Does the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program bariatric risk/benefit calculator hold its weight? An assessment of its accuracy

BACKGROUND

Bariatric clinical calculators have already been implemented in clinical practice to provide objective predictions of complications and outcomes. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Surgical Risk/Benefit Calculator is the most comprehensive risk calculator in bariatric surgery.

OBJECTIVES

Evaluate the accuracy of the calculator predictions regarding the 30-day complication risk, 1-year weight loss outcomes, and comorbidity resolution.

SETTING

MBSAQIP-accredited center.

METHODS

All adult patients who underwent primary laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy at our institution between 2012 and 2019 were included. Baseline characteristics were used to generate the individualized outcome predictions for each patient through the bariatric risk calculator and were compared to actual patient outcomes. Statistical analysis was performed using c-statistics, linear regression models, and McNemmar chi-square test.

RESULTS

One thousand four hundred fifty-three patients with a median age of 45 (37, 55) and consisting of 80.1% females were included in the study. The c-statistics for the complications and comorbidity resolution ranged from .533 for obstructive sleep apnea remission to .675 for 30-day reoperation. The number of comorbidity resolutions predicted by the calculator was significantly higher than the actual remissions for diabetes, hyperlipidemia, hypertension and obstructive sleep apnea (P < .001). On average, the calculator body mass index (BMI) predictions deviated from the observed BMI measurement by 3.24 kg/m2. The RYGB procedure (Coef -.89; P = .005) and preoperative BMI (Coef -.4; P = .012) were risk factors associated with larger absolute difference between the predicted and observed BMI.

CONCLUSIONS

The MBSAQIP Surgical Risk/Benefit Calculator prediction models for 1-year BMI, 30-day reoperation, and reintervention risks were fairly well calibrated with an acceptable level of discrimination except for obstructive sleep apnea remission. The 1-year BMI estimations were less accurate for RYGB patients and cases with very high or low preoperative BMI measurements. Therefore, the bariatric risk calculator constitutes a helpful tool that has a place in preoperative counseling.

Metabolic and bariatric surgery for obesity in Prader Willi syndrome: systematic review and meta-analysis

Obesity is the leading cause of morbidity and mortality in patients with Prader-Willi Syndrome (PWS). Our objective was to compare changes in body mass index (BMI) after metabolic and bariatric surgery (MBS) for the treatment of obesity (BMI ≥35 kg/m2) in PWS. A systematic review of MBS in PWS was performed using PubMed, Embase, and Cochrane Central, identifying 254 citations. Sixty-seven patients from 22 articles met criteria for inclusion in the meta-analysis. Patients were organized into 3 groups: laparoscopic sleeve gastrectomy (LSG), gastric bypass (GB), and biliopancreatic diversion (BPD). No mortality within 1 year was reported in any of the 3 groups after a primary MBS operation. All groups experienced a significant decrease in BMI at 1 year with a mean reduction in BMI of 14.7 kg/m2 (P < .001). The LSG groups (n = 26) showed significant change from baseline in years 1, 2, and 3 (P value at year 3 = .002) but did not show significance in years 5, 7, and 10. The GB group (n = 10) showed a significant reduction in BMI of 12.1 kg/m2 in the first 2 years (P = .001). The BPD group (n = 28) had a significant reduction in BMI through 7 years with an average reduction of 10.7 kg/m2 (P = .02) at year 7. Individuals with PWS who underwent MBS had significant BMI reduction sustained in the LSG, GB, and BPD groups for 3, 2, and 7 years, respectively. No deaths within 1 year of these primary MBS operations were reported in this study or any other publication.

Assessment of gastric pouch blood supply with indocyanine green fluorescence in conversional and revisional bariatric surgery: a prospective comparative study

Our study aimed to evaluate the usefulness of indocyanine green (ICG) angiography during conversional or revisional bariatric surgery. We prospectively enrolled all patients scheduled for reoperative bariatric surgery with gastric pouch resizing and ICG assessment and we compared them with a retrospective series of similar patients who did not receive ICG. The primary outcome was the rate of intraoperative change in the surgical strategy due to the ICG test. We included 32 prospective patients receiving intraoperatively an ICG perfusion test and 48 propensity score-matched controls. The mean age was 50.7 ± 9.7 years, 67 (83.7%) patients were female, and the mean BMI was 36.8 ± 5.3 kg/m2. The patient characteristics were similar in both groups. The ICG angiography was successfully conducted in all patients, and no change of the surgical strategy was necessary. Postoperative complications were similar in both groups (6.2% vs. 8.3%, p = 0.846), as well as operative time (125 ± 43 vs. 133 ± 47 min, p = 0.454) and length of hospital stay (2.8 ± 1.0 vs. 3.3 ± 2.2 days, p = 0.213). Our study suggested that ICG fluorescence angiography might not have been useful for assessing the blood supply of the gastric pouch in patients who underwent reoperative bariatric surgery. Therefore, it remains uncertain whether the application of this technique is indicated.

Quality evaluation of metabolic and bariatric surgical guidelines

OBJECTIVE

To evaluate the quality of surgical guidelines on bariatric/metabolic surgery.

METHODS

Four independent reviewers used the AGREE II (The Appraisal of Guidelines for Research and Evaluation II) tool to assess the methodological quality of the included guidelines and conducted a comparative analysis of the main recommendations for surgical methods of these guidelines.

RESULTS

Nine surgical guidelines were included in this study. Five articles with AGREE II scores over 60% are worthy of clinical recommendation. The field of rigor of development was relatively low, with an average score of 50.82%. Among 15 key recommendations and the corresponding best evidence in the guidelines, only 4 key recommendations were grade A recommendations.

CONCLUSIONS

The quality of metabolic and bariatric guidelines is uneven, and there is much room for improvement.

Defining Global Benchmarks in Elective Secondary Bariatric Surgery Comprising Conversional, Revisional, and Reversal Procedures

OBJECTIVE

To define "best possible" outcomes for secondary bariatric surgery (BS).

BACKGROUND

Management of poor response and of long-term complications after BS is complex and under-investigated. Indications and types of reoperations vary widely and postoperative complication rates are higher compared to primary BS.

