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SPA Newsletter.
By Thomas J. Mancuso, MD, FAAP Bariatric surgery for severely overweight adolescents: concerns and recommendations.
Bariatric surgery in adolescents: For treatment failures of health care failures?
Surgery for severely obese adolescents; Further insights for the American Society for Bariatric Surgery
Bariatric surgery for adolescents: A view from the American Pediatric Surgical Association
The multi-authored (17 pediatricians and surgeon) paper cited first include a review of the surgical procedures as well as the consensus of the authors on issues of patient evaluation and selection, patient consent and parental permission. Also discussed is proper timing of the procedure as well as some discussion of the advantages and disadvantages of various techniques. The immediate postoperative course is mentioned and long term follow-up for the pediatrician and later internist is discussed. The authors state that Bariatric surgery should be reserved only for adolescents who are severely obese and have serious obesity-related complications. Other recommendations include the need for a multi-disciplinary team to evaluate and manage these complex patients. Possible benefits and limitations of the procedure must be fully explained to the adolescent and parents and the procedure should only be performed at centers with not only the expertise in both the technical aspects of the surgery but also the expertise for evaluation and care of the child throughout the process. Dr. Barlow, a pediatric gastroenterologist, elaborates on the first criterion cited by the authors of the first paper, namely that the child must have failed at least six months of organized attempts at weight management. She thoughtfully remarks that the definition of organized weight management and of failure is important and must be specifically addressed. In addition, she notes that such well-organized programs are not available throughout the country. She asks if a 5%-10% reduction in weight is success in adolescents. Dr. Wittgrove, president of the American Society for Bariatric Surgery notes that Bariatric surgery has been offered to adolescents as far back as 50 years ago, at the origin of the surgical procedure. He differs with some of the recommendations in the Inge paper. He emphasizes the importance of an experienced, skilled surgeon (sadly no mention of anesthesiologists or intensivists) and takes exception with some of the inclusion criteria for consideration of a child for Bariatric surgery. He disagrees with several exclusion criteria for the surgery. As an example he states his opinion that the lack of comorbidities is not an important exclusion criteria for surgery since morbidity will come in time to these obese adolescents. He also makes the important point that there should be meticulous data collection on these children across all institutions performing Bariatric surgery so that care can be improved. The comments of Dr. Rodgers, president of the American Pediatric Surgical Association, more fully support the Inge paper. Dr. Rodgers supports the conservative criteria for patient selection and the importance of giving other non-surgical weight control measures a full and complete opportunity to help the adolescent prior to undertaking surgery. Commentary That these papers are all published in one issue of Pediatrics certainly tells us how important the health problem of obesity is in children. The papers, taken together, achieve what I imagine the editors wished to achieve, the topic of Bariatric surgery is thoroughly reviewed by experts with very different perspectives. The more aggressive approach of the Bariatric surgeons is balanced by the more conservative stance of pediatric gastroenterologists and pediatric surgeons. Given the increasing prevalence of obesity in adolescents, Bariatric surgery is going to become more common as time passes. Table of Contents
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