Current Guidelines for Weight Loss Surgery in Adolescents
Seven clinical practice guidelines met the inclusion criteria. All but one of the guidelines reviewed were issued by a professional organization or government agency ( Table ). Four of the guidelines reviewed related exclusively to weight loss surgery (Michalsky, Reichard, Inge, Pratt, & Lenders, 2012; Pratt et al., 2009; Society of American Gastrointestinal and Endoscopic Surgeons [SAGES], 2008; Yermilov, McGory, Shekelle, Ko, & Maggard, 2009). The other three were general obesity management guidelines that include sections or statements regarding weight loss surgery in adolescents (August et al., 2008; Barlow, 2007; Institute for Clinical Systems Improvement [ICSI], 2011). Two of the guidelines were published by surgical societies, the American Society for Metabolic and Bariatric Surgery (ASMBS) and the Society of American Gastrointestinal and Endoscopic Surgeons (Michalsky et al., 2012; SAGES, 2008). The Endocrine Society was the only expert committee that appears not to include a surgical representative (August et al., 2008). Each of the guidelines reports an extensive review of relevant literature and grading of the available evidence. When available, the level of evidence for specific recommendations was analyzed.
Age appropriateness criteria for surgical candidacy had some minor variation across the guidelines. The ASMBS and SAGES guidelines were the only guidelines with specified selection criteria that do not define adolescence (Michalsky, 2012; SAGES, 2008). Yermilov at al. (2009) define adolescents as ages 12 to 18 years old. One guideline defines adolescence as Tanner stage IV or V and near or at adult height (August et al., 2008), whereas others use physical maturity as the minimal age criterion but do not define it beyond stating it is generally at least 15 for boys and 13 for girls (Barlow, 2007). Skeletal maturity was recommended as the minimal age criterion by several studies (ICSI, 2011; Pratt et al., 2009). The Betsy Lehman Center for Patient Safety and Medical Error Reduction (Lehman Center) guidelines recommend documenting 95% of adult stature with radiography and conclude that this practice will typically limit surgical candidates to those older than 12 years (Pratt et al., 2009).
The evidence for minimum age of eligibility and physical maturity for weight loss surgery was limited by the lack of high-quality studies such as randomized controlled trials (August et al., 2008; Pratt et al., 2009; SAGES, 2008). The criteria appear to have been developed from expert opinion and retrospective cohort studies (Pratt et al., 2009; SAGES, 2008). The general consensus is that adolescents need to have achieved nearly full physical maturity to be considered appropriate candidates for weight loss surgery.
Consistent guidance is lacking about whether, and to what severity, comorbidities must be present to determine appropriate candidacy for adolescent weight loss surgery. The strength of the evidence for BMI parameters is based primarily on expert opinion and retrospective cohort studies as the basis for the guidelines (Pratt et al., 2009; SAGES, 2008). BMI parameters are specified in all of the included studies with some variations, primarily related to the requirement for comorbidities. A BMI greater than 50 kg/m is recommended for consideration for weight loss surgery (August et al., 2008; Barlow, 2007), whereas other guidelines recommend consideration for surgery at a BMI greater than 40 kg/m, regardless of whether comorbidities are present (ICSI, 2011; SAGES, 2008). The Endocrine Society (August et al., 2008) and Yermilov et al. (2009) report that adolescents with BMI scores greater than 40 kg/m are appropriate candidates for weight loss surgery only when significant or severe comorbidities are present. The ASMBS, Expert Committee, and the Lehman Center guidelines also use 40 kg/m with comorbidities as eligibility criteria but do not specify that the comorbidities must be moderate to severe at this BMI level (Barlow, 2007; Michalsky, 2012; Pratt et al., 2009). Additionally, the guidelines provided by ASMBS, ICSI, Lehman Center, SAGES, and Yermilov et al. (2009) deem adolescents with BMI scores greater than 35 kg/m and severe comorbidities as possible candidates (ICSI, 2011; Pratt et al., 2009; SAGES, 2008). The SAGES guidelines specify that comorbidities should be present but do not need to be severe to justify weight loss surgery (SAGES, 2008). Comorbidities considered include type II diabetes, obstructive sleep apnea, pseudotumor cerebri, nonalcoholic fatty liver/steatohepatitis, dyslipidemia, and impaired quality of life (Michalsky, 2012; Pratt et al., 2009; Yermilov et al., 2009). According to the ASMBS and Lehman Center guidelines, indicators of metabolic syndrome and cardiovascular disease are deemed weaker indications for weight loss surgery in the adolescent population. Both guidelines provide the same rationale for the distinction. The diagnostic criteria and clinical significance of metabolic syndrome in adolescents are not as well understood as they are in adults (Michalsky, 2012; Pratt et al., 2009). Cardiovascular risk factors attributed to childhood obesity, such as elevated blood and increased skinfold thickness, likely lead to cardiovascular disease in adulthood. However, the short-term sequelae during adolescence are still being substantiated (Michalsky, 2012; Pratt et al., 2009).
