1 / 40

Surgery: Considerations and Research

First Annual Minnesota Pediatric Obesity Conference Practical Approaches for Managing and Preventing Pediatric Obesity . Surgery: Considerations and Research . Sayeed Ikramuddin, MD. Aldolescent obesity. Disclosures. Fellowship support: Ethicon, Covidien R esearch grant support: Covidien

cody
Télécharger la présentation

Surgery: Considerations and Research

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. First Annual Minnesota Pediatric Obesity Conference Practical Approaches for Managing and Preventing Pediatric Obesity Surgery: Considerations and Research Sayeed Ikramuddin, MD

  2. Aldolescent obesity

  3. Disclosures • Fellowship support: Ethicon, Covidien • Research grant support: Covidien • Proctorship: Ethicon • I will discuss off label use of the gastric band system

  4. Pories, W.J., et al., Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg, 1995. 222(3): p. 339-50; discussion 350-2.

  5. Bariatric surgery procedures Roux En Y Gastric Bypass (RNYGP) 50% of procedures in 2008 Laparoscopic Adjustable Gastric Banding (LAGB) 40% of procedures in 2008 Biliopancriatic Diversion w/ Duodenal Switch (Switch) 3-5% of procedures in 2008 Laparoscopic Sleeve Gastrectomy (LSG) 5-7% of procedures in 2008

  6. Diabetes resolved = discontinued treatment, Diabetes improved = reduced treatment. Buchwald H. Estok R. Fahrbach K. Bantle D. Jensen MD. Pories WJ. Bantle JP. Sledge I. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. American Journal of Medicine. 122(3):248-256.e5, 2009 Mar.

  7. Glycemia as an Endpoint 7 |

  8. In which remission is defined as: No antihyperglycemic meds AND either A1c<6% or Glu<100, except in the case of both labs being available, in which case BOTH conditions must be met. When multiple lab values are available for one AV, the one closest to the midpoint (ie: 12, 24, 36 months, etc) is used. %Weight Loss (%WL) = [ (Weight Preop – Weight Postop) / Weight Preop ] *100

  9. Gastric bypass • Small divided gastric pouch (30 cc) • Roux limb 75cm-150cm Biliopancreatic limb 20cm-100cm • antecolic or retrocolic roux • “Gold Standard”

  10. Bypass considerations • Longest followup • moderate malabsorption (Iron, B12, Thiamine) • hypoglycemia • marginal ulcers • excluded stomach • internal hernia • Higher perioperative complications

  11. adjustable band • Restrictive procecure • Low volume high pressure band • Pars Flaccida Approach • adjust to produce wt loss of 0.5-1 kg/week

  12. Band considerations • Not FDA approved for < 18 • very low short term morbidity and mortality • poor results in the superobese • explantation 10% • long-term risk of slippage • long-term risk of erosion • need for adjustments

  13. Procedures • Band • Sleeve • Gastric bypass • Duodenal switch

  14. Sleeve considerations • little long term data • potential for leak • insurance coverage an issue • Increased incidence of GERD • No nutritional complications • ease of conversion to DS or to RNY

  15. Duodenal switch • Malabsorbtive and restrictive procedure • most durable weight loss • 4% incidence of revision for nutritional problems • 42F sleeve (32-60) • 100 cm common channel (50-125)

  16. Effectiveness of Weight Management Programs inChildren and Adolescents http://www.ahrq.gov/downloads/pub/evidence/pdf/childweight/chweight.pdf

  17. Effectiveness of Weight Management Programs inChildren and Adolescents http://www.ahrq.gov/downloads/pub/evidence/pdf/childweight/chweight.pdf

  18. Introduction Weight Loss Surgery in Adolescents • The treatment of the morbidly obese adolescent patient is controversial. • No clear consensus on best treatment of the morbidly obese adolescent. • Contention between bariatric surgeons and pediatricians.

  19. Adolescent Obesity and DiabetesWhat is Known • A steep rise in the prevalence of T2DM parallels the rise in obesity . • Young patients with T2DM have rapidly progressive disease. • 5 fold increase in the incidence of obesity since 1970’s • Progressive retinopathy and ASHD noted within 5yrs of diagnosis of T2DM in young adults. • Health-related QOL 5.5x more likely to be impaired compared to healthy kids. similar to those diagnosed as having cancer. # Kohn M and Booth M. Adol Med 2003 *Schwimmer JB, Burwinkle TM, Varni JW. JAMA 2003

  20. Adolescent ObesityWhat is Unknown • When is the best time in the course of development (physical and emotional) for surgical intervention? • How is compliance in this patient population? • What are the long-term nutritional sequelae? • What are the multi-generational sequelae? • What are the long-term outcomes and recidivism rates?

