The importance of transitioning care from pediatric to adult practitioners is an often overlooked aspect of chronic disease. The benefits of a planned transition in health care are that patients will learn valuable life-long lessons on healthcare maintenance, when and how to seek medical attention for new issues that may arise, and improvements on their overall well-being. The purpose of this SAGES White Paper was to summarize the available knowledge for several pediatric surgical conditions to aid in transition of care for this patient population. The members of the SAGES Pediatric Surgery Committee elected to produce this White Paper. The group chose to focus on several important gastrointestinal diseases that may require lifelong care: tracheoesophageal fistula, duodenal atresia, anorectal malformations, childhood obesity, and gastrointestinal malignancies. For each disease process a summary of long term issues facing these patients, stakeholders involved, and follow up recommendations if required were identified. Each disease process has its own unique set of long-term issues as well as multidisciplinary stakeholders and need for follow-up. However, individualized care is needed based on each patient’s unique needs. To facilitate consistent transfer of care standardization is needed for surgical diseases. Key aspects of standardization include identifying a multidisciplinary team, working towards consistent quality improvement, and implementation of policy guided processes with individual treatment plans. Continued work in standardizing transition of care is required for optimal treatment of this complex patient population.

Although MBS is endorsed for eligible adolescents, the optimal age for intervention remains unknown. This study evaluates body mass index (BMI) and weight outcomes after sleeve gastrectomy (SG) in different adolescent age groups. A multi-institutional chart review was performed at three children’s hospitals in the United States, including patients who underwent SG from March 2013 to September 2024. Demographics, comorbidities, and pre- and post-operative weight and BMI were compared between three subsets: patients 11–14 years of age (“<15”), between 15 and 17.99 (“15–17”), and 18–23 (“18+”). The Kruskal–Wallis rank sum test and Pearson’s Chi-squared test were used. Of 324 patients, 55 were < 15, 168 were 15–17, and 101 were 18+. Mean BMIs at time of initial consultation were 45 ± 9, 48 ± 10, and 48 ± 8 respectively. There were no differences in gender, race, insurance type or comorbidities among groups. The youngest patients were more likely to gain weight from consultation to surgery (+ 7.6

BACKGROUND:Prior research has shown higher rates of complications across a broad spectrum of surgeries in pediatric patients with higher Social Vulnerability Index (SVI). OBJECTIVE:This study aims to compare how SVI impacts outcomes in adolescents undergoing metabolic and bariatric surgery (MBS). SETTING:Academic Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program-adolescent accredited care center METHODS: We performed a retrospective cohort study of 126 adolescents and young adults undergoing laparoscopic sleeve gastrectomy between September 2014 and April 2021. Comparative analysis was performed for demographics, percent total body weight loss (%TBWL), and complications between those with high (≥ .75) and low (<.75) SVI. RESULTS:There were 47 patients in the high SVI group and 79 in the low SVI group. Age at surgery, gender, primary language, and insurance type were similar between groups. Preoperative weight and body mass index (BMI) were higher in the high SVI group compared to the low SVI group (145 kg vs 136 kg, P = .033, BMI 52 vs 46, P < .001). Average distance to the hospital was similar (82 miles in high SVI group vs 100 miles in low SVI group, P = .079). The high SVI group had a trend towards a higher percentage of patients who identified as Hispanic/Latino (64% vs 47%, P = .064) and less patients who identified as white (28% vs 51%, P = .054). There was no significant difference in mean %TBWL at 3 months, 6 months, or 12 months (23% in high SVI group (N = 40) compared to 22% in low SVI group (N = 66), P = .4). Complication rates were low in both groups, with no difference between SVI groups (6.5% vs 5.1%, P = .707). While the number of patients with long-term data decreased over time, there was no difference in %TBWL at 2, 3, or 4 years after surgery. CONCLUSIONS:Despite a diverse patient population and significant geographic barriers, the outcomes between high and low SVI in this cohort were comparable. Continued efforts need to be made to expand access to MBS for socioeconomic disadvantaged adolescent patients with obesity.

