Pediatric Metabolic and Bariatric Surgery: Evidence, Barriers, and Best Practices

Severe obesity among youth is an “epidemic within an epidemic” and portends a shortened life expectancy for today’s children compared with those of their parents’ generation. Severe obesity has outpaced less severe forms of childhood obesity in prevalence, and it disproportionately affects adolescents. Emerging evidence has linked severe obesity to the development and progression of multiple comorbid states, including increased cardiometabolic risk resulting in end-organ damage in adulthood. Lifestyle modification treatment has achieved moderate short-term success among young children and those with less severe forms of obesity, but no studies to date demonstrate significant and durable weight loss among youth with severe obesity.

Metabolic and bariatric surgery has emerged as an important treatment for adults with severe obesity and, more recently, has been shown to be a safe and effective strategy for groups of youth with severe obesity. However, current data suggest that youth with severe obesity may not have adequate access to metabolic and bariatric surgery, especially among underserved populations. This report outlines the current evidence regarding adolescent bariatric surgery, provides recommendations for practitioners and policy makers, and serves as a companion to an accompanying technical report, “Metabolic and Bariatric Surgery for Pediatric Patients With Severe Obesity,” which provides details and supporting evidence.

This policy statement uses the term “pediatric” in reference to a person under 18 years of age. The term “adolescent” may be defined differently in various studies and clinical settings on the basis of age or developmental stage. When making specific recommendations, this policy statement uses “adolescent” to refer to a person from age 13 years to age 18 years. “Severe” obesity (class 2 obesity or higher) is defined as having a BMI ≥35 or ≥120% of the 95th percentile for age and sex.1 Recent data from the NHANES (2014–2016) report the prevalence of severe obesity in youth at 7.9% overall, 9.7% in 12- to 15-year-olds, and 14% in 16- to 19-year-olds. These numbers represent a near doubling since 1999 and equate to 4.5 million children in the United States affected by severe obesity.2 These children are at high risk for developing chronic and progressive diseases, including hypertension, dyslipidemia, obstructive sleep apnea, polycystic ovarian syndrome, type 2 diabetes mellitus, fatty liver disease, bone and joint dysfunction, depression, social isolation, and poor quality of life.37

Roux-en-Y gastric bypass (RYGB) is often referred to as the gold standard for surgical management of severe obesity in adults8,9 and adolescents7 and is performed by using minimally invasive, laparoscopic surgical techniques. RYGB results in significant weight loss as a result of its effects on appetite, satiety, and regulation of energy balance.9

Vertical sleeve gastrectomy (VSG) leads to weight loss through similar effects on appetite, satiety, and regulation of energy balance and may reduce appetite through delayed gastric emptying and altered neurohormonal feedback mechanisms.10 VSG is the most common bariatric procedure performed in adults and is becoming more common among adolescents.11,12

Laparoscopic adjustable gastric band (LAGB), a reversible procedure that accounted for approximately one-third of all bariatric operations in the United States a decade ago,12 has experienced a significant decline in use among adults because of limited long-term effectiveness and higher-than-expected complication rates.13,14 Disappointing outcomes in the context of few prospective studies in the pediatric population have resulted in a similar decline in use of LAGB among adolescents.11 At present, LAGB is limited by the US Food and Drug Administration to people 18 years or older.

Pediatrics : Pediatric Metabolic and Bariatric Surgery: Evidence, Barriers, and Best Practices