RECOMMENDATIONS FOR BARIATRIC SURGERY IN ADOLESCENTS IN AUSTRALIA AND NEW ZEALAND A position paper from the Australian and New Zealand Association of Paediatric Surgeons, the Obesity Surgery Society of Australia and New Zealand and the Paediatrics & Child Health Division of The Royal Australasian College of Physicians March 2010 1 Members of Working Party Professor Louise A Baur PhD FRACP; The Royal Australasian College of Physicians; Chair of Working Party Clin. A/Professor Dominic Fitzgerald PhD FRACP; The Royal Australasian College of Physicians Mr Gregory T Armstrong RN MPH; The Royal Australasian College of Physicians A/Professor Deborah Bailey FRACS; Board of Paediatric Surgery, The Royal Australasian College of Surgeons (RACS); Executive Council Australian and New Zealand Association Paediatric Surgeons (ANZAPS) Professor Jennifer Batch MD FRACP; The Royal Australasian College of Physicians A/Professor John Dixon; PhD, FRACGP, Obesity Research Unit, Monash University Mr Robert Fris MBChB FRCS FACS FACP; Obesity Surgery Society of Australia and New Zealand (OSSANZ) Dr Anne Kynaston FRACP; The Royal Australasian College of Physicians Mr Phillip Morreau FRACS; Board of Paediatric Surgery, The Royal Australasian College of Surgeons (RACS); Executive Council Australian and New Zealand Association Paediatric Surgeons (ANZAPS) Dr Joanne Morris MBBS; Advanced Trainee, The Royal Australasian College of Physicians Professor Kate Steinbeck PhD FRACP; The Royal Australasian College of Physicians Professor Richard Stubbs FRACS; The Wakefield Clinic, Wellington, NZ. Dr Friederike Veit MD FRACP; The Royal Australasian College of Physicians © The Royal Australasian College of Physicians, the Australian and New Zealand Association of Paediatric Surgeons and the Obesity Surgery Society of Australia and New Zealand, 2010 The Royal Australasian College of Physicians 145 Macquarie Street Sydney, New South Wales 2000, Australia Tel: +61 2 9256 5409 Fax: +61 2 9256 5465 Email: [email protected], website: www.racp.edu.au The Australian and New Zealand Association of Paediatric Surgeons College of Surgeons' Gardens Spring Street Melbourne VIC 3000, Australia Tel: +61 3 9276 7416 Fax: +61 3 9249 1240 Email: [email protected], website: www.paediatricsurgeons.org The Obesity Surgery Society of Australia and New Zealand College of Surgeons' Building 51-54 Palmer Place PO Box 668 North Adelaide, SA 5006, Australia Tel: 1800 OSSANZ Fax: 61 8 8267 3069 Email: [email protected] website: www.ossanz.com.au 2 Names and titles for a published paper Louise A Baur The Children’s Hospital at Westmead Clinical School, University of Sydney, NSW 2006, Australia; Email: [email protected] Dominic A. Fitzgerald Department of Respiratory Medicine, The Children’s Hospital at Westmead, Sydney. Clinical Associate Professor, The Children’s Hospital at Westmead Clinical School, University of Sydney, NSW 2006, Paediatrics & Child Health Policy and Advocacy Committee, The Royal Australasian College of Physicians, Sydney, NSW. Gregory T. Armstrong The Royal Australasian College of Physicians Brisbane Qld 4006 Deborah Bailey Department Paediatric Surgery, Gold Coast Hospital Southport Qld 4215 Jennifer Batch Director of Endocrinology and Diabetes, Royal Children's Hospital Herston. Qld 4029 John Dixon Head, Obesity Research Unit, School of Primary Health Care Monash University Melbourne Vic 3168 Robert Fris The Northern Clinic Auckland New Zealand 3 Anne Kynaston Royal Children's Hospital Herston. Qld 4029 Phillip Morreau Department of Paediatric Surgery, Starship Children's Health Auckland New Zealand Joanne Morris The Children’s Hospital at Westmead Sydney, NSW 2006 Kate Steinbeck Endocrinology & Adolescent Medicine, Royal Prince Alfred Hospital Camperdown NSW Australia 2050 Richard S Stubbs The Wakefield Clinic Wellington, NZ. Friederike Veit Centre for Adolescent Health, Royal Children’s Hospital, Parkville Melbourne VIC 3153 4 Table of contents 1. Introduction..........................................................................................................................6 2. Recommendations................................................................................................................7 3. The problem of obesity and its consequences....................................................................12 4. Access to treatment services for adolescent obesity..........................................................14 5. Bariatric surgery in adults..................................................................................................16 6. Bariatric surgery in adolescents.........................................................................................19 7. Assessing the ability to give informed consent for surgery - Gillick competence............23 8. References..........................................................................................................................25 