Adolescent Bariatric Surgery: Weighing the Options

1. Adolescent Bariatric Surgery: Weighing the Options Mark L. Wulkan, M.D. Associate Professor of Surgery and Pediatrics Emory University School of Medicine Children’s Healthcare of Atlanta

2. Alternative Title The New Face of Pediatric Surgery 500 grams to 500 pounds

3. Jeffrey Friedman “Today, the lean carry genes that protect them from the consequences of obesity, where as the obese carry genes that are atavisms of a time of nutritional privation in which they no longer live.”

5. Why are kids obese? • Genetic Forces • Genetic Mutations • Genetic Predisposition • Social / Environmental Forces

6. Quality of Life Severely obese children and adolescents have lower health-related QOL than children and adolescents who are healthy and similar QOL as those diagnosed as having cancer. Schwimmer JB, Burwinkle TM, Varni JW. JAMA. 2003 Apr 9;289(14):1851-3.

7. They just want to be kids…

9. Glossory • Body mass index (BMI) BMI = weight (kg) / (height (m))2 • Excess weight (EW) Body weight – Ideal body weight • % Excess weight loss (%EWL) Current EW / Starting EW * 100

10. Treatment Options(Morbidly Obese) Behavior Modification Surgery

12. Pediatric Behavioral Modification Epstein, et.al., 1995

13. Most obese children will become obese adults The risk increases with increasing age Risk of Adult Obesity

14. Van Dam, et. al., Annals of Internal Medicine, July 2006

15. Co-Morbidities • Type II diabetes mellitus • Obstructive sleep apnea • Pseudotumor cerebri • Metabolic syndrome (obesity, dyslipidemia, hypertension, insulin resistance) • Venous stasis disease • Panniculitis • Stress Urinary incontinence • Impairment of ADL’s • Fatty liver (nonalcoholic) • Arthropathies in weight bearing joints • Hypertension • Dyslipidemia • Hyperinsulinemia • Significant psychosocial distress • Cardiac disease

16. This may be the first generation whose life expectancy is less than their parents!

17. Obesity at Children’s ** 85th – 95th percentile *** > 95th percentile

18. What can we REALLY do about this?

19. Surgery for Weight ManagementNIH consensus conference Weight loss surgery is an option for carefully selected patients with clinically severe obesity (BMI >= 40 or >= 35 with comorbid conditions) when less invasive methods of weight loss have failed and the patient is at high risk for obesity-associated morbidity or mortality. (Evidence Category B; 8 RCT)

20. Morbid obesity - rationale for surgical treatment • Nonsurgical weight loss not sustainable. • Surgically induced weight loss safely treats most comorbidities of obesity. • Surgery is the only treatment with proven, significant long-term excess wt loss

21. Which is Best?

22. AGB vs RYGBpositives AGB • Reversible • Reduces co-morbidities • Sustainable weight loss • Little nutritional perturbations • Adjustible • Less morbid complications • Slow and steady weight loss ( 1-2 lb/wk) • 50 – 60 %EWL • RYGB • Rapid weight loss • Reduces co-morbidities • Sustainable weight loss • “Gold Standard” • 60 –70 %EWL

23. AGB vs RYGBnegatives AGB • Foreign body • “Only” 15 year history • Requires close follow-up for good results • Not (yet) FDA approved for adolescents < 18 • Limited US experience • ? “Less” weight loss • RYGB • Potentially lethal complications • Close follow-up required for good results • ? Long term weight regain • Not adjustable

24. Gastric Bypass in adolescents • Retrospective survey 1981-2002 • Ages 12-18; mean age=16; n=33 • 3 gastroplasties, 28 GBP • Comorbidities: • DM, type 2=1 GERD=5 • HTN=10 OSAS=5 • Pseudotumor=2 DJD=10 • Preop BMI=52 Sugarman, J Gastrointest Surg. 2003 Jan;7(1):102-7

25. Gastric Bypass in adolescents RESULTS- Complications • EARLY: No deaths; no leaks; 1 PE, 5 wound infx, 3 stomal stenoses (endoscopically dilated), 4 marginal ulcers Sugarman, J Gastrointest Surg. 2003 Jan;7(1):102-7

