Exclusion Criteria History of clinical disease that the surgeons feel would prohibit weight loss surgery, including, but not limited to: congenital or acquired intestinal telangiectasia, Crohn's disease or ulcerative colitis; severe cardiopulmonary disease or severe coagulapathy; hepatic insufficiency or cirrhosis. Presence of dysphagia or documented esophageal dysmotility. Patients with autoimmune connective tissue disorders.Pregnancy or intention of becoming pregnant in the next 12 months. Presence of uncontrolled psychiatric disease or patient immaturity which would compromise cooperation with the clinical protocol. Chronic use of aspirin and/or non-steroidal anti-inflammatory medications and unwillingness to discontinue the use of these concomitant medications. Unwillingness to discontinue use of weight loss medications after surgery.
Laparoscopic Gastric Bypass: Restrictive and Mal-absorptive. Procedure reduces the size of the stomach as well as bypasses the small intestine. Most commonly performed in the US, weight loss usually exceeds 100# in 2 years. Laparoscopic Adjustable gastric band : wrapping a synthetic silicone adjustable band around the stomach to create a small pouch with a narrow outlet. restrictive, least invasive. Stomach size can be adjusted through saline injections and the stomach is not stapled or cut open. Advantages: reduced potatential for adverse nutritional consequences. Disadvantage: Not approved by the FDA for patients younger than 18 and very few insurance companies cover for the device. Studies suggests more surgical issues with a lesser degree of weight loss . Laparoscopic Sleeve Gastrectomy: 75% vertical gastrectomy which creates a narrow tube of stomach
Based on the DRI’s for 18 YO female. Energy was derived using IBW of 85% BMI growth chart and protein and fluids were derived using DRI’s based on actual weight.
Pediatric Rotation Major Case Study
Morbid Obesity and Implications of Bariatric Surgery in the Adolescent Population Children’s National Medical Center Case Study Amy Bortnick 1/22/2013 S
Presentation OutlineS Childhood obesity and the indication for Bariatric SurgeryS Bariatric Surgery in adolescentsS A Case Study of nutrition counseling for an 18 year old female in the IDEAL Outpatient Clinic considering Bariatric SurgeryS Clinical Analysis of the patient and her appropriateness for Bariatric SurgeryS Conclusion and questions
Childhood ObesityS The Percent overweight children in the United States has almost tripled in the past 30 years.S 15.5% of children are estimated to be obese.S 50-77% of obese children grow up to be obese adults.S Obesity in both adolescents and adults greatly increases the risk of developing chronic life threatening diseases and can lead to premature death.S Overweight children have a reduced quality of life compared with non-overweight children (1).
Bariatric Surgery in AdolescenceS For severely overweight children and adolescents who have tried and failed to lose weight for longer than 6 months through conventional weight loss methods, bariatric surgery may provide a practical alternative for achieving a healthy weight (1).S From 1996-2003, according to recent national trends, the US has seen a great increase in bariatric surgeries performed in adolescents.S There is very little data documenting long term effects of bariatric surgery in adolescents.
Bariatric Surgery in AdolescenceS Inclusion Criteria S >14 years of age S Tanner development stage 4 or greater S BMI >40 w/ obesity related comorbidity or BMI> 50. S Documented history of obesity for 3 years S Consent S Confirmation by psychologist or psychiatrist
Choice of Bariatric Surgery ProcedureS Laparoscopic Roux-en-Y Gastric Bypass (LGB)S Laparoscopic Adjustable gastric band (LAGB)S Laparoscopic Sleeve Gastrectomy (LSG) .
Critical Labs for Bariatric CandidatesS fasting glucoseS hemoglobin A1cS liver functionS lipid profileS complete blood countsS thyroid functionS PregnancyS micronutrient deficiencies.S Polysomograpy ( patients with sleep apnea)S Bone age assessment (younger patients)
Potential ComplicationsS Early Complications: pulmonary embolism, wound infections, stomal stenosis, dehydration and marginal ulcersS Late Complications: small bowl obstruction, incisional hernias, and late weight regain, sub optimal vitamin intake and micronutrient deficiencies.S Gastric Bypass: intestinal leakage, thromboembolic disease, small bowl obstruction, incisional hernia, protein calorie malnutrition, micronutrient deficiencies.S Adjustable Gastric Band: port mal absorption or mal function, tubing leaks, band slippage, infection, band erosion into stomach or esophagus
Pre-Operative Bariatric DietS Suggested full liquid diet of protein rich supplements for two weeks S Been show to result in greater weight loss after surgery S Shrinks the liver, decreasing surgery time S Displays ability to adhere to diet and lifestyle changes
Post Operative Bariatric DietS First 2-3 weeks: of a liquid diet. S Mainly supplements high in protein, low in fat, and carbohydratesS After 4-6 weeks: Pureed dietS After 6 weeks: Soft regular foodsS Vitamin and Mineral Supplements: 2 multivitamin’s daily, calcium, vitamin B12, and additional vitamins/minerals as needed
SubjectiveS XX is an 18 year old female presenting to the IDEAL Clinic with morbid obesity for her second follow up visit accompanied by her mother. She is currently considering bariatric surgery for weight loss. XX was pleasant and interactive during her last visit. She appears morbidly obese with a buffalo hump, acnathosis nigricans, and abnormal hirstuism present on the face.
