percentile and a co-morbidity or with a BMI>40 or>140% of the 95th percentile. Prior weight loss

Disclosures

T.I. is a consultant for Standard Bariatric. S.M. is a speaker for Gore and Mederi therapeutics. The remaining authors have no commercial associations that might be a conflict of interest in relation to this article.

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Cited by (314)

Sleeve gastrectomy for the treatment of adolescent obesity in children aged 13 and under: a retrospective study
2024, Surgery for Obesity and Related Diseases
Sleeve gastrectomy (SG) induces weight reduction and improves metabolic co-morbidities in children with severe obesity but remains underutilized, especially for young adolescents and preadolescents.
We hypothesized there would be no differences in weight loss or co-morbidity resolution at 1 year post-SG in children who underwent SG at 13 years or younger compared to children who underwent SG at 17–18 years old.
Academic medical center, United States.
Medical records of children who underwent laparoscopic SG at a quaternary academic center from September 2014 to October 2022 were reviewed. A cohort of 15 patients, ≤13 years of age, was compared to a matched cohort of 15 older adolescent patients. Preoperative characteristics and postoperative outcomes were collected.
Both cohorts had similar baseline characteristics. Median preoperative body mass index (BMI) was 51.8 kg/m² for the ≤13 cohort compared to 50.9 kg/m² in the older cohort (P = .87). Time to postoperative enteral feeds and length of stay were similar between both groups, and there were no 30-day readmissions or immediate postoperative complications. Median percentage excess BMI loss at 1 year postoperation was 54% (IQR, 25.5%–94.5%) for the ≤13 cohort compared with 44% (IQR, 34.0%–51.0%) for the older cohort (P = .34). Two of 11 patients were lost to follow-up in the younger group compared to 4 of 15 in the older group (P = .61). Both groups demonstrated significant improvement in metabolic syndrome co-morbidities after SG.
SG in younger children is associated with successful postsurgical outcomes compared with adolescents, with effective weight loss and improvement of obesity-related metabolic co-morbidities.
Bariatric surgery, through beneficial effects on underlying mechanisms, improves cardiorenal and liver metabolic risk over an average of ten years of observation: A longitudinal and a case-control study
2024, Metabolism: Clinical and Experimental
Bariatric surgery has long-term beneficial effects on body weight and metabolic status, but there is an apparent lack of comprehensive cardiometabolic, renal, liver, and metabolomic/lipidomic panels, whereas the underlying mechanisms driving the observed postoperative ameliorations are still poorly investigated. We aimed to study the long-term effects of bariatric surgery on metabolic profile, cardiorenal and liver outcomes in association with underlying postoperative gut hormone adaptations.
28 individuals who underwent bariatric surgery [17 sleeve gastrectomy (SG), 11 Roux-en-Y gastric bypass (RYGB)] were followed up 3, 6 and 12 and at 10 years following surgery. Participants at 10 years were cross-sectionally compared with an age-, sex- and adiposity-matched group of non-operated individuals (n = 9) and an age-matched pilot group of normal-weight individuals (n = 4).
There were durable effects of surgery on body weight and composition, with an increase of lean mass percentage persisting despite some weight regain 10 years postoperatively. The improvements in metabolic and lipoprotein profiles, cardiometabolic risk markers, echocardiographic and cardiorenal outcomes persisted over the ten-year observation period. The robust improvements in insulin resistance, adipokines, activin/follistatin components and postprandial gastrointestinal peptide levels persisted 10 years postoperatively. These effects were largely independent of surgery type, except for a lasting reduction of ghrelin in the SG subgroup, and more pronounced increases in proglucagon products, mainly glicentin and oxyntomodulin, and in the cardiovascular risk marker Trimethylamine-N-oxide (TMAO) within the RYGB subgroup. Despite similar demographic and clinical features, participants 10 years after surgery showed a more favorable metabolic profile compared with the control group, in conjunction with a dramatic increase of postprandial proglucagon product secretion.
We demonstrate that cardiorenal and metabolic benefits of bariatric surgery remain robust and largely unchanged ten years postoperatively and are associated with durable effects on gastrointestinal- muscle- and adipose tissue-secreted hormones.
ClinicalTrials.gov: NCT04170010.
Regional Variations in Pediatric Metabolic and Bariatric Surgeon Availability: A Call for Action
2024, Journal of Surgical Research
Obesity is a significant public health concern in children. The American Academy of Pediatrics recommends the use of metabolic and bariatric surgery (MBS) in children with severe obesity, however; MBS remains underutilized in part due to lack of access. This study aims to characterize the prevalence of pediatric obesity and compare this to regional pediatric MBS provider availability.
State-specific prevalence rates of childhood obesity in children aged 10-17 were obtained from the National Survey of Children's Health. The member directory provided by the American Society for Metabolic and Bariatric Surgeons was used to identify all pediatric MBS providers and used to calculate the prevalence of MBS providers by state.
The five states with the highest prevalence rates of childhood obesity were Kentucky, Mississippi, Louisiana, West Virginia, and Alabama. The five states with the highest prevalence (per 100,000 children with obesity) of MBS providers doing pediatric cases were North Dakota, New Jersey, Kansas, New York, and Utah. Notably, there was a negative correlation between the states with the lowest prevalence of pediatric MBS providers and states with the highest prevalence of childhood obesity (r −0.40, ∗P = 0.002).
Our study demonstrates significant state-to-state variation in the prevalence of pediatric obesity and MBS provider availability by state as a proxy for access to surgical care for pediatric obesity. Further work to establish accessible multidisciplinary pediatric weight loss centers is needed to ensure that children and adolescents with obesity receive thorough evaluation and have access to MBS.
