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.