Curr Obes Rep DOI 10.1007/s13679-017-0278-3

HEALTH SERVICES AND PROGRAMS (R WELBOURN, SECTION EDITOR)

Evidence Base for Multidisciplinary Care of Pediatric/Adolescent Bariatric Surgery Patients Mohamed O. Elahmedi 1 & Aayed R. Alqahtani 1

# Springer Science+Business Media, LLC 2017

Abstract Purpose of Review Severe childhood obesity, defined as having a body mass index (BMI) greater than the 99th percentile for age and gender, is rising in most countries and is associated with early morbidity and mortality. Optimal management of the health of the child with obesity requires a multidisciplinary approach that identifies and treats associated derangements. Recent Findings Lifestyle interventions such as diet, exercise, and behavioral therapy for the severely obese pediatric patient are generally not effective. Few centers worldwide offer bariatric surgery for adolescents in a multidisciplinary setting, and we are the only center that offers a multidisciplinary approach that incorporates bariatric surgery for severely obese children and adolescents across all age groups. Summary In this paper, we review up-to-date evidence in this subject including ours, and provide details on the multidisciplinary approach to pediatric obesity that accommodates bariatric surgery for children across all age groups.

Keywords Pediatric . Children and adolescents . Bariatric surgery . Sleeve gastrectomy . Multidisciplinary . Obesity

This article is part of the Topical Collection on Health Services and Programs * Aayed R. Alqahtani [email protected] 1

Department of Surgery, College of Medicine, King Saud University, 1 Baabda, Riyadh 11472, Saudi Arabia

Introduction Overweight and obesity affect one in three children and adolescents in the USA, and an estimated one in 20 has extreme obesity. While recent studies suggest that the overall prevalence of childhood obesity is plateauing, the number of children with extreme obesity is rising steadily [1]. Severe childhood obesity (defined as having a body mass index (BMI) that is greater than the 99th percentile for age and gender, or greater than 120% of the 95th percentile for age and gender) is associated with a host of diseases that are major risk factors for early morbidity and mortality [2–4]. The relationship between pediatric obesity and poor long-term outcomes has been well-documented in many longitudinal studies, such as the Bogalusa Heart Study and national data from several countries around the world [5–9]. Our studies suggest that more than 90% of children and adolescents with severe obesity have type 2 diabetes, hypertension, obstructive sleep apnea, or dyslipidemia, and that half of them have three or more of these comorbidities [10••]. The life of children with severe obesity is seriously impacted, and reports suggest that their quality of life is similar to that of those with cancer [11•]. However, recent evidence suggests that in young age groups, bariatric surgery safely induces significant weight loss and resolution of comorbidities [12••, 13••, 14••, 15••, 16••, 17••].

The Multidisciplinary Approach to Pediatric Obesity Pediatric obesity has a multitude of genetic, endocrine, behavioral, nutritional, and psychological causes and consequences [18, 19]. The numerous medical and psychosocial complications of childhood obesity led to its recognition as a public health priority by many groups and experts [20–25]. Optimal health management of the child with obesity requires a multidisciplinary

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approach that aims to identify and treat associated psychological, nutritional, endocrine, and metabolic derangements [26–28]. The National Institute for Health and Clinical Excellence (NICE) and many other national and international societies recommend that adults and children with obesity be managed through a multidisciplinary approach [24, 25, 29]. It is now agreed that non-surgical lifestyle interventions including diet and exercise counseling and behavioral therapy for the severely obese pediatric patient are not effective [30, 31•]. BMI z-score (a measure of BMI in comparison with a reference population [32]) reduction of at least 0.5 to 0.6 points is suggested to be a reliable estimate of reductions in fat and cardiovascular risk in obese children [33]. Interventional trials in pediatric obesity (not incorporating bariatric surgery) do not meet this target; a meta-analysis of 38 studies published between 1975 and 2010 found that lifestyle interventions had the potential for inducing statistically significant but clinically negligible effects on weight and cardiometabolic parameters. The mean absolute BMI reduction was just above one point. Additionally, lifestyle interventions effected short-term improvements in the lipid profile, blood pressure, and other features of the metabolic syndrome, but these improvements were not apparent in the studies that followed patients for 1 year or more [34].

