Bariatric surgery--as a last resort when conservative interventions have failed--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 journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.
But because of 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.
Bariatric Surgery in Children--Experts Review the Evidence
The Committee--made up of 12 European specialists in pediatric 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). Weight reduction through lifestyle change and diet is the best treatment for these conditions--however, the long-term results are often disappointing.
This has led to growing interest in bariatric surgery as an alternative for weight reduction in children and adolescents. Although studies are limited, "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," Prof Nobili and colleagues write.
Yet the appropriate use of bariatric surgery in pediatric 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 standardized approach to considering bariatric surgery in children and adolescents.
Statement Recommends Limited Use and Careful Patient Selection
Specifically, the ESPGHAN Hepatology Committee states that bariatric surgery should be limited to two groups of pediatric patients: those with body mass of 35 or higher (severe obesity), with severe NAFLD or other obesity-related medical conditions; and those with body mass index 40 or higher (morbid obesity), and mild medical conditions.
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.
The Committee also addresses the issue of which type of bariatric surgery should be performed. Gastric bypass procedures (especially "Roux-en-Y" gastric bypass) are most commonly used, in pediatric as in adult patients. However, concerns over the complex nutritional deficiencies occurring after these surgical procedures have limited their use in children and adolescents.
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. The same is true for alternative procedures such as laparoscopic adjustable gastric banding and sleeve gastrectomy. All of these approaches should be considered investigational in pediatric patients, according to the new statement.
"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," the Committee concludes. Until formal outcome studies are performed, they propose the "rigorous collection" of data on any and all children and adolescents undergoing any type of weight loss procedure.
By 2050, two-thirds of adults and one-third of adolescents could face obesity in the US