METHODS

Out of 44,884 BS performed in 18 high-volume centers from 4 continents between 06/2013-05/2019, 5,349 (12%) secondary BS cases were identified. Twenty-one outcome benchmarks were established in low-risk patients, defined as the 75th percentile of the median outcome values of centers. Benchmark cases had no previous laparotomy, diabetes, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, thromboembolic events, BMI> 50 kg/m2 or age> 65 years.

RESULTS

The benchmark cohort included 3143 cases, mainly females (85%), aged 43.8 ± 10 years, 8.4 ± 5.3 years after primary BS, with a BMI 35.2 ± 7 kg/m2. Main indications were insufficient weight loss (43%) and gastro-esophageal reflux disease/dysphagia (25%). 90-days postoperatively, 14.6% of benchmark patients presented ≥1 complication, mortality was 0.06% (n = 2). Significantly higher morbidity was observed in non-benchmark cases (OR 1.37) and after conversional/reversal or revisional procedures with gastrointestinal suture/stapling (OR 1.84). Benchmark cutoffs for conversional BS were ≤4.5% re-intervention, ≤8.3% re-operation 90-days postoperatively. At 2-years (IQR 1-3) 15.6% of benchmark patients required a reoperation.

CONCLUSION

Secondary BS is safe, although postoperative morbidity exceeds the established benchmarks for primary BS. The excess morbidity is due to an increased risk of gastrointestinal leakage and higher need for intensive care. The considerable rate of tertiary BS warrants expertise and future research to optimize the management of non-success after BS.

Association of Bariatric Surgery With Vascular Outcomes

IMPORTANCE

Bariatric surgical weight loss is associated with reduced cardiovascular mortality; however, the mechanisms underlying this association are incompletely understood.

OBJECTIVES

To identify variables associated with vascular remodeling after bariatric surgery and to examine how sex, race, and metabolic status are associated with microvascular and macrovascular outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This population-based longitudinal cohort included 307 individuals who underwent bariatric surgery. Participants were enrolled in the bariatric weight loss program at Boston Medical Center, a large, multi-ethnic urban hospital, with presurgical and postsurgical assessments. Data were collected from December 11, 2001 to August 27, 2019. Data were analyzed in September 2019.

EXPOSURE

Bariatric surgery.

MAIN OUTCOMES AND MEASURES

Flow-mediated dilation (FMD) and reactive hyperemia (RH) (as measures of macrovascular and microvascular function, respectively) and clinical variables were measured preoperatively at baseline and at least once postoperatively within 12 months of the bariatric intervention.

RESULTS

A total of 307 participants with obesity (mean [SD] age, 42 [12] years; 246 [80%] women; 199 [65%] White; mean [SD] body mass index, 46 [8]) were enrolled in this study. Bariatric surgery was associated with significant weight loss and improved macrovascular and microvascular function across subgroups of sex, race, and traditional metabolic syndrome (mean [SD] pre- vs postsurgery weight: 126 [25] kg vs 104 [25] kg; P < .001; mean [SD] pre- vs postsurgery FMD: 9.1% [5.3] vs 10.2% [5.1]; P < .001; mean [SD] pre- vs postsurgery RH: 764% [400] vs 923% [412]; P < .001). Factors associated with change in vascular phenotype correlated most strongly with adiposity markers and several metabolic variables depending on vascular territory (eg, association of weight change with change in RH: estimate, -3.2; 95% CI, -4.7 to -1.8; association of hemoglobin A1c with change in FMD: estimate, -0.5; 95% CI, -0.95 to -0.05). While changes in macrovascular function among individuals with metabolically healthy obesity were not observed, the addition of biomarker assessment using high-sensitivity C-reactive protein plasma levels greater than 2 mg/dL identified participants with seemingly metabolically healthy obesity who had low-grade inflammation and achieved microvascular benefit from weight loss surgery.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that bariatric intervention is associated with weight loss and favorable remodeling of the vasculature among a wide range of individuals with cardiovascular risk. Moreover, differences in arterial responses to weight loss surgery by metabolic status were identified, underscoring heterogeneity in physiological responses to adiposity change and potential activation of distinct pathological pathways in clinical subgroups. As such, individuals with metabolically healthy obesity represent a mixed population that may benefit from more refined phenotypic classification.

Safety and feasibility of resuming bariatric surgery under the cloud of COVID-19

INTRODUCTION

Because of the COVID-19 pandemic, numerous bariatric surgical units globally have halted weight loss surgery. Obesity itself has been shown to be a predictor of poor outcome in people infected with the virus. The aim of this study was to report our experience as a high-volume bariatric institution resuming elective weight loss surgery safely amidst emergency admissions of COVID-19-positive patients.

METHODS

A standard operating procedure based on national guidance and altered to accommodate local considerations was initiated across the hospital. Data were collected prospectively for 50 consecutive patients undergoing bariatric surgery following recommencement of elective surgery after the first national lockdown in the UK.

RESULTS

Between 28 June and 5 August 2020, a total of 50 patients underwent bariatric surgery of whom 94% were female. Median age was 41 years and median body mass index was 43.8 (interquartile range 40.0-48.8)kg/m2. Half of the patients (n = 25/50) underwent laparoscopic sleeve gastrectomy and half underwent Roux-en-Y gastric bypass (RYGB). Of these 50 patients, 9 (18%) had revisional bariatric surgery. Overall median length of hospital stay was 1 day, with 96% of the study population being discharged within 24h of surgery. The overall rate of readmission was 6% and one patient (2%) returned to theatre with an obstruction proximal to jejuno-jejunal anastomosis. None of the patients exhibited symptoms or tested positive for COVID-19.

CONCLUSION

With appropriately implemented measures and precautions, resumption of bariatric surgery during the COVID-19 pandemic appears feasible and safe with no increased risk to patients.

Learning Curves of Laparoscopic Roux-en-Y Gastric Bypass and Sleeve Gastrectomy in Bariatric Surgery: a Systematic Review and Introduction of a Standardization

BACKGROUND

The most commonly performed bariatric procedures are laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (LSG). Impact of learning curves on operative outcome has been well shown, but the necessary learning curves have not been clearly defined. This study provides a systematic review of the literature and proposes a standardization of phases of learning curves for RYGB and LSG.