Bariatric Surgery for Children and Adolescents with Severe Obesity Internationally, few centers provide bariatric surgery services to adolescents [12••, 13••, 14••, 15••, 16••, 35•, 36••, 37•], and no center except ours incorporates bariatric surgery in a standardized multidisciplinary protocol and clinical care pathway [17••] to children younger than 14 years of age [15••]. The view of several expert opinion guidelines is that bariatric surgery should be deferred until patients are at least 13 or 14 years of age [38, 39, 40•]. However, this practice is not backed by any evidence. On the contrary, postponing surgery only prolongs the suffering of those children. Obstructive sleep apnea, prevalent in up to 60% of obese children and adolescents, leads to neurocognitive impairment, poor quality of life, cardiovascular and renal disease, and systemic and pulmonary hypertension [41–50]. Type 2 diabetes rapidly causes hypertension and nephropathy, and reduces overall survival of severely obese children [51]. In fact, one in five adolescents in the Teen-LABS (Teen-Longitudinal Assessment of Bariatric Surgery) study has already developed kidney damage by the time they were enrolled [52]. More than half of the severely obese children and adolescents who underwent LSG in our center were found to have biopsy-proven non-alcoholic steatohepatitis (NASH) at the time of surgery, which was significantly more prevalent in younger children. [53••] All in all, severe childhood obesity leads to organ damage, irreversible

disease, significantly poor quality of life, and earlier mortality [54]. On the other hand, our studies have shown that bariatric surgery is beneficial in children. Contrary to concerns, we documented an improvement in growth of severely obese children after LSG. Children aged 5 to 9 years who underwent LSG gained a mean of 20 cm in height after 5 years from surgery, compared to a mean height gain of 9 cm for a gender-, age-, and height z-score-matched non-surgical control group [15••]. Additionally, our previous studies found that bariatric surgery induces significant and sustained weight loss with resolution of comorbidities and improvement in the quality of life [12••, 13••, 14••, 15••, 16••, 17••, 55••].

The Multidisciplinary Pediatric Bariatric Program Our clinic is a tertiary-level referral center that accepts children and adolescents referred for severe obesity. In our practice, we provide a comprehensive family-based multidisciplinary pediatric obesity management service including bariatric surgery for eligible children and adolescents. Several studies have shown that multidisciplinary obesity interventions are more effective than interventions with a single component [56, 57]. In a study conducted in the UK, it was found that patients who received a two-component intervention lost more weight on average (6% of baseline bodyweight) than those who received a single component intervention (2.3% of baseline bodyweight) [58]. As obesity is polyfactorial, the multidisciplinary approach we undertake targets the behavioral, dietary, and medical processes and incorporates bariatric surgery through a standardized clinical care pathway. We follow specific criteria that we previously elaborated on [17••]. Our multidisciplinary team consists of a pediatric endocrinologist, a bariatric surgeon who performs adult and pediatric bariatric surgery, nutritionists, behavioral therapists, physical therapists, bariatric nurses, and coordinators who counsel each patient and monitor their progress. Every month, we hold a family-focused workshop for new patients and their families where the endocrinologist, the senior nutritionist, the behavioral therapist, and a health educator give talks and host interactive sessions. In the workshop, examples of poor practices, substitutes of common unhealthy choices, hands-on training on preparing healthy meals, and physical education lessons are conducted. Each patient is then regularly seen in the clinic according to their health category. The involvement of each multidisciplinary team member varies according to the category (Table 1). All patients referred to our clinic visit the bariatric nurse to obtain measurements. Children and adolescents with a BMI <85th percentile (category I) and those with a BMI between the 85th and 95th percentile (overweight; category II) receive handouts and are referred to primary care. Patients with obesity (BMI ≥95th percentile; category III) attend the

