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Adolescent Bariatric Surgery Kirk Reichard MD, MBA, FACS, FAAP
CDC Obesity Trends 1998 2007 1990 No Data  <10%  10%–14%   15%–19%  20%–24%  25%–29%  ≥30%
Pediatric Obesity
 
Severe Pediatric Obesity <ul><li>BMI > 40  </li></ul><ul><li>BMI Z score >2.5 </li></ul><ul><li>Children with severe obesi...
How much extra weight? A gain of 10 extra pounds (physiologic 5-10lbs/yr) per year between kindergarten and high school = ...
Prevalence <ul><li>Between 1 to 3%  </li></ul><ul><li>of adolescents have BMI >40 </li></ul><ul><li>750,000 adolescents in...
BMI Tracking <ul><li>Children (age 12) with BMI>99% followed into adulthood (age 27) </li></ul><ul><ul><li>100% BMI>30 </l...
Obesity Complications
Pediatric Metabolic Syndrome <ul><li>Explains the relationship between obesity and CV Disease </li></ul><ul><ul><li>Centra...
Pediatric Metabolic Syndrome Cali, A. M. G. et al. J Clin Endocrinol Metab 2008;93:s31-s36
Pediatric Metabolic Syndrome Weiss, R. et al. N Engl J Med 2004;350:2362-2374 <ul><li>CRP goes up  (BAD!) </li></ul><ul><l...
Cardiovascular Risk Factors Risk Factors: Triglycerides Cholesterol HDL Insulin (fasting) Systolic BP Diastolic BP Freedma...
Atherosclerosis vs Cardiovascular Risk Factors Berenson GS, Srinivasan SR, Bao W, Newman WP III, Tracy RE, Wattigney WA. A...
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
Daviglus, et.al, JAMA, December 8, 2004 The Cost of Obesity
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 <ul><li>92 patients treated in 2005 with BMI over 40. </li></ul><ul><ul><li>55 with BMI 40-45 </li></ul>...
duPont Morbidity Rates <ul><li>Acanthosis/ Hyperinsulinism: 71% </li></ul><ul><ul><li>Diabetes: 4%  </li></ul></ul><ul><li...
duPont Weight Management
duPont Weight Management
duPont Weight Management
duPont Weight Management
Adult Bariatric Surgery <ul><li>NIH Consensus Panel- 1991 </li></ul><ul><ul><li>Failure of Medical and Dietary Treatments ...
“ Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus” Porie...
Bariatric Procedures <ul><li>Bypass of part of the intestine </li></ul><ul><ul><li>Roux-en-Y Gastric Bypass </li></ul></ul...
Adult Bariatric- RYGBP <ul><li>Outcomes </li></ul><ul><ul><li>50-75% Excess Wt Loss (3+ years) </li></ul></ul><ul><li>Comp...
Bariatric Procedures Restrictive <ul><ul><li>Decrease size of stomach, early Satiety </li></ul></ul><ul><ul><li>Vertical B...
Lap Band ®  Adverse Events <ul><li>Intra operative </li></ul><ul><ul><li>Conversion to open 1(0.1%) </li></ul></ul><ul><ul...
Comparing Weight-Loss Results Source:  O’Brien et al. Obesity is a Surgical Disease: Overview of Obesity and Bariatric Sur...
Adolescent Bariatric Surgery <ul><li>50% of bariatric surgeons have done a bariatric procedure on an adolescent in the pas...
Adolescent Bariatric Surgery <ul><li>Inge, et al.,  Pediatrics, 2004 </li></ul><ul><ul><li>Multidisciplinary Pediatric Pan...
Adolescent Bariatric Surgery  Contraindications   <ul><li>Physical immaturity </li></ul><ul><li>Medically Treatable Cause ...
Adolescent Bariatric Surgery Outcomes <ul><li>Meta-analysis November 2008 </li></ul>Treadwell, J, et al, Ann Surg 2008;248...
Adolescent Bariatric Surgery Outcomes <ul><li>APSA Adolescent Bariatric Study Group,  Adolescent Lap-Band ®  Group, Teen L...
DuPont Adolescent Lap-Band FDA Study <ul><li>FDA, CRRC, IRB approved trial </li></ul><ul><li>14-17 years of age </li></ul>...
Adolescent Lap-Band ®  Exclusions <ul><li>Age less than 14 years </li></ul><ul><li>History of inflammatory bowel disease <...
Our Treatment Program <ul><li>Family Behavioral Therapy </li></ul><ul><li>Individualized </li></ul><ul><li>Multidisciplina...
Team Composition <ul><li>Weight management team with adolescent experience </li></ul><ul><ul><li>Pediatrician </li></ul></...
Adolescent Lap-Band ®   Preoperative Program <ul><li>Monthly visits for 6 months </li></ul><ul><li>Evaluative Component </...
Adolescent Lap-Band ®  post-op issues <ul><li>Visits every 3-6 weeks for adjustments </li></ul><ul><li>Long-term Complianc...
duPont Lap Band ®  Results <ul><li>26 Patients to date </li></ul><ul><ul><li>21 Female </li></ul></ul><ul><ul><li>Average ...
duPont Lap Band ®  Results-  Excess Weight Loss
duPont Lap Band ®  Results-  Metabolic Syndrome
Adverse Events <ul><li>No perioperative complications </li></ul><ul><li>Hospital Stay: <48 hours. </li></ul><ul><li>No adv...
What We Have Learned <ul><li>Morbid obesity in adolescents is a disease state even without any other medical comorbidities...
Questions <ul><li>Is there any long term benefit (medical or psychological) in doing obesity surgery in childhood instead ...
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Adolescent Bariatric Surgery - October 2009

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Transcript of "Adolescent Bariatric Surgery - October 2009"

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