METHODS

A systematic literature search was performed using PubMed, Web of Science, and CENTRAL databases. All studies specifying a number or range of approaches to characterize the learning curve for RYGB and LSG were selected.

RESULTS

A total of 28 publications related to learning curves for 27,770 performed bariatric surgeries were included. Parameters used to determine the learning curve were operative time, complications, conversions, length of stay, and blood loss. Learning curve range was 30-500 (RYGB) and 30-200 operations (LSG) according to different definitions and respective phases of learning curves. Learning phases described the number of procedures necessary to achieve predefined skill levels, such as competency, proficiency, and mastery.

CONCLUSIONS

Definitions of learning curves for bariatric surgery are heterogeneous. Introduction of the three skill phases competency, proficiency, and mastery is proposed to provide a standardized definition using multiple outcome variables to enable better comparison in the future. These levels are reached after 30-70, 70-150, and up to 500 RYGB, and after 30-50, 60-100, and 100-200 LSG. Training curricula, previous laparoscopic experience, and high procedure volume are hallmarks for successful outcomes during the learning curve.

Type 2 diabetes and metabolic surgery guidelines and recommendations should urgently be unified

Metabolic surgery has been studied in the last decades as an effective and safe treatment for type 2 diabetes (T2D), and randomized controlled trials generally found surgery superior when compared with medical treatment. In 2016, the DSS-II Joint Statement recognized the importance of metabolic surgery in the treatment of T2D and urged clinicians to discuss, recommend, or at least consider this procedure for their patients. Diabetes societies also cogitate metabolic surgery as an option for T2D patients in their guidelines. However, there are some differences in recommendations that could lead a careful reader to some confusion. This was potentialized in a recent document published by the same DSS-II group concerning prioritization for surgery after the COVID-19 pandemic, in which the criteria suggested for an expedited recommendation that is not exactly evidence-based, and collided substantially with several clinical guidelines worldwide, especially with regard to secondary prevention of cardiovascular disease. A more harmonious discussion and unified guidelines between clinicians and surgeons are needed in order to provide the same message for those who read different articles.

Obesity and SARS-CoV-2: Considerations on bariatric surgery and recommendations for the start of surgical activity

The SARS-CoV-2 pandemic has a great impact worldwide, being Spain one of the most affected countries. The delay in bariatric surgery can have fatal consequences since up to 50% of the patients who are on the waiting list develop a new comorbidity during the time they remain on it and 1.5% of patients die while waiting for the intervention. That is why bariatric surgery should not be delayed, if the occupation of the hospital by COVID-19+ patients decreases significantly, and sufficient resources and safety are available to restart surgery in patients with benign pathology. This document contains the main recommendations for the bariatric surgery programs in our country from the point of view of safety, bariatric patient preparation and follow up during the SARS-CoV-2 pandemia.

Does Focus Improve Performance in Elective Surgery? A Study of Obesity Surgery in Sweden

Recent studies have found positive effects from hospital focus on both quality and cost. Some studies indicate that certain patient segments benefit from focus, while others have worse outcomes in focused hospital departments. The aim of this study was to establish the relationship between hospital focus and performance in elective surgery. We studied obesity surgery procedures performed in Sweden in 2016 (5152 patients), using data from the Scandinavian Obesity Surgery Registry (SOReg) complemented by a survey of all clinics that performed obesity surgery. We examined focus at two levels of the organization: hospital level and department level. We hypothesized that higher proportions of obesity surgery patients in the hospital, and higher proportions of obesity surgery procedures in the department, would be associated with better performance. These hypotheses were tested using multilevel regression analysis, while controlling for patient characteristics and procedural volume. We found that focus was associated with improved outcomes in terms of reduced complications and shorter procedure times. These positive relationships were present at both hospital and department level, but the effect was larger at the department level. The findings imply that focus is a viable strategy to improve quality and reduce costs for patients undergoing elective surgery. For these patients, general hospitals should consider implementing organizationally separate units for patients undergoing elective surgery.

SOFFCO-MM guidelines for the resumption of bariatric and metabolic surgery during and after the Covid-19 pandemic

Bariatric/metabolic surgery was paused during the Covid-19 pandemic. The impact of social confinement and the interruption of this surgery on the population with obesity has been underestimated, with weight gain and worsened comorbidities. Some candidates for this surgery are exposed to a high risk of mortality linked to the pandemic. Obesity and diabetes are two major risk factors for severe forms of Covid-19. The only currently effective treatment for obesity is metabolic surgery, which confers prompt, lasting benefits. It is thus necessary to resume such surgery. To ensure that this resumption is both gradual and well-founded, we have devised a priority ranking plan. The flow charts we propose will help centres to identify priority patients according to a benefit/risk assessment. Diabetes holds a central place in the decision tree. Resumption patterns will vary from one centre to another according to human, physical and medical resources, and will need adjustment as the epidemic unfolds. Specific informed consent will be required. Screening of patients with obesity should be considered, based on available knowledge. If Covid-19 is suspected, surgery must be postponed. Emphasis must be placed on infection control measures to protect patients and healthcare professionals. Confinement is strongly advocated for patients for the first month post-operatively. Patient follow-up should preferably be by teleconsultation.

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.

Rethinking Patient and Medical Professional Perspectives on Bariatric Surgery as a Medically Necessary Treatment

The prevalence of class 3 obesity (body mass index ≥40 kg/m²) is 7.7% of the United States adult population; thus, more than 25 million people may be medically appropriate for consideration of bariatric surgery as therapy for severe obesity. Although bariatric surgery is the most effective therapy for patients with severe obesity, the surgery is performed in less than 1% of patients annually for whom it may be appropriate. Patients' and medical professionals' misperceptions about obesity and bariatric surgery create barriers to accessing bariatric surgery that are not given adequate attention and clinical consideration. Commonly cited patient barriers are lack of knowledge about the severity of obesity, the perception that obesity is a lifestyle problem rather than a chronic disease, and fear that bariatric surgery is dangerous. Medical professional barriers include failing to recognize causes of obesity and weight gain, providing recommendations that are inconsistent with current obesity treatment guidelines, and being uncomfortable counseling patients about treatment options for severe obesity. Previous research has revealed that medical professional counseling and accurate perception of the health risks associated with severe obesity are strong predictors of patients' willingness to consider bariatric surgery. This article reviews patient and medical professional barriers to acceptance of bariatric surgery as a treatment of medical necessity and offers practical advice for medical professionals to rethink perspectives about bariatric surgery when it is medically and psychologically appropriate.

