The surgical approach to management of pediatric obesity: When to refer and what to expect

Weight loss surgery is recommended for adult patients with morbid obesity and has been used on a case by case basis in the pediatric population. Surgery, however, is just a tool added to the two mainstays of therapy for obesity: 1.) controlled dietary intake and 2.) increases in activity and exercise behaviors. For the pediatric population, the health consequences of obesity are profound with increased cardiovascular risk during adolescence and increased mortality in adulthood. Currently accepted guidelines for weight loss surgery referral use BMI cut points that are the same as for adults: BMI ≥ 35 kg/m² and serious comorbidities of obesity or BMI ≥ 40 kg/m² with minor comorbidities of obesity. A multidisciplinary approach to weight management must be utilized, and a lifetime of follow-up must be addressed. The most commonly performed operations for obesity are laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB). LAGB is safer and does not permanently alter gastrointestinal continuity; however, LAGB is not currently approved for implantation in adolescent patients. LRYGB involves a complex, permanent altering of the gastrointestinal anatomy and is associated with more complications around the time of surgery and is not subject to FDA approval because there is no associated implant. In each operation, appetite is suppressed by construction of a virtual (LAGB) or real (LRYGB) pouch. The dynamics and speed of appetite suppression and, consequently, weight loss are typically different for each operation though longer-term outcomes may be similar. Short- and long-term risks of surgery must be carefully weighed against the benefits of the associated weight loss for each patient. The patient must be empowered to understand the importance of lifestyle and behavior in achieving long-term health.