Mental health from 5 years before to 10 years after bariatric surgery in adolescents with severe obesity: a Swedish nationwide cohort study with matched population controls
2024, The Lancet Child and Adolescent Health
The long-term effects of bariatric surgery on the mental health of adolescents with severe obesity remain uncertain. We aimed to describe the prevalence of psychiatric health-care visits and filled prescription psychiatric drugs among adolescents with severe obesity undergoing bariatric surgery in the 5 years preceding surgery and throughout the first 10 years after surgery, and to draw comparisons with matched adolescents in the general population.
Adolescents with severe obesity and who underwent bariatric surgery were identified through the Scandinavian Obesity Surgery Registry. We included adolescents who had bariatric surgery between 2007 and 2017 and were younger than 21 years at time of surgery. Each adolescent patient was matched with ten adolescents from the general population by age, sex, and county of residence. Specialist psychiatric care and filled psychiatric prescriptions were retrieved from nationwide data registers.
1554 adolescents (<21 years) with severe obesity underwent bariatric surgery between 2007 and 2017, 1169 (75%) of whom were female. At time of surgery, the mean age was 19·0 years [SD 1·0], and the mean BMI was 43·7 kg/m² (SD 5·5). 15 540 adolescents from the general population were matched with adolescents in the surgery group. 5 years before the matched index date, 95 (6·2%) of 1535 surgery patients and 370 (2·5%) of 14 643 matched adolescents had a psychiatric health-care visit (prevalence difference 3·7%; 95% CI 2·4–4·9), whereas 127 (9·8%) of 1295 surgery patients and 445 (3·6%) of 12 211 matched adolescents filled a psychiatric drug prescription (prevalence difference 6·2%; 95% CI 4·5–7·8). The year before the matched index date, 208 (13·4%) of 1551 surgery patients and 844 (5·5%) of 15 308 matched adolescents had a psychiatric health-care visit (prevalence difference 7·9%; 95% CI 6·2–9·6), whereas 319 (20·6%) of 1551 surgery patients and 1306 (8·5%) of 15 308 matched adolescents filled a psychiatric drug prescription (prevalence difference 12·0%; 10·0–14·1). The prevalence difference in psychiatric health-care visits peaked 9 years after the matched index date (12·0%; 95% CI 9·0–14·9), when 119 (17·6%) of 675 surgery patients and 377 (5·7%) of 6669 matched adolescents had a psychiatric health-care visit. The prevalence difference in filled psychiatric drug prescription was highest 10 years after the matched index date (20·4%; 15·9–24·9), when 171 (36·5%) of 469 surgery patients and 739 (16·0%) of 4607 matched adolescents filled a psychiatric drug prescription. The year before the matched index date, 19 (1·2%) of 1551 surgery patients and 155 (1·0%) of 15304 matched adolescents had a health-care visit associated with a substance use disorder diagnosis (mean difference 0·2%, 95% CI –0·4 to 0·8). 10 years after the matched index date, the prevalence difference had increased to 4·3% (95% CI 2·3–6·4), when 24 (5·1%) of 467 surgery patients and 37 (0·8%) of 4582 matched adolescents had a health-care visit associated with a substance use disorder diagnosis.
Psychiatric diagnoses and psychiatric drug prescriptions were more common among adolescents with severe obesity who would later undergo bariatric surgery than among matched adolescents from the general population. Both groups showed an increase in prevalence in psychiatric diagnoses and psychiatric drug prescriptions leading up to the time of surgery, but the rate of increase in the prevalence was higher among adolescents with severe obesity than among matched adolescents. With the exception of health-care visits for substance use disorders, these prevalence trajectories continued in the 10 years of follow-up. Realistic expectations regarding mental health outcomes should be set preoperatively.
Swedish Research Council, Swedish Research Council for Health, Working Life and Welfare.
Comment on: Infrequent but serious? Thiamine deficiency among adolescents and young adults after bariatric surgery
2024, Surgery for Obesity and Related Diseases
Infrequent but serious? Beriberi And Thiamine deficiency among adolescents and young adults after bariatric surgery
2024, Surgery for Obesity and Related Diseases
Thiamine deficiency (TD) among adolescents following metabolic and bariatric surgery (MBS) has not been assessed.
We assessed TD among adolescents following MBS.
University Hospital.
A retrospective chart review was conducted for all adolescents and young adults (aged 10–25 years) who had MBS and subsequently presented with TD at our institution (n = 30). Diagnosis used clinical, laboratory, brain imaging, and neurophysiology criteria. Of 1575 patients, 7 subsequently had TD. Another 23 adolescents had MBS at private hospitals or overseas and presented at our institution with TD.
Based on MBS undertaken at our institution, TD prevalence was .45 cases per 100 MBS. The mean age of patients was 19.5 ± 3.23 years, 53.3% were male, 96.7% had sleeve gastrectomy, and time from MBS to admission averaged 4.97 ± 11.94 months. Mean weight loss from surgery to admission was 33.68 ± 10.90 kg. Associated factors included poor oral intake (90%), nausea and vomiting (80%), and noncompliance with multivitamins (71%). Signs and symptoms included generalized weakness, nystagmus, numbness, and paraparesis (83.3%–80%). Seven patients had Wernicke encephalopathy full triad; 16 displayed a mixed picture of Wernicke encephalopathy and dry beriberi; and there were no cases of wet beriberi. Half the patients achieved complete resolution of symptoms, whereas 47% and 40% had residual weakness or persistent sensory symptoms, respectively. There was no mortality. Most common concurrent nutritional deficiencies were of vitamins K, D, and A.
This is the first in-depth study of TD among adolescents after MBS. Although TD is uncommon among adolescents after MBS, it is serious, requiring diligent suspicion and prompt treatment. Bariatric teams should emphasize compliance with multivitamin regimens and follow it up.

