Introduction

Pediatric and adolescent obesity is a prevalent chronic disease associated with substantial cardiometabolic, psychosocial, and long-term health consequences. Obesity management has undergone a major transformation over the past decade and continues to evolve. Historically, treatment centered primarily on nutrition, physical activity, and behavioral modification. However, accumulating evidence supporting obesity as a complex, chronic, and relapsing disease has prompted a shift toward earlier, more intensive, and multimodal therapy.[1] Pharmacologic treatment has rapidly expanded with the availability of newer anti-obesity medications, including glucagon-like peptide-1 (GLP-1) receptor agonists, such as liraglutide and semaglutide, alongside other agents, such as orlistat and phentermine/topiramate, substantially broadening treatment options for adolescents who do not achieve adequate weight loss with lifestyle intervention alone.[1] Metabolic and bariatric surgery has similarly become an increasingly accepted treatment for adolescents with severe obesity. In the United States, pediatric procedure rates approximately doubled from 2.29 to 4.62 per 100,000 between 2010 and 2017, accompanied by a marked transition toward laparoscopic sleeve gastrectomy.[2] Reflecting this evolving evidence, the American Academy of Pediatrics (AAP) 2023 Clinical Practice Guideline recommends prompt, comprehensive obesity treatment, rather than prolonged watchful waiting. They recommend a focus on intensive health behavior and lifestyle treatment, ideally providing at least 26 hours of face-to-face, family-based, multicomponent treatment over 3 to 12 months, as its foundation.[1] The guideline further recommends offering weight-management pharmacotherapy to adolescents aged 12 years and older with obesity as an adjunct to behavior and lifestyle treatment and referral of adolescents aged 13 years and older with severe obesity for evaluation for metabolic and bariatric surgery.[1] Together, these changes represent a paradigm shift from a predominantly lifestyle-based approach toward individualized, longitudinal treatment that integrates behavioral intervention, pharmacotherapy, and surgery according to disease severity, comorbidities, treatment response, and patient and family preferences.

For pediatric surgeons, obesity is a prominent disease that directly impacts their practice. While few pediatric surgeons perform weight loss procedures, the increasing number of patients who undergo these procedures increase the likelihood that pediatric surgeons will encounter patients who have undergone weight loss surgery. In most cases, the pediatric surgeon is called upon to evaluate and treat the child or adolescent with obesity whose surgical problem is not related to a weight loss procedure (e.g., cholecystitis, trauma, malignancy). It is useful for surgeons facing a young patient with obesity to be aware of the issues associated with the condition and how they might impact care and treatment decisions.