BACKGROUND:Metabolic and bariatric surgery (MBS) is a highly durable, safe and effective treatment for severe obesity in adults. However, MBS remains underutilized in the pediatric and adolescent population, likely due to safety concerns of elective surgery in children. OBJECTIVES:We aimed to analyze whether the benefits of MBS outweigh the risks in adolescents when compared to young adults. SETTING:Multicenter, national database study. METHODS:Patients aged 10-39 who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Patients with prior foregut surgery were excluded. RESULTS:556,628 patients were identified; 10,883 (2.0%) were aged 10-19 (adolescents), 161,938 (29.1%) were 20-29 (young adults), and 383,807 (69.0%) were 30-39 (adults). Preoperative body mass index (BMI) was clinically similar between groups, though statistically significant due to large sample size (10-19: 46, 20-29: 45, 30-39: 45 kg/m2, P < .001). SG was more common in younger cohorts (10-19: 86%, 20-29: 77%, 30-39: 75%, P < .001). At 30 days postoperatively, adolescents demonstrated marginally greater BMI reduction (10-19: 2.91, 20-29: 2.69, 30-39: 2.53 kg/m2, P < .001). Adolescents had fewer postoperative complications, including surgical site infections, gastrointestinal bleeding, and blood transfusions (P < .001). Among adolescents, SG (aOR: .39, CI: .31-.48, P < .001) was associated with reduced postoperative complications. CONCLUSIONS:Adolescents undergoing MBS have BMI reductions similar to those of young adults and have lower rates of complications and readmissions. MBS should be offered as a safe treatment for adolescents to treat morbid obesity with at least similar frequency as it is offered to adults.

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) online calculator incorporates individual patient data to predict weight loss up to 1 year after MBS, but it was derived from an adult database and has not been validated in younger cohorts. This study evaluates the accuracy of this calculator for adolescent MBS patients and explores patient factors which may be associated with prediction inaccuracy. We include patients age ≤ 21 who underwent laparoscopic sleeve gastrectomy at two major academic institutions from 2013 to 2023. Data were stratified between patients age < 18 and 18–21. The calculator’s predictions were compared to actual weight loss values at 1 year. Relationships between various preoperative variables and the difference between predicted and actual weight loss were assessed using correlation, regression, and t-tests. There were 265 patients, with 176 age < 18. The correlation coefficients for predicted and actual weight loss were 0.48 for patients age < 18 and 0.38 for patients 18–21. On average, the proportion of predicted weight loss actually attained at 1 year was 0.73. There were no statistically significant associations between calculator inaccuracy and patient age, sex, preoperative body mass index, or area deprivation index (all p > 0.05). The MBASQIP calculator predictions show weak to moderate correlation with actual weight loss at 1 year and should be used with caution when counseling pediatric patients considering MBS. This project underscores the importance of building multi-institutional collaborations and databases specific to the pediatric MBS context.

This cohort study investigates the association between preoperative antiobesity medications and weight loss outcomes of adolescent patients undergoing metabolic and bariatric surgery.

Pediatric obesity is a growing epidemic associated with serious long-term health consequences, including diabetes, cardiovascular disease, and reduced life expectancy. Metabolic and bariatric surgery (MBS) is a safe, effective, and durable treatment for adolescents with severe or refractory obesity; however, it remains significantly underutilized. As a consequence, children with severe obesity and associated comorbidities progress to an advanced stage of disease that can be even more challenging to treat than in adults. Current evidence demonstrates that MBS in adolescents achieves comparable or even superior weight loss and comorbidity resolution compared to adults, with favorable long-term safety profiles. In select cases, GLP-1 receptor agonists (GLP-1RAs), may be used as an adjunct to MBS. Current evidence for GLP-1RA use in the preoperative period is limited, although when reinitiated early in the postoperative period, they may be associated with improved weight loss outcomes. Despite strong guideline support, <0.05 % of eligible children undergo MBS, likely due to poor access to adolescent MBS centers, limited insurance coverage, and a lack of awareness or misinformation surrounding MBS, among other causes. Multidisciplinary support including preoperative teaching, mental health services, and long-term postoperative follow-up is essential to the success of the procedure. Further research is needed to better characterize the disparities in access, improve outreach and education efforts, combat the stigma associated with adolescent MBS, and address this growing public health crisis.