Curr Obes Rep Table 1

Role of each member in the pediatric bariatric surgery multidisciplinary team

Provider

Activity

Details

Bariatric nurse

Measurements/clinic routine

Role

Anthropometric measurements, vital signs, routine laboratory workup request, clinic routine Clinical Medical record, case report forms, educational Case report forms, file summary, research blood sample, patient picture, booking coordinator workshop, appointments, laboratory workup educational workshop, appointment scheduling, issue routine pre-defined laboratory workup request Nutritionist Nutritional assessment and counseling Assess dietary patterns, preferences. Set family-based nutrition plans, goals, and monitoring Physical therapist Musculoskeletal, activity assessment and Assess musculoskeletal and physical activity; education, develop exercise, counseling and activity plan Behavioral Psychological assessment and counseling Counsel patient and family; structure a cognitive behavioral therapy program, therapist identify behavior issues that might be affecting weight, screen for psychiatric disorders Pediatric Medical assessment Medical assessment, ordering non-routine investigations, pre-operative endocrinologist assessment, medical follow-up Bariatric surgeon Bariatric surgery, surgical follow-up Counsel child and family on bariatric surgery, perform the procedure, postoperative follow-up

educational workshop before enrolment with the multidisciplinary team. They then receive 1- to 3-monthly follow-up with the nutritionist, physical therapist, behavioral therapist, and pediatric endocrinologist in addition to a battery of investigations aimed at detecting causes and consequences of obesity. These patients are then classified as category IV if they

Essential Essential

Essential Optional Optional

Essential Essential

have comorbidities and if their BMI is ≥35 kg−2 (or ≥99th percentile for age and gender). Those in category IV receive monthly follow-up with the whole multidisciplinary team. They are considered for bariatric surgery after 6 months of follow-up, provided that they meet the eligibility criteria described later (Fig. 1).

Multidisciplinary Pediatric BariatricPediatric Multidisciplinary Surgery Program Flowchart Bariatric Surgery Program Flowchart

Referral Referral

No

Referred

Provide educational handouts, web access

Family-focused Educational Workshop

BMI ≥ 95th centile

Bariatric Nurse

Refer to primary care

NSWM NSWM Protocol Protocol

Yes

Weight Management Program Clinical Nutritionist

Bariatric Nurse

Behavioral Therapist

Physical Therapist

Clinical Coordinator

BMI ≥ 40 kg/m2, or ≥ 35 kg/m2 (or ≥ 99th centile) + co-morbidities

Pediatric Endocrinologist

Yes

Consider Bariatric Surgery

B Baarr ii a a tt rr ii cc S Suu rr g ge e rr y y

S Su u rr g g ii cc a all P P rr o o tt o oc co o ll

No

Bariatric Surgery Continue weight management program until surgery

Preoperative workup (Table 2)

Book for surgery

Yes

Review Eligibility, Indications for Bariatric Surgery

Bariatric Surgeon

Last two weeks before surgery date Postoperative Follow-up Bariatric Nurse

Clinical Nutritionist

Behavioral Therapist

Physical Therapist

Clinical Coordinator

Pediatric Endocrinologist

Bariatric Surgeon

Undergo Bariatric Surgery

Ready

Re-interview, Review workup, answer questions

Fig. 1 Flowchart describing the eligibility and the team members of the multidisciplinary pediatric bariatric surgery program employed at the authors’ institution. BMI body mass index

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Multidisciplinary Team Member Roles The following is a description of the role of each multidisciplinary team member in our center. Bariatric Nurses The bariatric nurse is an essential member of the multidisciplinary team. They are trained on using standardized methods to obtain anthropometric measurements and vital signs from patients with severe obesity. The bariatric nurses plot weight, height, BMI, and blood pressure measurements on standardized percentile charts [59, 60]. Additionally, they handle patients with poor functional capacity, and transport bedridden and wheelchair-bound patients through the hospital. A ward nurse with additional training on handling patients with severe obesity is also recommended. Bariatric Coordinators The coordinator is the bridge between the patient, the team, and the hospital, and is thus an essential member. This member is tasked with patient and staff education, organizing the multidisciplinary team meetings, the monthly workshop, and the operating room schedule. Additionally, the bariatric coordinator is tasked with onsite coordination during clinic hours and scheduling patient follow-up visits with the different team members. The coordinators also contact patients who miss a follow-up appointment and reschedule the visit. They also manage the research database of the program and report program statistics. Nutritionist The ultimate goal of any bariatric procedure is to facilitate significant weight loss without compromising protein and micronutrient balance. The nutritionist therefore plays a vital role in prescribing and monitoring adherence to dietary recommendations that are part of the non-surgical weight management program and the pre-operative and postoperative periods. Readily access to nutritionists and periodic laboratory assessments of nutrition parameters may reduce the occurrence of nutrition-related complications and micronutrient deficiencies. In our center, the nutritionist is tasked with providing family-based dietary counseling and communicating potential compliance and nutritional deficiency problems to the multidisciplinary team. Physical Therapist The physical therapist educates the child and their family about important aspects of fitness, exercise, and how they relate to weight control and obesity. They measure body