Table 1. Studies of adjustable gastric banding in adolescents [adapted from Treadwell et al. 2008] [2].....................................................................................................................................24 5 1. Introduction The increasing prevalence of both obesity and obesity-associated complications in adolescents highlights the importance of primary prevention, as well as, effective treatment strategies. For those adolescents who are affected by obesity, the mainstay of treatment involves long-term behaviour change, dietary modification, increased physical activity, decreased sedentary behaviour and support for whole-of-family lifestyle change. As with any chronic disease, there is a spectrum of severity with obesity. For those who have moderate to severe obesity, treatment by a coordinated, multidisciplinary team offers the greatest likelihood of successful outcomes. Such treatment may involve the assessment and management of associated co-morbidities and, for adolescents, the use of pharmacotherapy. Notwithstanding these interventions, a small proportion of severely obese adolescents will require additional treatment. It is in this situation that consideration should be given to bariatric surgery, within the context of an ongoing and coordinated multidisciplinary approach. While there are rising numbers of reports of bariatric surgery in adolescents, there are as yet no Australian or New Zealand recommendations available to guide decisions as to which adolescents should receive such surgery and how they should best be managed. This is the reason for the development of this position paper on bariatric surgery in adolescents by representatives from the Australian and New Zealand Association of Paediatric Surgeons, the Obesity Surgery Society of Australia and New Zealand, and the Paediatrics & Child Health Division of The Royal Australasian College of Physicians. 6 2. Recommendations Surgical treatment Patient criteria for selection for bariatric surgery Patients for bariatric surgery should meet all of the following criteria: • Age. The majority of the Working Party was of the view that the minimum age should be 15 years, although surgery may be considered in exceptional circumstances at age 14 years • Attainment of Tanner stage 4 or 5 pubertal development • Attainment of final or near-final adult height (i.e. bone age ≥13.5 in females and ≥15.5 in males) • Severe obesity. The recommended threshold for bariatric surgical intervention is a body mass index (BMI) >40 kg/m2, although it should be considered in adolescents with a BMI >35 kg/m2 in the presence of severe obesity-associated complications • The presence of an associated severe co-morbidity, such as type 2 diabetes, hypertension, non-alcoholic steatohepatitis, benign intracranial hypertension or obstructive sleep apnoea • Persistence of the level of obesity despite involvement in a formal multidisciplinary and supervised program of lifestyle modification and pharmacotherapy. The majority of the Working Party was of the view that a minimum 6 months of supervised multidisciplinary therapy should be provided prior to bariatric surgery being performed • The adolescent and family understand, and are motivated to participate in, the on-going treatment, lifestyle change and review following surgery • The adolescent is able to provide informed consent for the surgery (see below). We recommend against bariatric surgery for: • Adolescents under the age of 14 years • Pregnant or breast-feeding adolescents • Patients with significant cognitive disabilities • Patients with an untreated or untreatable psychiatric or psychological disorder • Patients with Prader-Willi syndrome and other similar hyperphagic conditions. 7 Informed consent The adolescent should give written informed consent to the procedure. The capacity to give consent should be assessed by a consulting child and adolescent psychiatrist or adolescent physician who ideally would be part of the multidisciplinary weight management team. In addition, consent for surgery would involve: • Full consent from the parent or legal guardian • Complete understanding of treatment options, treatment outcomes, [the expected outcome], and the short and long term complications of the procedure and subsequent management • Knowledge of post-operative management and monitoring. Surgical expertise and facilities If surgery is proposed, then referral should be to an experienced bariatric surgeon. The surgeon would be affiliated with a team experienced in the assessment and long-term follow-up of the metabolic and psychosocial needs of the adolescent bariatric patient and family. The institution where the surgery is to be undertaken should be either participating in a study of the outcomes of bariatric surgery, or sharing such