COMMENTARY

Is Surgery the Answer to Fatty Liver Disease in Children?

New Guidelines

William F. Balistreri, MD; Valerio Nobili, MD; Stavra A. Xanthakos, MD

Disclosures

March 26, 2015

In This Article

The Problem of NAFLD in Children

William F. Balistreri, MD: I am Dr William Balistreri, professor of pediatrics at Cincinnati Children's Hospital Medical Center. Our discussion today addresses weight-loss surgery in children and adolescents: who, what, where, when, and how?

Morbid obesity is strongly associated with nonalcoholic fatty liver disease (NAFLD), which is rapidly becoming the most common cause of chronic liver disease worldwide. This epidemic is not limited to adults. An increasing number of children and adolescents are affected. In view of the significant adverse health effects of early-onset obesity, aggressive intervention must be considered.

Weight loss through lifestyle change—diet and exercise—is clearly the optimal approach to childhood obesity and related diseases, including type 2 diabetes and NAFLD. However, the potential for long-term success of this challenging strategy is limited.

This has led to a growing interest in bariatric surgery, an accepted and well-established option for adults, as an alternative for weight reduction in children and adolescents. Studies suggest that in carefully selected patients, early intervention using weight-loss surgery can reduce obesity-related comorbid conditions.[1] These studies have demonstrated that bariatric surgery in patients with nonalcoholic steatohepatitis (NASH) can reduce the grade of steatosis, hepatic inflammation, and fibrosis.

Thus, recently released clinical guidelines[2] for the appropriate application of this technology in children and adolescents are greatly welcomed. This new position paper was authored by experts from the Hepatology Committee of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN), under the leadership of Professor Valerio Nobili. Because of the risk/benefit imperative, this committee recommends that bariatric surgery be reserved for carefully selected subgroups of young children with medically complicated obesity.

The guidelines, which are based on the available evidence and expert opinion, outline a standardized approach for considering bariatric surgery in children and adolescents. The committee also addresses the issue of which type of bariatric surgery should be performed: the standard Roux-en-Y gastric bypass; investigational procedures (such as an intragastric balloon); or alternative procedures, such as laparoscopic adjustable gastric banding or sleeve gastrectomy.

We will discuss these aspects of weight-loss surgery in children and adolescents—specifically, who qualifies as a surgical candidate? Can we identify and stratify patients who are most likely to benefit? What is the ideal procedure, and when should we intervene?

I am joined by Valerio Nobili, MD, director of the hepatometabolic unit and chief of liver research at the Bambino Gesù Children's Hospital in Rome, Italy, and Stavra A. Xanthakos, associate professor of pediatrics and medical director of the surgical weight-loss program for teens and the steatohepatitis center here at Cincinnati Children's Hospital Medical Center.

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