The use of bariatric procedures in general appears to be steeply increasing in pediatric age groups over recent years, suggesting a need for appropriate assessment criteria prior to surgery and for prospectively and rigorously collected adolescent outcome data. As of yet, the scientific evidence base is not sufficiently robust to allow a precise discrimination of which procedures are optimal for adolescents. Indeed, experts have broadly characterized the quality of evidence for effectiveness and safety of adolescent bariatric surgery as fair to poor for all procedures that have been reported. Despite limitations in the evidence base, clinicians are faced with a need to manage myriad health problems in adolescents with extreme obesity and more recently, higher quality prospectively collected data have emerged documenting efficacy and safety of adolescent bariatric procedures. Recommendations for assessment and selection of adolescent patients that are thoughtfully derived from our knowledge of obesity and bariatric surgery provide useful tools for those faced with sometimes difficult treatment decisions.