The American Society for Metabolic and Bariatric Surgery Pediatric Committee has updated their evidence-based guidelines initially published in 2012 to reflect the significant increase in data supporting the use of metabolic and bariatric surgery (MBS) in adolescents.
The updated guidelines were published in Surgery for Obesity and Related Disease, and the increase in data since 2012 “strengthens these guidelines from prior reports,” wrote the guideline authors.
The major changes to the guidelines include:
- Vertical sleeve gastrectomy (VSG) has become the most used and most recommended operation in adolescents, but with more extensive long-term data available for Roux-en-Y gastric bypass (RYGB), the use of either RYGB or VSG in adolescents is recommended.
- There are no data showing that preoperative attempts at diet and exercise correlate with success after MBS. Compliance with a multidisciplinary pre-operative program may improve outcomes after MBS, but prior attempts at weight loss should be removed as a barrier to surgery.
- The most up-to-date definitions of childhood obesity are body mass index (BMI) cutoffs of 35 kg/m2 or 120% of the 95th percentile with a co-morbidity, or BMI 440 kg/m2 or 140% of the 95th percentile without a co-morbidity, whichever is lower. Early surgical intervention when the BMI is <45 kg/m2 may allow adolescents to reach a normal weight and avoid lifelong medication therapy and end-organ damage from comorbidities.
- Certain co-morbidities should be considered, such as the psychosocial burden of obesity, orthopedic diseases specific to children, type 2 diabetes, gastroesophageal reflux, and cardiac risk factors. These comorbidities may be an indication for MBS at a younger age and should be considered in children with a lower obesity percentile.
- Prophylactic vitamin B1 for the first 6 months after MBS is recommended, along with education of patients and primary care providers on the signs and symptoms of common deficiencies. Vitamin B deficiencies should also be screened for and treated.
- Unstable family environments, eating disorders, mental illness, and prior trauma should not be considered contraindications for MBS.
Indications and Contraindications for MBS
- Indications for adolescent MBS include:
- BMI ≥35 kg/m2 or 120% of the 95th percentile with clinically significant co-morbid conditions such as obstructive sleep apnea (Apnea-Hypopnea Index [AHI] >5), type 2 diabetes, non-alcoholic steatohepatitis, idiopathic intracranial hypertension, gastroesophageal reflux disease, Blount disease, slipped capital femoral epiphysis, or hypertension, or BMI ≥40 kg/m2 or 140% of the 95th percentile, whichever is lower.
- A multidisciplinary team should examine whether the patient and family have the ability and motivation to adhere to pre- and post-operative treatment recommendations, which includes consistent use of micronutrient supplements.
- Contraindications for adolescent MBS include:
- A medically correctable cause for obesity
- An ongoing substance abuse issue within the preceding year
- A medical, cognitive, psychiatric, or psychosocial condition that may prevent adherence to post-operative medication and dietary regimen recommendations
- Planned or current pregnancy within 12 to 18 months of the procedure
“MBS is clearly one of the main obesity treatment modalities with the best-sustained weight loss and control of obesity-related co-morbidities,” wrote the guideline authors.
Pratt JSA, Browne A, Browne NT, et al. ASMBS pediatric metabolic and bariatric surgery guidelines, 2018. Surg Obes Relat Dis. 2018;14(7):882-901.