BACKGROUND:While new medications are transforming the management of obesity, their association with outcomes in adolescents undergoing metabolic and bariatric surgery (MBS) is not clear. OBJECTIVES:The objective was to determine how preoperative prescription of antiobesity medications (AOMs) is associated with postoperative weight loss after MBS. SETTING:The study was conducted using data from 3 academic children's hospitals, spanning the period from March 2013 to September 2024. METHODS:This is a retrospective review in which demographics, obesity-related diseases, preoperative and postoperative weight and body mass index (BMI) were compared between patients who were treated preoperatively with topiramate or glucagon-like peptide-1 receptor agonists (GLP-1RAs) and those who were not. Statistical analyses included Wilcoxon rank-sum, Pearson's χ2, and Fisher's exact tests, plus 1:1 propensity score matching and multivariable linear regression sensitivity models adjusting for time-to-surgery. RESULTS:Of 324 patients, 22 were treated with topiramate and 30 with a GLP-1RA. Rates of obesity-related diseases were similar. Patients on GLP-1RA lost weight from first consultation to surgery (-2% BMI), while those on no medication gained (+1% BMI) and those on topiramate remained stable (0%, P = .023). There was no difference in weight/BMI at the time of surgery; however, patients pretreated with medications lost less weight than those not taking medications at 6 months (no medications: -20% BMI reduction; GLP-1RA: -18%; topiramate: -17%, P = .017) and 12 months (no medications -23% BMI reduction, GLP-1RA -15%, topiramate -17%, P = .015). From initial consultation to 12 months after surgery, the differences in weight loss between groups were not significant (P = .072). CONCLUSION:Preoperative exposure to topiramate or GLP-1RA was associated with less postoperative weight loss, despite similar starting weights/BMIs. Total weight loss from consultation through 12 months did not differ significantly between groups. These findings raise important questions regarding the use and timing of obesity management medications in relation to surgery for adolescents.

Background: Obesity is a prevalent medical condition among the pediatric population. Metabolic and bariatric surgery is recommended to treat severe obesity. Resting energy expenditure (REE) plays a vital role in weight homeostasis. This study aims to assess the impact of sleeve gastrectomy (SG) on REE in pediatric patients with severe obesity while comparing REE values with body composition. Methods: Participants were recruited from the Pediatric Weight Management Clinic and Bariatric Surgery Clinic at Lucile Packard Children's Hospital. REE was measured using indirect calorimetry. Body composition was assessed using dual energy X-ray absorptiometry scans. Data were collected prospectively and analyzed using a generalized linear model and correlation analyses. Results: Thirty-six participants with severe obesity were included. Correlation analyses showed significant differences in baseline REE/kg between age groups, with higher REE/kg in participants <16 years. No significant correlations were observed between pre-SG REE/kg and degree of weight loss post-SG. Pre-SG %lean body mass positively correlated with REE/kg. There was no significant change in REE/kg following SG with weight loss. Conclusions: SG remains an effective intervention for managing severe obesity. This study found no significant changes in REE after SG. Future research should focus on larger longitudinal studies to enhance understanding of the metabolic effects of SG in pediatric patients while optimizing strategies for improved health outcomes.

The standard of care for pediatric patients with severe obesity considering metabolic and bariatric surgery is a preoperative multidisciplinary evaluation. A multidisciplinary team allows for the efficient use of variable personnel expertise to evaluate, manage, and support a pediatric patient and family through metabolic and bariatric surgery. This review discusses the purpose, recommended team members, patient selection, content, and benefits of the multidisciplinary preoperative evaluation. This evaluation should reduce barriers to care and optimize patient safety and outcomes while taking into consideration the unique developmental needs of this age group.