Well-conducted cohort studies provided strong evidence for determining exclusion criteria for weight loss surgery in adolescents. Depression was the most commonly considered condition. If depression and other psychopathology are well controlled, four of the guidelines would not exclude these adolescents from possible weight loss surgery (August et al., 2008; Michalsky et al., 2012; Pratt et al., 2009; SAGES, 2008). Two of the guidelines state that disordered eating is not an exclusion criterion if it is under treatment and stable (Michalsky et al., 2012; Pratt et al., 2009). Pregnancy and Prader-Willi syndrome are exclusion criteria (August et. al, 2008), along with untreated endocrinopathies (ICSI, 2011). The Expert Committee (Barlow, 2007) discusses distance from an adolescent bariatric surgery center as a possible exclusion criterion because adolescents need long-term support after weight loss surgery. Overall, few contraindications were identified for adolescents meeting the BMI and comorbidity criteria.
None of the guidelines specifically endorses one procedure for adolescent weight loss surgery. However, validation for the use of certain procedures is provided. Some of the guidelines report the strengths and disadvantages of different types of weight loss surgery.
Roux en Y gastric bypass (RYGB) is the gold standard for weight loss surgery in adults and has been used in adolescents since the 1980s (ICSI, 2011; Rand & Macgregor, 1994), and several adolescent guidelines agree that it is suitable for adolescent weight surgery as well (Michalsky, 2012; Pratt et al., 2009; SAGES, 2008). The RYGB is a restrictive and malabsorptive procedure that can be performed laparoscopically. The stomach is divided to create a small pouch at the proximal end. The jejunal portion of the small intestine is then divided. The distal segment is attached to the newly created pouch, thus bypassing the distal stomach, duodenum, and part of the jejunum, resulting in malabsorption. The proximal segment is anastomosed to a distal portion of the jejunum (SAGES, 2008). Levels of vitamin B12, calcium, vitamin D, iron, and thiamine may become insufficient after RYGB is performed (Pratt et al., 2009), and the importance of long-term follow-up to monitor for nutritional deficiencies is emphasized (Michalsky, 2012; Pratt et al., 2009; SAGES, 2008). The biliopancreatic diversion and duodenal switch, which are restrictive procedures sometimes used in adults, are not favorable for use in the adolescent population because of the risk for significant malabsorption (Michalsky et al., 2012; Pratt et al., 2009).
Adjustable gastric banding (AGB) may be considered in severely obese adolescents in an off-label investigational manner after receiving investigational device exemption from the Food and Drug Administration, because it is not yet approved for use in persons younger than 18 years (Michalsky, 2012; Pratt et al., 2009). Laparoscopic AGB involves placing an inflatable restrictive band below the gastroesophageal junction. The band contains a balloon with tubing connected to a subcutaneous port that is attached to the rectus muscle of the abdomen. The stomach is restricted by filling the band with saline solution injected through the port (SAGES, 2008). The ICSI (2011) reports that AGB has the best short-term safety profile, but a significant need for reoperation exists because of complications, including slipping of the band or problems with the port. Large-scale use of the adjustable gastric band in adolescents is not yet supported (Pratt et al., 2009).