Lifestyle and pharmacologic management before and after bariatric surgery

As metabolic and bariatric surgery (MBS) increasingly becomes a treatment of choice for adolescents with severe obesity, there is a need to understand how to deliver pre- and postoperative care in ways that maximize long-term safety and efficacy. This article describes major pre- and postoperative goals, lifestyle modification targets, and, when necessary, pharmacologic management strategies for adolescents undergoing MBS. Three categories of evidence were used-studies of pre- and postoperative interventions and factors influencing MBS outcomes in adolescents, studies of pre- and postoperative associations and interventions in adults, and studies of non-surgical weight management applicable to adolescents pursuing MBS. Finally, priority areas for future research within this topic are identified.

Bariatric Surgery: Safety, Efficacy, Disease State, Collaboration, Future

Obesity provides an opportunity for bariatric and orthopedic surgeons to collaborate through emphasis on safety, effectiveness and patient experience. A value equation can be offered for combining weight loss for the patient with obesity and joint disease.

[Meta-analysis on safety of application of enhanced recovery after surgery to laparoscopic bariatric surgery]

OBJECTIVE

To systematically review the safety of application of enhanced recovery after surgery(ERAS) to laparoscopic bariatric surgery.

METHODS

The randomized controlled trials (RCTs) or case-controlled trials concerning application of ERAS principles in bariatric surgery were collected by searching several national and international online databases, including PubMed, Cochrane Library, CNKI, EMBASE and Wanfang databases. Data collection was completed in October 2016. The ERAS protocol covered three phases (preoperative, intraoperative, and postoperative), including preoperative counseling, reduced fasting, early ambulation, early oral feeding, etc. The endpoints included at least one of the following parameters: length of stay (LOS), operation time, readmission rate within 30 days, morbidity of postoperative complication (major/minor), and reoperation rate within 30 days. The quality of enrolled literatures was evaluated according to Cochrane Handbook and Newcastle-Ottawa Scale. RevMan 5.2 software was applied to perform meta analysis. The weighted mean difference (WMD) was used to combine the statistics for the measurement data, and the ratio and its 95% confidence interval were used to combine the statistics for the counting data. Subgroup analysis was conducted based on the quality of the enrolled literatures for the results of high heterogeneity.

RESULTS

A total of 7 studies, including 1 randomized controlled trail and 6 case-control studies, with 3264 patients were enrolled. Among the 3264 patients, 2051 received ERAS management (ERAS group) and 1213 received traditional perioperative management (control group). Meta analysis showed that compared with control group, ERAS group had shorter operative time (WMD=-17.56, 95%CI: -29.50 to -5.62, P=0.00), shorter length of hospital stay (WMD=-1.11, 95%CI: -1.31 to -0.92,P=0.00). There were no statistically significant differences between the two groups in the morbidity of postoperative major complication(OR=1.21, 95%CI:0.87 to 1.69, P=0.26) or minor complication (OR=1.25, 95%CI:0.99 to 1.58, P=0.06), re-admission rate within 30 days (OR=1.07, 95%CI: 0.81 to 1.43, P=0.63) and re-operation rate within 30 days(OR=1.33, 95%CI: 0.84 to 2.11, P=0.23).

CONCLUSION

Application of ERAS protocols to bariatric surgery is safe and feasible, which can also reduce length of hospital stay and operative time, and accelerate recovery.

Current guidelines for the management of non-alcoholic fatty liver disease: A systematic review with comparative analysis

The current epidemic of non-alcoholic fatty liver disease (NAFLD) is reshaping the field of hepatology all around the world. The widespread diffusion of metabolic risk factors such as obesity, type2-diabetes mellitus, and dyslipidemia has led to a worldwide diffusion of NAFLD. In parallel to the increased availability of effective anti-viral agents, NAFLD is rapidly becoming the most common cause of chronic liver disease in Western Countries, and a similar trend is expected in Eastern Countries in the next years. This epidemic and its consequences have prompted experts from all over the word in identifying effective strategies for the diagnosis, management, and treatment of NAFLD. Different scientific societies from Europe, America, and Asia-Pacific regions have proposed guidelines based on the most recent evidence about NAFLD. These guidelines are consistent with the key elements in the management of NAFLD, but still, show significant difference about some critical points. We reviewed the current literature in English language to identify the most recent scientific guidelines about NAFLD with the aim to find and critically analyse the main differences. We distinguished guidelines from 5 different scientific societies whose reputation is worldwide recognised and who are representative of the clinical practice in different geographical regions. Differences were noted in: the definition of NAFLD, the opportunity of NAFLD screening in high-risk patients, the non-invasive test proposed for the diagnosis of NAFLD and the identification of NAFLD patients with advanced fibrosis, in the follow-up protocols and, finally, in the treatment strategy (especially in the proposed pharmacological management). These difference have been discussed in the light of the possible evolution of the scenario of NAFLD in the next years.

Effective Implementation of Peri-operative Local Guidelines for Metabolic Surgery in Patients with Diabetes Mellitus in a Tier 4 Setting Demonstrate Improved Work Efficiency and Resource Allocation

BACKGROUND

Dynamic changes in glycaemia predominate peri-operatively in patients with type 2 diabetes mellitus (T2DM) undergoing metabolic surgery. There is a lack of consensus and clear guidance on effective glycaemic management of such patients. The aim of this study was to design, pilot, and implement a proforma to improve consistency of glycaemic management and clarity of communication with healthcare professionals following metabolic surgery in patients with T2DM, thereby reducing unnecessary diabetes specialist nurse (DSN) referrals.