Introduction Glucagon-like peptide-1 receptor agonist (GLP-1A) medications are gaining widespread popularity for the treatment of obesity. The optimal use of these drugs in pediatric bariatric populations, and especially in those considering metabolic and bariatric surgery (MBS), is yet to be established. We sought to characterize current practice patterns of GLP-1A use at major pediatric bariatric centers across the United States. Materials and Methods We administered an online survey to a purposive sample of 46 surgeons who perform MBS on children and adolescents. Survey questions explored practices prescribing GLP-1As in patients considering MBS, holding them prior to elective operations, and restarting them postoperatively following MBS. Responses were summarized with descriptive statistics and inductive content analysis. Results There were 22 responses (48% response rate) representing 19 institutions. Most (86%) respondents do sometimes prescribe GLP-1As for patients considering MBS, but the specific indications vary. Practices for holding GLP-1As preoperatively also vary, from not at all to holding for 2 wk. Over half (55%) of respondents sometimes restart GLP-1As after MBS. Free-response themes included still-evolving preoperative utilization patterns, difficulty with access and insurance coverage, and a lack of data informing GLP-1A use in the pre and postoperative periods. Conclusions Given the increasing use of these medications for weight loss purposes, this substantial variation in practice highlights a need for further research to examine the safest and most effective use of GLP-1As in the pre and postoperative periods and for practice guidelines to standardize care pathways in pediatric bariatric contexts.

Introduction: Obesity is a significant public health concern in children. The American Academy of Pediatrics recommends the use of metabolic and bariatric surgery (MBS) in children with severe obesity, however; MBS remains underutilized in part due to lack of access. This study aims to characterize the prevalence of pediatric obesity and compare this to regional pediatric MBS provider availability. Methods: State-specific prevalence rates of childhood obesity in children aged 10-17 were obtained from the National Survey of Children's Health. The member directory provided by the American Society for Metabolic and Bariatric Surgeons was used to identify all pediatric MBS providers and used to calculate the prevalence of MBS providers by state. Results: The five states with the highest prevalence rates of childhood obesity were Ken-tucky, Mississippi, Louisiana, West Virginia, and Alabama. The five states with the highest prevalence (per 100,000 children with obesity) of MBS providers doing pediatric cases were North Dakota, New Jersey, Kansas, New York, and Utah. Notably, there was a negative correlation between the states with the lowest prevalence of pediatric MBS providers and states with the highest prevalence of childhood obesity (r-0.40, *P 1/4 0.002). Conclusions: Our study demonstrates significant state-to-state variation in the prevalence of pediatric obesity and MBS provider availability by state as a proxy for access to surgical care for pediatric obesity. Further work to establish accessible multidisciplinary pediatric weight loss centers is needed to ensure that children and adolescents with obesity receive thorough evaluation and have access to MBS. 2023 Elsevier Inc. All rights reserved.

Metabolic and bariatric surgery (MBS) is widely considered the most effective option for treating obesity, a chronic, relapsing, and progressive disease. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued new guidelines on the indications for MBS, which have superseded the previous 1991 National Institutes of Health guidelines. The aim of this study is to establish the first set of consensus guidelines for selecting procedures in Class I and II obesity, using an Expert Modified Delphi Method. In this study, 78 experienced bariatric surgeons from 32 countries participated in a two-round Modified Delphi consensus voting process. The threshold for consensus was set at an agreement or disagreement of ≥ 70.0% among the experts. The experts reached a consensus on 54 statements. The committee of experts reached a consensus that MBS is a cost-effective treatment option for Class II obesity and for patients with Class I obesity who have not achieved significant weight loss through non-surgical methods. MBS was also considered suitable for patients with Type 2 diabetes mellitus (T2DM) and a body mass index (BMI) of 30 kg/m 2 or higher. The committee identified intra-gastric balloon (IGB) as a treatment option for patients with class I obesity and endoscopic sleeve gastroplasty (ESG) as an option for patients with class I and II obesity, as well as for patients with T2DM and a BMI of ≥ 30 kg/m 2 . Sleeve gastrectomy (1) and Roux-en-Y gastric bypass (RYGB) were also recognized as viable treatment options for these patient groups. The committee also agreed that one anastomosis gastric bypass (OAGB) is a suitable option for patients with Class II obesity and T2DM, regardless of the presence or severity of obesity-related medical problems. The recommendations for selecting procedures in Class I and II obesity, developed through an Expert Modified Delphi Consensus, suggest that the use of standard primary bariatric endoscopic (IGB, ESG) and surgical procedures (SG, RYGB, OAGB) are acceptable in these patient groups, as consensus was reached regarding these procedures. However, randomized controlled trials are still needed in Class I and II Obesity to identify the best treatment approach for these patients in the future.