The laparoscopic sleeve gastrectomy, another new restrictive weight loss procedure, is only recommended as investigational in adolescents because of insufficient data (Pratt et al., 2009). Sleeve gastrectomy is the vertical separation of the stomach and excision of the greater curvature and fundus. The lesser curvature is then stapled shut, creating a sleeve (ICSI, 2011).
The evidence for selecting a weight-loss surgical procedure for adolescents is steadily increasing. However, strong definitive evidence about the results of AGB in adolescents is still lacking (Michalsky, 2012). Meta-analysis and multicenter studies on the RYGB have been conducted, and the safety and efficacy of RYGB in adolescents has been shown to be commensurate with outcomes in adults (Michalsky et al., 2012; Pratt et al., 2009). Still, sufficient evidence does not exist even among adults for experts to endorse one type of weight loss procedure as superior; rather, decisions are made on an individual basis, considering both patient and surgeon choice (SAGES, 2008).
Preoperative Recommendations. Most guidelines make recommendations for the preoperative period. Psychiatric evaluation to assess mental stability and maturity is widely recommended (August et al., 2008; ICSI, 2011; Pratt et al., 2009; SAGES, 2008). Ensuring psychosocial well-being and maturity is important to the consent process, as is the assessment of the adolescent's ability to comply with postoperative instructions (Pratt et al., 2009). Some guidelines recommend a thorough preoperative metabolic, nutritional, and vitamin screening (ICSI, 2011; SAGES, 2008). According to SAGES (2008), this screening generally consists of a complete blood cell count, ferritin level, coagulation analysis, metabolic profile, lipid panel, and thyroid function tests. For malabsorptive procedures, SAGES (2008) recommends considering inclusion of levels of fat-soluble vitamins and vitamin B12. ICSI (2011) does not define the general pre–weight loss surgery nutritional and vitamin screen, but it does specify that an albumin level should be checked. ISCI outlines a panel of B vitamins for malabsorptive procedures that includes B12, folic acid, thiamine, and riboflavin (ICSI, 2011).
Adolescents need to preoperatively demonstrate the ability to comply with healthy lifestyle regimens (August et al., 2008; Barlow, 2007; Michalsky et al., 2012; Pratt et al., 2009). The ICSI (2011) guidelines state the ideal surgical candidates are those who have shown successful weight loss with nonsurgical therapy. However, the SAGES (2008) guidelines report that mandated weight loss prior to weight loss surgery does not affect weight loss or reduction in comorbidities.
Counseling in the preoperative period regarding pregnancy is recommended by the two most recent guidelines, with the rationale being that adolescent females' fertility increases as a result of the postoperative weight loss and pregnancy in the first 1 to 2 years after weight loss surgery has risks (Michalsky et al., 2012; Pratt et al., 2009). Pregnancy during the postoperative period of rapid weight loss after bariatric surgery may lead to malnutrition of the mother and fetus (Bebber et al., 2011). Evidence for preoperative counseling regarding pregnancy in adolescents is low level, but clearly the benefits outweigh the risk.
Informed consent for adolescent weight loss surgery is seen across the guidelines as requiring in-depth counseling regarding the risk and benefits and careful assessment of the adolescent's ability to understand them, although some guidelines address concerns about possible parental coercion (Michalsky et al., 2012; Pratt et al., 2009). The ASMBS and Lehman Center guidelines address proper informed consent/assent (Michalsky et al., 2012; Pratt et al., 2009). The ICSI (2011) guidelines recommend a process of shared decision making for weight loss surgery that goes beyond informed consent to explore patient preference, lifestyle, and future ramifications.
Surgical Setting/Care Team. The guidelines are not consistent about the appropriate surgical setting for adolescent weight loss surgery. The Lehman Center and ICSI guidelines recommend that the surgery take place in a high-volume center to ensure adequate surgical experience, because risk likely increases if surgeons and institutions have limited weight loss surgery experience (ICSI, 2011; Pratt et al., 2009). The SAGES (2008) guidelines recommend a specialty center with the necessary adaptations for bariatric patients and their providers. Other guidelines made general recommendations for the surgical setting, such as maintaining databases and being capable of long-term follow-up (August et al., 2008; Barlow, 2007). Evidence for surgical setting recommendations appears to be based largely on case series and expert opinion.