composition, aerobic capacity, flexibility, and strength and assess baseline fitness and functional capacity levels. Accordingly, an exercise plan is prescribed. Children are monitored on a regular basis, and the exercise plan is modified according to progress. However, general exercise counseling can be tasked to the bariatric coordinator, and children with special needs can be referred to the hospital’s physiotherapy department for extended assessment and care. As such, the physical therapist is a complementary member of the multidisciplinary team. Behavioral Therapist The behavioral therapist is a team member who holds a master’s degree in clinical psychology. They perform pretreatment assessment and provide cognitive behavioral counseling through several family- and child-centered approaches including motivational interviewing, self-monitoring, stimulus control, and goal setting. Additionally, they screen for psychiatric conditions especially eating and mood disorders. However, not all children need formal behavioral therapy. The pediatric endocrinologist and the nutritionist can identify patients who would benefit from being referred to the hospital’s clinical psychologist. Therefore, the behavioral therapist is not an essential member of the multidisciplinary team. Pediatric Endocrinologist The pediatric endocrinologist performs a full assessment looking for potential medical causes and complications of obesity in the child. The endocrinologist is also tasked with initiating and adjusting relevant medical treatment and ordering of special laboratory and radiologic investigations that are not included in the routine investigational workup. The pediatric endocrinologist also oversees the medical weight management program. As part of the bariatric team, the pediatric endocrinologist participates in the pre-operative assessment and postoperative follow-up. They also monitor the micronutrient status and the growth of the children and adolescents under follow-up. Lastly, the endocrinologist also refers the child to other services that are not part of the multidisciplinary team (e.g., pediatric cardiologist, geneticist). Bariatric Surgeon The bariatric surgeon oversees the multidisciplinary team and manages workflow in the clinic. The surgeon does not routinely see all patients who are in the Multidisciplinary Pediatric Bariatric Surgery Program, but only those who meet the eligibility criteria for bariatric surgery. The surgeon assesses and counsels those children and adolescents, operates

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on them, and sees them routinely during the first 6 months after surgery.

children and adolescents including those with Prader-Willi syndrome and severe obstructive sleep apnea. Surgical Technique

Eligibility for Bariatric Surgery All children and adolescents who are referred to our clinic are enrolled into the non-surgical weight management program. Those who fail to lose at least 10% of their baseline bodyweight within 6 months of follow-up in the nonsurgical weight management program, and those with significant, life-threatening obesity-related comorbidities, are considered for bariatric surgery provided that they meet the following criteria: & & & & & & &

BMI > 40kg/m2, or Comorbidity + BMI>35kg/m2, or Comorbidity + BMI> 99th percentile for age and gender Supportive psychological evaluation Dedicated caretaker from the child’s family Motivation, realistic expectations Informed consent or assent with concomitant parental consent for patients aged <17 years Absence of medical and surgical contraindications Children and adolescents with genetic forms of obesity (e.g., Prader-Willi syndrome) are still offered bariatric surgery if they meet the eligibility criteria, unless they have a contraindication for surgery (e.g., heart failure, respiratory compromise)

