Evan Nadler, MD - 2024 Pediatric Bariatric Surgery Update Course

Approximately 0.05% of children who need bariatric surgery receive it, a rate well below adult treatment rates

MBSAQIP requirements for verified surgeon at freestanding children's hospital are 100 lifetime cases (75 can be as fellow) and 20 stapled cases per year

The 2019 AAP clinical guidelines did not have an age cutoff, but the newer guidelines introduced a cutoff of 13 years, representing a backward step

In MBSAQIP data of approximately 4800 teens and 50 preteens, preteens undergoing surgery had higher rates of insulin-dependent diabetes and sleep apnea compared to teens

Safety outcomes in preteens were the same or better than teens, following the pattern that younger patients have better outcomes

Decrease in BMI was the same between preteens and teens in propensity-matched MBSAQIP data

The youngest patients operated on were two 4-year-olds: one homozygous for MC4R receptor deficiency and one with Rohhad syndrome

Using percentiles instead of straight BMI values in insurance submissions can help with approval because insurance companies find percentiles confusing

In the DC area, there are no age cutoffs for bariatric surgery in most Medicaid programs after years of education, and approximately 90% of young patient cases are insurance approved

The ideal age to operate is somewhere between 12 and 14 because those kids still listen to their parents, are still developing habits, and do better than other age groups

10 and 11 year olds may do even better than 12-14 year olds because they go through puberty at normal or lower weight, listen to parents, and cannot access food without parental help

Off-label use of medications including phentermine, topiramate, Vyvanse, and GLP-1 agonists has been standard practice for years in young patients because the disease needs to be treated

Medications may be no safer than surgery, with less long-term data in children, similar gallstone risk, and likely higher weight regain due to medication cessation

Phentermine has less addictive properties than ADD medications

Younger patients in non-surgical weight management clinics are better at following instructions and have mental health issues addressed more appropriately, making post-surgical management easier

In a cohort of 490 patients from 2018-2022, 34 had special healthcare needs including autism spectrum disorder, intellectual/developmental disabilities, Trisomy 21, and Prader-Willi syndrome

Patients with special healthcare needs lost weight after bariatric surgery, though not quite as well as typically developing patients

When separated into autism spectrum disorder (16 patients) and intellectual/developmental disabilities (13 patients), autism spectrum kids may do better than IDD kids, though numbers were too low for statistical significance except at 6-month excess weight loss

Males tend to do better with obesity surgery than females

Some autism spectrum disorder patients are very black-and-white thinkers who follow post-operative rules extremely well

Patients with autism spectrum disorder and selective eating did better with their selective eating after surgery because post-operative requirements (protein, water, multivitamin) fit into their brain function as a new form of selective eating

Not all patients with special healthcare needs have high-functioning families with resources; some had parents who could barely care for their child, and surgery made care easier

Prader-Willi patients do not do as well with bariatric surgery but do better than if not operated on

Syndromic genetic obesity patients need everything: medications, surgery, and continued medications post-operatively

One surgical operation costs approximately $50,000, equivalent to 3-4 years of GLP-1 agonist therapy at current prices