ALEX KLOEHN, CAMI MANDELL
Bariatric Surgery: A Major Decision for Minors
http://www.cdc.gov/nchs/data/hestat/obesity_child_09_10/obesity_child_09_10.htm
Childhood and Adolescent Obesity Statistics
Obesity rates in children age 6-11 increased from 7% to 18% between 1980 and 2010 in the US (Ogden, 2012)
Obesity rates in adolescents age 12-19 increased from 5% to 18.4% between 1980 and 2010 in the US (Ogden, 2012)
http://arch1design.com/blog/latest_environmental_health_news/childhood-obesity-prevalence-and-prevention/
Concerns of Childhood Obesity
Obese adolescents are likely to be obese as adults (Freedman, 2005)
Increased risk of depressive symptoms and lower quality of life scores. (Schwimmer, 2003)
Increased risk of Hypertension Hypercholesterolemia Hypertriglyceridemia Hyperinsulinemia Atherosclerosis Metabolic syndrome Obstructive sleep apnea PCOS Non-alcoholic fatty liver
disease Certain cancers (Flynn, 2006)
Brief History of Bariatric Surgery
1952- First recorded operation to cure obesity was performed by Viktor Henrikson as a small bowel resection
Shortly followed by jejunocolic bypasses that led to loss of fluid, electrolytes, and led to liver failure. (On left)
Mid 1950’s - Jejunoileal Bypass came next and remained popular through the 1970’s
(Deitel, 2012)
Brief History of Bariatric Surgery (Cont’d)
1960’s - Gastric Bypass was first developed
1970’s - Roux-en-Y GB was developed and has been modified several times since.
(Deitel, 2012)
Brief History of Bariatric Surgery (Cont’d)
1970’s - Biliopancreatic Diversion and Duodenal Switch were also introduced to address concerns over Blind Loop Syndrome.
1980’s – Adjustable gastric banding procedures were popularized
(Deitel, 2012)
Brief History of Bariatric Surgery (Cont’d)
2000’s – The first sleeve gastrectomy procedures were recorded.
(Deitel, 2012)
Common Types of BS Performed Today
http://www.hormone.org/questions-and-answers/2012/bariatric-surgery
Adolescent Bariatric Surgery (ABS) Statistics
US Nationwide Inpatient Sample: 2,744 ABS procedures were performed in the US between 1996 and 2003. (Black, 2013)
Healthcare Cost and Utilization Project Kids’ Inpatient Database (KID), 1009 ABS procedures were performed in 2009. (Kelleher, 2013)
Trends towards minimally invasive procedures
Plateau of ABS procedures since 2003.
Trends in Surgery Performed 2000-20009
2000 2003 2006 20090
200
400
600
800
1000
1200
Ages 10 - 17Ages 18 - 19total
Adapted from data in Kelleher, 2013
Physical & Psychological Benefits
BMI reduction Wide range, depending on study follow-up
length Most occurs in first year
Some alleviation of comorbid conditions Most occurs in first year Hard to accurately assess due to follow-up loss
Increased in quality of life Pre-operative scores similar to children with
cancer (Loux, 2008)
Significantly increased scores post-operatively (Loux, 2008)
BMI Reduction
Very little long-term follow-up dataWide range of results
RYGB, 12 month follow-up (Lawson, 2006) Pre-op 56.5±10.1 Post-op 35.8±6.9
RYGB, 17.1±12.3 month follow-up (Loux, 2008) Pre-op 54.1±7.6 Post-op 35.1±9.3
LSG, 12 month follow-up (Nadler, 2012) Pre-op 52±9, Post-op 39±8
RYGB, 24 month follow-up (Teeple, 2012) Pre-op 58.8±10.7, Post-op mean 34.9±5.6
Co-morbid Conditions
Most common pre-operative: Impaired glucose
tolerance Insulin resistance Hypertension Sleep apnea Dyslipidemia Fatty liver disease
Post-operative results Improvement in glucose
tolerance and insulin resistance
Resolution of dyslipidemia
Resolution of sleep apnea
Decrease in blood pressure
(Teeple, 2012; Nadler, 2012, Lennerz, 2013, Lawson, 2006, Loux, 2008)
Risks and Complications of Surgery
Complications are similar to adults (Inge, 2013)
Late weight regain (up to 20%) (Xanthakos, 2008)
Recurrence of depression and eating disturbances that affect QOL (Pratt, 2009)
Marginal ulcers, small bowel obstruction, protein and micronutrient deficiencies
Gastric band slippage Pregnancy
Risks and Complications of Surgery (Cont’d)
May cause problems with proper growth if children are not done growing (Barnett, 2013)
Low adherence to follow-up (Lennerz, 2013)
Best Practice Eligibility Criteria
BMI >35 with severe comorbidities >40 with any comorbities
Physiological Maturity Height ~ 95% adult height based on estimate of bone
age Pubertal Maturity based on Tanner Stages (IV+)
Girls usually ≥13; Boys usually ≥15
Lifestyle Change Demonstrate ability to make sustained dietary and
physical activity changes (Pratt, 2009)
Best Practice Eligibility Requirements
Psychosocial Maturity Appropriate decision
making skills and understanding of risks and benefits
Social support network Psychiatric conditions
managed under treatment Evidence of patient/family
ability to comply with treatment plan pre- and post- surgery
(Pratt, 2009)
Future Directions
Necessity of long-term data on physical and psychological outcomes
Options of minimally invasive surgeries (Shebrain, 2013)
Need to address possibility of weight regain Rethink criteria using BMI for weight loss
surgery to catch adolescents before they become severely/morbidly obese
Assert that surgeons performing surgery are qualified to do so with the special considerations of adolescents
Questions?
