Bariatric surgery referral criteria and instructions - Lucile Packard Children's Hospital


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Bariatric Surgery Information for Health Care Professionals

How to Refer a Patient

To refer a patient who meets the referral criteria (below) for bariatric surgery, health care providers should fill out the Pediatric Weight Clinic referral form (PDF). Please check the “bariatric surgery evaluation” box and then fax the form to the Lucile Packard Children's Hospital Referral Center at (650) 721-2884. Please call (800) 995-5724 for more information.

Parents will be asked to fill out the Parent Questionnaire (PDF) (en español) and to bring it to the first appointment.

The patient will first be seen at our Pediatric Weight Clinic.

Referral Criteria

Adolescents being considered for bariatric surgery should:

Have a Body Mass Index (BMI) ≥ 40 with serious obesity-related comorbidities or have a BMI ≥ 50 with less serious comorbidities
Have participated in at least six consecutive months of medically-supervised attempts at weight management
Have attained physical maturity. This may vary depending on the severity of any comorbidities. Pediatric Weight Clinic physicians will evaluate patients to diagnose and determine the severity of comorbidities.
Demonstrate commitment to comprehensive medical and psychological evaluation before and after the surgery
Agree to avoid pregnancy for at least two years after bariatric surgery
Be capable of and willing to adhere to postoperative nutritional guidelines and exercise program
Provide informed consent to surgery
Attend four support group sessions per year

Comorbidities include:

Type 2 diabetes mellitus
Obstructive sleep apnea
Pseudotumor cerebri
Hypertension
Dyslipidemias
Non-alcoholic steatohepatitis
Venous stasis disease
Significant impairment in activities of daily living
Intertriginous soft tissue infections
Stress urinary incontinence
Gastroesophageal reflux disease
Weight-related arthropathies which impair physical activity
Obesity-related psychosocial stress

Lucile Packard Children's Hospital is located in Palo Alto, adjacent to Stanford University Hospital, approximately 20 miles north of San Jose, CA and 40 miles south of San Francisco.

Lucile Packard Children's Hospital
725 Welch Road
Palo Alto, California 94304
(650) 497-8000