Perioperative Course Once a child/adolescent is deemed candidate for surgery, the senior pediatric bariatric surgeon counsels them and assesses their readiness. Patients then undergo additional and selective investigations as indicated, including cardiac echocardiography, electrocardiography, dual energy X-ray absorptiometry (DXA) scan, wrist X-ray for bone age, abdominal ultrasound, pelvic ultrasound, and polysomnography. Additionally, any investigation result that is older than 6 months is repeated. Patients continue on the non-surgical weight management program until the final pre-operative visit, which takes place in the last 2 weeks before surgery. In this visit, patients are reinterviewed, their investigational workup is reviewed, and their questions are answered. They are then provided with a pre-printed information brochure regarding surgery, perioperative care, and postoperative commitments. At the patient’s admission for surgery, nurses are provided with a detailed set of pre-typed pre-operative orders for each patient. Patients are admitted on the morning of the surgery or the preceding night depending on hospital policy. Additionally, an intensive care unit bed is routinely booked for high-risk

We offer all types of bariatric procedures including revisional surgery. However, the most frequent procedure that is recommended to all children and adolescents in our institution is laparoscopic sleeve gastrectomy (LSG). For this procedure, patients are positioned in the reverse Trendelenburg French position and a five-trocar approach is used. The abdominal cavity is insufflated with a pressure of 15 mmHg using a 10mm optic port placed at or within a variable distance above the umbilicus based on the patient’s age. Two 5-mm trocars are inserted on the right side, one 5-mm trocar is inserted in the midline few centimeters below the xiphisternum to assist in liver retraction, and one 12-mm trocar is inserted on the left side. A nasogastric tube is inserted to deflate the stomach. The greater curvature is then freed close to the gastric wall, beginning from approximately 2 cm proximal to the pylorus and extending to the angle of His using a LigaSure™ (Covidien, Medtronic, USA) or ENSEAL™ (Ethicon, Johnson & Johnson, USA) device. The left crus is then dissected and the angle of His is delineated. Posterior adhesions to the pancreas are lysed. A 36-Fr calibrating tube 34-Fr for patients below the age of 12) is placed transorally and carefully advanced through the pylorus to the duodenum. At 2–3 cm from the pylorus, the stomach is divided using a linear stapler (Echelon 60™). A green load (4.1 mm) followed by gold (3.8 mm) and blue loads (3.5 mm) are used for all patients except for those younger than 12 years with thinner stomachs, where only gold and blue loads are used. There is no routine staple line reinforcement or routine testing for leak or drain placement. The left 12-mm port is slightly enlarged using a Kelly clamp. The resected stomach is extracted through this port site, and the site is closed using the Endo Close device (US Surgical™). Wound sites are sutured and patients are extubated while awake. Children and adolescents with prebooked ICU beds are sent to the ICU depending on their breathing effort and oxygenation during and after extubation. Postoperative Care Patients are encouraged to ambulate once they are fully awake, vitally stable, and back in the ward. In the evening of the day of surgery, and upon ambulation, they are asked to start sips of water. The multidisciplinary team visits patients during the first postoperative day, providing the patients and their families with specific instructions and guidance as per protocol [57]. Patients are evaluated at the end of this day, and depending on toleration of oral intake, patients are discharged with home instructions and long-term follow-up schedule (Table 2).

Curr Obes Rep Table 2 surgery

The multidisciplinary perioperative care protocol and clinical care pathway for severely obese children and adolescents undergoing bariatric

Perioperative management

Medical consultation

Pre-operative

Operative

Postoperative

Pre-admission within the last Admission day 1 (or 2 weeks before surgery morning of surgery)

Surgery day 0

Post-surgery day 1

MDT: endocrinologist (pediatrician), surgeon, dietician, behavioral therapist (if indicated), physical therapist, coordinator review all clinical and workup data; test patient knowledge. Diagnostics/procedures/orders Lab tests Routine: CBC, U&E, coagulation profile, blood group, LFT, lipid profile, FPG, HbA1C, TFT, urine analysis, uric acid, ferritin Optional: OGTT, fasting insulin, C-peptide, PTH, ACTH, cortisol, LH, FSH, prolactin (girls >12), iron, TIBC, transferrin, folate, pre-albumin, VitD [25], vitamins B1 (whole blood, serum) B6, B12, copper, phosphorous, zinc, magnesium, CRP. Imaging: Routine: Abdominal U/S, pelvic U/S (girls >12) Optional: cardiac echo, ECG, DXA scan, bone age (hand X-ray), CXR Special tests: Polysomnography (as indicated by history or exam), genetic study (FISH, DNA methylation test), PFT (selective). Evaluation/nurses’ care Based on the weight management program and the assessment from the multidisciplinary team, evaluate the patient’s suitability for surgery.

