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

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

“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.” Jeffrey Friedman

Why are kids obese? Genetic Forces Genetic Mutations Genetic Predisposition Social / Environmental Forces Genetic forces will be more apparent in children

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., 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!

Total at Risk or Overweight (%) Obesity at Children’s Race 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 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) Other 62 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) The panel reviewed 14 RCTs that examined the effect of surgical procedures on weight loss; 8 were deemed appropriate. All of the studies included individuals who had a BMI of 40 kg/m2 or above, or a BMI of 35 to 40 kg/m2 with comorbidity. These trials provide strong evidence that surgical interventions in adults with clinically severe obesity, i.e., BMIs >= 40 or >= 35 with comorbid conditions, result in substantial weight loss, and suggestive evidence that lifelong medical surveillance after surgery is necessary. Therefore, the panel makes the following recommendation: 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.

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? The efficacy of the procedure is probably due to the increased sense of fullness with a reduced gastric volume and the symptoms of "dumping" associated with the passage of gastric contents into the intestines, which act as deterrents to eating. Excess consumption of liquid or semisolid foods can negate the benefits of surgery.

AGB vs RYGB positives AGB RYGB Reversible Rapid weight loss 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 RYGB negatives AGB RYGB 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):102-7

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):102-7

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):102-7

Gastric Bypass in adolescents Sugarman, J Gastrointest Surg. 2003 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):102-7

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 Reversible Adjustable Gastric Band

Emory Bariatrics Adolescent Program Multi-Disciplinary Program Pediatric Surgery Endocrine Psychology Nutrition Nurse Practitioner Patient Coordinator Research Coordinator

Emory Bariatrics Adolescent Program Initial Evaluation Screen for elegibility Complete History and Physical Including family history of obesity Detailed dietary history Look for comorbidities

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

Patient Work-up Selective Sleep Study Cardiac Echo Pulmonary Function Studies RUQ U/S

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 20 40 60 80 100 120 140 160 180 200 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