A multidisciplinary approach is widely endorsed and is based on established norms (Barlow, 2007; Michalsky et al. 2012; Pratt et al., 2009; SAGES, 2008). Commonly endorsed team members include the following professionals: experienced bariatric surgeon, coordinator, pediatric specialist, mental health clinician, and registered dietitian (Michalsky et al., 2012; Pratt et al., 2009). According to the ASMBS guidelines, the use of multidisciplinary teams for adult and adolescent weight loss is the prevailing standard of care (Michalsky et al., 2012). The Lehman Center collaborative guidelines do not define "pediatric specialist." The ASMBS guidelines specify that a "pediatric specialist" might be a pediatrician or an internist/family practitioner with adolescent medicine specialty (Michalsky et al., 2012).
Postoperative Recommendations. Postoperative recommendations were less abundant in the guidelines but were based on meta-analysis, case series, and retrospective reviews. Nutritional follow-up for all procedure types and appropriate vitamin supplementation (e.g., calcium, vitamin D, B vitamins, and iron) is emphasized (Barlow, 2007; ICSI, 2011). The Expert Committee also mentions psychological support as part of appropriate long-term follow-up (Barlow, 2007). Two of the guidelines indicate that contraception should be offered to female adolescents (Michalsky et al., 2012; Pratt et al., 2009). The ICSI (2011) guidelines advise close surveillance of patients' medications after weight loss surgery. Chronic medications may not need to be continued as comorbidities resolve, and altered absorption may affect extended-release medications (ICSI, 2011). Dosage adjustments may need to be made as weight loss occurs (ICSI, 2011).
Results
Guideline Characteristics
Seven clinical practice guidelines met the inclusion criteria. All but one of the guidelines reviewed were issued by a professional organization or government agency ( Table ). Four of the guidelines reviewed related exclusively to weight loss surgery (Michalsky, Reichard, Inge, Pratt, & Lenders, 2012; Pratt et al., 2009; Society of American Gastrointestinal and Endoscopic Surgeons [SAGES], 2008; Yermilov, McGory, Shekelle, Ko, & Maggard, 2009). The other three were general obesity management guidelines that include sections or statements regarding weight loss surgery in adolescents (August et al., 2008; Barlow, 2007; Institute for Clinical Systems Improvement [ICSI], 2011). Two of the guidelines were published by surgical societies, the American Society for Metabolic and Bariatric Surgery (ASMBS) and the Society of American Gastrointestinal and Endoscopic Surgeons (Michalsky et al., 2012; SAGES, 2008). The Endocrine Society was the only expert committee that appears not to include a surgical representative (August et al., 2008). Each of the guidelines reports an extensive review of relevant literature and grading of the available evidence. When available, the level of evidence for specific recommendations was analyzed.
Age/Physical Maturity Criteria
Age appropriateness criteria for surgical candidacy had some minor variation across the guidelines. The ASMBS and SAGES guidelines were the only guidelines with specified selection criteria that do not define adolescence (Michalsky, 2012; SAGES, 2008). Yermilov at al. (2009) define adolescents as ages 12 to 18 years old. One guideline defines adolescence as Tanner stage IV or V and near or at adult height (August et al., 2008), whereas others use physical maturity as the minimal age criterion but do not define it beyond stating it is generally at least 15 for boys and 13 for girls (Barlow, 2007). Skeletal maturity was recommended as the minimal age criterion by several studies (ICSI, 2011; Pratt et al., 2009). The Betsy Lehman Center for Patient Safety and Medical Error Reduction (Lehman Center) guidelines recommend documenting 95% of adult stature with radiography and conclude that this practice will typically limit surgical candidates to those older than 12 years (Pratt et al., 2009).