Treatment/medication

Patients can be admitted the Surgery team day of surgery or 1 day before

Any procedures per surgeon’s/physician’s order

• Perform planned bariatric procedure as described

MDT

• No routine contrast study. Only in the case of persistent tachycardia or fever

• Encourage ambulation • Ensure oral intake as per protocol • Ensure frequent and adequate incentive spirometry • Review wounds. • Prepare patient for discharge after approval from surgeon or attending physician • Pantoprazole 20–40 mg • Correction of deficiencies • IV NS 500 ml bolus over • Keep NPO • IVF D5 ½ NS (as per 30mins at 7 a.m. such as vitamin D, iron, PO QD for 6 weeks. CBW). • IVF D5 ½ NS infusion (as etc. • Pethidine 0.5–1 mg/kg • Granisetron IV 1 mg per CBW) • Ensure patient meets criteria CBW IM/SC Q6h PRN OD or Ondansetron IV • Pantoprazole IV 20-40 mg for surgery until discharge 4–8 mg Q8h regular (night before surgery) • Talk to the patient if • Regular follow-up with for 24 h • Granisetron IV 1 mg or bariatric surgery is MDT • Pantoprazole IV ondansetron (as advisable • Solpadeine 1–2 tab Q6h 20–40 mg QD. antiemetic) IV 4-8 mg PRN • Review MDT assessments. • Check venous access and lab reports • Review lab work as per • Administer antibiotic protocol, BMI, sleep prophylaxis study, BP chart, cardiac echo, abdominal U/S (no • Administer all necessary medication (according need to repeat all labs if to pre-op orders) done within 6 months) • Ensure DVT prophylaxis

Curr Obes Rep Table 2 (continued) Perioperative management

Pre-operative

Operative

Postoperative

Pre-admission within the last Admission day 1 (or 2 weeks before surgery morning of surgery)

Surgery day 0

Post-surgery day 1

on-call to OR Metoclopramide IV 5-10 mg on-call to OR • Heparin S/C 5000 Units or LMW Heparin 2 h prior to surgery • Cefuroxime IV 1.5 g at induction • TED stockings • Pneumatic Compression.

Nutrition and diet

Activity and safety

Education and information

• Weight loss prior to surgery is not mandatory but highly recommended. • Ensure that the patient and family know about the dietary commitments and have them familiarized with the post-op diet. Pre-operative and postoperative instructions on activity Patient consent; provide booklet on surgical procedures, the risks-benefits of surgery, and the post-op diet and exercise protocols

• Clear fluid diet the day before surgery. • Start NPO at midnight before surgery

• Metoclopramide IV 5–10 mg Q8h PRN • Heparin SC 5000 units BID or LMW heparin • Acetaminophen IV 15 mg/kg CBW Q6h • Pethidine 0.5–1 mg/kg CBW IM/SC Q6h PRN • Cefuroxime IV 750 mg Q8h for 2 doses • Incentive spirometry • Pneumatic compression device. • TED stockings Start 30 cm3 of water • Clear liquids for 3 days • Full liquids for 7 days every 30 min once • Pureed diet for 14 days patient ambulates • Soft foods for 7 days • Regular healthy diet onwards

Frequent ambulation, Ambulate the patient incentive spirometry, within 2 h of arrival to personal hygiene the surgery floor. Education on pain Ensure the patient and their Education on pain management, diet family have received the management, incentive selection/volumes, wound info booklets on the diet, spirometry exercises, care, medication and exercise, the surgical diet discharge plan, physical process and the post-op selections/volumes, activity and follow-up measures. wound care, schedule. First follow-up medication, and in 1 week discharge plan Usual physical activity and personal hygiene.