  21. Bariatric surgery Outcomes

  22. Lap Band Outcomes

  23. Current Management of the Morbidly Obese Adolescent at the University of Minnesota • Evaluation by multidisciplinary team(statewide). • Pediatric gastroenterologist / weight loss specialist • Pediatric psychologist • Bariatric surgeon with > 50 cases adolescent • Dietician: minimum of 6 months • Intensive medical weight loss program • Outpatient / inpatient treatment • Bariatric surgery candidate • Demonstrated compliance with medical weight loss • Serious medical comorbidities

  24. Demographics: LRYGB (n=30)Laparoscopic Weight Loss Surgery in Adolescents • Mean age 17.0 (range 12-19) • 8 patients ≤ 15 years • Mean BMI 55 kg/m2 (range 35-100) • Mean weight 156 kg (range 99-275 kg) • All > 95th percentile for BMI • Two patients with BMI > 90 kg/m2 were hospitalized ≥ 1 month preoperatively for intensive medical management.

  25. Comorbid Disease

  26. Follow-UpLaparoscopic Weight Loss Surgery in Adolescents • Range 0 to 45 months, mean 15.8 months. • 14 patients had ≥ 12 month follow-up. • Poor overall compliance with follow-up. • 28.1% (n=9) lost to follow-up. • Letters sent, phone calls made. • Of those who didn't follow-up • 55.6% (n=5) lost within first year • 44.4% (n=4) lost after 18 months

  27. Adolescent Outcomes

  28. Results: LRYGB Weight LossWeight Loss Surgery in Adolescents • 12 y/o Pseudotumor cerebri BMI 47 • 33 months post op BMI 25.5 = 90% EWL • Normal growth exceeding mid-parental height

  29. Summary of Findings Weight Loss Surgery in Adolescents • Adolescent bariatric surgery appears to be similar to adult bariatric surgery in terms of weight loss and complications. • surgery safe in short term followup across the age spectrum • followup can be more difficult than the adult population • Absolute commitment to post-operative follow-up schedules need to be made pre-operatively with adolescent patients and their parents. • evidence for choice of operation mixed

  30. Band Lower BMI(30-40) • it is the amount of weight loss not the method that determines the remission of type 2 diabetes Dixon et al JAMA January 23rd 2008

  31. The Effects of Bariatric Surgery on Type 2 Diabetes The Entero-insular Axis • Glucagon-Like Peptide-1 or GLP-1 (“Enteroglucagon”) • Secreted by ileal “L-cells” in (rapid) response to a meal • Actions • Potent stimulator of insulin / supresses glucagon • Slows gastric emptying • Reduces appetite • Increases beta cell mass • Increased after gastric bypass (??) • Peptide YY (PYY) • Gastric Inhibitory Polypeptide (GIP) Wynne K. J Clin Endo Met, 2004

  32. The Effects of Bariatric Surgery on Type 2 Diabetes The Entero-insular Axis • Enteral glucose ingestion yields a greater insulin release than does parenteral glucose infusion * • Secreted gut hormones effect insulin production, secretion and usage = “incretins” / “anti-incretins” • Select “known” peptides with various effects * Elrick H. J Clin Endocrinol Metab. 1964

  33. The Effects of Bariatric Surgery on Type 2 Diabetes The Entero-insular Axis 1967 – Gastric Bypass Rehfeld J, 2004

  34. Peptides in T2DM • GLP-1 response to mixed meal is blunted compared to non diabetics • GIP response is blunted • After weight loss GLP-1 response improves

  35. Exaggerated GLP-1 and Blunted GIP Secretion are Associated with Gastric Bypass but not Gastric Banding Korner J, Bessler M, Inabnet WB et al. Surg Obes Relat Dis. 2007 Oct 10; [Epub ahead of print].

  36. Insulin response with OGTT RNY LaFerre et al JCEM 2008

  37. Ghrelin Cummings et al NEJM

  38. Bariatric Surgery: Effects on Weight Loss and Mortality 29% 14 0 Control 12 Control 10 -10 Band 8 Change in Weight (%) Cumulative Mortality (%) Surgery VBG 6 -20 4 p = 0.04 Gastric Bypass -30 2 0 15 0 8 0 2 4 6 8 10 12 16 4 Years Years Sjostrom, L, et.al.; N Engl J Med. 2007;357:741-52 38 | 38 | | May 30, 2012 | Confidential

  39. Case Matched Mortality (Mean Follow up of 7.1 years; out to 18 years

  40. Conclusion • Type 2 DM is a complex disease • It is most strongly associated with obesity • Patient and physicians struggle to meet therapeutic goals • Bariatric surgery is established as a treatment of obesity • The effect on diabetes is profound • Clinical trials will allow for treatment of lower BMI individuals • Adolescents want to look like their peers but they also want to eat like their peers

More Related