Adolescent Bariatric Surgery - October 2009

Adolescent Bariatric SurgeryAdolescent Bariatric Surgery

Kirk Reichard MD, MBA, FACS, FAAP

CDC Obesity Trends

1998

2007

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Pediatric Obesity

Severe Pediatric Obesity

BMI > 40

BMI Z score >2.5

Children with severe obesity start with early onset morbid obesity– 4 yo who weighs >80 lbs– 8 yo who weighs > 160lbs

How much extra weight?

BMI 25 BMI 40 BMI 45 BMI 50

15 yo Female

Ht: 64 inches145 235 265 290

15 yo Male

Ht: 69 inches170 270 305 340

A gain of 10 extra pounds (physiologic 5-10lbs/yr) per year between kindergarten and high school = BMI of 40

Prevalence

Between 1 to 3%

of adolescents have BMI >40

750,000 adolescents in the United States with BMI>40

More common disease than cystic fibrosis, juvenile diabetes, and childhood cancer combined

BMI Tracking

Children (age 12) with BMI>99% followed into adulthood (age 27)– 100% BMI>30– 90% with BMI>35– 65% with BMI>40

Freedman et al. Cardiovascular Risk Factors and Excess Adiposity Among Overweight Children and Adolescents: The Bogalusa Heart Study. Journal of Pediatrics. 2007; 15: 12-7

Obesity Complications

Pediatric Metabolic Syndrome

Explains the relationship between obesity and CV Disease– Central Obesity– Insulin resistance– Dyslipidemia– Hypertension– Glucose intolerance

Cook, S, et al. Arch Pediatr Adolesc Med. 2003;157:821-827.

MS = 3 or more


Cali, A. M. G. et al. J Clin Endocrinol Metab 2008;93:s31-s36


Weiss, R. et al. N Engl J Med 2004;350:2362-2374

CRP goes up (BAD!)

Adiponectin goes down (also BAD!)

Cardiovascular Risk Factors

≥1 ≥ 2 ≥ 3 ≥ 4

50-85% 36% 9% 2% 0%

85-95% 51% 19% 5% 1%

95-99% 70% 39% 18% 5%

>99% 84% 59% 33% 11%

Risk Factors:Triglycerides

Cholesterol

HDL

Insulin (fasting)

Systolic BP

Diastolic BP

Freedman et al. Cardiovascular Risk Factors and Excess Adiposity Among Overweight Children and Adolescents: The Bogalusa Heart Study. Journal of Pediatrics. 2007; 15: 12-7

Berenson GS, Srinivasan SR, Bao W, Newman WP III, Tracy RE, Wattigney WA. Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults: the Bogalusa Heart Study. N Engl J Med. 1998; 338: 1650–1656.

Atherosclerosis vs Cardiovascular Risk Factors

Pediatric Obesity and Mortality

Neovius, M, et al. BMJ 2009;338:b496

The Cost of Obesity

Wee, et al., Am Journal of Public Health, January, 2005

0

20000

40000

60000

80000

100000

120000

140000

160000

180000

200000

<25 25-30 30-35 >35

BMI

$Males

Females

Daviglus, et.al, JAMA, December 8, 2004

The Cost of Obesity

Cost of Childhood Obesity

Thompson Medstat Research Brief, , 2006

Childhood Obesity

Thompson Medstat Research Brief, , 2006

duPont WTM Cohort

92 patients treated in 2005 with BMI over 40.– 55 with BMI 40-45– 20 with BMI 45-50– 13 with BMI 50-55– 4 with BMI >55

duPont Morbidity Rates

Acanthosis/ Hyperinsulinism: 71%– Diabetes: 4%

Asthma: 48% Dyslipidemia: 45% PCOS: 35% of females Psych (Depression, Anxiety, Bipolar): 29% Nonalcoholic Steatohepatitis: 24% Hypertension: 22% Sleep Disordered Breathing: 20% Ortho (SCFE, Blounts): 8%

duPont Weight Management

BMI>40 Patients by Age (n=95)

0

5

10

15

20

25

30

<= 12 13 14 15 16 17 18 19+

Years of Age (Avg=17.2, Range 8-23)

Fre

qu

ency


Diagnosis Codes

0

500

1000

1500

2000

2500

0 1 2 3 4 5 6 7+

# of Diagnosis codes (Median=2.3, Range 1-15)

En

co

un

ters


Weight Change

8

5

50

28

0 10 20 30 40 50 60

<5% decrease

3-5% decrease

No change

Increased BMI

% of Patients


# Unique Patients 95

Inpatient and Outpatient Encounters 6576Hospital Discharges 63Avg Encounters per Unique Pt 69.2Ranges of Encounters per Unique Pt. 5-425

Charges per Unique Patient $52,939Total Charges $5,029,205

Adult Bariatric Surgery

NIH Consensus Panel- 1991– Failure of Medical and Dietary Treatments– Substantial excess morbidity and Mortality

Surgery Indicated for selected pts:– Documented failure of non-surgical weight loss – BMI> 40– BMI> 35 with at least 2 co-morbidities– Adults Age 18+

“Who would have thought it? An operation proves to be the most effective therapy for adult-onset

diabetes mellitus”

Pories WJ, Swanson MS, MacDonald KG, et al 1995;222:339-350

Bariatric Procedures

Bypass of part of the intestine– Roux-en-Y Gastric

Bypass– Duodenal switch, etc.