Reproduced from [17••] MDT multidisciplinary team, CBC complete blood count, U&E urea and electrolytes, LFT liver function test, FPG fasting plasma glucose, TFT thyroid function test, OGTT oral glucose tolerance test, PTH parathyroid hormone, ACTH adrenocorticotropic hormone, LH luteinizing hormone, FSH folliclestimulating hormone, TIBC total iron binding capacity, CRP C-reactive protein, U/S ultrasound, DXA dual-energy X-ray absorptiometry, CXR chest xray, FISH fluorescence in situ hybridization, DNA deoxyribonucleic acid, PFT pulmonary function test, CO2 carbon dioxide, DVT deep vein, NPO no oral intake, IV intravenous, NS normal saline, CBW corrected body weight, OR operating room, S/C subcutaneous, LMW low molecular weight, TED thromboembolism-deterrent, Q8h every 8 h, PRN as required, BID twice daily, Q6h every 6 h, PO orally, QD once daily, Q4–6h every 4 to 6 h, IM intramuscular, SC subcutaneous thrombosis

Follow-up Protocol Patients are informed that follow-up with the multidisciplinary team is lifelong. The first postoperative outpatient visit is within the first 2 weeks after discharge. In this visit, patient wounds are examined, and the postoperative dietary and lifestyle instructions are reviewed. Patients are then seen at 1, 3, and 6 months after surgery, and once a year afterwards. In each visit, anthropometric measurements are taken, a medical assessment is performed, medications and supplements taken are evaluated, and nutritional and fitness counseling is performed. Patients who reach the age of 21 years are seen

separately. We have a unique setup where specific clinic days are set aside for adult patients. In this clinic, the senior surgeon (ARA) and the clinic’s nutritionist follow those patients. Statistics The children and adolescents who underwent bariatric surgery spent an average of 1.6 ± 1.0 years in the non-surgical weight management program before undergoing LSG at our center. Until the time of writing this article, 1359 children and adolescents with obesity were recruited, of whom 673 satisfied our surgery criteria and underwent LSG (Fig. 2). The mean

Curr Obes Rep Fig. 2 Distribution of children and adolescents with severe obesity currently enrolled in the authors’ institution’s multidisciplinary pediatric obesity management program, which includes bariatric surgery as an option for those who fail non-surgical multidisciplinary weight management. NSWM nonsurgical weight management, LSG laparoscopic sleeve gastrectomy

age of those who had surgery was 14.1 ± 4.0 years, and 49% were aged ≤14 years old. At the time of surgery, 121 patients (18%) had type 2 diabetes, 303 (45%) had hypertension, 299 (44.4%) had obstructive sleep apnea, 215 (31.9%) had dyslipidemia, and the prevalence of biopsy-confirmed NASH in a representative sample of 296 children and adolescents was 39.9% [53••]. Children and adolescents who missed a postoperative follow-up visit were contacted by the coordinator. A predetermined set of questions was asked to the children or their parents depending on the age. Additionally, patients were offered a rescheduled visit and travel assistance through the Ministry of Health. Those who could not visit the clinic were instructed to visit their primary care physician and send us a report containing their anthropometric measurements, complaints, results of laboratory workup, and information on comorbidity status. Of 2852 follow-up visits, data on 2559 visits was available. The current follow-up compliance rate at our center is 89.7%. There were 46 patients (6.9%) who defaulted on long-term (post-1-year) follow-up, defined as having missed two or more of the latest scheduled consecutive follow-up visits. A major reason of defaulting on follow-up is city of residence. Forty (87%) of those who defaulted on follow-up live outside Riyadh, where our clinic is located.

Discussion Our experience is that LSG is similarly safe and effective in children, adolescents, and adults. We observed no mortality or significant morbidity in the 673 children and adolescents who have thus far underwent LSG at our center. In 2015, we analyzed outcomes of up to 5 years of followup from 724 children and adolescents, 302 of whom underwent LSG at our center. We aimed to identify whether

