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MORBID OBESITY IN ADOLESCENTS AND CHILDREN

MORBID OBESITY IN ADOLESCENTS AND CHILDREN

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MORBID OBESITY IN ADOLESCENTS AND CHILDREN

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  1. MORBID OBESITY IN ADOLESCENTS AND CHILDREN Marjorie J. Arca, M.D. Children’s Hospital of Wisconsin Milwaukee, WI

  2. 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

  3. 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

  4. 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

  5. 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

  6. OBESITY PROGRAM: Key Players • Primary care MD • Nutrition specialist • Psychologist/psychiatrist • Gastroenterologist • Endocrinologist • Anesthesiologist • Exercise physiologist • Nurse Clinician • Surgeon

  7. 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.

  8. SURGICAL OPTIONS FOR SEVERELY OBESE PATIENTS • Jejunoileal bypass • Pancreaticobiliary diversion • Gastroplasty • Horizontal • Vertical • Lap-band • Laparoscopic Gastric Bypass

  9. LAP-BAND

  10. 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)

  11. 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

  12. LAP BAND ADVANTAGES • Technically easier • Reversible • No aspects of malabsorption

  13. LAP BAND COMPLICATIONS • Band erosion • Infection • Slippage • Gastric obstruction • Port migration • Esophageal dilation

  14. LAP BAND SUCCESS • Needs serial close follow-up • Needs serial band adjustment • Will FAIL if patient likes sweets, high carbohydrate liquids

  15. 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.

  16. GASTRIC BYPASS COMPLICATIONS/PROBLEMS • Anastomotic leak • Bowel obstruction • Infection • Hernia • DVT,micronutrient problems • Limits access to distal stomach

  17. 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

  18. 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.