The evidence for minimum age of eligibility and physical maturity for weight loss surgery was limited by the lack of high-quality studies such as randomized controlled trials (August et al., 2008; Pratt et al., 2009; SAGES, 2008). The criteria appear to have been developed from expert opinion and retrospective cohort studies (Pratt et al., 2009; SAGES, 2008). The general consensus is that adolescents need to have achieved nearly full physical maturity to be considered appropriate candidates for weight loss surgery.
BMI and Comorbidity Criteria
Consistent guidance is lacking about whether, and to what severity, comorbidities must be present to determine appropriate candidacy for adolescent weight loss surgery. The strength of the evidence for BMI parameters is based primarily on expert opinion and retrospective cohort studies as the basis for the guidelines (Pratt et al., 2009; SAGES, 2008). BMI parameters are specified in all of the included studies with some variations, primarily related to the requirement for comorbidities. A BMI greater than 50 kg/m is recommended for consideration for weight loss surgery (August et al., 2008; Barlow, 2007), whereas other guidelines recommend consideration for surgery at a BMI greater than 40 kg/m, regardless of whether comorbidities are present (ICSI, 2011; SAGES, 2008). The Endocrine Society (August et al., 2008) and Yermilov et al. (2009) report that adolescents with BMI scores greater than 40 kg/m are appropriate candidates for weight loss surgery only when significant or severe comorbidities are present. The ASMBS, Expert Committee, and the Lehman Center guidelines also use 40 kg/m with comorbidities as eligibility criteria but do not specify that the comorbidities must be moderate to severe at this BMI level (Barlow, 2007; Michalsky, 2012; Pratt et al., 2009). Additionally, the guidelines provided by ASMBS, ICSI, Lehman Center, SAGES, and Yermilov et al. (2009) deem adolescents with BMI scores greater than 35 kg/m and severe comorbidities as possible candidates (ICSI, 2011; Pratt et al., 2009; SAGES, 2008). The SAGES guidelines specify that comorbidities should be present but do not need to be severe to justify weight loss surgery (SAGES, 2008). Comorbidities considered include type II diabetes, obstructive sleep apnea, pseudotumor cerebri, nonalcoholic fatty liver/steatohepatitis, dyslipidemia, and impaired quality of life (Michalsky, 2012; Pratt et al., 2009; Yermilov et al., 2009). According to the ASMBS and Lehman Center guidelines, indicators of metabolic syndrome and cardiovascular disease are deemed weaker indications for weight loss surgery in the adolescent population. Both guidelines provide the same rationale for the distinction. The diagnostic criteria and clinical significance of metabolic syndrome in adolescents are not as well understood as they are in adults (Michalsky, 2012; Pratt et al., 2009). Cardiovascular risk factors attributed to childhood obesity, such as elevated blood and increased skinfold thickness, likely lead to cardiovascular disease in adulthood. However, the short-term sequelae during adolescence are still being substantiated (Michalsky, 2012; Pratt et al., 2009).
Conditions Subject to Exclusion From Weight Loss Surgery
Well-conducted cohort studies provided strong evidence for determining exclusion criteria for weight loss surgery in adolescents. Depression was the most commonly considered condition. If depression and other psychopathology are well controlled, four of the guidelines would not exclude these adolescents from possible weight loss surgery (August et al., 2008; Michalsky et al., 2012; Pratt et al., 2009; SAGES, 2008). Two of the guidelines state that disordered eating is not an exclusion criterion if it is under treatment and stable (Michalsky et al., 2012; Pratt et al., 2009). Pregnancy and Prader-Willi syndrome are exclusion criteria (August et. al, 2008), along with untreated endocrinopathies (ICSI, 2011). The Expert Committee (Barlow, 2007) discusses distance from an adolescent bariatric surgery center as a possible exclusion criterion because adolescents need long-term support after weight loss surgery. Overall, few contraindications were identified for adolescents meeting the BMI and comorbidity criteria.