METHODS

A proforma was designed and piloted for 12 months to guide healthcare professionals on managing glycaemic therapies for T2DM patients undergoing metabolic surgery. Glycaemic control (HbA1c) and glycaemic therapies were reviewed 3 weeks pre-operatively and a proforma was completed accordingly.

RESULTS

Of the patients with T2DM (n = 34) who underwent metabolic surgery prior to the new proforma being implemented, 71% (n = 24) had a DSN referral. Half of these referrals were deemed unnecessary by the DSNs. Of the patients with T2DM (n = 33) who underwent metabolic surgery following implementation of the proforma, 21% (n = 7) had a DSN referral. Only 10% of these were deemed unnecessary. Despite the reduced DSN input, no diabetes-related complications were reported.

CONCLUSION

Implementation of our proforma effectively halved the proportion of patients with T2DM requiring a DSN referral. Additionally, there was a 40% absolute reduction in the proportion of unnecessary DSN referrals. The proforma improved clarity of communication and guidance for healthcare professionals in the glycaemic management of patients. This also facilitated improved work efficiency and resource allocation.

ASMBS pediatric metabolic and bariatric surgery guidelines, 2018

The American Society for Metabolic and Bariatric Surgery Pediatric Committee updated their evidence-based guidelines published in 2012, performing a comprehensive literature search (2009-2017) with 1387 articles and other supporting evidence through February 2018. The significant increase in data supporting the use of metabolic and bariatric surgery (MBS) in adolescents since 2012 strengthens these guidelines from prior reports. Obesity is recognized as a disease; treatment of severe obesity requires a life-long multidisciplinary approach with combinations of lifestyle changes, nutrition, medications, and MBS. We recommend using modern definitions of severe obesity in children with the Centers for Disease Control and Prevention age- and sex-matched growth charts defining class II obesity as 120% of the 95th percentile and class III obesity as 140% of the 95th percentile. Adolescents with class II obesity and a co-morbidity (listed in the guidelines), or with class III obesity should be considered for MBS. Adolescents with cognitive disabilities, a history of mental illness or eating disorders that are treated, immature bone growth, or low Tanner stage should not be denied treatment. MBS is safe and effective in adolescents; given the higher risk of adult obesity that develops in childhood, MBS should not be withheld from adolescents when severe co-morbidities, such as depressed health-related quality of life score, type 2 diabetes, obstructive sleep apnea, and nonalcoholic steatohepatitis exist. Early intervention can reduce the risk of persistent obesity as well as end organ damage from long standing co-morbidities.

Five Years, Two Surgeons, and over 500 Bariatric Procedures: What Have We Learned?

BACKGROUND

Bariatric surgery has become an increasingly popular method for weight loss and mitigation of co-morbidities in the obese population. Like any field, there is a desire to standardize and accelerate the postoperative period while maintaining safe outcomes.

METHODS

All laparoscopic sleeve gastrectomies (LSG) and gastric bypasses (LGB) were performed over a 5-year period were logged along with several aspects of postoperative care. Trends were followed in aspects of postoperative care over years as well as any documentation of complications or re-admissions.

RESULTS

A total of 545 LSGs and LBPs were performed between 2012 and 2016. Improvements were noted in nearly every field over time, including faster Foley removal, decreased length of hospital stay, decreased use of patient controlled analgesics (PCAs), and faster advancement of diet. There was also an abandonment of utilization of the ICU and step down setting for these patients, leading to significant decreases in hospital cost. There was no change in complications, re-operations, or re-admission in this time period.

CONCLUSIONS

The surgeons involved in this project have built a busy bariatric surgery practice, while continually evolving the postoperative algorithm. Nearly every aspect of postoperative care has been deescalated while decreasing length of stay and cost to the hospital. All of this has been obtained without incurring any increase in complications, re-operations, or re-admissions. The authors of this paper hope to use this article as a launching point for a formal advanced recovery pathway for bariatric surgery at their institution and others.

Patient perspectives about bariatric surgery unveil experiences, education, satisfaction, and recommendations for improvement

BACKGROUND

Following bariatric surgery, up to 35% of patients struggle with strict regimens and experience weight recidivism within 2 years [1-5]. Accredited weight management centers (WMC) must provide educational programs and support patients in lifestyle changes before and after surgery. Educational programs, however, may not be evidence-based or patient-centered and may vary in curriculum, approach, and educator type [6].

OBJECTIVE

To obtain patient descriptions about the weight loss surgery (WLS) experience, including education, satisfaction, and recommendations for improvement.

SETTING

Participants were recruited from a university hospital-based WMC in Pennsylvania.

METHODS

This qualitative descriptive study used purposive sampling and inductive content analysis.

RESULTS

A NEW ME-VERSION 2.0, encompassed themes from semistructured interviews with 11 participants (36% male). Theme 1: Programming and Tools, explained how individuals undergoing WLS found support through educational programming. Theme 2: Updates and Upgrades, identified issues surrounding quality of life and challenges before and after surgery. Theme 3: Lessons Learned and Future Considerations, identified satisfaction levels and recommendations for improving the WLS experience. Participants reported positive experiences, acknowledging educational programs and extensive WMC resources, yet also offered recommendations for improving educational programming.

CONCLUSION

Patient narratives provided evidence about the WLS experience. Achievement of weight goals, adherence to rules, and improved health status contributed to perceptions of WLS success. Participants encouraged educators to identify expected outcomes of educational programming, monitor holistic transformations, foster peer support, and use technology in WMC programming. Results also validated the need for the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program's education requirement (standard 5.1). Future educational research could help develop best practices in WLS patient education and assess associations between education and clinical outcomes.

The history of metabolic and bariatric surgery: Development of standards for patient safety and efficacy

Weight loss surgery, also referred to as bariatric surgery, has been in existence since the 1950's. Over the decades, it has been demonstrated to successfully achieve meaningful and sustainable weight loss in a large number of patients who undergo these procedures. Additionally, the benefits observed across a number of metabolic disorders such as type 2 diabetes mellitus and hyperlipidemia, are often to a degree, independent of the weight loss, thus the term "metabolic bariatric surgery (MBS)" has become a better descriptor. Throughout its long history, MBS has evolved from an era of high morbidity and mortality to one of laudable safety despite the high-risk nature of the patients undergoing these major gastrointestinal procedures. This article will describe the historic evolution of MBS and concentrate on those events that were instrumental in reducing the morbidity of these operations.

