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bariatric paediatric surgery

Surgery can benefit some obese paediatric patients

Considerations other than comorbidities and BMI must remain an important part of medical decision-making for adolescents
Existing data is not sufficient to recommend widespread and general use of weight loss intervention in this patient population

As a last resort when conservative interventions have failed, bariatric surgery can improve liver disease and other obesity-related health problems in severely obese children and adolescents, according to a position paper in the Journal of Pediatric Gastroenterology and Nutrition, official journal of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.

"The associated risk/benefit analysis should obviously also include the consideration of the potential long-term health risks of untreated or inadequately treated obesity for each patient individually.”

Due to the potential for serious complications, an expert panel recommends that bariatric surgery be reserved for carefully selected subgroups of young children with severe or morbid obesity and associated medical conditions. The recommendations appear in a new position paper authored by the ESPGHAN Hepatology Committee, under the leadership of Prof Valerio Nobili of Bambino Gesù Children's Hospital, Rome.

The Committee, made up of 12 European specialists in paediatric liver disease, was tasked with reviewing and analyzing the available evidence on bariatric surgery for obese children and adolescents. The epidemic of childhood obesity has brought an increase in obesity-related diseases, including type 2 diabetes and nonalcoholic fatty liver disease (NAFLD).

"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 diseases, including NAFLD," Nobili and colleagues write.

Yet the appropriate use of bariatric surgery in paediatric patients remains unclear, mainly because of limited research data and the known risks of the procedure. Based on the available evidence and expert opinion, the position paper outlines a standardised approach to considering bariatric surgery in children and adolescents.

Statement recommendations

Specifically, the ESPGHAN Hepatology Committee states that bariatric surgery should be limited to two groups of paediatric patients: those with BMI>35, with severe NAFLD or other obesity-related medical conditions; and those with BMI>40 or higher and mild medical conditions.

"Sleeve gastrectomy, and other types of weight loss surgery, which have gained significant use in adults, should also be considered investigational.”

Several additional factors must be taken into account when considering bariatric surgery, including the patient's physical and psychological maturity, desire to undergo the procedure, previous attempts at weight loss, and ability to comply with follow-up medical care. The position statement outlines the preoperative patient evaluation and procedures for obtaining informed consent.

“Considerations other than comorbidities and BMI must remain an important part of medical decision-making for adolescents. These include, and are not limited to, physical and psychological maturity, treatment and stability of psychological comorbidities, the desire of the patient to have surgery, adequacy of prior weight loss attempts, and firm evidence of ability to comply with follow-up medical care,” the authors note. “Contraindications to adolescent bariatric surgery include a documented substance abuse problem, a medically correctable cause of obesity, and a disability that would impair adherence to postoperative treatment, current pregnancy or breastfeeding. The associated risk/benefit analysis should obviously also include the consideration of the potential long-term health risks of untreated or inadequately treated obesity for each patient individually.”

The Committee also addresses the issue of which type of bariatric surgery should be performed, as well as highlighting concerns over the complex nutritional deficiencies occurring after these surgical procedures have limited their use in children and adolescents.

“RYGB is considered a safe and effective option for extremely obese adolescents, as long as appropriate long-term follow-up is provided. LAGB has not been approved by FDA for use in adolescents, and therefore should be considered investigational only. Sleeve gastrectomy, and other types of weight loss surgery, which have gained significant use in adults, should also be considered investigational.”

The paper states that temporary devices, such as an intragastric balloon, are appealing for use in younger patients, as the effects are fully reversible. However, there are limited data on the use of these procedures in adolescents. It also states that he same is true for alternative procedures such as laparoscopic adjustable gastric banding and sleeve gastrectomy. All of these approaches should be considered investigational in paediatric patients, according to the new statement.

With regards to pre- and post surgical treatmentthe paper states: “Pre- and post-operative therapeutic patient education programmes, involving a new multidisciplinary approach based on patient-centred education, may be useful for increasing patients’ long-term compliance, which is often poor. The role of the general paediatrician also must be emphasized: clinical visits and follow-ups should be monitored and coordinated with the bariatric team, including the surgeon, the obesity specialist, the dietitian and mental health professionals.”

Conlusions

The paper concludes that the existing data is not sufficient to recommend widespread and general use of weight loss intervention in this patient population. “However, the burden of obesity–associated comorbidity such as NASH in selected patients may impact intolerably on the child´s long-term prospects that allows us to agree with a list of exceptional indications... Future studies and a long-term risk analysis of patients with obesity associated liver disease are much needed to clarify the exact indications for bariatric surgery in adolescents; and the multitude and complexity of nutritional deficiencies after these procedures still limit the choice of technique in children and adolescents. We propose the rigorous collection of experiences of any and all weight loss interventions in children until prospective and controlled trials are performed.”

To access this paper, please click here and click on the pdf link on the page

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