Preferred Surgical Procedure
None of the guidelines specifically endorses one procedure for adolescent weight loss surgery. However, validation for the use of certain procedures is provided. Some of the guidelines report the strengths and disadvantages of different types of weight loss surgery.
Roux en Y gastric bypass (RYGB) is the gold standard for weight loss surgery in adults and has been used in adolescents since the 1980s (ICSI, 2011; Rand & Macgregor, 1994), and several adolescent guidelines agree that it is suitable for adolescent weight surgery as well (Michalsky, 2012; Pratt et al., 2009; SAGES, 2008). The RYGB is a restrictive and malabsorptive procedure that can be performed laparoscopically. The stomach is divided to create a small pouch at the proximal end. The jejunal portion of the small intestine is then divided. The distal segment is attached to the newly created pouch, thus bypassing the distal stomach, duodenum, and part of the jejunum, resulting in malabsorption. The proximal segment is anastomosed to a distal portion of the jejunum (SAGES, 2008). Levels of vitamin B12, calcium, vitamin D, iron, and thiamine may become insufficient after RYGB is performed (Pratt et al., 2009), and the importance of long-term follow-up to monitor for nutritional deficiencies is emphasized (Michalsky, 2012; Pratt et al., 2009; SAGES, 2008). The biliopancreatic diversion and duodenal switch, which are restrictive procedures sometimes used in adults, are not favorable for use in the adolescent population because of the risk for significant malabsorption (Michalsky et al., 2012; Pratt et al., 2009).
Adjustable gastric banding (AGB) may be considered in severely obese adolescents in an off-label investigational manner after receiving investigational device exemption from the Food and Drug Administration, because it is not yet approved for use in persons younger than 18 years (Michalsky, 2012; Pratt et al., 2009). Laparoscopic AGB involves placing an inflatable restrictive band below the gastroesophageal junction. The band contains a balloon with tubing connected to a subcutaneous port that is attached to the rectus muscle of the abdomen. The stomach is restricted by filling the band with saline solution injected through the port (SAGES, 2008). The ICSI (2011) reports that AGB has the best short-term safety profile, but a significant need for reoperation exists because of complications, including slipping of the band or problems with the port. Large-scale use of the adjustable gastric band in adolescents is not yet supported (Pratt et al., 2009).
The laparoscopic sleeve gastrectomy, another new restrictive weight loss procedure, is only recommended as investigational in adolescents because of insufficient data (Pratt et al., 2009). Sleeve gastrectomy is the vertical separation of the stomach and excision of the greater curvature and fundus. The lesser curvature is then stapled shut, creating a sleeve (ICSI, 2011).
The evidence for selecting a weight-loss surgical procedure for adolescents is steadily increasing. However, strong definitive evidence about the results of AGB in adolescents is still lacking (Michalsky, 2012). Meta-analysis and multicenter studies on the RYGB have been conducted, and the safety and efficacy of RYGB in adolescents has been shown to be commensurate with outcomes in adults (Michalsky et al., 2012; Pratt et al., 2009). Still, sufficient evidence does not exist even among adults for experts to endorse one type of weight loss procedure as superior; rather, decisions are made on an individual basis, considering both patient and surgeon choice (SAGES, 2008).
Perioperative Management
Preoperative Recommendations. Most guidelines make recommendations for the preoperative period. Psychiatric evaluation to assess mental stability and maturity is widely recommended (August et al., 2008; ICSI, 2011; Pratt et al., 2009; SAGES, 2008). Ensuring psychosocial well-being and maturity is important to the consent process, as is the assessment of the adolescent's ability to comply with postoperative instructions (Pratt et al., 2009). Some guidelines recommend a thorough preoperative metabolic, nutritional, and vitamin screening (ICSI, 2011; SAGES, 2008). According to SAGES (2008), this screening generally consists of a complete blood cell count, ferritin level, coagulation analysis, metabolic profile, lipid panel, and thyroid function tests. For malabsorptive procedures, SAGES (2008) recommends considering inclusion of levels of fat-soluble vitamins and vitamin B12. ICSI (2011) does not define the general pre–weight loss surgery nutritional and vitamin screen, but it does specify that an albumin level should be checked. ISCI outlines a panel of B vitamins for malabsorptive procedures that includes B12, folic acid, thiamine, and riboflavin (ICSI, 2011).
