Obesity Surgery

Bariatric Surgery: A Major
Decision for Minors
Childhood and Adolescent Obesity Statistics
 Obesity rates in children age 6-11 increased from 7% to 18% between
1980 and 2010 in the US (Ogden, 2012)
 Obesity rates in adolescents age 12-19 increased from 5% to 18.4%
between 1980 and 2010 in the US (Ogden, 2012)
Concerns of Childhood Obesity
 Obese adolescents are
likely to be obese as adults
(Freedman, 2005)
 Increased risk of depressive
symptoms and lower
quality of life scores.
(Schwimmer, 2003)
 Increased risk of
Metabolic syndrome
Obstructive sleep apnea
Non-alcoholic fatty liver disease
Certain cancers
(Flynn, 2006)
Brief History of Bariatric Surgery
 1952- First recorded operation to
cure obesity was performed by
Viktor Henrikson as a small bowel
 Shortly followed by jejunocolic
bypasses that led to loss of fluid,
electrolytes, and led to liver failure.
(On left)
 Mid 1950’s - Jejunoileal Bypass
came next and remained popular
through the 1970’s
(Deitel, 2012)
Brief History of Bariatric Surgery (Cont’d)
 1960’s - Gastric
Bypass was first
 1970’s - Roux-enY GB was
developed and has
been modified
several times since.
(Deitel, 2012)
Brief History of Bariatric Surgery (Cont’d)
 1970’s -
Diversion and
Duodenal Switch were
also introduced to
address concerns over
Blind Loop Syndrome.
 1980’s – Adjustable
gastric banding
procedures were
(Deitel, 2012)
Brief History of Bariatric Surgery (Cont’d)
 2000’s – The first
sleeve gastrectomy
procedures were
(Deitel, 2012)
Common Types of BS Performed Today
Adolescent Bariatric Surgery (ABS) Statistics
 US Nationwide Inpatient Sample: 2,744 ABS
procedures were performed in the US between 1996
and 2003. (Black, 2013)
 Healthcare Cost and Utilization Project Kids’
Inpatient Database (KID), 1009 ABS procedures
were performed in 2009. (Kelleher, 2013)
 Trends towards minimally invasive procedures
 Plateau of ABS procedures since 2003.
Trends in Surgery Performed 2000-20009
Ages 10 - 17
Ages 18 - 19
Adapted from data in Kelleher, 2013
Physical & Psychological Benefits
 BMI reduction
Wide range, depending on study follow-up
Most occurs in first year
 Some alleviation of comorbid
Most occurs in first year
Hard to accurately assess due to follow-up loss
 Increased in quality of life
Pre-operative scores similar to children with
cancer (Loux, 2008)
Significantly increased scores post-operatively
(Loux, 2008)
BMI Reduction
 Very little long-term follow-up data
 Wide range of results
 RYGB, 12 month follow-up (Lawson, 2006)
 Pre-op 56.5±10.1
 Post-op 35.8±6.9
 RYGB, 17.1±12.3 month follow-up (Loux, 2008)
 Pre-op 54.1±7.6
 Post-op 35.1±9.3
 LSG, 12 month follow-up (Nadler, 2012)
 Pre-op 52±9,
 Post-op 39±8
RYGB, 24 month follow-up (Teeple, 2012)
Pre-op 58.8±10.7,
 Post-op mean 34.9±5.6
Co-morbid Conditions
 Most common pre-operative:
Impaired glucose tolerance
Insulin resistance
Sleep apnea
Fatty liver disease
 Post-operative results
Improvement in glucose
tolerance and insulin
Resolution of dyslipidemia
Resolution of sleep apnea
Decrease in blood pressure
(Teeple, 2012; Nadler, 2012, Lennerz, 2013, Lawson, 2006, Loux, 2008)
Risks and Complications of Surgery
 Complications are similar to adults (Inge, 2013)
 Late weight regain (up to 20%) (Xanthakos, 2008)
 Recurrence of depression and eating disturbances that affect
QOL (Pratt, 2009)
 Marginal ulcers, small bowel obstruction, protein and
micronutrient deficiencies
 Gastric band slippage
 Pregnancy
Risks and Complications of Surgery (Cont’d)
 May cause problems with proper growth if children
are not done growing (Barnett, 2013)
 Low adherence to follow-up (Lennerz, 2013)
Best Practice Eligibility Criteria
 >35 with severe comorbidities
 >40 with any comorbities
 Physiological Maturity
 Height ~ 95% adult height based on estimate of bone age
 Pubertal Maturity based on Tanner Stages (IV+)
Girls usually ≥13; Boys usually ≥15
 Lifestyle Change
 Demonstrate ability to make sustained dietary and physical
activity changes
(Pratt, 2009)
Best Practice Eligibility Requirements
 Psychosocial Maturity
 Appropriate decision making
skills and understanding of
risks and benefits
 Social support network
 Psychiatric conditions
managed under treatment
 Evidence of patient/family
ability to comply with
treatment plan pre- and postsurgery
(Pratt, 2009)
Future Directions
 Necessity of long-term data on physical and
psychological outcomes
Options of minimally invasive surgeries (Shebrain, 2013)
Need to address possibility of weight regain
Rethink criteria using BMI for weight loss surgery to
catch adolescents before they become
severely/morbidly obese
Assert that surgeons performing surgery are
qualified to do so with the special considerations of
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