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  • 1. © Freund Publishing House Ltd., London Journal of Pediatric Endocrinology & Metabolism, 20, 751-761 (2007) Bariatric Surgery in Pediatrics - Is it Time? Manoel Carlos Prieto Velhote1, Durval Damiani2 and Sergio Santoro3 1 Pediatric Surgery and 2Pediatric Endocrinology Unit, Instituto da Criança, Hospital das Clínicas, São Paulo University Medical School and 3Hospital Israelita Albert Einstein, São Paulo, Brazil ABSTRACT INTRODUCTION In view of the increasing prevalence of The world is gaining weight, and very few obesity all over the world, we have seen morbid countries have been spared from this ‘pandemic’ of obesity occurring at earlier ages, and especially obesity with all its implications. The efforts to curb in adolescents. The first and main approach has this epidemic have not been very successful, and been a conservative one, including change of much is still unknown about the roots and the lifestyle - implying better feeding habits and origins of the problem. physical activity. However, our weapons to deal Quoting Rosenbaum and Liebel1: “Obesity is a with this ‘pandemic of obesity’ have not solved a complex phenotype that resolves the influence of large number of cases, and we have to admit genes, development and environment”, and so it that bariatric surgery should be contemplated in must be understood. Since genes in the population special cases. Many different approaches have are stable to act in the remaining factors, a been devised by bariatric surgeons and although behavioral change is urgently needed, and educa- the complications over the short- and long-term tion of our children and adolescents is essential to are high and potentially severe, in some cases it make a leaner world in the future. is the only approach that has the potential to put Although obesity has to be clinically treated and the patient back to a more ‘normal’ metabolic efforts for its prevention must be made, including situation with a significant weight loss. We feeding habits, physical activity and support2, in the discuss the main surgical approaches for morbid present state of our knowledge extreme obesity is a obesity and we comment on the pros and cons of condition in which only surgical approaches may each of them. have good results in the long run3,4. In the USA, the growing epidemic of obesity is a reality, it has been noticed for decades5, and has KEY WORDS been growing even in children and adolescents, spreading out now to other developed and under- obesity, overweight, metabolic syndrome, bariatric developed countries6. In the last decades, the lack surgery, leptin, hyperinsulinemia, GLP-1, adoles- of response to measures intending to avoid a world cents explosion of obesity is a strong sign of the failure of the proposed therapies to curb the problem. Among adults, a surgical approach is the first- choice therapy for the extremely obese3. Bariatric surgery has shown a huge growth in recent years (103,000 operations were performed in 2003 in the USA), and the number of associates of the Ameri- can Society for Bariatric Surgery (ASBS) has increased from 258 surgeons in 1998 to 1,070 in Reprint address: Manoel Carlos Prieto Velhote 20037. In children, there has always been a Rua São Firmo 81 resistance to accept this modality of treatment, CEP-05454-060-SP mainly due to concerns about the risks of surgery8 Brazil and about growth and psychological disturbances. e-mail: VOLUME 20, NO. 7, 2007 751
  • 2. 752 M.C.P. VELHOTE ET AL. As in adults, however, these children are prone to In children, due to the variability of BMI with develop metabolic consequences, as well as regard to sex and age, we have to evaluate the physical and social constraints which imply a poor degree of obesity by comparing the BMI using quality of life and low survival. population charts14 (Fig. 1). The definition of over- Obese children, like adults, may have insulin weight is BMI between the 85th and 95th per- resistance and type 2 diabetes mellitus, high blood centiles, while obesity is defined as BMI above the pressure, dyslipidemia, orthopedic problems, sleep 95th percentile. In these charts, there is no recog- apnea, hepatic steatosis, cholecystopathy, poly- nition of extreme obesity and super-obesity. cystic ovary syndrome with hyperandrogenism, From a practical point of view, we can say that menstrual irregularities and even infertility, cere- for an adolescent who has completed at least 80% bral pseudo-tumor, alveolar hypoventilation, skin of his/her bone maturation, it is adequate to use the problems, besides low self-esteem and social same parameters as in adults. However, when we isolation9. pay attention to the distribution of the population Due to refractoriness to clinical treatment and BMI curves, we can see that in adolescents younger the severity of the associated co-morbidities, the than 18 years of age the BMIs that define