Surgical Weight Loss
for Adolescents

An Interview with Kirk Reichard, MD, ASMBS Pediatric Surgery Committee Chair

Published in July 2013 Issue             

The increasing incidence of morbid obesity, Type 2 diabetes, obstructive sleep apnea, nonalcoholic fatty liver disease, hypertension and cardiovascular risk factors in children and adolescents has been dramatic. According to the Centers for Disease Control and Prevention (CDC), obesity has more than doubled in children and tripled in adolescents in the past 30 years. In 2010, more than one-third were overweight or obese and about 215,000 Americans younger than 20 years old had either Type 1 or Type 2 diabetes.

These alarming statistics have given rise to greater consideration of bariatric surgery for a younger population. Since its inception in 2007, the ASMBS Pediatric Surgery Committee has been at the forefront in helping to define best practices and the role bariatric and metabolic surgery should play in treating disease.

connect recently interviewed Kirk Reichard, MD, FACS, FAAP, ASMBS Pediatric Surgery Committee Chair, about the work of the 23-member committee, the unique challenges clinicians facing in treating a pediatric population for obesity and related diseases, and the committee's goals for the future.

connect:  Why was the ASMBS Pediatric Surgery Committee formed in 2007?

The committee was formed at a time when less adolescent procedures were being performed and limited data on the risks and benefits of bariatric surgery in this patient population was available. However, interest in bariatric surgery for adolescents with severe obesity was increasing since studies were suggesting that the results achieved in adolescents were comparable to those in adults. Additionally, non-surgical approaches were having (and are still having) limited success in this population. Many of us in the society saw a real need to provide leadership in this emerging area and the committee was formed to do just that. Over the last six years the committee has quickly developed into an authoritative resource focused on all aspects of bariatric care for the adolescent patient. The committee membership is a blend of pediatric and adult bariatric surgeons and integrated health professionals experienced in addressing the unique issues facing adolescents.

connect: What are the major focus areas for the committee?  

We have worked very hard to foster awareness and understanding of the surgical treatment of morbid obesity in teens. This includes providing data, expert opinion and best practices information about surgical methods, patient selection, informed consent, ethical considerations, perioperative care, aftercare and patient compliance. We've done this through educational activities and presentations at the ASMBS Annual Meeting and through collaborations with the American Academy of Pediatrics, American College of Surgeons and other organizations. In addition, we're focused on improving access to care, which remains a challenge in both the adult and adolescent
patient population.

connect:  What have been some of the biggest developments in the area of adolescent bariatric surgery over the last few years?

The 2009 publication of "Best Practice Updates for Pediatric/Adolescent Weight Loss Surgery," in the journal Obesity was an important development. Co-authored by ASMBS members including Drs. Pratt, Lenders, Inge, Meyers, Rosenblum and Sanchez, this paper updated evidence-based best practice guidelines for pediatric/adolescent weight loss surgery. In 2011, the ASMBS Pediatric Committee abstracted from this update and supplemented it with more recent publications, including a systematic review and meta-analysis, and published its own best-practice guidelines in SOARD. These guidelines cover the prevention of early obesity related mortality and morbidity, patient selection criteria, and the long-term outcomes of adolescent bariatric surgery.

This publication was a seminal moment in that this was the first time the ASMBS as a whole took an official position on bariatric surgery for adolescents. It sparked healthy conversation and debate inside and outside the society, which raised awareness and understanding of the critical issues facing adolescents and the state of the evidence on bariatric surgery for this population. Debate still continues in various circles, but since its publication, we've seen more insurance companies acknowledge that bariatric surgery can be an option for pediatric patients, which was rarely done in the past. There's more work to do in this area, but progress is being made.

Another important effect of the guidelines was that it gave us a seat at the table when discussing credentialing. The guidelines made it clear that specific criteria would be helpful in identifying surgeons qualified to perform bariatric surgery on adolescents. Dr. Marc Michalsky, former chair of our committee, is working with other members to develop those credentialing guidelines. In addition, an entire section of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) will be dedicated to adolescents, which is also a big step for greater acceptance of surgery and continuous
quality improvement.

connect:  According to a 2012 study published in  Archives of Pediatrics & Adolescent Medicine, the number of inpatient bariatric procedures among adolescents appear to have plateaued since 2003 to about 1,000 procedures annually. Do you expect the number of procedures to grow at some point and if so, what will trigger that growth?

The prevalence of morbid obesity in adolescents is conservatively estimated at 1 million. The growth of obesity rates have leveled off some, but are likely to continue to rise some in the near term. The main drivers in the flattening of the number of procedures are likely to be related more to access than demand. The work of the Pediatric Committee and of the MBSAQIP is designed to address this. We will also be seeing outcome data from the Teen-Longitudinal Assessment of Bariatric Surgery
(Teen-LABS) consortium this year.

connect:  Do you think there is greater acceptance of bariatric surgery for adolescents amongst surgeons who treat adults only?

Yes. We have seen very good attendance at our plenary sessions, even amongst bariatric surgeons that traditionally only treat adults. Not every adult bariatric surgeon is going to be interested in operating on teens, but most will come into contact with them, be it through referrals, or even just the son or daughter of an adult patient. These surgeons realize that they need to know how to approach and deal with adolescents with obesity, and so they’re interested in getting educated about available options and the state of the evidence. Each new study, I believe, leads to greater acceptance and the evidence is mounting. We are going to need surgeons who perform the surgery on adults to begin to include adolescents in their practices. There are not enough pediatric surgeons to serve the potential need. Each practice is going to have a different way of integrating pediatrics, whether it’s an adult program that includes adolescents, or a pediatric weight-management program that includes surgery as a treatment option.

connect:  What are some of the biggest challenges to treating severe obesity
in adolescents?

Obesity is a complex disease that adolescents will struggle with for a lifetime. Our challenge is find ways to prevent and stop the progression of the disease as early as possible. We cannot operate our way out of the childhood obesity crisis, but surgery is an important option for carefully selected patients. We must continue to provide leadership about its appropriate use in the appropriate setting and foster better understanding amongst all health professionals, insurers, government, policy makers and society at large. If we can do that, we can help many children live longer and healthier lives.

connect:  What is the committee currently working on?

We are working on creating an informational ‘toolkit’ for developing and existing pediatric centers, creating web content for the professional and public sections of the ASMBS website and developing a symposium for the plenary session at ObesityWeek.

Links are available to the 2011 and 2012 pediatric symposium presentations given by both surgeons and integrated health professionals, as well as Adolescent & Pediatric Obesity Related Journal References that include 38 different categories with a total of 363 references.

connect: What does the future hold for the ASMBS Pediatric Surgery Committee?

In the next three to five years, our goals are to establish well-defined criteria for adolescent programs, develop more collaboration between pediatric weight management programs and adult bariatric surgeons and have insurance companies cover pediatric patients more readily. It is my hope that bariatric surgery becomes as mainstream for pediatrics as it currently is for adults, that we continue to build collaboration with pediatric providers in the AAP as well as adult bariatric providers, and that more health care professionals with an interest in adolescent obesity become part of the ASMBS.

Kirk W. Reichard, MD, is Clinical Director of the Division of General Surgery at duPont Hospital for Children. He is a graduate of the University of Pennsylvania School of Medicine. Dr. Reichard served his fellowship in Pediatric Surgery at the St. Christopher’s Hospital for Children. He is certified by the American Board of Surgery in general and pediatric surgery. His special interests include pediatric bariatric surgery, pediatric surgical oncology, minimally invasive surgery, chest wall deformities, inflammatory bowel disease, and surgery
of newborns.