Join the Behind the Knife Bariatric Surgery Team as they kick off 2025 with a crucial discussion on pediatric and adolescent bariatric surgery. Drs. Matt Martin, Adrian Dan and Katherine Cironi delve into the latest ASMBS guidelines, comparing long-term outcomes of gastric bypass and sleeve gastrectomy in adolescents versus adults. They explore key comorbidities, including type 2 diabetes, hypertension, and orthopedic issues, and emphasize the importance of early intervention. This episode also tackles the complex ethical considerations surrounding surgery in this vulnerable population, including consent, multidisciplinary care, and the evolving role of medical therapies like GLP-1 agonists.

Show Hosts:
- Matthew Martin
- Adrian Dan
- Katherine Cironi

Learning Objectives: 
·  Identify the current ASMBS guidelines for pediatric and adolescent bariatric surgery, including BMI thresholds and associated comorbidities. 
·  Describe common comorbidities seen in the pediatric population eligible for bariatric surgery, such as type 2 diabetes, hypertension, and orthopedic issues. 
·  Compare and contrast long-term outcomes of bariatric surgery (gastric bypass and sleeve gastrectomy) in adolescents and adults, including remission rates of comorbidities and reoperation rates. 
·  Discuss the importance of a multidisciplinary approach, including psychological and ethical considerations, when evaluating adolescent patients for bariatric surgery. 
·  Explain the ethical framework used in evaluating adolescents for bariatric surgery, including consent/assent, parental involvement, and addressing potential coercion. 
·  Recognize the evolving role of medical management (e.g., GLP-1 agonists) in conjunction with or as an alternative to bariatric surgery in adolescents.

Article #1: Inge 2019 – Five-year outcomes of gastric bypass in adolescents as compared with adults
https://pubmed.ncbi.nlm.nih.gov/31461610/
- The cumulative effect of sustained severe obesity (BMI >35) from adolescence into adulthood increases the likelihood of diabetes, hypertension, respiratory conditions, kidney dysfunction, walking limitations, and venous edema in legs/feet (when compared to adults that did not report severe obesity in adolescence)
- American Society for Metabolic and Bariatric Surgery (ASMBS) guidelines for adolescents who should be considered for bariatric surgery: BMI is ≥35 with a co-morbidity or if they have a BMI ≥40 (class 3 obesity, 140% of the 95th percentile)
- This article utilizes the Teen-Longitudinal Assessment of Bariatric Surgery (TEENS LAB) and LABS (adults) databases to evaluate the outcomes of adolescents vs. adults who underwent bariatric surgery Roux-en-Y gastric bypass (2006-2009)
- 161 adolescents (13-19 at the time of surgery) with severe obesity (BMI>35) vs 396 adults (25-50 years old at the time of surgery) who have remained obese (BMI>30) since adolescence 
- Both groups had the gastric bypass procedure as their primary bariatric operation 
- Both groups had unadjusted similar demographics, however, BMI was higher in adolescence (54) when compared to adults (51) 

- Results were analyzed using linear mixed and Poisson mixed models to analyze weight and coexisting conditions
- After surgery, adolescents were significantly more likely than adults to have remission of type 2 diabetes and hypertension
- Increased likelihood of remission of diabetes due to the shorter duration of diabetes, lower baseline glycated Hgb, less use of medications, and increased baseline C-peptide levels 
- Increased vascular stiffness in adults along with a longer duration of hypertension make the cessation of hypertension less responsive with surgery in adults 
- No significant difference in percent weight changes between adolescents and adults 5 years after surgery 
- Both adults and adolescent groups had decreased rates of hypertriglyceridemia and low HDL levels, albeit not significantly different when comparing the two groups 
- Of note, the rate of abdominal reoperations was significantly higher among adolescents (20%) than among adults (16%) with cholecystectomy representing nearly half the procedures in both groups

- Limitations
- At baseline, adults had a high prevalence of both diabetes and hypertension
- only 14% of adolescents had diabetes vs 31% of adults 
- Only 30% of adolescents had hypertension vs 61% of adults 

Article #2: Ryder 2024 – Ten-year outcomes after bariatric surgery in adolescents 
https://pubmed.ncbi.nlm.nih.gov/39476348/
- The goal is to discuss the long-term durability of weight loss and remission of coexisting conditions in adolescents after bariatric surgery 
- This article utilizes the Teen-Longitudinal Assessment of Bariatric Surgery (TEENS LABS) database to evaluate the 10-year outcomes in adolescents who underwent gastric bypass or sleeve gastrectomy 
- 260 adolescents with an average age of 17 years old at the time of surgery (ages ranged from 13-19 years old)
- 161 adolescents underwent gastric bypass, 99 adolescents underwent sleeve gastrectomy 

