Recommendations for bariatric surgery in adolescents in Australia and New Zealand
A position paper from the Australian and New Zealand Association of Paediatric Surgeons, the Obesity Surgery Society of Australia and New Zealand, and the Paediatrics & Child Health Division of The Royal Australasian College of Physicians.
On behalf of the Royal Australasian College of Physicians Paediatric Policy and Advocacy Committee Working Party on Bariatric Surgery for Adolescents.
Professor Louise A Baur, Clinical School, The Children's Hospital at Westmead, Locked Bag 4001, Westmead NSW 2145, Australia. Fax: +02 9845 3389; email: firstname.lastname@example.org
The prevalence of severe obesity and associated co-morbidities is increasing in adolescence. Although support for long-term whole-of-family lifestyle change is the mainstay of paediatric obesity treatment, there is increasing recognition of the place of other therapies, including bariatric surgery, in the management of severely obese adolescents. While there are rising numbers of reports of bariatric surgery in adolescents, there are as yet no Australian or New Zealand recommendations available to guide decisions as to which adolescents should receive such surgery and how they should best be managed. This paper presents a summary of the recommendations that are contained within the full position paper developed on behalf of the Royal Australasian College of Physicians Paediatric Policy and Advocacy Committee Working Party on Bariatric Surgery for Adolescents, working in conjunction with the Australia and New Zealand Association of Paediatric Surgeons and the Obesity Surgery Society of Australia and New Zealand.
The increasing prevalence of both obesity and obesity-associated complications in adolescents highlights the importance of primary prevention as well as effective treatment strategies.1–7 For those adolescents who are affected by obesity, the mainstay of treatment involves long-term behaviour change, dietary modification, increased physical activity, decreased sedentary behaviour and support for whole-of-family lifestyle change.8,9 As with any chronic disease, there is a spectrum of severity with obesity. For those who have moderate to severe obesity, treatment by a coordinated, multidisciplinary team offers the greatest likelihood of successful outcomes.8 Such treatment may involve the assessment and management of associated co-morbidities and for adolescents, the use of pharmacotherapy.
Notwithstanding these interventions, a small proportion of severely obese adolescents will require additional treatment. It is in this situation that consideration should be given to bariatric surgery within the context of an ongoing and coordinated multidisciplinary approach.10–14
While there are rising numbers of reports of bariatric surgery in adolescents, there are as yet no Australian or New Zealand recommendations available to guide decisions as to which adolescents should receive such surgery and how they should best be managed. This is the reason for the development of this position paper on bariatric surgery in adolescents by representatives from the Australian and New Zealand Association of Paediatric Surgeons, the Obesity Surgery Society of Australia and New Zealand, and the Paediatrics & Child Health Division of The Royal Australasian College of Physicians.
Following are the recommendations that are contained within the full position paper that can be accessed via The Royal Australasian College of Physicians’ web site.15
- 1Bariatric surgery should be considered for a minority of severely obese adolescents under the direction of a multidisciplinary weight management team after a supervised program of lifestyle modification and pharmacotherapy has been undertaken.
- 2The adolescent must be able to provide informed consent and understand the nature of the operation, the risks involved and the need for long term follow-up.
- 3There is a need for long term follow-up data in patients undergoing bariatric surgery, ideally through nationally co-ordinated and funded programs.
Patient criteria for selection for bariatric surgery
Patients for bariatric surgery should meet all of the following criteria:
The adolescent should give a written informed consent to the procedure. The capacity to give consent should be assessed by a consulting child and adolescent psychiatrist or adolescent physician who ideally would be part of the multidisciplinary weight management team. In addition, consent for surgery would involve:
- • Full consent from the parent or legal guardian
- • Complete understanding of treatment options, treatment outcomes, (the expected outcome) and the short- and long-term complications of the procedure and subsequent management
- • Knowledge of post-operative management and monitoring.
Surgical expertise and facilities
If surgery is proposed, then referral should be to an experienced bariatric surgeon. The surgeon would be affiliated with a team experienced in the assessment and long-term follow-up of the metabolic and psychosocial needs of the adolescent bariatric patient and family. The institution where the surgery is to be undertaken should be either participating in a study of the outcomes of bariatric surgery or sharing such data in a proposed national registry of bariatric surgery and patient outcomes.
In practice, surgeons performing bariatric surgery on adolescents should be credentialed for bariatric surgery. Such surgeons should ideally have experience in the management of patients in the adolescent age group.
Given the increasing prevalence of obesity and related co-morbidities in adolescents and adults, and the potentially large financial pressures that the resultant burden of disease will place upon not just the health system but the economy as a whole, it is strongly recommended that publicly funded bariatric surgery be made available to those in need.
