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MORBID OBESITY IN ADOLESCENTS AND CHILDREN. Marjorie J. Arca, M.D. Children’s Hospital of Wisconsin Milwaukee, WI. NIH CONSENSUS FOR SURGICAL INTERVENTION FOR MORBID OBESITY. Adults with BMI >40

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morbid obesity in adolescents and children

MORBID OBESITY IN ADOLESCENTS AND CHILDREN

Marjorie J. Arca, M.D.

Children’s Hospital of Wisconsin

Milwaukee, WI

nih consensus for surgical intervention for morbid obesity
NIH CONSENSUS FOR SURGICAL INTERVENTION FOR MORBID OBESITY
  • Adults with BMI >40
  • BMI > 35 with high risk comorbid conditions such as severe sleep apnea, Pickwickian syndrome, obesity related cardiomyopathy, diabetes mellitus, obesity induced physical problems interfering with lifestyle
bariatric surgery for severely overweight adolescents concerns and recommendations
BARIATRIC SURGERY FOR SEVERELY OVERWEIGHT ADOLESCENTS: CONCERNS AND RECOMMENDATIONS
  • Consensus panel recognized several key differences between adults and children
  • Severity of complications in children and adolescents with BMI > 30 may not warrant surgical therapy
  • Children cannot give legal consent
  • Behavioral therapy is more effective in adolescents
  • 20-30% of obese adolescents will NOT become obese adults

Inge et al, Pediatrics 114, July 2004

consensus recommendations adolescents being considered for bariatric surgery should
CONSENSUS RECOMMENDATIONSAdolescents Being Considered for Bariatric Surgery Should:
  • Have failed 6 months of organized attempts at weight management, as determined by their primary care provider
  • Have attained or nearly attained physiologic maturity
  • Be very severely obese (BMI >40) with serious obesity-related comorbidities or have a BMI of >50 with less severe comorbidities
  • Demonstrate commitment to comprehensive medical and psychologic evaluations both before and after surgery
  • Agree to avoid pregnancy for at least 1 year postoperatively
  • Be capable of and willing to adhere to nutritional guidelines postoperatively
  • Provide informed assent to surgical treatment
  • Demonstrate decisional capacity
  • Have a supportive family environment

Inge et al, Pediatrics 114, July 2004

serious co morbidities
Type 2 diabetes mellitus

 Obstructive sleep apnea

 Pseudotumor cerebri

Less serious comorbidities

 Hypertension

 Obesity-related psychosocial distress

Weight-related arthropathies that impair physical activity

 Dyslipidemias

 Nonalcoholic steatohepatitis

 Venous stasis disease

 Significant impairment in activities of daily living

 Intertriginous soft-tissue infections

 Stress urinary incontinence

 Gastroesophageal reflux disease

SERIOUS CO-MORBIDITIES
obesity program key players
OBESITY PROGRAM: Key Players
  • Primary care MD
  • Nutrition specialist
  • Psychologist/psychiatrist
  • Gastroenterologist
  • Endocrinologist
  • Anesthesiologist
  • Exercise physiologist
  • Nurse Clinician
  • Surgeon
surgical eligibility
SURGICAL ELIGIBILITY

A multidisciplinary team with expertisein adolescent weightmanagement and bariatric surgery shouldcarefully consider theindications, contraindications, risks,and benefits of bariatricsurgery for individual patients.

  • This team must agree that surgical approach is the best alternative for the patient
  • Adolescent bariatricsurgery should be performed only at facilitiescapable of treatingadolescents with complications of severeobesity, where detailedclinical data collection can occur.
surgical options for severely obese patients
SURGICAL OPTIONS FOR SEVERELY OBESE PATIENTS
  • Jejunoileal bypass
  • Pancreaticobiliary diversion
  • Gastroplasty
    • Horizontal
    • Vertical
    • Lap-band
  • Laparoscopic Gastric Bypass
lap band10
LAP-BAND
  • An adjustable band is placed around the proximal part of the stomach
  • The band is progressively tightened to create a small pouch and outlet
  • Need for serial adjustment of balloon within a band (IR)
lap band results
LAP-BAND RESULTS
  • Italy (Angrisani, 2004): BMI < or = 35, 27 centers; N=3,319 (Data on 210)
    • 8.1% complications
    • Average decreased from BMI 34% to 28% by 60 months
  • US (Ren, 2004), BMI average >49, 2 academic centers, N=444
    • 15% complications
    • 44.3% excess body weight lost at 1 year
lap band advantages
LAP BAND ADVANTAGES
  • Technically easier
  • Reversible
  • No aspects of malabsorption
lap band complications
LAP BAND COMPLICATIONS
  • Band erosion
  • Infection
  • Slippage
  • Gastric obstruction
  • Port migration
  • Esophageal dilation
lap band success
LAP BAND SUCCESS
  • Needs serial close follow-up
  • Needs serial band adjustment
  • Will FAIL if patient likes sweets, high carbohydrate liquids
gastric bypass
GASTRIC BYPASS
  • Combines principles of gastric restrictive operation and jejunoileal bypass
  • Small proximal gastric pouch
  • Roux en Y gastroenterostomy
  • Isolated gastric bypass entails division of the stomach.
gastric bypass complications problems
GASTRIC BYPASS COMPLICATIONS/PROBLEMS
  • Anastomotic leak
  • Bowel obstruction
  • Infection
  • Hernia
  • DVT,micronutrient problems
  • Limits access to distal stomach
lap band versus gastric bypass
Technically easier

Easily reversible

No malabsorption

More manipulation post-op

Minimal data with pregnancy

Foreign body

Current “gold standard”

More difficult operation

More permanent; difficult to reverse

Malabsorption throughout life

Limited access to distal stomach and proximal duodenum for the patient’s lifetime

LAP BAND VERSUS GASTRIC BYPASS
conclusions
CONCLUSIONS
  • There is a role of Lap-Band in the surgical treatment of morbidly obese children and adolescents
  • The patients should meet strict criteria as outlined
  • Need for multi-institutional trials to get evaluable data for this epidemic.