Bariatric Surgery Registries: Can They Contribute to Improved Outcomes?

PURPOSE OF REVIEW

Clinical registries systematically collect prospective information about patients with a particular medical condition, who have had a medical device implanted or who have undergone a particular procedure. When these variables are collected with pre-defined quality indices included, the benched-marked risk-adjusted data may be a valuable resource for providing feedback on outcomes, including performance, to practitioners, patients, health services and device manufacturers.

RECENT FINDINGS

There are examples of feedback from clinical registries positively influencing patient care. The Australian National Joint Registry identified a poorly performing hip prosthesis which was ultimately withdrawn from the market. Feedback from the Victorian State Prostate Cancer Registry has contributed to improved patient care and fewer positive surgical margins noted over a 5-year reporting period. There are several national and regional registries collecting information on patients undergoing bariatric surgery, however, few currently focus on quality outcome measures. Whilst, current bariatric registries have contributed to improved understanding of some of the clinical situations relating to bariatric surgery, as well as developing composite risk scores and measuring quality cultures, they have not as yet demonstrably directly influenced patient care. This may reflect the fact that many of the registries do not hold data that are mature enough for proper analysis, but may also reflect problems with systematic data collection, bias from missing results and lack of appropriate funding. It will be important in the future that bariatric surgery registries actively seek to measure and validate their contribution to patient outcomes.

[Interpretation of the International Joint Statement on Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes]

Along with the soaring prevalence of obesity and type 2 diabetes mellitus (T2DM) globally, metabolic and bariatric surgery (MBS) has been rapidly developing into a major surgical subspecialty. However, the indications, benefits and potential risks of MBS are still controversial so far. In September 2015, the 2nd Diabetes Surgery Summit (DSS-II() was successfully convened, and later on an international joint statement on metabolic surgery in the treatment algorithm for T2DM was released based upon the consensus reached in DSS-II(, aiming to serve as a new global clinical guideline. The DSS-II( joint statement was initiated and endorsed by 5 leading international diabetes organizations, including American Diabetes Association (ADA), International Diabetes Federation (IDF), Chinese Diabetes Society (CDS), Diabetes India, as well as Diabetes UK, and was developed by an expert committee comprised of 48 international authorities as voting delegates. Up to the date of publication, the DSS-II( statement has been officially endorsed by 45 international professional associations/societies, including 30 non-surgical and 15 surgical organizations. In this statement, the following six aspects were recommended to differentiate MBS from traditional bariatric surgery: 1)The primary goal of MBS is to treat T2DM and to reduce the risk of T2DM complications; 2) In addition to a 50% or more of excess weight loss and normalization of glycemia, outcomes of diabetes complications should also be considered as clinical endpoints of MBS; 3) For patient selection, body mass index (BMI), T2DM treatment, as well as long-term risks versus benefits, including its effects on cardiovascular events (CVD), should all be considered; 4) T2DM and its complications, as well as pancreatic function reserve should be assessed pre-operatively; 5) Major surgical options include laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic sleeve gastrectomy (LSG), laparoscopic adjustable gastric banding (LAGB), and bilio-pancreatic diversion with duodenal switch(BPD-DS). BPD-DS has the best outcome in T2DM remission followed by LRYGB, LSG and LAGB; 6) Glycemic variation should be intensively monitored, and if needed, managed following surgery. Clinical follow-up should be conducted at least once every six months within two years after surgery. For patients achieving complete remission from T2DM, diabetes complications should still be monitored within five years after surgery with the same frequency and protocols as pre-operatively.

Quality Improvement Processes in Obesity Surgery Lead to Higher Quality and Value, Lower Costs

In the era of changes in the evaluation of medical services and performance, the Centers for Medicare and Medicaid Services (CMS) has determined that the key components are quality, value, and clinical practice improvement (MACRA). Weight Loss Surgery, also called Bariatric or Obesity Surgery, has been at the forefront of quality improvement and quality reporting through the Center of Excellence Program since 2005. As a result, weight loss surgery is now as safe as gallbladder surgery.1 Even within this culture of quality and safety, improvements are still possible, as described in this article. [Full article available at http://rimed.org/rimedicaljournal-2017-03.asp].

Hospital Charge and Health-Care Quality in Bariatric Surgery

To determine if hospital charges correlate with patient outcomes after bariatric surgery. A retrospective review of 46,180 patients who underwent bariatric surgery from 2004-2010 was performed. Patients were identified using the New York Statewide Planning and Research Cooperative System database. Hospitals were categorized on estimates from a multiple linear regression model for charge: low (<$25,027.00), medium ($25,027.00-$35,449.00), and high (≥$35,449.01). Patient outcomes were compared among the charge classification. Of the 46,180 patients, 24 per cent underwent operations in low-, 26 per cent in medium-, and 23,082 (50%) in high-charge hospitals. Controlling for patient demographics, comorbidity, insurance, and operative procedure, multivariable logistic regression demonstrated no significant difference in major complication or mortality among charges. Hospital charge does not correlate with improved outcomes. This is significant given the adverse association between price inflation and rising insurance premiums. Inflated hospital charges may also discriminate against certain patient populations including the uninsured and those with high-deductible insurance plans.