data in a proposed national registry of bariatric surgery and patient outcomes. In practice, surgeons performing bariatric surgery on adolescents should be credentialed for bariatric surgery. This is important due to the higher rates of complications in adolescents undergoing bariatric surgery. Such surgeons should ideally have experience in the management of patients in the adolescent age group. Given the increasing prevalence of obesity and related co-morbidities in adolescents and adults, and the potentially large financial pressures that the resultant burden of disease will place upon not just the health system but the economy as a whole, it is strongly recommended that publicly funded bariatric surgery be made available to those in need. Pre-operative assessment Pre-operative assessment of the patient and family may involve the following: • Assessment of the adolescent’s general health and developmental status • Evaluation of the patient and family’s motivation, expectations, and adherence 8 • Evaluation of the patient and family’s knowledge of the procedure and postoperative requirements • Evaluation of the patient and family’s capacity for self care • Independent psychological or psychiatric evaluation confirming the stability and competence of the family unit • Evaluation of obesity-related co-morbidities. Ideally, such assessment should be undertaken by a multidisciplinary team of health professionals including an accredited practising dietitian. Pre-operative education The patient and family should receive education about the following: • The procedure and postoperative requirements, including the need for ongoing dietary modification and supervision • Outcomes of surgery, and possible problems/complications • Consequences of not undergoing treatment. Type of surgical procedure The majority of the Working Party was of the view that the primary bariatric surgical procedure of choice for adolescents in Australia and New Zealand is laparoscopic adjustable gastric banding as it has good weight based outcomes, has a low complication rate and is potentially reversible. Anaesthetic considerations All patients should be managed by an anaesthetist experienced with bariatric surgery. Patients should receive a careful pre-operative anaesthetic assessment and be informed about potential anaesthetic complications. Post-operative management Patients should be managed in the immediate post-operative period by a surgeon and bariatric surgical team with experience in adolescent care. Availability of a high dependency unit or intensive care unit may be required, particularly where complications such as sleep apnoea are present. 9 Follow-up Although all bariatric patients require regular follow-up, especially early post procedure, adolescent patients are likely to require more frequent follow-up than is needed for adult patients. Follow-up of the adolescent patient should be on a 4–6 weekly basis. Early post-surgery involvement of the multi-disciplinary team is important for ongoing patient engagement in the treatment plan. Follow-up needs to be done by a team skilled both in gastric band management and the recognition of its complications, as well as those experienced in adolescent health. Importantly, issues such as improved fertility following weight loss, and hence the need for contraception, need to be considered. The long term follow-up for any intervention in paediatrics, including bariatric surgery, needs to extend beyond 10 years, and ideally for the whole of life. In addition, appropriate after-care and long-term follow-up are critical for bariatric surgery outcome success. Patients require long-term support for behavioural change in relation to nutrition and eating behaviours, physical activity and sedentary behaviour. Follow-up should be by a multi-disciplinary team which includes an experienced dietitian and psychologist. Appropriate transition from adolescent services to adult services for on-going follow-up should be anticipated and effectively managed. Guidelines for the thorough recording and collection of a range of physiological and behavioural parameters for audit and research purposes should be developed, including agreement as to prescribed times for data collection (e.g. 3, 6 and 12 months, and thereafter annually). A national database for outcome and long term monitoring of bariatric surgery in adolescents should be established and funded. Given the poor level of evidence on long term outcomes, it is recommended that all adolescents undergoing bariatric surgery in New Zealand and Australia are enrolled in a properly designed clinical trial. Funding for the trial should come through the funding service (District Health Boards, States etc) with liaison with the Health Research Council of New Zealand and its Australian counterpart the National Health and Medical Research Council. An existing model 10