obesity surgical approach in obese adolescents has gained and overweight are lower than in adults. Especially more and more adepts10. This attitude makes sense in 4-6 year-old children, a BMI of 18 is the limit in view of the poor results even in very well for obesity and not a BMI of 30 as used for adults. structured clinical groups in which patient compliance is high11 as opposed to the initial good results of bariatric surgery12. INDICATIONS FOR BARIATRIC SURGERY In adults, there has been a consensus for more EVALUATION OF THE DEGREE OF OBESITY than 15 years that whenever BMI is greater than 35 WITH THE AIM OF SURGERY with co-morbidities and above 40 even without co- morbidities this is an indication for surgery3. Body mass index (BMI) calculated by the In children, cure of extreme exogenous obesity quotient of the weight by the height squared has is extremely difficult, if not impossible, employing been extensively used in adults to evaluate the conventional clinical strategies. The best results degree of obesity. As shown in Table 1, it is with behavioral, dietetic, and clinical approaches in possible to classify individuals according to BMI13. the long run (5-10 years) show that only 30% reach stability or some degree of improvement15. Those children who do not improve with clinical therapy may, with time, develop co-morbidities that shorten TABLE 1 life expectancy and compromise physical and Classification of individuals based on psychological status16, and will be obese adults. body mass index (BMI) The American Pediatric Surgical Association (APSA) accepted the recommendation for surgery BMI (kg/m2) Classification in girls older than 13 years and boys older than 15 18-25 Normal years when BMI is greater than 40 with co- morbidities and above 50 as an isolated index17. 25-30 Overweight Many authors state that, due to the failure of 30 -35 Moderately obese behavioral therapy in these highly obese patients, the benefit of surgery must be offered to children, 35-40 Intensely obese using at least the same parameters as in adults12,18-24. 40-50 Extremely obese Since good results have been obtained in 50-60 Super-obese adolescents submitted to bariatric surgery, there is no point in being more stringent in terms of Above 60 Super-super-obese indications for surgery or even postponing surgery JOURNAL OF PEDIATRIC ENDOCRINOLOGY & METABOLISM
  • 4. 754 M.C.P. VELHOTE ET AL. to an age greater than 18 years, since BMI will (LAGB) and gastric bypass with Roux-en-Y have increased even more. The risk of waiting for reconstruction, devised by Fobi-Capella (RYGBP) surgery till adult age is probably small, but the In the USA, LAGB was only approved by the natural history of obesity indicates that it keeps on FDA in 2001, and this is the reason why the longer deteriorating9. This increases the surgical risks, and follow-up studies are European. It consists of worsens self-esteem and social behavior, which laparoscopic placement of a silicon band, which is may leave permanent psychological scars4. On the adjusted in the region of the cardia, keeping the other hand, the sooner the orthopedic lesions, gastric capacity above the band, at around 20 ml. diabetes mellitus, and hypertension are stabilized or The degree of compression of the band is adjusted cured, the better the surgical results. in the post-operative period through the injection of Recent reports have been more liberal in the saline into the subcutaneous reservoir, under radio- indications for surgery (younger patients, with scopic control (Fig. 2B). This method has many smaller BMIs) using the same parameters as in advantages, being easily and quickly placed, keeps adults (BMI >40 or BMI >35 with co-morbi- the patient in the hospital for a short time, has low dities)18,20,25. Even in adults, there has been a indices of complications, and is totally reversible. tendency of being more flexible in individual cases, The first reports used vertical-banded gastrec- accepting for surgery patients with smaller BMIs26. tomy (VBG) (Fig. 2A), later replaced by the This strategy takes into account the fact that higher RYGBP, today the most often performed surgery risks of surgical complications are associated with for obesity all over the world, including the USA. late surgical indication, high BMI, and longer time From 1993, RYGBP began to be performed suffering from diabetes mellitus or hypertension27. laparoscopically, with transection of the stomach As new data in adolescents have demonstrated close to the cardia, creating a gastric chamber with good results in the long run, low complication capacity around 25 ml. The remaining part of the indices, and low morbidity and mortality, the stomach is left in the abdominal cavity. A Roux-en- acceptance of bariatric surgery has increased for Y loop in the jejunum is created, just after the extremely obese adolescents and even in the not- Treitz angle, whose length goes from 