Metabolic bariatric surgery (MBS) for adolescents is an effective treatment for severe obesity, but its clinical application is fraught with controversy and challenges. From an ethical perspective, careful consideration must be given to balancing patient autonomy with guardian involvement and the suitability of surgery for special populations. Regarding patient selection, criteria for factors such as BMI thresholds and preoperative health status require further clarification, and multi-dimensional assessments of physiological and psychological factors complicate decision-making. Regarding surgical procedure selection, long-term outcomes vary among different procedures, and the safety and efficacy of certain procedures require further research validation. Postoperative complications may include nutritional deficiencies, impacts on bone health, and the need for reoperation, while adolescents’ compliance also poses challenges to long-term outcomes. While cost-benefit ratios may become evident in the long term, initial costs are high. These issues highlight the necessity of multidisciplinary collaboration and individualized management in adolescent MBS to better align with adolescents’ growth and developmental characteristics and health needs, thereby providing robust safeguards for surgical safety and long-term efficacy.

In October 2024, the National Health Commission released Clinical Practice Guidelines for the Obesity Diagnosis and Treatment (2024 Edition), which leads to significant implications for clinical diagnosis and treatment of obesity, and potentially impacts the future trend of metabolic and bariatric surgery. The guidelines reflect a more comprehensive and scientific understanding of obesity as a standalone disease. Based on this understanding, the role of metabolic and bariatric surgery in obesity management will be further strengthened, and homogeneous management of obesity will be more widely implemented in future. With the rapid advancement of anti-obesity medications, future solutions for obesity therapy will involve the combined application of multiple treatment modalities, enhance treatment efficiency and improve patient outcomes. As practitioners in the field of metabolic and bariatric surgery, surgeons will need to pragmatically adapt to the discipline’s evolution, expand their knowledge and skillsets, and upgrade themselves from surgeon to metabolic and bariatric specialists proficient in various obesity treatment approaches.

Bariatric surgery serves as an effective treatment for adolescent obesity, but its successful implementation requires systematic management. Indications for surgery should be strictly determined, with a recommendation for adolescents aged 13 and above who have severe obesity with associated comorbidities. A comprehensive preoperative assessment of developmental status, metabolic indicators, and psychosocial factors is essential, supported by a multidisciplinary team. Postoperative management priorities include: (1) Lifestyle modification: focusing on the critical 6-12-month behavioral reshaping period. (2) Nutritional monitoring: adopting a stepwise approach to track micronutrient levels. (3) Psychological intervention: implementing phased dietary adjustment, emotional management, and social adaptation training. (4) Special issue management: enhancing reproductive health guidance and follow-up care. By establishing a medical-family-social support network and implementing personalized intervention strategies, long-term surgical outcomes can be ensured, promoting holistic physical and psychological recovery. Multidisciplinary collaboration remains the cornerstone of treatment quality assurance.

With the rise of adolescent obesity, metabolic and bariatric surgery (MBS) yields clear and durable improvements in weight and comorbidities; however, ethical decision-making, growth and development, and healthcare equity remain contested. We propose an “ethics-clinical integrated” framework: (1) anchor decisions in the four principles, operationalized as parental permission plus adolescent assent; (2) shift indications from BMI-only to phenotype- and risk-driven criteria, supported by multidisciplinary team (MDT) assessment and standardized perioperative management; (3) implement long-term surveillance plans for growth/bone health, nutrition, and psychological well-being, with predefined risk-mitigation strategies. We advocate early referral for evaluation when BMI ≥140% of the 95th percentile or when severe obesity-related complications are present, prioritizing sleeve gastrectomy or Roux-en-Y gastric bypass as preferred options where appropriate. To promote justice and access, we recommend standardized referral and payment pathways and active reduction of stigma and delays. This framework aims to maximize net benefit while ensuring safety, thereby enhancing the standardization and accessibility of MBS for adolescents.

With the increasing of metabolic and bariatric surgery(MBS) performed in adolescents, the failure of MBS becomes an important issue that surgeons have to face. The management of MBS failures should follow a systematic and step-by-step principle. Based on comprehensive and in-depth evaluation by the multidisciplinary team(MDT) group, the reasons for surgical failure can be identified and develop individualized treatment. Lifestyle improvement is the foundation for management of adolescent MBS failure, and if necessary, anti-obesity medications can be used as adjuvant therapy. When non-surgical treatment is ineffective and there are indications for surgery, careful consideration may be given to revision surgery. Establishing an effective lifetime follow-up and support system is of great significance for further improving the results of MBS in adolescents.