Adolescents need to preoperatively demonstrate the ability to comply with healthy lifestyle regimens (August et al., 2008; Barlow, 2007; Michalsky et al., 2012; Pratt et al., 2009). The ICSI (2011) guidelines state the ideal surgical candidates are those who have shown successful weight loss with nonsurgical therapy. However, the SAGES (2008) guidelines report that mandated weight loss prior to weight loss surgery does not affect weight loss or reduction in comorbidities.
Counseling in the preoperative period regarding pregnancy is recommended by the two most recent guidelines, with the rationale being that adolescent females' fertility increases as a result of the postoperative weight loss and pregnancy in the first 1 to 2 years after weight loss surgery has risks (Michalsky et al., 2012; Pratt et al., 2009). Pregnancy during the postoperative period of rapid weight loss after bariatric surgery may lead to malnutrition of the mother and fetus (Bebber et al., 2011). Evidence for preoperative counseling regarding pregnancy in adolescents is low level, but clearly the benefits outweigh the risk.
Informed consent for adolescent weight loss surgery is seen across the guidelines as requiring in-depth counseling regarding the risk and benefits and careful assessment of the adolescent's ability to understand them, although some guidelines address concerns about possible parental coercion (Michalsky et al., 2012; Pratt et al., 2009). The ASMBS and Lehman Center guidelines address proper informed consent/assent (Michalsky et al., 2012; Pratt et al., 2009). The ICSI (2011) guidelines recommend a process of shared decision making for weight loss surgery that goes beyond informed consent to explore patient preference, lifestyle, and future ramifications.
Surgical Setting/Care Team. The guidelines are not consistent about the appropriate surgical setting for adolescent weight loss surgery. The Lehman Center and ICSI guidelines recommend that the surgery take place in a high-volume center to ensure adequate surgical experience, because risk likely increases if surgeons and institutions have limited weight loss surgery experience (ICSI, 2011; Pratt et al., 2009). The SAGES (2008) guidelines recommend a specialty center with the necessary adaptations for bariatric patients and their providers. Other guidelines made general recommendations for the surgical setting, such as maintaining databases and being capable of long-term follow-up (August et al., 2008; Barlow, 2007). Evidence for surgical setting recommendations appears to be based largely on case series and expert opinion.
A multidisciplinary approach is widely endorsed and is based on established norms (Barlow, 2007; Michalsky et al. 2012; Pratt et al., 2009; SAGES, 2008). Commonly endorsed team members include the following professionals: experienced bariatric surgeon, coordinator, pediatric specialist, mental health clinician, and registered dietitian (Michalsky et al., 2012; Pratt et al., 2009). According to the ASMBS guidelines, the use of multidisciplinary teams for adult and adolescent weight loss is the prevailing standard of care (Michalsky et al., 2012). The Lehman Center collaborative guidelines do not define "pediatric specialist." The ASMBS guidelines specify that a "pediatric specialist" might be a pediatrician or an internist/family practitioner with adolescent medicine specialty (Michalsky et al., 2012).
Postoperative Recommendations. Postoperative recommendations were less abundant in the guidelines but were based on meta-analysis, case series, and retrospective reviews. Nutritional follow-up for all procedure types and appropriate vitamin supplementation (e.g., calcium, vitamin D, B vitamins, and iron) is emphasized (Barlow, 2007; ICSI, 2011). The Expert Committee also mentions psychological support as part of appropriate long-term follow-up (Barlow, 2007). Two of the guidelines indicate that contraception should be offered to female adolescents (Michalsky et al., 2012; Pratt et al., 2009). The ICSI (2011) guidelines advise close surveillance of patients' medications after weight loss surgery. Chronic medications may not need to be continued as comorbidities resolve, and altered absorption may affect extended-release medications (ICSI, 2011). Dosage adjustments may need to be made as weight loss occurs (ICSI, 2011).
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