100 to 150 so-obese. cm, anastomosed to the gastric remnant (Fig. 2D). Disabsorptive techniques decrease the intestinal RATIONALE OF THE SURGICAL TECHNIQUES absorptive area, preventing the meal running through the whole digestive tract, since there is an The first trials to treat obesity with surgery date internal bypass. The pattern of this surgery is the back to the 1950s. To create malabsorption, an bilio-pancreatic bypass (BPD) by Scopinaro with internal jejuno-ileal bypass was performed by or without duodenal switch. It consists of Kremen et al. in 195428. Although the weight loss transverse gastrectomy with reconstruction in was considerable, the maintenance of a normal Roux-en-Y which keeps 50-100 cm of ileal loop gastric reservoir, profuse diarrhea with intense with digestive enzymes (Fig. 2C). This technique undernutrition, deficient calcium, vitamins B12, A, has not usually been performed in children due to and D absorption, cholelithiasis and renal stones, severe long-term complications (proteic-caloric precluded carrying on with this form of surgery. malabsorption, bacterial overgrowth in the blind Observing the weight loss in patients submitted loop, the need to supplement vitamins, and the need to gastrectomy, Mason and Ito in 1967 proposed for close medical follow-up for life)13. gastric septation as a surgical procedure to treat Recently, a new protocol has been proposed for obesity29. This pioneer technique branched into modulated surgery which may also be used in different approaches with the aim of creating a tiny pediatric patients. It is neither disabsorptive nor gastric reservoir. The restrictive approach leads to does it use obstructive devices, and aims at difficulty in ingestion through the creation of a reactivating entero-hormones in the postprandial small gastric camera with a slow emptying outlet. period, leading to early satiety. It has been named The most used are adjustable gastric banding ‘digestive adaptation with intestinal reserve’ JOURNAL OF PEDIATRIC ENDOCRINOLOGY & METABOLISM
  • 5. BARIATRIC SURGERY IN PEDIATRICS 755 satiety sensation is also obtained quickly after full FIG 2 (DAIR), and consists of vertical gastrectomy, omentectomy and reduction of the small intestine to 3 meters (40 cm of jejunum and 260 cm of ileum). At its simplest it consists only of vertical gastrectomy (sleeve gastrectomy), a procedure suggested for super-obese or pre-adolescents. At the other extreme the reconstruction of the bowel is in Roux-en-Y gastroileal anastomosis, depicted in Figure 2E, keeping the pylorus and leaving the duodenum and 120 cm of small bowel in transit30,31. The modern diet, processed and easy to obtain, hypercaloric, and easy digestible in the proximal intestine, does not stimulate the terminal ileum to produce the entero-hormones (glucagon-like peptide 1 [GLP-1], PYY, and oxyntomodulin) implicated, among many different and interesting actions, in satiety and in the activation of an adequate insulin response to ingestion of food. In addition, the VOLUME 20, NO. 7, 2007
  • 6. 756 M.C.P. VELHOTE ET AL. BARIATRIC SURGERY IN CHILDREN AND ADOLESCENTS Bariatric surgery is far from being a cosmetic procedure. It is an extensive surgery, performed in patients with high surgical risk and with mortality7. The option of the surgical approach in adoles- cents has always faced strong opposition2,6 but the data are accumulating on the procedure and new techniques have been devised to try to solve or attenuate a very serious health problem with less risk to the patients. The first reports on adolescents submitted to bariatric surgery date back to 1985 by Silber, employing the gastric-ileal bypass technique. Although the weight loss is still significant after 10 years of follow-up, this technique has been abandoned due to high indices of severe complications (encephalo- pathy, nephrolithiasis, hypoproteinemia, cortical nephropathy, hepatopathy, etc.) and the need for frequent revisions. Since then, different modalities of surgery have revolutionized obesity surgery in adults due to much fewer complications and mortality. At the end of the 1990s, although recognizing the risks of infantile obesity, bariatric surgery for adolescents was not recommended, except in extreme cases, due to the risks of the procedure11,33. These restrictions have not been endorsed by other repletion of the stomach with small amounts of groups working with children who, although food. This technique takes into consideration all utilizing low number of patients, had low indices of these factors. Vertical gastrectomy and entero- complications and good results with regard to omentectomy are performed, and promising results weight loss and patient satisfaction21-23,34,35. More have been shown, although the time of follow-up is recent data from adolescents confirm the good up to 4 years in the oldest patient. The gastrectomy results with RYGBP18,25,37-39, placing this