Adolescent obesity has serious immediate and long-term health consequences. There are no effective behavioral or pharmacologic treatments of extreme obesity among adolescents. Bariatric surgery is the most effective means to achieve durable weight loss, with amelioration or resolution of most obesity-related co-morbidities. Surgery should be performed when: 1) the risk of operative complications and of recidivism is lowest; 2) the outcomes of the operation are likely to be the best possible; and 3) there is little need to consider subsequent bariatric surgery for weight regain and reappearance of co-morbidities. A higher BMI is an independent risk factor for operative morbidity and mortality, and is associated with less weight loss and greater likelihood of weight regain. The higher BMI criterion for adolescent bariatric surgery exposes the adolescent to a higher risk for operative death and complications, and suboptimal outcomes following bariatric surgery.