Bariatric Surgery: A Major Decision for Minors ALEX KLOEHN, CAMI MANDELL http://www.cdc.gov/nchs/data/hestat/obesity_child_09_10/obesity_child_09_10.htm 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) http://arch1design.com/blog/latest_environmental_health_news/childhood-obesity-prevalence-and-prevention/ 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 Hypertension Hypercholesterolemia Hypertriglyceridemia Hyperinsulinemia Atherosclerosis Metabolic syndrome Obstructive sleep apnea PCOS 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 resection 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 developed 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 - Biliopancreatic Diversion and Duodenal Switch were also introduced to address concerns over Blind Loop Syndrome. 1980’s – Adjustable gastric banding procedures were popularized (Deitel, 2012) Brief History of Bariatric Surgery (Cont’d) 2000’s – The first sleeve gastrectomy procedures were recorded. (Deitel, 2012) Common Types of BS Performed Today http://www.hormone.org/questions-and-answers/2012/bariatric-surgery 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 1200 1000 800 Ages 10 - 17 600 Ages 18 - 19 total 400 200 0 2000 Adapted from data in Kelleher, 2013 2003 2006 2009 Physical & Psychological Benefits BMI reduction Wide range, depending on study follow-up length Most occurs in first year Some alleviation of comorbid conditions 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 Hypertension Sleep apnea Dyslipidemia Fatty liver disease Post-operative results Improvement in glucose tolerance and insulin resistance 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 BMI >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 adolescents Questions? 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