Transcript BARIATRIC SURGERY IN ADOLESCENTS

RATIONALE FOR BARIATRIC
SURGERY IN ADOLESCENTS
SCOPE OF THE OBESITY
PROBLEM
26% of children and adolescents aged 2 to 17
years were overweight (18%) or obese (8%) Canadian Community Health Survey 2004
For adolescents 12 to 17 yrs - overweight rate
more than doubled and obesity rate tripled over
past 25 yrs
SCOPE OF THE OBESITY
PROBLEM
SCOPE OF THE OBESITY
PROBLEM
26% of children and adolescents aged 2 to 17
years were overweight (18%) or obese (8%) Canadian Community Health Survey 2004
For adolescents 12 to 17 yrs - overweight rate
more than doubled and obesity rate tripled over
past 25 yrs
Obesity during adolescence is the single best
predictor for adult obesity
WHY WOULD WE EVEN THINK ABOUT
DOING SURGERY FOR OBESITY IN
CHILDREN?
Because diets, pills, lifestyle
changes, and prevention strategies
don’t seem to be working…
What’s the best kind of bariatric
procedure for children?
What’s the best kind of bariatric
procedure for children?
Malabsorptive
Restrictive
What’s the best kind of bariatric
procedure for children?
Malabsorptive
Restrictive
– Laparoscopic band
– Roux-en-Y gastric bypass
– Sleeve gastrectomy
OUTCOMES: ADOLESCENTS
O’Brien et al. JAMA. 2010; 303(6):519-526
OUTCOMES: ADOLESCENTS
Treadwell et al. Ann Surg. 2008; 248(5)
OUTCOMES: ADOLESCENTS
OUTCOMES: ADOLESCENTS
OUTCOMES: ADOLESCENTS
25
Annual cases
20
15
Bypass
Sleeve
10
5
0
2001
2002
2003
2004
2005
2006
2007
2008
Year
CCHMC Bariatric Case Volume
(n=144 total over 10 years)
2009
2010
ADOLESCENT BARIATRIC
SURGERY IN ONTARIO
Who should be doing it, and in what
kind of environment?
ADOLESCENT BARIATRIC
SURGERY IN ONTARIO
Children are not just small adults…
ADOLESCENT BARIATRIC
SURGERY IN ONTARIO
Integrated multidisciplinary pediatricoriented medical program
–
–
Pediatric medical specialties
Psychosocial support for child and family
Surgical expertise
Academic environment as part of overall
pediatric obesity strategy
SICKKIDS TEAM OBESITY MANAGEMENT
PROGRAM (STOMP)
Multidisciplinary medical/psychosocial program
funded through MOHLTC Diabetes Strategy
Bariatric surgery funded by MOHLTC through
University of Toronto Bariatric Surgery Collaboration
High Impact Strategies Toward Obesity Reduction in
Youth (HISTORY) multidisciplinary grant funded by
CIHR
Province-wide initiative for obesity prevention and
management
Intake/Initial Assessment
Intake/Initial Assessment
Parent Group Support
Adolescent Group
Support
Adolescent Individual
Appointments
Diet/Behaviour/Exercise
Intake/Initial Assessment
Adolescent Individual
Appointments
Adolescent Group
Support
Parent Group Support
Diet/Behaviour/Exercise
3-6 Months
Team Re-Assessment
Ongoing support and
treatment
Bariatric surgery
SICKKIDS EXPERIENCE SO FAR
Pre-STOMP
Seven cases
– 4 craniopharyngioma
– 3 morbid obesity
First two: Roux-en-Y bypass
– Excellent weight loss
Last five: laparoscopic band
– All inflated with good initial weight loss
– Two required reoperation
– One removed at 2.5 years - converted to Roux-en-Y bypass
– One removed at 2.0 years - converted to Roux-en-Y bypass
– Weight loss results mixed
SICKKIDS EXPERIENCE SO FAR
Post-STOMP
Nine cases
– 1 craniopharyngioma
– 8 morbid obesity
First three: laparoscopic band
– Excellent weight loss in 1, poor weight loss in 2
– One removed after 10 months - converted to sleeve gastrectomy
– No complications
Last six:
– 3 Roux-en-Y bypass and 3 sleeve gastrectomy
– Excellent early weight loss
– No complications
SICKKIDS EXPERIENCE SO FAR
ONGOING ISSUES
What is the best operation for adolescents?
Laparoscopic band
– Potentially reversible and lower mortality
– Higher complication and reoperation rate
– Lower efficacy
Roux-en-Y bypass
– “Gold standard”
– Long term issues with vitamin deficiencies and compliance
in adolescents
Sleeve gastrectomy
ONGOING ISSUES
How many funded pediatric centres should there
be in Ontario?
– For complex medical care
– For bariatric surgery
Which model is better?
– Pediatric centre with help from adult surgeons
– Adult centre with help from pediatric medical specialists
Transitioning to adult centres
THANKS FOR YOUR
ATTENTION!