References
Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010. Journal of the American Medical Association 2012; 307(5):483-490
Freedman DS, Kettel L, Serdula MK, Dietz WH, Srinvasan SR, Berenson GS. The relation of childhood BMI to adult adiposity: the Bogalusa Heart Study. Pediatrics 2005; 115:22-27.
Schwimmer JB, Burwinkle TM, Varni JW. Health-Related Quality of Life of Severely Obese Children and Adolescents. Journal of the American Medical Association 2003; 289(14):1813-1819
Flynn MAT, McNeil DA, Maloff B, Mutasingwa D, Wu M, Ford C, Tough SC. Reducing obesity and related chronic disease risk in children and youth: a synthesis of evidence with “best practice” recommendations. The International Association for the Study of Obesity: Obesity reviews 2006; 7(Suppl. 1):7-66
Deitel M, Crosby RD, Gagner M. The First International Consensus Summit for Sleeve Gastrectomy (SG), New York City, October 25-27, 2007. Obesity Surgery. 18:487-496
Deitel, M. “History of Bariatric Surgery.” Bariatric Surgery: Technical Variations and Complications, Ed. Michael Korenkov, New York: Springer, 2012. 1-8
Kelleher DC, Merrill CT, Cottrell LT, Nadler EP, Burd RS. Recent National Trends in the Use of Adolescent Inpatient Bariatric Surgery. Journal of the American Medical Association Pediatrics 2013; 167(2):126-132
Black, JA, White B, Viner RM, Simmons RK. Bariatric surgery for obese children and adolescents: a systematic review and meta-analysis. The International Association for the Study of Obesity: Obesity reviews 2013; 14:634-644
Barnett SJ. Surgical management of adolescent obesity. Advances in Pediatrics 2013; 60:311-325.
Garcia VF, DeMaria EJ. Adolescent bariatric surgery: treatment delayed, treatment denied, a crisis invited. Obesity Surgery 2006; 16:1-4.
Inge TH, Zeller MH, Jenkins TM, Helmrath M, Brandt ML, Michalsky MP, Harmon CM, et al. Perioperative outcomes of adolescents undergoing bariatric surgery: the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) Study. The Journal of the American Medical Association Pediatrics 2013; doi:10.1001/jamapediatrics.2013.4296.
Kubik JF, Gill RS, Laffin M, Karmali S. The impact of bariatric surgery on psychological health. Journal of Obesity 2013; 2013(837989):1-5.
Lennerz BS, Wabitsch M, Lippert H, Wolff S, Knoll C, Weiner R, Manger T, et al. Bariatric surgery in adolescents and young adults-safety and effectiveness in a cohort of 345 patients. International Journal of Obesity 2013; 1-7.
Nadler EP, Barefoot LC, Qureshi FG. Early results after laparoscopic sleeve gastrectomy in adolescents with morbid obesity. Surgery 2012;152(2):212-217.
Teeple EA, Teich S, Schuster DP, Michalsky MP. Early metabolic improvement following bariatric surgery in morbidly obese adolescents. Pediatric Blood Cancer 2012;58:112-116.
Xanthakos SA. Bariatric surgery for extreme adolescent obesity: indications, outcomes, and physiologic effects on the gut-brain axis. Pathophysiology 2008;15:135-146.
Loux TJ, Haricharan RN, Clements RH, Kolotkin RL, Bledsoe SE, Haynes B, Leath T, et al. Health-related quality of life before and after bariatric surgery in adolescents. Journal of Pediatric Surgery 2008; 43:1275-1279.
Lawson ML, Kirk S, Mitchell T, Chen MK, Loux TJ, Daniels SR, Harmon CM, et al. One-year outcomes of Roux-en-Y gastric bypass for morbidly obese adolescents: a multicenter study from the Pediatric Bariatric Study Group. Journal of Pediatric Surgery; 2006: 41:137-143.
Shebrain S, Patel N. Advances in foregut and bariatric surgery in adolescents. Adolescent Medicine 2013; 024:242-263.
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