**9. Indications for bariatric surgery in adolescents**

Surgery should be considered if adolescents had BMI >40 kg/m2 , or >35 kg/m2 with severe comorbidities, including type 2 diabetes mellitus, aged >15 years, with Tanner pubertal stage 4 or 5 and skeletal maturity, and could provide informed consent and patients have failed a lifestyle and pharmacotherapy for six months [80]. International Diabetes Federation position statement advised that only two procedures Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding are currently conventional bariatric surgical procedures for adolescents [60].


**Table 1.** Current recommendations for surgical treatment in type 2 diabetes

**Contraindications for bariatric surgery in the treatment of type 2 diabetes mellitus** are: secondary diabetes, pancreatic autoantibodies (anti glutamic acid decarboxilasis, islet cells antibodies) positivity, C-peptide < 1ng/ml or unresponsive to mixed meal challenge.

**Which surgical procedures are indicated for obese type 2 diabetes patients?** Nowadays there is no evidence in favor of any particular procedure but the impact on weight loss, lipid profile, glycated hemoglobin and diabetes remission is increasing according to the surgical procedures as follows: adjustable gastric banding, sleeve gastrectomy, Roux-en-Y gastric bypass, bilio‐ pancreatic diversion with duodenal switch, biliopancreatic diversion. A laparoscopic techni‐ que should be considered as the preferable approach to the operation. Some pre-operative factors specific to type 2 diabetes mellitus could influence the choice of surgical procedures: duration of diabetes, pre-operative level of glycated hemoglobin, number of antidiabetic drugs used, and fasting C-peptide levels. [60, 77]

ities not achieving targets on conventional therapies (blood pressure, dyslipidaemia, and obstructive sleep apnea). [60] There are insufficient data to generally recommend surgery in

indications of bariatric surgery in type 2 diabetes mellitus according different international

morbidities, including type 2 diabetes mellitus, aged >15 years, with Tanner pubertal stage 4 or 5 and skeletal maturity, and could provide informed consent and patients have failed a lifestyle and pharmacotherapy for six months [80]. International Diabetes Federation position statement advised that only two procedures Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding are currently conventional bariatric surgical procedures for

outside of a research protocol. [76] Table 1 summarized

**Type 2 diabetes mellitus and**

**BMI >30, <35 kg/m2**

individual basis

individual basis

individual basis

individual basis

against

**Contraindications for bariatric surgery in the treatment of type 2 diabetes mellitus** are: secondary diabetes, pancreatic autoantibodies (anti glutamic acid decarboxilasis, islet cells

**Which surgical procedures are indicated for obese type 2 diabetes patients?** Nowadays there is no evidence in favor of any particular procedure but the impact on weight loss, lipid profile, glycated hemoglobin and diabetes remission is increasing according to the surgical procedures as follows: adjustable gastric banding, sleeve gastrectomy, Roux-en-Y gastric bypass, bilio‐ pancreatic diversion with duodenal switch, biliopancreatic diversion. A laparoscopic techni‐ que should be considered as the preferable approach to the operation. Some pre-operative

antibodies) positivity, C-peptide < 1ng/ml or unresponsive to mixed meal challenge.

, or >35 kg/m2

with severe co-

**Type 2 diabetes mellitus and**

**BMI <30 kg/m2**

Research only

Research only

Research only

Research only

patients with BMI under 35 kg/m2

**9. Indications for bariatric surgery in adolescents**

Surgery should be considered if adolescents had BMI >40 kg/m2

**Type 2 diabetes mellitus and BMI >35kg/m2**

IDF 2011 [60] Yes May be considered on

ADA 2014 [76] Yes May be considered on

AACE 2013 [79] Yes May be considered on

EASO/IFSO EC 2013 [77] Yes May be considered on

**Table 1.** Current recommendations for surgical treatment in type 2 diabetes

AHA/ACC/TOS 2013 [78] Yes No recommendation for or

organizations.

210 Treatment of Type 2 Diabetes

adolescents [60].

The assessment of bariatric surgery outcomes in type 2 diabetes and factors indicating the beneficial effects of bariatric surgery in diabetes: There is not an international consensus regarding definition of success of bariatric surgery in diabetes mellitus.

Partial remission of diabetes is characterized by: HbA1c >6% but <6.5%, fasting plasma glucose 100-125 mg/dl, at least 1 year duration, no active pharmacological therapy or ongoing procedures. Complete remission of diabetes is characterized by: HbA1c <6%, fasting plasma glucose <100 mg/dl, at least 1 year duration, no active pharmacological therapy or ongoing procedures. Prolonged remission is characterized by complete remission of at least 5 years duration. [60, 76, 77]

According IDF optimization of the metabolic state may be defined as: HbA1c ≤ 42 mmol/mol (6%); no hypoglycaemia; total cholesterol < 4mmol/l; LDL cholesterol <2 mmol/l; triglycerides <2.2mmol/l; blood pressure < 135/85 mmHg; >15% weight loss; with reduced medication from the pre-operated state or without other medications. A substantial improvement in the metabolic state may be defined as: lowering of HbA1c by >20%; LDL cholesterol <2.3 mmol/l; blood pressure <135/85 mmHg with reduced medication from the pre-operated state. [60]

**Adverse events**: The morbidity and mortality associated with bariatric surgery is generally low and similar to that of well-accepted procedures such as elective gall bladder or gallstone surgery. [60] There are patients and surgical procedures factors that can modify the risk of operation. The surgical complexity and potential surgical risks of procedures decrease in following order: biliopancreatic diversion, biliopancreatic diversion with duodenal switch, Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy, adjustable gastric bypass. [77]

**Follow-up** should be provided to all patients who underwent bariatric surgery in interdisci‐ plinary (medical and surgery) joint clinics. Generally the follow-up starts at 1 month after surgery and after that every 3 months in the first year, every 6 months for the second year and annually thereafter. Patients with type 2 diabetes who underwent to metabolic surgery need lifelong nutritional support and medical monitoring. The nutritional support consists in: adequate protein intake (minimum advised protein intake of approximately 90 g/day after biliopancreatic diversion) in order to prevent excessive lean body mass loss, avoidance of ingestion of concentrated sweets to prevent dumping syndrome, vitamin and other micronu‐ trients supplementations according to the type of surgical procedures. Medication for diabetes and insulin should be adjusted immediately after surgery in order to decrease the risk of hypoglycaemia. After biliopancreatic diversion procedure, proton pump inhibitors/histamine 2 receptor antagonists for the entire first post-operative year are recommended. [60, 77, 78]

It is necessary to perform more research (larger, well-designed, randomized control trial with longer-term follow-up) in order to bring up evidence for guidelines in the following areas: which type 2 diabetes patients are most likely to benefit from and least likely to have adverse events of bariatric surgery and which surgical procedures are best fitted to different populations.
