Bariatric Surgery in Children

Bariatric surgery is a treatment option for carefully selected severely obese youth for whom all other medical, dietary, and behavioral approaches have been unsuccessful. The history, indications, risks, and benefits of bariatric surgery in children are reviewed briefly, ending with controversies and future directions. The terms children, adolescents, and youth are used interchangeably.

The history of surgical treatment of extreme obesity in children and adolescents dates back to the 1970s, with initial reports appearing in the literature on small series of youth treated with surgery for weight loss, including some with Prader-Willi Syndrome. In 1991, a National Institutes of Health (NIH) consensus development conference recommended that gastric restrictive or bypass procedures could be considered for well-informed and motivated patients with acceptable operative risks, but indicated that children and adolescents had not been sufficiently studied to allow a recommendation for surgery. Since 1991, Roux-en-Y gastric bypass has become the most commonly performed procedure in the United States. However, the published literature on bariatric surgery in children remains scant, and no definitive, evidence-based guidelines exist for youth.

Patient selection begins with a detailed, multidisciplinary assessment, including medical, surgical, nutritional, and psychiatric expertise, ideally conducted in a specialized and experienced program setting. Due to the permanent impact of gastric bypass on gastrointestinal anatomy and lifestyle, presurgical evaluation and education in children is extensive. Eligible patients have attained or nearly attained physiologic maturity, failed more conservative approaches to treatment, and must meet additional eligibility criteria including weight greater than 100 pounds overweight. The family environment plays an important role in postoperative support and compliance, and both parents and child are involved in the process of obtaining informed consent.

The risks and benefits of gastric bypass in children appear to include the same outcomes seen in adults. Rarely seen, but early complications include bowel obstruction, bleeding, blood clots, and persistent nausea. Late problems can include gallstones, hernias, vitamin and iron deficiencies, inadequate weight loss, or weight regain. Potential benefits include improvements in long-term weight control, reduced medical comorbidities such as diabetes, and enhanced psychosocial functioning. Unfortunately, no reliable predictors of outcome have been identified. Lifelong medical and nutritional surveillance is mandatory.

The role of bariatric surgery in the treatment of severe obesity in children remains controversial. Some express concerns over the potential adverse long-term impact on growth and development, and [Page 74]question a child's ability to consent to a procedure that has lifelong effects; others focus on the serious health and psychosocial consequences of childhood obesity that may persist into adulthood in the absence of surgical intervention. Future directions indicate the need for long-term prospective outcome analyses of various bariatric surgery procedures in younger patients, including the role of behavioral weight control as an adjunct for effective longitudinal management of this patient population.