26. Gastric Bypass in adolescents RESULTS- Complications • LATE: • 1 SBO • 4 incisional hernias • 2 sudden deaths @ 2 & 6 years postop Sugarman, J Gastrointest Surg. 2003 Jan;7(1):102-7

27. Gastric Bypass in adolescents Sugarman, J Gastrointest Surg. 2003 Jan;7(1):102-7 n=30 26/28 17/22 11/15

28. Bariatric Surgery for Adolescents CONCLUSIONS • Surgical weight loss results in resolution of the majority of comorbidities • 15% (5/33) regained weight by 5-10 yrs • Bariatric surgery safe in highly selected severely obese adolescents Sugarman, J Gastrointest Surg. 2003 Jan;7(1):102-7

29. RYGB • 39 Patients • Multi-center • 1 year results • BMI fell 37% (56.5 to 35.8) • Improved co-morbidities • 9 minor/ 4 moderate/ 2 major comp (incl death) • No peri-operative deaths Lawson, et.al. JPS 41 (1); 137-143.

30. Adjustable Gastric Band • 11 pts. • Age 16 (11-17) • BMI 46 (38-57) • Co-morbidities • Heart failure /pulmonary hypertension • Amenorrhea 2 pts • Gallstones 1 pt Abu-Abeid, et. al., JPS 38 (9), 2003

31. Adjustable Gastric Band • No complications • Pts d/c’d post-op day 1 (1 pt POD 2) • BMI 47 to 32 • No late complications • Mean follow-up 23 months (6-36) Abu-Abeid, et. al., JPS 38 (9), 2003

32. Adjustable Gastric Band • 17 patients (age 12-19, median 17) • Median follow-up 25 mo (12-46) • BMI 44.7 to 30.2 @ 24 months (59.3 %EWL) • 2 complications • Slipped band • Leaking port Dolan, et. al., Obes Surg. 2003 Feb;13(1):101-4

33. Other Options • Gastric sleeve resection • Gastric sleeve resection with biliary pancreatic diversion

34. What influenced my decision? Less Morbidity Reversible Adjustable Gastric Band

36. Emory BariatricsAdolescent Program • Multi-Disciplinary Program • Pediatric Surgery • Endocrine • Psychology • Nutrition • Nurse Practitioner • Patient Coordinator • Research Coordinator

37. Emory BariatricsAdolescent Program • Initial Evaluation • Screen for elegibility • Complete History and Physical • Including family history of obesity • Detailed dietary history • Look for comorbidities

38. Patient Work-upRequired • Labs • Thyroid function • Lipid profile • Hepatic profile • Glucose • HbA1c • Insulin • And whatever else endocrine wants! • Imaging • Upper GI Series • Psychiatric Evaluation

39. Patient Work-upSelective • Sleep Study • Cardiac Echo • Pulmonary Function Studies • RUQ U/S

40. Pre-op • Must Qualify • Informed Consent from parents • Informed Assent from child • Liquid protein diet pre-op for 1 Week

44. Post-op Care • Liquid Diet for 2-4 weeks • Full liquid diet until first visit • Protein Shake • MVI • Calcium Supplement or Skim Milk

45. Follow-up • Monthly visits for the first year • First band adjustment usually at 1 month • Try to find “sweet-spot” • Reasons for adjustment • Hunger • No or less than expect weight loss • Weight gain

46. Potential Complications • Band erosion • Slipped band – really a “para-band” hernia • Esophageal dilatation • GERD • Dysphagia (food stuck) • Port problems

47. Emory Outcomes • 26 LapBands placed over 3 ½ years • 9 patients with > 6 months follow-up (as of last November) • Mean BMI 51.9 • Mean Age 16.5 years (13-19.5)

48. Post-operative Weight Loss 200 180 160 Mean BMI 140 (kg/m2) 120 Mean %EWL 100 80 Median Weight 60 (kg) 40 20 0 0 3 6 9 12 18 24 30 Months Postop

49. What Needs to be Done? • Determine the best operation • Funding • Research • Clinical • Make it so I don’t have to do this…