Preoperative Optimization and Management - Caren Mangarelli, MD - 2024 Pediatric Bariatric Surgery Update Course

The American Academy of Pediatrics section on obesity published technical report and policy statement in 2019 with less conservative bariatric surgery criteria more aligned with adult criteria.

AAP 2019 selection criteria include BMI ≥40 or ≥140% of 95th percentile (whichever is lower), or BMI ≥35 or ≥120% of 95th percentile (whichever is lower) with a comorbid condition.

The 2019 AAP guidelines removed minimum age limits for bariatric surgery and changed from automatic exclusion to case-by-case consideration for patients with developmental disability or cognitive impairment.

Critical multidisciplinary team members are surgeon, medical specialist, behavioral/mental health specialist, and registered dietitian.

Since December 2020, the FDA has approved three new medications for obesity treatment in patients 12 years and older, including two GLP-1 medications.

The American Society of Anesthesiologists released consensus-based guidance recommending stopping daily GLP-1 medications on the day of procedure and weekly GLP-1 medications one week prior to procedure due to delayed gastric emptying and aspiration risk.

The Teen Labs 5-year data showed micronutrient deficiencies do occur postoperatively, with iron being the most common deficiency both pre- and postoperatively, followed by vitamin D.

The percentage of patients with micronutrient deficiencies increased over time postoperatively.

In the past year, the program had several patients present postoperatively with B1 (thiamine) deficiency and one with folate deficiency, prompting reconsideration of preoperative screening protocols.

Studies in adult populations up to 2 years have not shown that outcomes are different in patients who disclosed marijuana use.

Anxiety disorders have increased approximately 4 times pre- versus post-COVID.

Teen Labs data shows alcohol use disorder is not uncommon postoperatively and requires ongoing screening and patient/family education about risk.

Some insurance companies (CMS) require drug screens and deny coverage if results are positive.

One insurer has treated marijuana use similarly to nicotine smoking and requested ABG and pulmonary function tests.

Nicotine use leads to ulcers after gastric bypass surgery, making it contraindicated in bypass patients.

There is no data showing cannabis makes any difference in outcomes for sleeve gastrectomy.

Excess cannabis can lead to cannabis hyperemesis syndrome causing continuous vomiting.

A 2019 Surgery for Obesity and Related Diseases study of phentermine and topiramate before and after sleeve gastrectomy in adults with BMI >50 showed no negative signal and suggested greater weight loss both preoperatively and postoperatively when medications were continued.

Rapid gastric emptying induced by sleeve gastrectomy is believed to be part of the mechanism for increasing GLP-1 levels postoperatively.

Preoperative GLP-1 use could potentially interfere with post-bariatric surgery outcomes through feedback mechanisms affecting gastric emptying and receptor regulation, though no data currently exists on this question.