Diet Prior to AdmissionS XX admits to trying several diets in the past. Prior to admission she was following a diet that involved having 8 very small-portioned meals a day. Additionally, on 7/4/12 patient became a vegetarian. XX has never seen a dietitian in the past.
PES StatementsS Overweight/obesity (N.C-3.3) related to excessive energy intake, and food and knowledge related deficit as evidenced by BMI > 95%, inability to apply some nutrition related recommendations.S Physical Inactivity (NB-2.1) related to lack of value for behavior change or competing values, as evidenced by obesity >97th percentile, infrequent/ low duration exercise, large amounts of sedentary activities e.g. T.V. watching, computer, and phone use and reports of getting tired easily.S Not Ready for Diet/ Lifestyle Change (NB-1.3) related to lack of self efficacy for making change or demoralization from previous failures at change as evidenced by lack of eye contact, lack of focus, and lack of efficacy to make change or to overcome barriers to change
Anthropometrics Anthropometrics Growth EvaluationS Height: 5’5” S Weight trends: 11/27: 158.8 kg, 12/18: 156.5 kg, 1/22: 156.6S Weight: 345 lbs. S BMI trends: 11/27 56.93S BMI: 99.5% (>97%), 12/18: 55.38 (>97%), 1/22: 56.28 (>97%).S BMI percentile: >97th S Height trends: 11/27:167cm, 12/18: 168.1 cm, 1/22: 166.8 cm
Notable Labs S 12/44 S HgA1c: 5.8 S Low HDL: 26 S HOMA-IR: 17.9 –elevated, insulin resistant, on metformin S Low Vitamin D: 9.5 (deficient) – on vitamin D supplements S ALT 37Labs are significant for: impaired fasting glucose,hypertriglyceridemia, low HDL, mild elevation of ALT, andelevated HOMA-IR
AssessmentS Estimated Energy Needs S Kcals/kg: 31-43/kg ADBW/day: 2223-2438 kcal S Grams protein/ kg: 0.8/kcal/kg = 125.8 g protein S mL/day to meet maintenance fluid needs: 20/kg/day 3132 ml
Plan/ GoalsS Physical Activity Goals S Move at least 10 minutes 3/day a week (Tuesday, Wednesday, Saturday).S Nutrition Goals S Pre-op diet for one week (bariatric guide, RD email address provided) S Use meal replacement instead of skipping breakfast
XX and Bariatric SurgeryS BMI of 56.28 meets criteriaS 18 YO meets maturation and bone growthS IDEAL clinic provides multi-disciplinary support (patient is seeing a physician, psychiatrist and RD)S Patient is currently trying to lose weight through nutrition and physical activity without significant successS Mother displays evidence of a supportive family member, respecting the patient’s decision.S However patient shows concern for adherence to dietary demands of bariatric surgeryS Patient and mother have been receiving on going education on bariatric surgery
Case ConclusionS It is too early to tell if XX will be appropriate for weight loss surgery. Her personal desire for the surgery as well her efficacy and ability to understand and adhere to dietary restrictions will be critical. However, her current BMI status places her a substantial risk for chronic life threatening conditions, she has documented her weight has interfered with her quality of life. For now the focus is physical activity a healthful diet and the ability to follow a pre-operative diet.
DiscussionS More research on bariatric surgery in adolescence is needed to determine long term impacts on overall health and well being.S Israel Study: Comparing inpatient intervention with bariatric surgeryS Netherlands Study: Interventional study comparing laparoscopic adjustable band surgery and behavioral therapyS Results of such studies won’t be forth coming for several years
References1. Inge T et al. Bariatric Surgery for Severely Overweight Adolescents: Concerns and Recommendations. Pediatrics Vol 114 No. 1 July 2004 217-223.2. Ingelfinger, Julie. Bariatric Surgery in Adolescents. N Engl Med 365;153. Wilson S. Tsai, MD; Thomas H. Inge, MD, PhD; Randall S. Burd, MD, PhD. “Baratric Surgery in Adolescents- Recent National Trends in Use and In-Hospital outcome”. American College of Medicine.4. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med. 1997;25:869-873. Reousce: http://www.nejm.org/doi/full/10.1056/NEJM199709253371301#t=arti cleTop5. University of Michigan Health System: Adult Bariatric Surgery Program. http://www.med.umich.edu/bariatricsurgery/about/bypass/postop.shtm l