1. Pediatric Bariatric Surgery?
Kenneth G. MacDonald, MD, FACS,
William Chapman, MD, FACS
Walter J. Pories, MD, FACS
East Carolina University
Greenville, North Carolina

2. Health Problems Associated with Morbid Obesity: the Co-morbidities
Diabetes
Sleep apnea
Pulmonary Failure
Asthma
Hypertension
Infertility
Depression
Arthritis
Heart disease
Stroke
Hernias
Pseudotumor cerebri
Immune suppression
Reflux
Stress incontinence
Pulmonary embolism

3. The Greenville Gastric Bypass
ml gastric pouch
mm. anastomosis
cm alimentary loop
Total group = 831
16 year cohort =147

4. Follow-up Was Rigorous
147 patients underwent the gastric bypass between Jan
95% 16 year follow-up
8 (5%) were lost
17 (12%) patients died
122 (83%) alive after 16 years

5. Weight Loss After Bariatric Surgery @ 16 Years

7. The weight loss
is sustained
300
250 LB
200
150 1 2 5 16 10
Years

8. Yes, durable weight control is possible in the morbidly obese

9. 30 day Complications Mortality: 1.5%, (now <1%)
Pulmonary emboli, cardiac, infections
Serious complications: 10% (now c. 6%)
Serious Infections: 10% (now c. 3%)
Technical problems: leaks, stenoses, bowel obstructions, splenic injuries, dehisshences

10. 608 morbidly obese 121/146 (83%) 150/152 (99%) euglycemic euglycemic
165 IGT
“impaired”
165 Type 2
Diabetics
146 long enough
followup
152 long enough
followup
121/146 (83%)
euglycemic
150/152 (99%)
euglycemic
27 non-responders
10 staple line failures
17 true nonresponders

11. Mortality 232 Morbidly Obese Diabetics 14/154 (9%)/ 9 yrs78
Operation refused
for personal or
insurance reasons
Gastric Bypass
Mortality
14/154 (9%)/ 9 yrs
22/78 (28%)/6.2 yrs
1%/yr
4.5%/yr
P<0.0003

12. Health Problems Associated with Morbid Obesity
Diabetes
Sleep apnea
Pulmonary Failure
Asthma
Hypertension
Infertility
Depression
Arthritis
Heart disease
Stroke
Hernias
Pseudotumor cerebri
Immune suppression
Reflux
Stress incontinence
Pulmonary embolism

13. Surgical Goals The “best” operation for each person Technically easy
Rare complications
Limited resource needs
Excellent long-term outcomes

14. Pediatric Surgical Goals
The “best” operation for each person ?

15. Two operative options: Adjustable gastric band
Gastric bypass
Adjustable gastric band

16. Two operative options:
Open vs. Laparoscopic?
Stapled or divided?
Size of Anastomosis?
Length of loops?
Gastric bypass

17. Two operative options: Adjustable gastric band
Which band?
How to adjust?
No long-term studies
Revision difficult
Adjustable gastric band

18. Pediatric Surgical Goals
The “best” operation for each person
Gastric bypass
Technically easy? No, but feasible
Rare complications?
Mortality < 1%, major complications <6%
Limited resource needs
We have the OR and PICU resources
Excellent long-term outcomes
Unknown

19. Essentials for the surgical study
Defined research questions and protocols
Defined research team and hierarchy
Smooth inter-disciplinary cooperation
Sophisticated, detailed, retrievable records
Agreed upon indications
Psycho-socially stable patient and family
Failure of medical therapies
Contract for long-term compliance
Operate for co-morbidities not only weight
Research team meets monthly

20. Summary The need is great The opportunities for our center are great
Let’s build the best pediatric obesity program in the US
Surgery is a small part of the endeavor
We are with you

22. Pt. LT Remission of diabetes after gastric bypass Insulin Requirements
Date
Glucose
Insulin given
16 Nov PREOP/OP
495 90
17 Nov
281 8
18 Nov
308 16
19 Nov
240
20 Nov
210 4
21 Nov
230
22 Nov
216
28 Nov
193
30 Nov
153
14 Dec
155
Pt. LT
Insulin
Requirements
Pre & post
Gastric
Bypass

23. 17 Non-responders? Older Had the diabetes longer
The morbidly obese diabetic should be considered for early surgery

24. Hunger signal:
Ghrelin
From Michael Swart

25. Plasma Ghrelin Profile in Humans
300
400
500
600
700
800
900
Plasma
Ghrelin
(pg/ml)
0600
0700
0800
0900
1000
1100
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
2200
2300
2400
0100
0200
0300
0400
0500
Time of Day B D L
n = 10
From Michael Swart

26. From Michael Swart Plasma Ghrelin (pg/ml) Normal Weight Gastric Bypass
100
200
300
400
500
600
700
800
Plasma
Ghrelin
(pg/ml)
0600
0800
1000
1200
1400
1600
1800
2000
2200
2400
0200
0400
Clock Time
Gastric Bypass
Normal Weight
Detection
Limit L B D
From Michael Swart

27. Dohm: the gastric bypass obliterates
the BMI/insulin resistance relationship

28. The pediatric challenges
What is a reliable measure of adiposity?
In what groups do medical measures fail?
Who will benefit, who will not, from surgery?
Degree of obesity
Socio-psychologic background
Compliance with short and long-term therapies
What are the long-outcomes?
What are the critical research questions?
Costs?