Review of Childhood Obesity: From Epidemiology, Etiology, and Comorbidities to Clinical Assessment and Treatment

Childhood obesity has emerged as an important public health problem in the United States and other countries in the world. Currently 1 in 3 children in the United States is afflicted with overweight or obesity. The increasing prevalence of childhood obesity is associated with emergence of comorbidities previously considered to be "adult" diseases including type 2 diabetes mellitus, hypertension, nonalcoholic fatty liver disease, obstructive sleep apnea, and dyslipidemia. The most common cause of obesity in children is a positive energy balance due to caloric intake in excess of caloric expenditure combined with a genetic predisposition for weight gain. Most obese children do not have an underlying endocrine or single genetic cause for their weight gain. Evaluation of children with obesity is aimed at determining the cause of weight gain and assessing for comorbidities resulting from excess weight. Family-based lifestyle interventions, including dietary modifications and increased physical activity, are the cornerstone of weight management in children. A staged approach to pediatric weight management is recommended with consideration of the age of the child, severity of obesity, and presence of obesity-related comorbidities in determining the initial stage of treatment. Lifestyle interventions have shown only modest effect on weight loss, particularly in children with severe obesity. There is limited information on the efficacy and safety of medications for weight loss in children. Bariatric surgery has been found to be effective in decreasing excess weight and improving comorbidities in adolescents with severe obesity. However, there are limited data on the long-term efficacy and safety of bariatric surgery in adolescents. For this comprehensive review, the literature was scanned from 1994 to 2016 using PubMed using the following search terms: childhood obesity, pediatric obesity, childhood overweight, bariatric surgery, and adolescents.

Patient Safety and Quality Improvement Initiatives in Contemporary Metabolic and Bariatric Surgical Practice

Patient safety and quality improvement have been part of bariatric surgery since its inception, and there have been significant improvements in outcomes of bariatric surgery over the past 2 decades. A strong accreditation program exists. This program defines 2 tiers of accredited centers: low-acuity and comprehensive centers similar to the trauma systems. Accreditation has been shown to have a favorable impact on outcomes of bariatric surgery. Bariatric surgery lends itself well to improvements in processes and use of perioperative protocols, such as ulcer and thromboembolic prophylaxis prevention or gallstone prevention and management.

Practical Recommendations of the Obesity Management Task Force of the European Association for the Study of Obesity for the Post-Bariatric Surgery Medical Management

Bariatric surgery is today the most effective long-term therapy for the management of patients with severe obesity, and its use is recommended by the relevant guidelines of the management of obesity in adults. Bariatric surgery is in general safe and effective, but it can cause new clinical problems and is associated with specific diagnostic, preventive and therapeutic needs. For clinicians, the acquisition of special knowledge and skills is required in order to deliver appropriate and effective care to the post-bariatric patient. In the present recommendations, the basic notions needed to provide first-level adequate medical care to post-bariatric patients are summarised. Basic information about nutrition, management of co-morbidities, pregnancy, psychological issues as well as weight regain prevention and management is derived from current evidences and existing guidelines. A short list of clinical practical recommendations is included for each item. It remains clear that referral to a bariatric multidisciplinary centre, preferably the one performing the original procedure, should be considered in case of more complex clinical situations.

A Core Outcome Set for the Benefits and Adverse Events of Bariatric and Metabolic Surgery: The BARIACT Project

BACKGROUND

Bariatric and metabolic surgery is used as a treatment for patients with severe and complex obesity. However, there is a need to improve outcome selection and reporting in bariatric surgery trials. A Core Outcome Set (COS), an agreed minimum set of outcomes reported in all studies of a specific condition, may achieve this. Here, we present the development of a COS for BARIAtric and metabolic surgery Clinical Trials-the BARIACT Study.

METHODS AND FINDINGS

Outcomes identified from systematic reviews and patient interviews informed a questionnaire survey. Patients and health professionals were surveyed three times and asked to rate the importance of each item on a 1-9 scale. Delphi methods provided anonymised feedback to participants. Items not meeting predefined criteria were discarded between rounds. Remaining items were discussed at consensus meetings, held separately with patients and professionals, where the COS was agreed. Data sources identified 2,990 outcomes, which were used to develop a 130-item questionnaire. Round 1 response rates were moderate but subsequently improved to above 75% for other rounds. After rounds 2 and 3, 81 and 14 items were discarded, respectively, leaving 35 items for discussion at consensus meetings. The final COS included nine items: "weight," "diabetes status," "cardiovascular risk," "overall quality of life (QOL)," "mortality," "technical complications of the specific operation," "any re-operation/re-intervention," "dysphagia/regurgitation," and "micronutrient status." The main limitation of this study was that it was based in the United Kingdom only.

CONCLUSIONS

The COS is recommended to be used as a minimum in all trials of bariatric and metabolic surgery. Adoption of the COS will improve data synthesis and the value of research data. Future work will establish methods for the measurement of the outcomes in the COS.

Accredited bariatric surgery centers have fewer postoperative complications

Eight of 11 studies that evaluated postoperative complications found that undergoing a bariatric operation in an accredited facility reduced the odds of experiencing a serious complication by 9 percent to 39 percent (odds ratios of 1.09 to 1.39), the researchers reported.

A population-based analysis of use and outcomes of laparoscopic bariatric surgery across socioeconomic groups in Taiwan

BACKGROUND

With the growing development of minimally invasive techniques for the treatment of morbid obesity, laparoscopic bariatric surgery (LBS) is increasingly performed. This study aimed to assess the association between patients' socioeconomic status (SES) and the likelihood of undergoing LBS and related outcomes in Taiwan.

METHODS

This nationwide population-based study was conducted by using data from Taiwan's National Health Insurance Research Database. A total of 3678 morbidly obese patients aged 18 years and older who underwent conventional open bariatric surgery or LBS were identified between 2004 and 2011. Regression analyses were performed using generalized estimating equation (GEE) models to account for the nesting of patients within physician to assess patients' SES category associated with the use of LBS and related outcomes. Odds ratios (ORs) and 95 % confidence intervals (CIs) were estimated.

RESULTS

Compared with those with medium and low SES (84.6 % and 80.2 %), patients with high SES (88.1 %) had the highest percentage of undergoing LBS (P < 0.001). After adjusting for patient demographics, institution and surgeon characteristics, the multivariate GEE analysis revealed that the highest likelihood of undergoing LBS was noted in morbidly obese patients with high SES (OR = 1.45, 95 % CI 1.10-1.90), followed by those with medium SES (OR = 1.27, 95 % CI 1.04-1.56). In addition, patients with high SES had slightly lower length of hospital stay (LOS; OR = 0.90, 95 % CI 0.82-0.99) and hospital treatment cost (OR = 0.93, 95 % CI 0.87-0.99) than their counterparts after adjustment.