there were any valid concerns against offering bariatric surgery to young children with severe obesity [15••]. We divided the cohort according to age at baseline and whether the patient had surgery or stayed in the non-surgical weight management program. We compared several covariates including growth, weight loss, complications, comorbidity resolution, and compliance to follow-up. There was no significant difference in weight loss after LSG comparing children with adolescents who had the procedure. Additionally, comorbidity resolution and complication rates were similar between children and adolescents. Strikingly, the children who underwent LSG demonstrated a significantly higher growth rate compared to those who did not. This led us to conclude that severely obese children who undergo LSG experience an improvement in growth, contrary to the opinion that bariatric surgery may stunt the growth of children. In 2012, we compared the outcomes of LSG in 108 pediatric patients with 114 adults who had the procedure with the same surgeon (ARA). The pediatric arm had a 30-day complication rate of 5.6% with no major complications, while for the adult arm the 30-day complication rate was 7% with three major complications. At the end of 2 years of follow-up, the pediatric patients had a percentage of excess weight loss (%EWL) of 64.9 ± 31.5, and the adults had a %EWL of 69.7 ± 16.9. Additionally, the pediatric patients showed significantly better compliance to follow-up, possibly owing to the fact that the multidisciplinary program in our center is family-based, and stresses on the importance of having a caretaker from the child’s family [13••]. In their study that compared outcomes after Roux-en-Y gastric bypass (RYGB), the Adolescent Morbid Obesity Surgery (AMOS) cohort investigators observed that postoperative weight loss was comparable in adolescents and adults. Mean weight change in the adolescent and adult groups was −32 and −31%, respectively [35•]. The 3-year results from the

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Teen-LABS study, which included patients who had LSG or RYGB, were similar to the AMOS results; mean weight change was −27% [55••]. However, five (6%) adolescents in the AMOS study were reoperated on for internal hernia, which is a known complication of RYGB. For the Teen-LABS study, 27 patients (11.8%) had postoperative complications that were related to the bariatric procedure. Twenty-two (13.7%) were post-RYGB and 7 (7.5%) were post-LSG. Additionally, one adolescent with type 1 diabetes died 3 years after RYGB from complications of a hypoglycemic event. While the TeenLABS study was not powered to detect differences between RYGB and LSG, it appears that LSG yields similar weight loss results to RYGB but with a better safety profile. This is in line with results from adult series [61, 62], and is the reason we prefer LSG for pediatric patients. Based on results from our center, and mounting evidence from elsewhere, we see no justification for denying children access to bariatric surgery. There has been not a single shred of evidence that suggests harm from bariatric surgery in children. On the other hand, the dire consequences of prolonged obesity are well-known. For instance, adults who undergo bariatric surgery after a prolonged period with type 2 diabetes exhibit lower remission rates [63]. Data from the German Bariatric Surgery registry, in which the youngest patient was 12 years old, suggest that the comorbidity resolution rate is higher in adolescents than in adults. Interestingly, this observation held true for every compared comorbidity in that registry [64•]. In our study that identified outcomes in those younger than 14 years of age, we noticed that the remission rates of hypertension, dyslipidemia, and type 2 diabetes were slightly better in younger children [15••]. As for the performance of bariatric surgery in children and adolescents with syndromic forms of obesity, we previously published results on sleeve gastrectomy in patients with Prader-Willi, Bardet-Biedl, Klinefelter and Alström syndromes. Results confirmed that those patients lose significant weight loss and resolution of comorbidities with no mortality or significant morbidity [14••]. Moreover, we closely reviewed our data on 25 children and adolescents with Prader-Willi syndrome. No mortality or excess morbidity after sleeve gastrectomy was observed, and the children had significant weight loss and resolution of comorbidities for the 5 years of study [16••].

Conclusions A multidisciplinary approach to management of obesity is now universally recommended. However, most pediatric guidelines restrict access to bariatric surgery. This is especially true for children who are severely obese and younger than 14 years of age. Evidence continues to demonstrate that children and adolescents across all age groups stand to benefit

from a multidisciplinary program that accommodates bariatric surgery as an option. We believe that young children with severe obesity and life-threatening comorbidities should not be denied bariatric surgery. However, surgery should only be performed in experienced centers and within a multidisciplinary setting in order to ensure optimal outcomes. Compliance with Ethical Standards Conflict of Interest Prof. Alqahtani and Dr. Elahmedi declare no conflicts of interest. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.

References Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance 1.

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enrolled in the German Bariatric Surgery Registry. The paper concluded that sleeve gastrectomy yields similar results in both age groups.