modality reduces the gastric capacity to around 200 ml, of surgery as an acceptable tool to deal with adapting the chamber size to the high caloric extreme obesity in adolescents. density of modern food, and diminishing ghrelin In 2005, a review of members of the ASBS production, involved in the hunger sensation in revealed that 53% had already performed some fasting periods. The enterectomy allows the surgical procedure in obese adolescents, 70% nutrients to reach the ileum, increasing the planned to start a regular program of surgery in secretion of GLP-1 and PYY (leading to early adolescents, and 84% were interested in partici- satiety and higher and faster insulin secretion - the pating in multicenter studies in this area. This incretin effect). The removal of the epiplon reduces demonstrates an increasing interest in bariatric the dangerous visceral fat, an important factor in surgery in pediatrics and forecasts its more triggering metabolic syndrome, decreasing a source disseminated utilization in the future40. of IL-6, IL-8, TNF-α, and resistin, with reduction Apovian et al. in 200541, in a study on evidence- of insulin resistance in the liver32. based medicine, emphasizes the need for more research with regard to indications and long-term JOURNAL OF PEDIATRIC ENDOCRINOLOGY & METABOLISM
  • 7. BARIATRIC SURGERY IN PEDIATRICS 757 results of bariatric surgery, and recognizes that the emphasize the importance of referral centers that techniques applicable to adolescents are RYGBP follow well-designed protocols to allow for com- and LAGB. parisons, since the total number of patients is small13. Analyzing the existing data, the initial Laparoscopic adjustable gastric banding (Fig. 2B) results are uniformly good with 33% of weight loss up to the 6th month, 47% up to one year, and 53% Adjustable silicon banding (LAGB), created in up to 2 years of follow-up37. There was a good 1990, has been extensively used in Europe18-20,39. resolution of co-morbidities, such as diabetes This procedure was only approved in the USA in mellitus, hypertension, and sleep apnea12,22,37, as 2001, which makes the European experience more well as improvement in self-esteem and social extensive. In adults, the long-term European and life36,38. On the other hand, some patients deve- Australian results have been very good: decrease in loped cholelithiasis12,22,23,25 and needed surgery co-morbidities, absence of malabsorption, persis- (laparoscopic in the majority of cases). tent weight loss, with decreased mortality and low This modality of surgery, to be effective in the complication indices. However, the weight loss is long run, needs the maintenance of a small gastric slower and less intense than with RYGBP13. chamber, with slow emptying (calibrated Compared to RYGBP, LAGB has five-fold less anastomosis). Vomiting is frequent when the mortality and much fewer complications, which ingested volume surpasses the gastric capacity, or make this procedure preferred over gastric when there is stenosis in the anastomosis. The com- bypass13. It has the advantage of being reversible plications directly related to the procedure are less and preserves the gastrointestinal physiology and than 5%, including deficiencies of vitamins D, anatomy39, and does not lead to malabsorption. The B1, B12 and A22,25,43, as well as micronutrients, weight loss of 33% of the excess in the first B especially iron and calcium22,36. Other complica- 6 months, and 58% in the first year, caused BMI to tions include dehiscent stitches in the remaining fall from 44.7 kg/m2 in the pre-operative period to stomach37, suppuration of the abdominal wall38, 30.2 kg/m2 in 2 years19. Therapeutic failures incisional hernia22,38, stenosis of the anastomosis, occurred in 2-3% of cases18,39. deep venous thrombosis37,38, and occlusive scars22,38. The indices of satisfaction and self-esteem in Four patients died some time after surgery and the post-operative period are improved, although these deaths were not directly related to the the resolution of co-morbidities is lower than with surgical procedure23,38. After 5 years, however, RYGBP (67%)39. Surgical complications are some patients started gaining weight38, and some of few24,39, including gastric erosion with migration of them were submitted to another surgery to further the band18, wrong positioning of the band which reduce the gastric chamber25. requires re-operation18,20, no weight loss18 and Many patients got pregnant after the bariatric secondary megaesophagus. It has been shown surgery and the pregnancy ran normally22. recently that gastric banding negatively interferes The main criticisms of the procedure are: it with esophagic motility42. creates an intestinal bypass, leading to malabsorp- The biggest criticism of this procedure is that tion of nutrients that have exclusive proximal the weight loss comes from an iatrogenic sub- absorption. It does not allow gastric digestion, and esophagical gastric stenosis, caused by a foreign potentially, changes the intestinal flora, due to the body. The patient may cheat weight loss by lack of gastric acid. The stomach itself stays imbibing caloric fluids since the procedure does not isolated and is not accessible to endoscopic lead to dumping. examination, in case this should be a necessary procedure. The ingestion of hyperosmolar meals Roux-en-Y gastric bypass (Fig. 2D) leads to dumping. Until 2004, there were 171 adolescent patients reported in the medical literature submitted to this modality of bariatric surgery12,21-25,34-38. The reports VOLUME 20, NO. 7, 2007