CONCLUSIONS

The increased likelihood of undergoing LBS and lower LOS and hospital treatment cost were noted among morbidly obese patients with higher SES. This finding suggests there is the need to improve clinical practice and reduce health disparities in the surgical treatment of morbidly obese patients.

Obesity in children: bariatric surgery

INTRODUCTION

The prevalence of childhood obesity in the UK and in many countries worldwide remains high. Behavioural interventions to modify lifestyle, such as diet and physical activity, usually form part of weight management strategies for obese children. Whether or not surgical interventions are effective and safe in treating childhood obesity is unclear.

METHODS AND OUTCOMES

We conducted a systematic overview, aiming to answer the following clinical question: What are the effects of surgical interventions for the treatment of childhood obesity? We searched Medline, Embase, The Cochrane Library, and other important databases up to August 2014 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this overview).

RESULTS

At this update, after deduplication and removal of conference abstracts, 67 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 19 studies and the further review of 48 full publications. Of the 48 full articles evaluated, two systematic reviews were included at this update.

CONCLUSIONS

In this systematic overview, we categorised the efficacy for two comparisons based on information about the effectiveness and safety of bariatric surgery versus no intervention and different types of bariatric surgery versus each other.

Bariatric and metabolic surgery: a shift in eligibility and success criteria

The obesity epidemic, combined with the lack of available and effective treatments for morbid obesity, is a scientific and public health priority. Worldwide, bariatric and metabolic surgeries are increasingly being performed to effectively aid weight loss in patients with severe obesity, as well as because of the favourable metabolic effects of the procedures. The positive effects of bariatric surgery, especially with respect to improvements in type 2 diabetes mellitus, have expanded the eligibility criteria for metabolic surgery to patients with diabetes mellitus and a BMI of 30-35 kg/m(2). However, the limitations of BMI, both in the diagnosis and follow-up of patients, need to be considered, particularly for determining the actual adiposity and fat distribution of the patients following weight loss. Understanding the characteristics shared by bariatric and metabolic surgeries, as well as their differential aspects and outcomes, is required to enhance patient benefits and operative achievements. For a holistic approach that focuses on the multifactorial effects of bariatric and metabolic surgery to be possible, a paradigm shift that goes beyond the pure semantics is needed. Such a shift could lead to profound clinical implications for eligibility criteria and the definition of success of the surgical approach.

Interdisciplinary European guidelines on metabolic and bariatric surgery

In 2012, an expert panel composed of presidents of each of the societies, the European Chapter of the International Federation for the Surgery of Obesity (IFSO-EC), and of the European Association for the Study of Obesity (EASO), as well as of the chair of EASO Obesity Management Task Force (EASO OMTF) and other key representatives from IFSO-EC and EASO, devoted the joint Medico-Surgical Workshop of both institutions to the topic of metabolic surgery in advance of the 2013 European Congress on Obesity held in Liverpool. This meeting was prompted by the extraordinary advancement made in the field of metabolic and bariatric surgery during the past decade. It was agreed to revise and update the 2008 Interdisciplinary European Guidelines on Surgery of Severe Obesity produced by focusing in particular on the evidence gathered in relation to the effects on diabetes and the changes in the recommendations of patient eligibility criteria. The expert panel allowed the coverage of key disciplines in the comprehensive management of obesity and obesity-associated diseases, aimed specifically at updating the clinical guidelines to reflect current knowledge, expertise and evidence-based data on metabolic and bariatric surgery.

Adolescent bariatric surgery program characteristics: the Teen Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study experience

The number of adolescents undergoing weight loss surgery (WLS) has increased in response to the increasing prevalence of severe childhood obesity. Adolescents undergoing WLS require unique support, which may differ from adult programs. The aim of this study was to describe institutional and programmatic characteristics of centers participating in Teen Longitudinal Assessment of Bariatric Surgery (Teen-LABS), a prospective study investigating safety and efficacy of adolescent WLS. Data were obtained from the Teen-LABS database, and site survey completed by Teen-LABS investigators. The survey queried (1) institutional characteristics, (2) multidisciplinary team composition, (3) clinical program characteristics, and (4) clinical research infrastructure. All centers had extensive multidisciplinary involvement in the assessment, pre-operative education, and post-operative management of adolescents undergoing WLS. Eligibility criteria and pre-operative clinical and diagnostic evaluations were similar between programs. All programs have well-developed clinical research infrastructure, use adolescent-specific educational resources, and maintain specialty equipment, including high weight capacity diagnostic imaging equipment. The composition of clinical team and institutional resources is consistent with current clinical practice guidelines. These characteristics, coupled with dedicated research staff, have facilitated enrollment of 242 participants into Teen-LABS.

Bariatric surgery for obese children and adolescents: a review of the moral challenges

BACKGROUND

Bariatric surgery for children and adolescents is becoming widespread. However, the evidence is still scarce and of poor quality, and many of the patients are too young to consent. This poses a series of moral challenges, which have to be addressed both when considering bariatric surgery introduced as a health care service and when deciding for treatment for young individuals. A question based (Socratic) approach is applied to reveal underlying moral issues that can be relevant to an open and transparent decision making process.

DISCUSSION

A wide range of moral issues with bariatric surgery for children and adolescents is identified in the literature. There is a moral imperative to help obese minors avoiding serious health problems, but there is little high quality evidence on safety, outcomes, and cost-effectiveness for bariatric surgery in this group. Lack of maturity and family relations poses a series of challenges with autonomy, informed consent, assent, and assessing the best interest of children and adolescents. Social aspects of obesity, such as medicalization, prejudice, and discrimination, raise problems with justice and trust in health professionals. Conceptual issues, such as definition of obesity and treatment end-points, present moral problems. Hidden interests of patients, parents, professionals, industry, and society need to be revealed.

SUMMARY

Performing bariatric surgery for obese children and adolescents in order to discipline their behavior warrants reflection and caution. More evidence on outcomes is needed to be able to balance benefits and risks, to provide information for a valid consent or assent, and to advise minors and parents.