Pre-operative assessment of the patient and family may involve the following:
- • Assessment of the adolescent's general health and developmental status
- • Evaluation of the patient and family's motivation, expectations and adherence
- • Evaluation of the patient and family's knowledge of the procedure and post-operative requirements
- • Evaluation of the patient and family's capacity for self care
- • Independent psychological or psychiatric evaluation confirming the stability and competence of the family unit
- • Evaluation of obesity-related co-morbidities
Ideally, such assessment should be undertaken by a multidisciplinary team of health professionals including an accredited practicing dietitian.
The patient and family should receive education about the following:
- • The procedure and post-operative requirements, including the need for ongoing dietary modification and supervision
- • Outcomes of surgery and possible problems/complications
- • Consequences of not undergoing treatment.
Type of surgical procedure
The majority of the Working Party was of the view that the primary bariatric surgical procedure of choice for adolescents in Australia and New Zealand is laparoscopic adjustable gastric banding as it has good weight-based outcomes, has a low complication rate and is potentially reversible.
All patients should be managed by an anaesthetist experienced with bariatric surgery. Patients should receive a careful pre-operative anaesthetic assessment and be informed about potential anaesthetic complications.
Patients should be managed in the immediate post-operative period by a surgeon and bariatric surgical team with experience in adolescent care. Availability of a high-dependency unit or intensive care unit may be required, particularly where complications such as sleep apnoea are present.
Although all bariatric patients require regular follow-up, especially early post-procedure, adolescent patients are likely to require more frequent follow-up than is needed for adult patients. Follow-up of the adolescent patient should be on a four to six weekly basis. Early post-surgery involvement of the multidisciplinary team is important for ongoing patient engagement in the treatment plan. Follow-up needs to be performed by a team skilled both in gastric band management and the recognition of its complications as well as those experienced in adolescent health. Importantly, issues such as improved fertility following weight loss, and hence, the need for contraception, need to be considered.
The long-term follow-up for any intervention in paediatrics, including bariatric surgery, needs to extend beyond 10 years and ideally, for the whole of life. In addition, appropriate aftercare and long-term follow-up are critical for bariatric surgery outcome success.
Patients require long-term support for behavioural change in relation to nutrition and eating behaviours, physical activity and sedentary behaviour. Follow-up should be by a multidisciplinary team that includes an experienced dietitian and psychologist.
Appropriate transition from adolescent services to adult services for on-going follow-up should be anticipated and effectively managed.
Guidelines for the thorough recording and collection of a range of physiological and behavioural parameters for audit and research purposes should be developed, including agreement as to prescribed times for data collection (e.g. three, six and 12 months and thereafter annually). A national database for outcome and long-term monitoring of bariatric surgery in adolescents should be established and funded.
Given the poor level of evidence on long-term outcomes, it is recommended that all adolescents undergoing bariatric surgery in New Zealand and Australia are enrolled in a properly designed clinical trial. Funding for the trial should come through the funding service (District Health Boards, states, etc.) with liaison with the Health Research Council of New Zealand and its Australian counterpart the National Health and Medical Research Council. An existing model such as that used in childhood cancer, which has had considerable success in the identification of successful treatment programmes, could be adopted for use in bariatric surgery. For example, the comparative group could initially be adolescents undergoing non-surgical treatment, but over time, alternative comparative groups including different surgical techniques could be incorporated.
Members of Working Party
Professor Louise A Baur, PhD, FRACP, The Royal Australasian College of Physicians, Chair of Working Party; A/Professor Dominic Fitzgerald, PhD, FRACP, The Royal Australasian College of Physicians; Mr Gregory T Armstrong, RN, MPH, The Royal Australasian College of Physicians; A/Professor Deborah Bailey, FRACS, Board of Paediatric Surgery, The Royal Australasian College of Surgeons (RACS), Executive Council Australian and New Zealand Association Paediatric Surgeons (ANZAPS); Professor Jennifer Batch, MD, FRACP, The Royal Australasian College of Physicians; A/Professor John Dixon, PhD, FRACGP, Obesity Research Unit, Monash University; Mr Robert Fris, MBChB, FRCS, FACS, FACP, Obesity Surgery Society of Australia and New Zealand (OSSANZ); Dr Anne Kynaston, FRACP, The Royal Australasian College of Physicians; Mr Phillip Morreau, FRACS, Board of Paediatric Surgery, The Royal Australasian College of Surgeons (RACS), Executive Council Australian and New Zealand Association Paediatric Surgeons (ANZAPS); Dr Joanne Morris, MBBS, Advanced Trainee, The Royal Australasian College of Physicians; Professor Kate Steinbeck, PhD, FRACP, The Royal Australasian College of Physicians; Professor Richard Stubbs, FRACS, The Wakefield Clinic, Wellington, New Zealand; and Dr Friederike Veit, MD, FRACP, The Royal Australasian College of Physicians.