Adolescents with obesity often have psychological problems and lower treatment adherence, so perioperative management needs to incorporate continuous psychological and behavioral interventions and build a systematic and lifelong postoperative follow-up system. Techniques such as cognitive-behavioral therapy, family-involved psychological interventions, mindfulness-based stress reduction, and virtual reality (VR)-assisted treatments can improve the psychological health and treatment adherence of adolescents with obesity. Postoperative follow-up management should focus on nutritional status and growth and development. Using telemedicine, smart wearable devices, and other technological means, combined with multidimensional incentive strategies, can effectively enhance follow-up adherence and reduce the risks of weight regain and nutritional deficiencies. The perioperative management of adolescent bariatric surgery needs to move towards multidisciplinary collaboration, comprehensive intervention, and precise individualization to provide safer, more effective, and more comprehensive bariatric surgical treatment for adolescents with obesity.  

The rate of adolescent obesity continues to increase, and metabolic and bariatric surgery (MBS) remains the most effective weight-loss option. While quality of life generally improves after surgery, adolescents’ physiological and psychological immaturity limits their understanding of the risks of obesity and the details of MBS. Additionally, their developmental stage heightens the need for multivitamins and trace elements, making them more susceptible to nutritional challenges and psychosocial issues after surgery. A large body of evidence indicates that severely obese adolescents who undergo MBS, as well as those who receive lifestyle interventions, are at risk of impaired mental health, eating disorders, and reduced health- and weight-related quality of life. Except for active psychosis, suicidal ideation, or substance abuse, these baseline psychosocial impairments are not considered contraindications to MBS. Moreover, despite significant postoperative weight loss and improvements in comorbidities, preoperative mental health functioning is likely to remain unchanged or only temporarily improve after surgery. Greater attention must therefore be given to mental health and nutritional challenges following surgery. Managing postoperative eating disorders and ensuring long-term follow-up requires a collaborative, multidisciplinary approach involving parents.

Adolescent compliance management after metabolic and bariatric surgery is a systematic project involving physiological, psychological, and social aspects. The family, as the most central support system, plays a decisive role in determining the long-term effectiveness of the surgery. The family-hospital collaborative management model enhances preoperative cognitive building, intraoperative support, and postoperative dynamic follow-up. It transforms the emotional and behavioral support from families into motivation for adolescents’ compliance, while hospitals provide scientific guidance to families with their professional expertise, creating a synergistic effect where “1+1>2”. Only by respecting the autonomy of adolescents and understanding the practical challenges faced by families can a truly sustainable collaborative ecosystem be established, offering solid support for the long-term prevention and management of adolescent obesity.

Adolescent obesity has become a serious public health issue. Adolescents are at a unique stage of physiological and psychological development, where lifestyle interventions and pharmacological treatments show limited effectiveness for some severely obese cases. While bariatric surgery yields significant results, it carries risks such as high invasiveness and potential complications. Endoscopic bariatric therapies offer a minimally invasive, reversible, and effective new option for treating ado-lescent obesity, bridging the gap between lifestyle interventions and surgical procedures. In the future, the field of endoscopic bariatric treatment for adolescents will advance toward greater precision, systematization, and humanization. Through multidis-ciplinary collaboration, a comprehensive management system will be established, while psychological support and family in-volvement will enhance overall health outcomes.

In recent years, weight-loss medications such as glucagon-like peptide-1 receptor agonist, and PHEN/TPM have brought breakthrough progress in the treatment of adolescent obesity. By targeting appetite control centers or inhibiting neurotransmitter re-uptake, they significantly improve clinical outcomes in obese adolescents. These drugs not only effectively reduce body weight but also ameliorate metabolic issues such as insulin resistance and dyslipidemia. However, their long-term safety, cost accessibility, and individualized medication strategies still require improvement. Moving forward, it is necessary to advance long-term follow-up studies and establish real-world databases to support personalized treatment. Medication therapy should be integrated with lifestyle interventions, building a “family-medical-society” tripartite management model to achieve precise prevention and management of adolescent obesity.