Transcript Adolescent Bariatric Surgery Kirk Reichard MD, MBA, FACS, FAAP CDC Obesity Trends No Data 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Adolescent Bariatric Surgery
Kirk Reichard MD, MBA, FACS, FAAP
CDC Obesity Trends
1990
1998
2007
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Pediatric Obesity
Severe Pediatric Obesity
 BMI > 40
 BMI Z score >2.5
 Children with severe obesity start with early onset
morbid obesity
– 4 yo who weighs >80 lbs
– 8 yo who weighs > 160lbs
How much extra weight?
15 yo Female
Ht: 64 inches
15 yo Male
Ht: 69 inches
BMI 25
BMI 40
BMI 45
BMI 50
145
235
265
290
170
270
305
340
A gain of 10 extra pounds (physiologic 5-10lbs/yr) per year between
kindergarten and high school = BMI of 40
Prevalence
 Between 1 to 3%
of adolescents have BMI >40
 750,000 adolescents in the United States with
BMI>40
 More common disease than cystic fibrosis,
juvenile diabetes, and childhood cancer combined
BMI Tracking
 Children (age 12) with BMI>99% followed into adulthood
(age 27)
– 100% BMI>30
– 90% with BMI>35
– 65% with BMI>40
Freedman et al. Cardiovascular Risk Factors and Excess Adiposity Among Overweight Children
and Adolescents: The Bogalusa Heart Study. Journal of Pediatrics. 2007; 15: 12-7
Obesity Complications
Pediatric Metabolic Syndrome
 Explains the relationship
between obesity and CV
Disease
– Central Obesity
– Insulin resistance
– Dyslipidemia
– Hypertension
– Glucose intolerance
MS = 3 or more
Cook, S, et al. Arch Pediatr Adolesc Med. 2003;157:821-827.
Pediatric Metabolic Syndrome
Cali, A. M. G. et al. J Clin Endocrinol Metab 2008;93:s31-s36
Pediatric Metabolic Syndrome
CRP goes up (BAD!)
Adiponectin goes
down (also BAD!)
Weiss, R. et al. N Engl J Med 2004;350:2362-2374
Cardiovascular Risk Factors
≥1
≥2
≥3
≥4
Risk Factors:
50-85%
36%
9%
2%
0%
85-95%
51%
19%
5%
1%
95-99%
70%
39%
18%
5%
Triglycerides
Cholesterol
HDL
Insulin (fasting)
Systolic BP
>99%
84%
59%
33%
11%
Diastolic BP
Freedman et al. Cardiovascular Risk Factors and Excess Adiposity Among Overweight Children
and Adolescents: The Bogalusa Heart Study. Journal of Pediatrics. 2007; 15: 12-7
Atherosclerosis vs Cardiovascular Risk Factors
Berenson GS, Srinivasan SR, Bao W, Newman WP III, Tracy RE, Wattigney WA. Association between multiple cardiovascular risk factors and
atherosclerosis in children and young adults: the Bogalusa Heart Study. N Engl J Med. 1998; 338: 1650–1656.
Pediatric Obesity and Mortality
Neovius, M, et al. BMJ 2009;338:b496
The Cost of Obesity
Wee, et al., Am Journal of Public Health, January, 2005
The Cost of Obesity
200000
180000
160000
140000
120000
Males
$ 100000
Females
80000
60000
40000
20000
0
<25
25-30
30-35
BMI
Daviglus, et.al, JAMA, December 8, 2004
>35
Cost of Childhood Obesity
Thompson Medstat Research Brief, , 2006
Childhood Obesity
Thompson Medstat Research Brief, , 2006
Childhood Obesity
Thompson Medstat Research Brief, , 2006
duPont WTM Cohort
 92 patients treated in 2005 with BMI over 40.
