MORBID OBESITY IN ADOLESCENTS AND CHILDREN Marjorie J. Arca, M.D. Children’s Hospital of Wisconsin Milwaukee, WI
NIH CONSENSUS FOR SURGICAL INTERVENTION FOR MORBID OBESITY • Adults with BMI >40 • BMI > 35 with high risk comorbid conditions such as severe sleep apnea, Pickwickian syndrome, obesity related cardiomyopathy, diabetes mellitus, obesity induced physical problems interfering with lifestyle
BARIATRIC SURGERY FOR SEVERELY OVERWEIGHT ADOLESCENTS: CONCERNS AND RECOMMENDATIONS • Consensus panel recognized several key differences between adults and children • Severity of complications in children and adolescents with BMI > 30 may not warrant surgical therapy • Children cannot give legal consent • Behavioral therapy is more effective in adolescents • 20-30% of obese adolescents will NOT become obese adults Inge et al, Pediatrics 114, July 2004
CONSENSUS RECOMMENDATIONSAdolescents Being Considered for Bariatric Surgery Should: • Have failed 6 months of organized attempts at weight management, as determined by their primary care provider • Have attained or nearly attained physiologic maturity • Be very severely obese (BMI >40) with serious obesity-related comorbidities or have a BMI of >50 with less severe comorbidities • Demonstrate commitment to comprehensive medical and psychologic evaluations both before and after surgery • Agree to avoid pregnancy for at least 1 year postoperatively • Be capable of and willing to adhere to nutritional guidelines postoperatively • Provide informed assent to surgical treatment • Demonstrate decisional capacity • Have a supportive family environment Inge et al, Pediatrics 114, July 2004
Type 2 diabetes mellitus Obstructive sleep apnea Pseudotumor cerebri Less serious comorbidities Hypertension Obesity-related psychosocial distress Weight-related arthropathies that impair physical activity Dyslipidemias Nonalcoholic steatohepatitis Venous stasis disease Significant impairment in activities of daily living Intertriginous soft-tissue infections Stress urinary incontinence Gastroesophageal reflux disease SERIOUS CO-MORBIDITIES
OBESITY PROGRAM: Key Players • Primary care MD • Nutrition specialist • Psychologist/psychiatrist • Gastroenterologist • Endocrinologist • Anesthesiologist • Exercise physiologist • Nurse Clinician • Surgeon
SURGICAL ELIGIBILITY A multidisciplinary team with expertisein adolescent weightmanagement and bariatric surgery shouldcarefully consider theindications, contraindications, risks,and benefits of bariatricsurgery for individual patients. • This team must agree that surgical approach is the best alternative for the patient • Adolescent bariatricsurgery should be performed only at facilitiescapable of treatingadolescents with complications of severeobesity, where detailedclinical data collection can occur.
SURGICAL OPTIONS FOR SEVERELY OBESE PATIENTS • Jejunoileal bypass • Pancreaticobiliary diversion • Gastroplasty • Horizontal • Vertical • Lap-band • Laparoscopic Gastric Bypass
LAP-BAND • An adjustable band is placed around the proximal part of the stomach • The band is progressively tightened to create a small pouch and outlet • Need for serial adjustment of balloon within a band (IR)
LAP-BAND RESULTS • Italy (Angrisani, 2004): BMI < or = 35, 27 centers; N=3,319 (Data on 210) • 8.1% complications • Average decreased from BMI 34% to 28% by 60 months • US (Ren, 2004), BMI average >49, 2 academic centers, N=444 • 15% complications • 44.3% excess body weight lost at 1 year
LAP BAND ADVANTAGES • Technically easier • Reversible • No aspects of malabsorption
LAP BAND COMPLICATIONS • Band erosion • Infection • Slippage • Gastric obstruction • Port migration • Esophageal dilation
LAP BAND SUCCESS • Needs serial close follow-up • Needs serial band adjustment • Will FAIL if patient likes sweets, high carbohydrate liquids
GASTRIC BYPASS • Combines principles of gastric restrictive operation and jejunoileal bypass • Small proximal gastric pouch • Roux en Y gastroenterostomy • Isolated gastric bypass entails division of the stomach.
GASTRIC BYPASS COMPLICATIONS/PROBLEMS • Anastomotic leak • Bowel obstruction • Infection • Hernia • DVT,micronutrient problems • Limits access to distal stomach
Technically easier Easily reversible No malabsorption More manipulation post-op Minimal data with pregnancy Foreign body Current “gold standard” More difficult operation More permanent; difficult to reverse Malabsorption throughout life Limited access to distal stomach and proximal duodenum for the patient’s lifetime LAP BAND VERSUS GASTRIC BYPASS
CONCLUSIONS • There is a role of Lap-Band in the surgical treatment of morbidly obese children and adolescents • The patients should meet strict criteria as outlined • Need for multi-institutional trials to get evaluable data for this epidemic.