Disclosures I have nothing to disclose Outline Growing obesity - - PDF document

 5/18/13  1

Disclosures

I have nothing to disclose

Outline

 Growing obesity epidemic  Not just about weight loss: treating

metabolic disease and reducing mortality.

 RY gastric bypass, gastric band,

sleeve gastrectomy: what is the difference?

 Current AAP recommendations

 5/18/13  2

Outline

 Growing obesity epidemic

2000

Obesity Trends* Among U.S. Adults BRFSS, 1990, 2000, 2010

(*BMI ≥30, or about 30 lbs. overweight for 5’4” person) 2010 1990 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity reduces life expectancy

For young men, BMI >45 took off 13 years of life expectancy For young women, BMI >45 took off 8 years of life expectancy

 5/18/13  3

Age 1976-80 2003-04 2-5 years 5.0% 13.9% 6-11 years 6.5% 18.8% 12-19 years 5.0% 17.4%

Outline

 Growing obesity epidemic  Not just about weight loss: treating

metabolic disease and reducing mortality.

courtesy of ASMBS

Metabolic benefits

• f

bariatric surgery

Metabolic benefits of bariatric surgery in children and adolescents? UNKNOWN

 5/18/13  4

Resolution of Medical Comorbidities

Treadwell et al, Ann Surg, 2008

Outline

 Growing obesity epidemic  Not just about weight loss: treating

metabolic disease and reducing mortality.

 RY gastric bypass, gastric band,

sleeve gastrectomy: what is the difference?

• Gold Standard – Long-term weight loss
• Increased mortality and operative morbidity
• Permanently alters GI anatomy
• Not Reversible
• Requires lifelong nutritional supplementation
• ? osteoporosis, short stature, gastric CA,

fetal anomalies, infertility?

 5/18/13  5

 No in-hospital deaths

• 1 death at 9 months postop (C diff colitis,

hypovolemia, MOF)

• 3 additional unrelated deaths

 Reported postop complications

• shock
• PE
• severe malnutrition and micronutrient

deficiency (most common)

• bleeding
• GI obstruction

Treadwell et al, Ann Surg, 2008

Connection with the subcutaneous reservoir Gastric pouch

• Slower weight loss – less long-term data
• Reduced mortality and operative

morbidity

• Reversible
• Not associated with nutritional

deficiencies

• ? sustainability



84/151 patients who underwent gastric banding from 1994-1997 39% experienced major complications (28% had erosions) 49% of the bands were removed 17% required conversion to a gastric bypass

 5/18/13  6

 No in-hospital or postoperative deaths  Reoperations 28/352 (8%)

band slippage 12/352 (3%) gastric dilation intragastric band migration psychologic intolerance of band hiatal hernia cholecystitis tubing crack

 8 cases of Fe deficiency  5 cases of hair loss

Treadwell et al, Ann Surg, 2008 Kelleher et al, JAMA Pediatrics, 2013 Treadwell et al, Ann Surg, 2008

 5/18/13  7

band sleeve bypass

Change in BMI after bariatric surgery

NO PUBLISHED DATA FOR CHILDREN

So what about kids?….

 5/18/13  8

Outline

 Growing obesity epidemic  Not just about weight loss: treating

metabolic disease and reducing mortality.

 RY gastric bypass, gastric band,

sleeve gastrectomy: what is the difference?

 Current AAP recommendations

NIH Consensus Panel – March 25-27, 1991

Am J Clin Nutr 1992; 55: 615-619

Surgery for the Severely Obese

Severely obese adolescents: completed linear growth & been 
 unsuccessful at organized attempts at weight management.

• BMI ≥ 40

BMI ≥ 50

Continue behavioral approaches Severe Comorbidity? Severe or less severe comorbidity?* Continue behavioral approaches Any contraindications to surgery?** Consider specific bariatric surgical

• ptions

 5/18/13  9

Table 2: Obesity-related Conditions

• Serious comorbities:
• Type 2 diabetes mellitus
• Obstructive sleep apnea
• Pseudotumor cerebri
• Less serious comorbities:
• Hypertension
• Non-alcoholic steatohepatitis
• Significant impairment in activities of daily living
• Intertriginous soft tissue infections
• Stress urinary incontinence
• Gastroesophageal reflux disease
• Weight-related arthorpathies that impair physical activity
• Obesity-related psychosocial distress
• Dyslipidemias
• Venous stasis disease

Table 3: Contraindications

• Presence of medically correctable cause of obesity
• Patient or family is unable or unwilling to participate in long-term

follow-up

• Absence of decision capacity on the part of patient
• Existence of medical, psychiatric, or cognitive condition that

may impair patient’s ability to assent to surgery or adhere to post-op dietary and medication regimen

• Existence of substance abuse in preceding year
• Current lactation, pregnancy, or plans for pregnancy in

upcoming 2 yrs

Bariatric Surgery

Why?



Obesity in childhood =

• besity in adulthood



Better weight loss



Reduction of long-term metabolic disease and mortality?



Improved quality of life

Why Not?



20-30% of children who do not become obese in adulthood



No long-term studies of metabolic benefits



Concern for nutritional complications



Unknown perioperative morbidity and mortality

Summary Points

 Children not immune to the growing obesity

epidemic.

 Metabolic benefits of bariatric surgery for children

are unknown. Long-term studies needed.

 Current recommendations: gastric restrictive

procedures (gastric band, possibly sleeve gastrectomy) to avoid the nutrient deficiency seen in gastric bypass procedures.

 Importance of preoperative psychological

evaluation and long-term medical surveillance in the setting of a multidisciplinary team approach.

 5/18/13  10

References

 Treadwell et al, Systemic Review and Meta-Analysis

• f Bariatric Surgery for Pediatric Obesity, Ann Surg

2008; 248: 763-776.

 Kelleher et al, Recent National Trends in the Use of

Adolescent Inpatient Bariatric Surgery, JAMA Pediatr 2013; 167(2): 126-132.

 Inge et al, Bariatric Surgery for Severely

Overweight Adolescents: Concerns and Recommendations, Pediatrics 2004; 114-217.