–
–
–
–
55 with BMI 40-45
20 with BMI 45-50
13 with BMI 50-55
4 with BMI >55
duPont Morbidity Rates
 Acanthosis/ Hyperinsulinism: 71%
– Diabetes: 4%








Asthma: 48%
Dyslipidemia: 45%
PCOS: 35% of females
Psych (Depression, Anxiety, Bipolar): 29%
Nonalcoholic Steatohepatitis: 24%
Hypertension: 22%
Sleep Disordered Breathing: 20%
Ortho (SCFE, Blounts): 8%
duPont Weight Management
BMI>40 Patients by Age (n=95)
30
Frequency
25
20
15
10
5
0
<= 12
13
14
15
16
17
Years of Age (Avg=17.2, Range 8-23)
18
19+
duPont Weight Management
Diagnosis Codes
Encounters
2500
2000
1500
1000
500
0
0
1
2
3
4
5
6
# of Diagnosis codes (Median=2.3, Range 1-15)
7+
duPont Weight Management
Weight Change
28
Increased BMI
50
No change
3-5% decrease
5
<5% decrease
8
0
10
20
30
% of Patients
40
50
60
duPont Weight Management
# Unique Patients
95
Inpatient and Outpatient Encounters
Hospital Discharges
Avg Encounters per Unique Pt
Ranges of Encounters per Unique Pt.
6576
63
69.2
5-425
Charges per Unique Patient
Total Charges
$52,939
$5,029,205
Adult Bariatric Surgery
 NIH Consensus Panel- 1991
– Failure of Medical and Dietary Treatments
– Substantial excess morbidity and Mortality
 Surgery Indicated for selected pts:
– Documented failure of non-surgical weight loss
– BMI> 40
– BMI> 35 with at least 2 co-morbidities
– Adults Age 18+
“Who would have thought it? An
operation proves to be the most effective
therapy for adult-onset diabetes
mellitus”
Pories WJ, Swanson MS, MacDonald KG, et al 1995;222:339-350
Bariatric Procedures
 Bypass of part of the
intestine
– Roux-en-Y Gastric
Bypass
– Duodenal switch, etc.
Adult Bariatric- RYGBP
 Outcomes
– 50-75% Excess Wt Loss (3+ years)
 Complications
– GI Leak (5%), Bleeding (3.5%), Wound (9%), Pulm (6%),
DVT/PE (3%)
– Stenosis, bowel obstruction (up to 20% each), Ulcers, Gall
Stones, Iron and vitamin deficiency
– Mortality 0.5-2%
Bariatric Procedures Restrictive
– Decrease size of
stomach, early Satiety
– Vertical Banded
Gastroplasty, Sleeve
Gastroplasty
– Lap-Band 
Laparoscopic Adjustable
Gastric Banding*
*FDA
approved for age 18+ only
Lap Band® Adverse Events
 Intra operative
– Conversion to open
– Iatrogenic gastrostomy
1(0.1%)
1(0.1%)
 Early Post-operative
–
–
–
–
Hemorrhage
Port infection
Stomal obstruction
Perforation
1(0.1%)
6(0.6%)
14(1.4%)
3(0.3%)
 Late
– Mechanical dysfunction
– Erosion
– Slippages
5 (0.4%)
2(0.2%)
23(2.3%)
Ponce, et al., 2005
Comparing Weight-Loss Results
Gastric Bypass
LAP BAND®
Source: O’Brien et al. Obesity is a Surgical Disease: Overview of Obesity and
Bariatric Surgery, ANZ J Surg, 2004; 74: 200-204.
Adolescent Bariatric Surgery
 50% of bariatric surgeons have done a bariatric
procedure on an adolescent in the past year
 Most not done in a pediatric setting
 Estimated 1,000 – 10,000 bariatric procedures
done in children < 18 yearly.