- Results were analyzed using propensity score-adjusted linear and generalized mixed models 
- At 10 years, the average BMI had decreased significantly with both groups experiencing about a 20% change in BMI on average
- To assess comorbidities, both groups were analyzed together
-  55% of patients who had DM2 at baseline, were in remission at 10 years
- 57% of patients who had HTN at baseline, were in remission at 10 years
-  54% of patients who had dyslipidemia at baseline, were in remission at 10 years

- Limitations 
- Neither of these studies compare surgery to medical management. GLP-1s have shown promise for weight loss management but we need more data in terms of long-term outcomes in co-morbidities like diabetes, hypertension, dyslipidemia 

- Highlighted Outcomes 
- Metabolic bariatric surgery is quite effective in the adolescent population 
- Adolescents tend to have weight loss that is similar to that of adults and improved resolution of comorbid conditions (DM2, HTN, dyslipidemia)

Article #3: Moore 2020 – Development and application of an ethical framework for pediatric metabolic and bariatric surgery evaluation https://pubmed.ncbi.nlm.nih.gov/33191162/
- The purpose of this paper is to describe the ethical framework that supports the use of metabolic & bariatric surgery (MBS) on the principle of justice, and how providers can conduct a thorough evaluation of patients presenting for these surgeries
- Highlights adolescents with intellectual and developmental disabilities (IDD) and preadolescent children who pose more ethical questions before considering surgery 
- This article utilizes the bariatric surgery center at one children’s hospital and the institution’s ethics consult service to develop an ethical framework to evaluate pediatric patients seeking bariatric surgery – using the national ASMBS guidelines 
- This ethical framework utilized 4 central ethical questions

1.     Should any patients be automatically excluded from evaluation for MBS?

2.     How should it be determined that the benefits of MBS outweigh the risks?

3.     How do we ensure the patient fully understands and is capable of cooperating with the surgery and follow-up care?

4.     How do we make sure the decision to have surgery is truly voluntary, and not coerced by family or others?

- Results: this ethical framework was discussed in depth in two case studies 
- Overview of framework: an ethical question would arise from the bariatric team they would review & apply the ethical framework. The question is either resolved by the bariatric team OR ethics consult, continue pre-operative workup vs no surgery
- Case 1: 17M (BMI 42) with a history of autism spectrum disorder, pre-DM, depression with behavior challenges, HTN, dyslipidemia. Testing at school demonstrates intellectual functioning at a fourth-grade level. Pt lives with mom and 11-year-old sister. Mom endorses food insecurity (on supplemental nutrition assistance benefits) and struggles with her son’s large intake of food. 

1.     Co-morbidities should not be exclusionary, but pt should undergo a comprehensive psychosocial evaluation with attention to family dynamics and support and the patient’s decision-making capacity 

2.     Discuss benefits vs risks. Benefits – decreased progression of DM2, HTN, hyperlipidemia, cardiometabolic dx. Risks – gastric leak, infection, bleeding, dumping syndrome, etc. 

3.     Can assess decision-making capacity with the surgical team or if need be other teams. In this case, the pt had limited decision-making capacity 

- His level of understanding remained stable during the pre-op visits, and he gave assent to surgery
- The mom identified a second source of support (extended family)
- The team talked to both the patient and mother alone and then, together, found that the patient developed an independent desire for surgery, and thus moved forward. 

- Case 2: 8F (BMI 50) with a history of mod OSA, L slipped capital femoral epiphysis s/p surgical stabilization (6 mos prior). The patient is neurotypical & excels in school, and lives with mom & dad. Referred by mom & dad (mom with a recent history of sleeve gastrectomy). 
1.     An 8-year-old should not be discriminated against based solely on age, but the patient should be offered more conservative/less invasive options before OR. 

a.     In this case, the family had not yet been offered these nonsurgical approaches (structured weight management program, physical support, dietician)

2.     Discuss benefits vs risks. Benefits – preventing progression of hip disease, improvement of OSA, decreased risk of cardiometabolic dx. Risks – anatomic/infectious/nutrition risks 

3.     Decision-making capacity was assessed. Found that the parents were more advocating for the surgery saying she has a poor quality of life physically and socially. When the patient was separated from her parents, she said she could lose weight if she had healthier foods at home and someone to exercise with. The patient had decision-making capacity & did not assent to surgery. 

4.     When the ethics team interviewed the patient and parents, the parents had a strong preference toward surgery vs patient was scared of surgery and wanted to try other approaches first 

a.      Decided that the child’s dissent outweighed the medical necessity for surgery and that there were conservative treatment options still available to try 

- Highlighted Outcomes 
- ASMBS guidelines give us good direction on who qualifies for surgery and emphasize an interdisciplinary approach to decision-making. The decision to pursue surgery should always weigh the benefits and risks and should be made collaboratively with the patient, family, and care team

***SPECIALTY TEAM APPLICATION LINK: https://docs.google.com/forms/d/e/1FAIpQLSdX2a_zsiyaz-NwxKuUUa5cUFolWhOw3945ZRFoRcJR1wjZ4w/viewform?usp=sharing

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.