Metabolic and bariatric surgery (MBS) is gaining traction as a treatment option for adolescents with severe obesity. Since our weight center last published results in 2014, trends have shown increasingly diverse patient populations undergoing MBS and a shift from laparoscopic Roux-en-Y gastric bypass (LRYGB) to sleeve gastrectomy (LSG). We assessed outcomes including follow-up, weight loss, comorbidity resolution, and complications among our recent adolescent and young adult MBS patients. This is a retrospective cohort analysis of patients under 21 years of age with severe obesity who underwent MBS at a single institution between 2014 and 2020. Data on demographics, comorbidities, body mass index (BMI), percent of total body weight loss (

OBJECTIVE:The American Academy of Pediatrics (AAP) recently released clinical guidelines for the treatment of childhood obesity, including surgery being appropriate for children 13 years of age and older. The use of this age cut-off was due to a lack of data for children younger than 13. To address this knowledge gap, the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was queried to compare outcomes in preteens to teens after bariatric surgery hypothesizing that there would be no difference in outcomes between the two groups. METHODS:Patients from the MSAQIP database (2016-2021) were identified and divided into groups <13 years and 13-18 years and were matched using propensity scores based on race, sex, and preoperative BMI. Outcomes were compared including change in BMI, complication rates, 30-day readmission or reoperation, and mortality. Additionally, the centers responsible for the bulk of the preteen patient entries queried their center-specific databases to evaluate weight loss over time. RESULTS:A total of 4755 patients were identified, 47 of whom were <13 years of age. Preteens had similar sex distribution (66% vs. 75% female), were more likely to be Black (27.7% vs. 18.3%) or Hispanic (21.3% vs. 7.6%) race, and weighed less (274 ± 58 vs. 293 ± 85 lb, p = 0.01), but they had similar BMI (46.9 ± 7 vs. 47 ± 13 kg/m2 ) as their teen counterparts. Preteens were more likely to suffer from sleep apnea (34% vs. 19%, p < 0.01) and insulin-dependent type 2 diabetes (10.6% vs. 1.8%, p < 0.01). There were no complications in the preteens compared to teens (0% vs. 0.5%), and they did not undergo any unplanned readmissions (0% vs. 2.9%) or reoperations (0% vs. 0.8%) within 30 days of surgery. There were also no mortalities reported in preteens (0% vs. 0.1%). The risk-adjusted decrease in BMI between preteens and teens was also comparable at 30 days (4.2 [95% CI: 3.0-5.4] vs. 4.6 [95% CI: 4.4-4.7], p = 0.6). Decrease in BMI in preteens was 7 ± 3 kg/m2 at 3 months and 9 ± 4 kg/m2 at 12 months after surgery, which represented a percentage BMI change of 16 ± 7 and 20 ± 8, respectively. CONCLUSIONS:This study demonstrates that bariatric surgery in preteens is safe and efficacious when performed at specialized centers, and that age criteria may not be required. The AAP and others are encouraged to include age cut-offs in their guidelines for children with obesity and bariatric surgery only when data are available to support their inclusion.

With the global epidemic of obesity, the importance of metabolic and bariatric surgery (MBS) is greater than ever before. Performing these surgeries requires academic training and the completion of a dedicated fellowship training program. This study aimed to develop guidelines based on expert consensus using a modified Delphi method to create the criteria for metabolic and bariatric surgeons that must be mastered before obtaining privileges to perform MBS. Eighty-nine recognized MBS surgeons from 42 countries participated in the Modified Delphi consensus to vote on 30 statements in two rounds. An agreement/disagreement among ≥ 70.0