Adult Bariatric- RYGBP

Outcomes– 50-75% Excess Wt Loss (3+ years)

Complications– GI Leak (5%), Bleeding (3.5%), Wound (9%), Pulm (6%),

DVT/PE (3%)– Stenosis, bowel obstruction (up to 20% each), Ulcers, Gall

Stones, Iron and vitamin deficiency– Mortality 0.5-2%

Bariatric Procedures Restrictive

– Decrease size of stomach, early Satiety

– Vertical Banded Gastroplasty, Sleeve Gastroplasty

– Lap-Band Laparoscopic Adjustable Gastric Banding*

*FDA approved for age 18+ only

Lap Band® Adverse Events

Intra operative– Conversion to open 1(0.1%)– Iatrogenic gastrostomy 1(0.1%)

Early Post-operative– Hemorrhage 1(0.1%)– Port infection 6(0.6%)– Stomal obstruction 14(1.4%)– Perforation 3(0.3%)

Late– Mechanical dysfunction 5 (0.4%)– Erosion 2(0.2%)– Slippages 23(2.3%)

Ponce, et al., 2005

Comparing Weight-Loss Results

Source: O’Brien et al. Obesity is a Surgical Disease: Overview of Obesity and Bariatric Surgery, ANZ J Surg, 2004; 74: 200-204.

Gastric Bypass

LAP BAND®

Adolescent Bariatric Surgery

50% of bariatric surgeons have done a bariatric procedure on an adolescent in the past year

Most not done in a pediatric setting Estimated 1,000 – 10,000 bariatric procedures

done in children < 18 yearly.

Adolescent Bariatric Surgery

Inge, et al., Pediatrics, 2004– Multidisciplinary Pediatric Panel– Lack of evidence-based guidelines– More restrictive criteria:

BMI>40 with severe co-morbidity (Type II DM, Obstructive sleep apnea, Pseudotumor cerebri)

BMI>50 with less severe co-morbidity

Adolescent Bariatric Surgery Contraindications

Physical immaturity Medically Treatable Cause of Obesity Inability to participate in follow-up Patient cognitively unable to participate in decision Active psychiatric/ behavioral issues that would preclude

participation Substance Abuse Current or planned pregnancy (within 2 years)

Inge, et al.

Adolescent Bariatric SurgeryOutcomes

Meta-analysis November 2008

Procedure Number Outcome Evidence Rating

Band 8 studies

352 Pts

Wt Loss

Co-morbiditiesMod/Weak

Weak

Bypass 5 Studies

131 Pts

Wt Loss

Co-morbidities

Mod/Weak

Insuff/weak

Other 5 Studies

158 Pts

Wt. Loss

Co-Morbidities

Insuff

Insuff

Treadwell, J, et al, Ann Surg 2008;248: 763-776

Adolescent Bariatric Surgery Outcomes

APSA Adolescent Bariatric Study Group, Adolescent Lap-Band® Group, Teen LABS (NIH)

ASMBS Pediatric Committee

Teen LABS (NIH)

FDA trials

DuPont has been granted an Investigational Devise Exemption (IDE) from the FDA for Lap Band use

DuPont Adolescent Lap-Band FDA Study

FDA, CRRC, IRB approved trial

14-17 years of age

BMI>40

Co-morbidity

Obesity for at least 5 years

At least 6 months supervised treatment

Commit to 5 year follow-up

Adolescent Lap-Band® Exclusions

Age less than 14 years

History of inflammatory bowel disease

Chronic use of anti-inflammatory medication

Pregnancy or planning pregnancy

Uncontrolled eating disorder

Uncontrolled mental health disorder

Our Treatment Program

Family Behavioral Therapy

Individualized

Multidisciplinary

Well balanced hypocaloric diet

Home exercise regimen

Surgical option is not primary focus

Team Composition

Weight management team with adolescent experience– Pediatrician– Surgeon– Nutritionist– Psychologist– Exercise Physiologist– Study Coordinator: organization of data

Adolescent Lap-Band® Preoperative Program

Monthly visits for 6 months

Evaluative Component

Completion of Preoperative Workbook

Improve: – Fitness– Nutrition– Family Functioning– Psychological Functioning

Protein sparing fast for 2 weeks

Adolescent Lap-Band® post-op issues

Visits every 3-6 weeks for adjustments Long-term Compliance is Critical

– Family/ peer support– Band Adjustments– Ongoing nutritional support– Exercise– Behavior Modification

Transition to “adult” life

duPont Lap Band® Results

26 Patients to date21 FemaleAverage age 16 years old

duPont Lap Band® Results- Excess Weight Loss

0

10

20

30

40

50

60

70

0 6 12 18

Months

%E

WL

duPont Lap Band® Results- Metabolic Syndrome

Adverse Events

No perioperative complications

Hospital Stay: <48 hours.

No adverse events requiring a second operation

No adolescents asking for their band to be removed

No pregnancies

None lost to follow-up

What We Have Learned

Morbid obesity in adolescents is a disease state even without any other medical comorbidities

Modest to Significant Lifestyle changes result in weight stability but only clinically significant weight loss (5-10% decrease in BMI) in a small percentage of patients

Severe calorie restriction (<1000 calories/day) will result in weight loss

All weight loss options require lifestyle changes

Questions

Is there any long term benefit (medical or psychological) in doing obesity surgery in childhood instead of early adulthood

What (if any) surgical procedure is best to do in children

What should we do with severely morbidly obese children who have limited decisional capacity or with non stable family units

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Adolescent Bariatric Surgery - October 2009

Health & Medicine

Transcript of Adolescent Bariatric Surgery - October 2009