New Guidelines Address Bariatric Surgery in Children

Miriam E. Tucker

January 19, 2015

Bariatric surgery should be considered as an option in carefully selected obese children and adolescents, according to a new position statement from the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

The position statement was published online January 15 in the Journal of Pediatric Gastroenterology and Nutrition by a 12-member pediatric hepatologist panel chaired by Valerio Nobili, MD, professor and chief of the Hepatometabolic Unit and head of the Laboratory of Liver Diseases at the Bambino Gesù Hospital in Rome, Italy.

The group advises consideration of bariatric surgery in "carefully selected" patients with body mass indexes of greater than 40 kg/m2 who have severe comorbidities such as nonalcoholic fatty liver disease (NAFLD), or in those with a body mass index of greater than 50 kg/m2 who have milder comorbidities.

This is the first guideline on the use of bariatric surgery in youth since the 2012 joint document from the National Association of Children's Hospitals and Related Institutions and the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition addressed the nutritional needs of adolescents undergoing the procedure ( J Pediatr Gastroenterol Nutr. 2012;54:125-135).

"The aim of this position paper is to outline current indications and limitations in this controversial field of therapy and to define a standardized approach for extremely affected adolescents with complications such as NAFLD. Despite only limited evidence for bariatric interventions, the authors aim to provide guidance for clinical scenarios of complicated obesity in the presence of advanced NAFLD and other comorbidities when all established therapy has failed," the authors write.

The authors point out that although lifestyle intervention and diet are the mainstays of current medical management of obesity and its medical complications, long term-results are "often disappointing," and recent evidence suggests that "in carefully selected patients an early intervention by bariatric surgery can strongly reduce the risk of adulthood obesity and obesity-related conditions," including NAFLD, type 2 diabetes, and sleep apnea.

Additional factors to consider in deciding whether a child or adolescent should undergo bariatric surgery include physical and psychological maturity, personal desire to undergo the procedure, previous attempts at weight loss, and ability to adhere to follow-up care.

The position statement also includes recommendations for preoperative evaluation and for obtaining informed consent from families.

The Roux-en-Y gastric bypass, laparoscopic adjustable gastric band, and sleeve gastrectomy are the most widely used procedures in pediatric obesity, but their use is associated with subsequent nutritional deficiencies. Temporary intragastric devices could represent a better option for initial treatment in pediatric populations, Dr Nobili and colleagues write.

The position statement gives no age threshold. Dr Nobili told Medscape Medical News that he personally believes children aged 10 years and older could benefit, and even rare exceptions could be made for younger children with extremes of body mass index or comorbidities.

Dr Nobili said the European panel intended the recommendations to be helpful to physicians in the United States, where "despite the relative effectiveness of bariatric surgery for the treatment of severe obesity and its associated comorbidities, too few patients are eligible owing to lack of insurance coverage and relatively stringent eligibility criteria....We tried to write 'eligibility criteria' which could be used by all pediatricians who care for these patients."

Because of rapid evolution in the field, the panel intends to revise the guidelines in 2 years, Dr Nobili told Medscape Medical News.

The authors have disclosed no relevant financial relationships.

J Pediatr Gastroenterol Nutr. Published online January 15, 2015. Abstract

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