Adolescent Bariatric Surgery
 Inge, et al., Pediatrics, 2004
– Multidisciplinary Pediatric Panel
– Lack of evidence-based guidelines
– More restrictive criteria:
 BMI>40 with severe co-morbidity (Type II DM, Obstructive
sleep apnea, Pseudotumor cerebri)
 BMI>50 with less severe co-morbidity
Adolescent Bariatric Surgery
Contraindications
 Physical immaturity
Medically Treatable Cause of Obesity
Inability to participate in follow-up
Patient cognitively unable to participate in decision
Active psychiatric/ behavioral issues that would preclude
participation
 Substance Abuse
 Current or planned pregnancy (within 2 years)
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

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Inge, et al.
Adolescent Bariatric Surgery
Outcomes
 Meta-analysis November 2008
Procedure
Number
Outcome
Evidence Rating
Band
8 studies
Wt Loss
Mod/Weak
352 Pts
Co-morbidities
Weak
5 Studies
Wt Loss
Mod/Weak
131 Pts
Comorbidities
Insuff/weak
5 Studies
Wt. Loss
Insuff
158 Pts
CoMorbidities
Insuff
Bypass
Other
Treadwell, J, et al, Ann Surg 2008;248: 763-776
Adolescent Bariatric Surgery Outcomes
 APSA Adolescent Bariatric Study Group,
Adolescent Lap-Band® Group, Teen LABS (NIH)
 ASMBS Pediatric Committee
 Teen LABS (NIH)
 FDA trials
 DuPont has been granted an Investigational
Devise Exemption (IDE) from the FDA for Lap Band
use
DuPont Adolescent Lap-Band FDA Study
 FDA, CRRC, IRB approved trial
 14-17 years of age
 BMI>40
 Co-morbidity
 Obesity for at least 5 years
 At least 6 months supervised treatment
 Commit to 5 year follow-up
Adolescent Lap-Band® Exclusions
 Age less than 14 years
 History of inflammatory bowel disease
 Chronic use of anti-inflammatory medication
 Pregnancy or planning pregnancy
 Uncontrolled eating disorder
 Uncontrolled mental health disorder
Our Treatment Program
 Family Behavioral Therapy
 Individualized
 Multidisciplinary
 Well balanced hypocaloric diet
 Home exercise regimen
 Surgical option is not primary focus
Team Composition
 Weight management team with adolescent
experience
–
–
–
–
–
–
Pediatrician
Surgeon
Nutritionist
Psychologist
Exercise Physiologist
Study Coordinator: organization of data
Adolescent Lap-Band®
Preoperative Program
 Monthly visits for 6 months
 Evaluative Component
 Completion of Preoperative Workbook
 Improve:
–
–
–
–
Fitness
Nutrition
Family Functioning
Psychological Functioning
 Protein sparing fast for 2 weeks
Adolescent Lap-Band® post-op issues
 Visits every 3-6 weeks for adjustments
 Long-term Compliance is Critical
–
–
–
–
–
Family/ peer support
Band Adjustments
Ongoing nutritional support
Exercise
Behavior Modification
 Transition to “adult” life
duPont Lap Band® Results
26 Patients to date
21 Female
Average age 16 years old
duPont Lap Band® ResultsExcess Weight Loss
70
60
%EWL
50
40
30
20
10
0
0
6
12
Months
18
duPont Lap Band® ResultsMetabolic Syndrome
Adverse Events
 No perioperative complications
 Hospital Stay: <48 hours.
 No adverse events requiring a second operation
 No adolescents asking for their band to be
removed
 No pregnancies
 None lost to follow-up
What We Have Learned
 Morbid obesity in adolescents is a disease state even
without any other medical comorbidities
 Modest to Significant Lifestyle changes result in
weight stability but only clinically significant weight
loss (5-10% decrease in BMI) in a small percentage of
patients
 Severe calorie restriction (<1000 calories/day) will
result in weight loss
 All weight loss options require lifestyle changes
Questions
 Is there any long term benefit (medical or
psychological) in doing obesity surgery in childhood
instead of early adulthood
 What (if any) surgical procedure is best to do in children
 What should we do with severely morbidly obese
children who have limited decisional capacity or with
non stable family units
.