In response to the unremitting rise of childhood obesity in the United States,1,2 a growing body of literature supports the utilization of metabolic and bariatric surgery (MBS) for the treatment of severe obesity (body mass index [BMI] ≥120% of the 95th percentile or BMI ≥35 kg/m2) in the pediatric population.3–5 In addition to offering important insight regarding the physiologic and psychosocial phenotypes observed among individuals presenting for MBS, numerous studies to date have shown improvement and/or complete resolution of most comorbid conditions with significant improvements in quality of life. Despite favorable results and a recent rise in procedural prevalence, ongoing controversy, including professional bias related to the treatment of childhood obesity and misinformation among the general public, access to care remains limited compared with the corresponding adult population.6–10 In a series of recently published policy statements and clinical practice guidelines, the American Academy of Pediatrics (AAP) and the American Society of Metabolic and Bariatric Surgery have recommended approaches to address disparities in the use of MBS in the pediatric population and have unambiguously stated that pediatric health care providers should refer eligible patients to comprehensive multidisciplinary pediatric MBS centers.2–4In this issue of Pediatrics, Shapiro et al describe the proportion of adolescents receiving care in a large multicenter health care system in Southern California that met clinical criteria to receive MBS.11 Among the 603 041 adolescents included in the analysis, 9.3% (n = 56 082) were classified as having class 2 obesity or higher (5.4% class 2 and 3.9% class 3), thus satisfying anthropomorphic qualifications for bariatric surgical eligibility. Interestingly, the initial exclusion of 10 individuals from the analysis cohort because of a history of having had a bariatric procedure, representing a procedural prevalence of only 0.002%, stands out as a striking reminder of the relative infrequency of MBS in the pediatric population. Additionally, the low frequency of MBS highlights the disparity of access to care compared with the procedural prevalence (1%) often cited in the adult population.12,13Although the current study offers important insights into patient eligibility and associated availability of MBS, it also highlights important limitations associated with retrospective analysis of large administrative data sets that should prompt the need for additional prospective and uniform multi-institutional studies. For example, although the reported prevalence of obesity with the study cohort (22.2%) appears to align with previous reports, including 10% being considered class 2 obesity or higher, the associated prevalence of related comorbid diseases across the entirety of the cohort may be a gross underestimation in that the authors found only 3.2% had gastroesophageal reflux, 0.5% nonalcoholic fatty liver disease, 0.4% Blount disease, and 0.4% type 2 diabetes. Although it is acknowledged that direct comparison of the reported disease prevalence with prospective interventional studies related to adolescent MBS is difficult, these low percentages differ from comorbid illnesses observed among the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABORATORIES) study cohort, the largest prospective observation study of adolescents undergoing MBS. For example, Teen-LABS reported significantly higher rates of obesity-related illnesses, including obstructive sleep apnea (57%), hypertension (45%), nonalcoholic fatty liver disease (37%), type 2 diabetes (14%), and Blount disease (4%), to name a few.14Reading between the lines, the current report not only shows the underuse of MBS to treat severe childhood obesity but serves to highlight the potential lack of evaluation for underlying comorbidities within the affected pediatric population. Furthermore, the highly heterogeneous composition of the study cohort (ie, >65% ethnic minorities) serves to support recent data demonstrating disparities in care related to race, ethnicity, and socioeconomic status of youth undergoing MBS.15,16Although the root causes responsible for a failure to recognize and treat severe obesity are multifactorial, including systemic biases pertaining to the nature and treatment of obesity as a disease and the inadequate access to pediatric obesity–directed multidisciplinary care; the outcome is leaving the current generation of children extremely vulnerable to the cumulative impact of untreated disease. As clearly demonstrated in recent large longitudinal studies, untreated childhood obesity will undoubtedly lead to higher rates of cardiometabolic disease risk and related rates of early mortality.17,18In addition to continued efforts to expand our overarching knowledge related to health outcomes after MBS in the pediatric population, robust efforts must be undertaken to address the systemic shortcomings resulting in significant disparities of care on an individual, organizational, and governmental level as outlined by the AAP. Pediatricians need to heed the AAP recommendations for screening and treatment of comorbidities and obesity simultaneously. Open discussion of MBS and its benefits should start at the primary care level. More centers using advanced therapies for pediatric obesity must be funded by insurance and Centers for Medicare & Medicaid Services. Systemic bias with regard to pediatric obesity and its treatment must be counteracted with better education about the genetic nature, the aggressive progression, and the effective treatments for pediatric obesity. In most pediatric patients meeting BMI eligibility criteria for MBS, surgery will be delayed by limited access to MBS programs, insurance denials, or simply never being referred. The opportunity for a health system like that studied here is immense: as an integrated care system, the institution of standard screening for comorbidities based on BMI and standard referrals to advanced therapies such as MBS could become a reality.