View all citing articles on Scopus

^☆: This manuscript was created by a subset of the Pediatric committee of the ASMBS with support of relevant additional experts where needed. It was reviewed and approved by the ASMBS Pediatric, Clinical Issues and Executive Committees as well as the general ASMBS membership before publication. It was also endorsed by the Society of American Gastrointestinal and Endoscopic Surgeons, SAGES.

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Review articleASMBS pediatric metabolic and bariatric surgery guidelines, 2018☆

Abstract

Section snippets

Methods and procedures

Cardiovascular disease

Patient selection

Types of metabolic and bariatric surgery

Mortality data from adult studies

Discussion

Conclusions

Disclosures

Med Clin North Am

J Pediatr Nurs

Lancet Diabetes Endocrinol

Surg Obes Relat Dis

Surg Obes Relat Dis

J Am Cardiol

J Pediatr Surg

Lancet Diabetes Endocrinol

Lancet

J Diabetes Complications

Semin Pediatr Surg

J Pediatr Surg

Sleep Med Rev

Sleep Med Rev

Surg Obes Relat Dis

Gastroenterology

J Pediatr

Surg Obes Relat Dis

J Pediatr Surg

Int J Surg Case Rep

Orthop Clin North Am

Surg Obes Relat Dis

J Pediatr Surg

Surg Obes Relat Dis

Severe obesity in children and adolescents: identification, associated health risks, and treatment approaches: a scientific statement from the American Heart Association

Circulation

The stigma of obesity: a review and update

Obesity (Silver Spring)

The mixed impact of medical school on medical students' implicit and explicit weight bias

Med Educ

Health consequences of weight stigma: implications for obesity prevention and treatment

Curr Obes Rep

Obesity stigma reduction in medical students

Int J Obes Relat Metab Disord

An obesity educational intervention for medical students addressing weight bias and communication skills using standardized patients

BMC Med Educ

Bariatric surgery for obese children and adolescents: a systematic review and meta-analysis

Obes Rev

Bariatric surgery in morbidly obese adolescents: a systematic review and meta-analysis

Obes Surg

Long-term (7 years) follow-up of Roux-en-Y gastric bypass on obese adolescent patients (<18 years)

Obes Facts

Cost-effectiveness of bariatric surgery in adolescents with obesity

JAMA Surg

Systematic review of psychological and social outcomes of adolescents undergoing bariatric surgery, and predictors of success

Clin Obes

Weight loss and health status 3 years after bariatric surgery in adolescents

N Engl J Med

Inpatient treatment of children and adolescents with severe obesity in the Netherlands: a randomized clinical trial

JAMA Pediatr

Weight loss maintenance: a hard nut to crack

JAMA Pediatr

Systematic review and meta-analysis of bariatric surgery for pediatric obesity

Ann Surg

Stability of relative weight category and cardiometabolic risk factors among moderately and severely obese middle school youth

Obesity (Silver Spring)

Response of severely obese children and adolescents to behavioral treatment

Arch Mediatr Adoesc Med

Body-mass index in 2.3 million adolescents and cardiovascular death in adulthood

N Engl J Med

Obesity and cardiovascular disease: pathophysiology, evaluation, and effect of weight loss: an update of the 1997 American Heart Association Scientific Statement on Obesity and Heart Disease from the Obesity Committee of the Council on Nutrition, Physical Activity, and Metabolism

Circulation

Effects of bariatric surgery on cardiac structure and function: a systematic review and meta-analysis

Am J Hypertens

Early metabolic improvement following bariatric surgery in morbidly obese adolescents

Pediatr Blood Cancer

Reversal of type 2 diabetes mellitus and improvements in cardiovascular risk factors after surgical weight loss in adolescents

Pediatrics

Perioperative outcomes of adolescents undergoing bariatric surgery: the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study

Review article
ASMBS pediatric metabolic and bariatric surgery guidelines, 2018☆