  • 8. 758 M.C.P. VELHOTE ET AL. Digestive adaptation with intestinal reserve (Fig. 2E) to a second procedure (DPB or RYGBP). We think that in children, LSG could have two indications: in This technique consists of vertical laparoscopic prepubertal children with BMI >50 refractory to gastrectomy, preserving the antrum, followed by a clinical therapy, and in Prader-Willi syndrome. small abdominal incision to complete the procedure Since it does not affect nutrition and meal with a resection of the greater epiplon and part of absorption at all, it is presumed not to impair the small intestine, leaving 40 cm of jejunum and children’s growth, while it provokes consistent 260 cm of ileum30, as illustrated in Figure 2E. weight reduction. A 12 year-old child of 164 kg The advantages of this procedure are many: it (BMI 58), obese from 3 years of age, with does not use a prosthesis, and there are no areas progressive increase in weight, underwent LSG. excluded from the intestinal transit. The duodenum After 1.5 year, he lost 52 kg and had a BMI of 42. is kept on transit. There are no detectable signals of His growth during this year has been unimpaired malabsorption, no diarrhea, no vomiting, and it and he is asymptomatic (personal communication). allows the digestion of vitamins and oligonutrients. There are few reports on performing bariatric It gives early satiety and an outstanding improve- surgery with success in Prader-Willi syndrome. ment in insulin resistance, blood pressure and RYGBP and BPD have been used in children with dyslipidimia31. Prader-Willi syndrome with variable results47-49. Some bariatric surgeons criticize the enterec- The rationale to use LSG in Prader-Willi syndrome tomy performed in this procedure but this is part of rests on the knowledge that it is the only situation the adaptation of a long intestine to the kind of in obesity where basal blood levels of ghrelin are nutrients available in the modern diet, which seem elevated. Gastrectomy, by reducing the bulk of the to be insufficient for the proper stimulation of site of production, promotes a sustained reduction entero-hormones which produce a feeling of of ghrelin levels50 and could be useful as an satiety. In a series of 12 adolescents, seven have endocrine-restrictive based surgery. It has already been followed for 2 years. The mean BMI fell from been performed in three patients (BMI 66, 65 and 54 to 30, and there was a complete reversion of co- 50) with good control of feeding compulsion and morbidities: five patients presented insulin resis- initial weight loss (33, 80 and 21 kg 2 years, 1 year tance which normalized, four hypertensive patients and 8 months after LSG, respectively). The blood normalized their blood pressure, and two dys- ghrelin levels showed a significant reduction (per- lipidemic patients normalized their serum lipids. sonal communication). One of our patients presented transitory peripheral polyneuropathy, which regressed with temporary vitamin B1 supplementation. SELECTION OF PATIENTS Laparoscopic sleeve gastrectomy (Fig. 2F) The following conditions must be taken into account for bariatric surgery in children and In adult surgery, performing only a vertical adolescents: gastrectomy (also known as laparoscopic sleeve • Exogenous obesity; gastrectomy [LSG]) in the super-super-obese • Multidisciplinary team evaluation of patients patient is nowadays accepted as a first stage who do not show satisfactory results after a 1- procedure to reduce weight with simpler laparo- year period of treatment; scopic surgery44. It is not intended to completely correct the excess weight, but it has the advantage • Age >13 years in girls and >15 years in boys; of producing a reduction of 45 kg after 6 months, • Patients who reached 80% of his/her adult with low surgical risk. This procedure improves stature or the equivalent bone age; health conditions in preparation for a second • BMI >40 or BMI >35 with co-morbidities; surgical stage45. Mognol et al.46 suggested that • Understanding and acceptance of the surgical laparoscopic LSG can be used in bariatric surgery procedure and its consequences; either as an isolated procedure, or as the first step JOURNAL OF PEDIATRIC ENDOCRINOLOGY & METABOLISM
