Adolescent Bariatric Surgery: Weighing the Options

Mark L. Wulkan, M.D.Associate Professor of Surgery and Pediatrics

Emory University School of MedicineChildren’s Healthcare of Atlanta

The New Face of Pediatric Surgery

Alternative Title

500 gramsto 500 pounds

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.”

Why are kids obese?

• Genetic Forces– Genetic Mutations– Genetic Predisposition

• Social / Environmental Forces

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.

They just want to be kids…

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

Treatment Options(Morbidly Obese)

Behavior Modification

Surgery

Pediatric Behavioral Modification

Epstein, et.al., 1995Epstein, et.al., 1995

Risk of Adult Obesity

• Most obese children will become obese adults

• The risk increases with increasing age

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

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

This may be the first generation whose life expectancy is less

than their parents!

Obesity at Children’sRace N Ave BMI AVE %’tile* # at Risk

(%)**#

Overweight (%)***

Total at Risk or

Overweight (%)

All 500 19 55 53 (11) 98 (20) 151 (31)White 254 19 55 22 (9) 47 (19) 69 (28)Black 188 20 56 25 (13) 41 (22) 66 (35)Hispanic 32 17 50 2 (6) 7 (22) 9 (28)Asian 7 16 42 1 (14) 0 (0) 1 (14)Other 19 19 62 3 (16) 3 (16) 6 (32)2003 Georgia 15% 11% 26%

** 85th – 95th percentile

*** > 95th percentile

What can we REALLY do about this?

Surgery for Weight Management

NIH 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)

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

Which is Best?

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

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

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):102-7Sugarman, J Gastrointest Surg. 2003 Jan;7(1):102-7

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):102-7Sugarman, J Gastrointest Surg. 2003 Jan;7(1):102-7

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):102-7Sugarman, J Gastrointest Surg. 2003 Jan;7(1):102-7

Gastric Bypass in adolescents

n=30 26/28 17/22 11/15n=30 26/28 17/22 11/15 Sugarman, J Gastrointest Surg. Sugarman, J Gastrointest Surg.

2003 Jan;7(1):102-72003 Jan;7(1):102-7

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):102-7Sugarman, J Gastrointest Surg. 2003 Jan;7(1):102-7

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.

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

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

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

Other Options

• Gastric sleeve resection

• Gastric sleeve resection with biliary pancreatic diversion

What influenced my decision?

Less Morbidity

ReversibleAdjustable Gastric Band

• Multi-Disciplinary Program– Pediatric Surgery– Endocrine– Psychology– Nutrition– Nurse Practitioner– Patient Coordinator– Research Coordinator

Emory BariatricsAdolescent Program

• Initial Evaluation• Screen for elegibility• Complete History and Physical

– Including family history of obesity– Detailed dietary history– Look for comorbidities

Emory BariatricsAdolescent Program

Patient Work-upRequired

• Labs– Thyroid function– Lipid profile– Hepatic profile– Glucose– HbA1c– Insulin– And whatever else endocrine wants!

• Imaging– Upper GI Series

• Psychiatric Evaluation

• Sleep Study• Cardiac Echo• Pulmonary Function Studies• RUQ U/S

Patient Work-upSelective

Pre-op

• Must Qualify• Informed Consent from parents• Informed Assent from child

• Liquid protein diet pre-op for 1 Week

Post-op Care

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

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

Potential Complications

• Band erosion• Slipped band – really a “para-band” hernia• Esophageal dilatation• GERD• Dysphagia (food stuck)

• Port problems

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)

Post-operative Weight Loss

0

20

40

60

80

100

120

140

160

180

200

0 3 6 9 12 18 24 30

Months Postop

Mean BMI

(kg/m2)

Mean %EWL

Median Weight

(kg)

What Needs to be Done?

• Determine the best operation

• Funding– Research– Clinical

• Make it so I don’t have to do this…

Acknowledgements

• Beryl Lindsay – Bariatric Coordinator• Andrew Muir, MD – Endocrine• Eric Felner, MD – Endocrine• Laura Mee, PhD – Psychology• Brenda Middlebrooks, MS – Bariatric PNP• Christina Ryan-Ramey, RN – Research Coordinator• Ed Lin, MD – Emory Bariatrics• Barbara Stoll, MD – Unwavering support

• Thomas Inge, MD, PhD – Pediatric Bariatric Surgeon Cincinnati Children’s Hospital, University of Cincinnati