1. 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

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

3. “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

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

6. 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 Apr 9;289(14):

7. They just want to be kids…

9. 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

10. Treatment Options (Morbidly Obese)
Behavior Modification
Surgery

12. Pediatric Behavioral Modification
Epstein, et.al., 1995

13. Risk of Adult Obesity Most obese children will become obese adults
The risk increases with increasing age

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

15. 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

16. This may be the first generation whose life expectancy is less than their parents!

17. 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

18. What can we REALLY do about this?

19. 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.

20. 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

21. 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.

22. 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

23. 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

24. Gastric Bypass in adolescents
Retrospective survey
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 Jan;7(1):102-7

25. 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 Jan;7(1):102-7

26. Gastric Bypass in adolescents
RESULTS- Complications
LATE:
1 SBO
4 incisional hernias
2 sudden 2 & 6 years postop
Sugarman, J Gastrointest Surg Jan;7(1):102-7

27. Gastric Bypass in adolescents
Sugarman, J Gastrointest Surg Jan;7(1):102-7

28. 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 Jan;7(1):102-7

29. 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);

30. 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

31. 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

32. Adjustable Gastric Band
17 patients (age 12-19, median 17)
Median follow-up 25 mo (12-46)
BMI 44.7 to 24 months (59.3 %EWL)
2 complications
Slipped band
Leaking port
Dolan, et. al., Obes Surg Feb;13(1):101-4

33. Other Options Gastric sleeve resection
Gastric sleeve resection with biliary pancreatic diversion

34. What influenced my decision?
Less Morbidity
Reversible
Adjustable Gastric Band

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

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

38. 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

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

40. Pre-op Must Qualify Informed Consent from parents
Informed Assent from child
Liquid protein diet pre-op for 1 Week

44. Post-op Care Liquid Diet for 2-4 weeks
Full liquid diet until first visit
Protein Shake
MVI
Calcium Supplement or Skim Milk

45. 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

46. Potential Complications
Band erosion
Slipped band – really a “para-band” hernia
Esophageal dilatation
GERD
Dysphagia (food stuck)
Port problems

47. 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 ( )

48. Post-operative Weight Loss20 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)

49. What Needs to be Done? Determine the best operation Funding Research
Clinical
Make it so I don’t have to do this…

51. 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