  • 9. BARIATRIC SURGERY IN PEDIATRICS 759 • Psychological evaluation attesting that the be an approach that effectively leads to maintained patient has emotional conditions to withstand weight loss with acceptable surgical risk. the procedure; All the modalities of bariatric surgery have • To agree in participating in follow-up visits as shown much better results, in terms of weight loss, well as following nutritional orientation; when compared to more conservative approaches. • The surgery has to be performed in a reference The procedures, although invasive, have demon- center, structured to provide a comprehensive strated that they diminish co-morbidities, and carry approach to the patient, with well trained a low risk and a low rate of complications. surgeons and a good system of data collection; The best modality of surgery and the best time for it to be performed still depend on studies with a • The approach has to be individualized and has to high number of pediatric patients and long-term take into account all the indications and follow-up. As the number of cases increases, limitations of the whole process13,18; there has been a tendency to indicate surgery at • Informed consent given by parents or guardians. younger ages and with less severe degrees of obesity4,12,13,18,26,27. THE IMPROVEMENT OF CO-MORBIDITIES The initial criteria in the phase of acquisition of LINKED TO EXTREME OBESITY experience with this procedure have to be more rigid, but the number of patients operated upon The association of obesity with morbidities, until now allows us to see the procedure as a useful such as metabolic syndrome, with dyslipidimia, tool in extremely obese patients27, even at young hyperinsulinemia, and systemic hypertension, is age. well known51. Even before weight loss, some Once the procedure has been proven to be safe complications associated with obesity disappear or and effective, we can have indications before the decrease in intensity. RYGBP and DAIR tend to deleterious metabolic consequences of the obesity correct the carbohydrate disturbances, and this take place, since they increase surgical morbidity improvement has been attributed to the increase in and mortality. The sustained improvement of GLP-1, secreted by the L-cells of the terminal conditions, such as insulin resistance, sleep apnea ileum once there are nutrients in the lumen of this and hypertension, has to be taken into account in portion of the intestine. Although this improvement the indication of the procedure. also occurs, less intensely, with LAGB, besides The acknowledgment that obesity is more than weight loss the mechanisms involved are not yet an esthetic problem, but a disease with a very clear. complex set of metabolic disturbances that poses With weight loss, whatever the therapeutic serious risks to health and quality of life, induces modality employed, surgical or not, there is us to regard surgical and more aggressive improvement of sleep apnea, hepatic steatosis, and modalities of therapy as possible actions to be joint problems, and in particular there is good taken to circumvent the disturbances created by improvement in social life and self esteem. obesity. The procedure has a clear cost-benefit relationship, since reducing obesity dramatically decreases the later costs of complications in the CONCLUSIONS medium- and long-term. However, in future generations, with new approaches to health care51, Clinical treatment of obesity, always the first we hope that surgery for obese children, that today step in the approach to this complex metabolic looks like being the future, will become outdated. condition, has faced problems in solving the most severe cases, especially in the young. In this context, in selected cases, the possibility of REFERENCES submitting the patient to a surgical procedure has to be taken into account2, since it has been shown to 1. Rosenbaum M, Leibel RL. The physiology of body weight regulation: the relevance to the etiology of VOLUME 20, NO. 7, 2007
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  • 12. 762 M.C.P. VELHOTE ET AL. Fig. 1: Body mass index (BMI) growth charts from 2 to 20 years of age, for males and females. National Center for Health Statistics14. Fig. 2: Different modalities of bariatric surgery. VGB = vertical banded gastroplasty; LAGB = laparoscopic adjustable gastric banding; BPD = bilio-pancreatic diversion; RYGBP = Roux-en-Y gastric bypass; DAIR = digestive adaptation with intestinal reserve; LSG = laparoscopic sleeve gastrectomy. Fig. 1: Body mass index (BMI) growth charts from 2 to 20 years of age, for males and females. National Center for Health Statistics14. Fig. 2: Different modalities of bariatric surgery. VGB = vertical banded gastroplasty; LAGB = laparoscopic adjustable gastric banding; BPD = bilio-pancreatic diversion; RYGBP = Roux-en-Y gastric bypass; DAIR = digestive adaptation with intestinal reserve; LSG = laparoscopic sleeve gastrectomy. JOURNAL OF PEDIATRIC ENDOCRINOLOGY & METABOLISM