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Case Presentation:Case Presentation: Morbidly Obese AdolescentMorbidly Obese Adolescent
DanielDaniel DeUgarteDeUgarte, MD, MDDivision of Pediatric SurgeryDivision of Pediatric Surgery
Surgical Director, UCLA FIT ProgramSurgical Director, UCLA FIT Program
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R.A.15y/o Adolescent Girl138kg / 160.8cm – 53.4 BMIOverweight since age 4.Gaining 20 lbs/year.
Comorbidities:Morbid ObesityAcanthosis NigricansHypertensionPolycystic Ovarian DiseaseSleepinessDepression
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R.A.Readiness to ChangePatient 4.5/5Parents 5/5
HistoryWeight WatchersWeight MD 15 lb weight loss
Family HistoryGrandparents, mother, and one of two brothers are
overweight. Father is not overweight. Aunt had bariatric surgery.
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R.A.HomeMother is a nurse and works nights. 3+ hours qd of screen time. Brother teases her about weight.Father is truck-driver -> negative interactions.Mother has at times been been critical/hurtful/unsupportive.
SocialSexually active.History of drinking and marijuana.
Sleep7 hours per night (3am to 10am). + Sleepiness scale.
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R.A.School
Independent study; embarassed by appearance.
C & D student.
Physical Activity
Walks. Parks nearby are safe.
DietSkips breakfast. No binge-eating. 2 meals/per day.Rarely drinks soft drinks. 1% milk.
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R.A.ExamAcneAcanthosisHirsutismTanner Stage V
Abnormal LabsThiamine - 64 (70-180)Vitamin D - 7 (30-80)
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R.A.
8/26/2008 138kg (303) 160.8cm 53.4 BMI 130/893/30/2010 146kg (321) 161.3 56.0 BMI 132/80
Abnormal LabsThiamine - 64 (70-180)Vitamin D - 7 (30-80)
Normal LabsThyroid Panel; LFTs; Cholesterol Panel; PTH/Ca
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R.A.Psychiatric clearance.>6-month UCLA Fit Program.
GoalsAttend 4-hour bariatric class, homework, & quiz.Reduce weight by 5% (136kg) by limiting diet to 1500 calories
& 60 grams proteins.Increase physical activity from to 3 to 7 times per week (45-60
minutes).
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Research Study
Outcomes
BOLD (Bariatric Outcomes Longitudinal Database)Surveys
Epworth Sleepines ScaleBAROS QOLSF-36Obstetrical/Offspring Health and Fertility Survey
Calorimetry, Biomarkers, and Epigenome (GCRC)Body Composition (CHLA) – Vitamin D / Calcium
CT-scanDEXACarotid Duplex (Intima/Media)
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BariatricBariatric Surgery OptionsSurgery Options
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Adolescent Outcomes:Adolescent Outcomes: Band vs. BypassBand vs. Bypass
Treadwell et al. Systematic Review and Meta-Analysis of Bariatric Surgery for Pediatric Obesity. Annals of Surgery 2008.
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20052005--2007 California Data: Age <212007 California Data: Age <21
Jen et al. Presented at AAP 2009.
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20052005--2007 California Data: Age <182007 California Data: Age <18
Jen et al. Presented at AAP 2009.
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20052005--2007 California Data: Age <212007 California Data: Age <21
Jen et al. Presented at AAP 2009.
Bypass Band p-value
Ambulatory Surgery Center 0% 46% <0.01
Center of Excellence 71% 37% <0.01
Children’s Hospital 7% 11% NS
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20052005--2007 California Data: Age <212007 California Data: Age <21
Relative Risk of Procedure on Insurance Type
Private Insurance Public Insurance Self Pay
Bypass 1 0.89 (0.67-1.11) 0.45 (0.33-0.58)
Band 0.21 (0.09-0.32) 0.86 (0.01-1.88) 3.51 (2.11-5.32)
Multinomial logistic regression while controlling for year of operation, hospital volume, centers of excellence, age, sex, race and distance travelled.
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20052005--2007 California Data: Age <212007 California Data: Age <21Bypassn= 410
Bandn=103
Mean F/U 18 months 12 months
Deaths 0% 0%
In-Hospital Complications 6% 3%
Hospital Readmission 11% 5%
Emergency Room Visits 9% 8%
Ambulatory Surgery Center Visits 7% 2%
Reoperation 2.9% -
Band Revision/Removal - 4.7%
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Adolescent Indications for SurgeryAdolescent Indications for SurgeryPhysical Maturity (Girls >13; Boys >15)Emotional and Cognitive Maturity (Informed Assent)Weight Loss Efforts > 6 Months (Behavior-Based)Long-Term Follow Up (Nutrition & Psychological Support)Avoid Pregnancy for > 1 Year
New OldBMI > 40 BMI > 50
BMI > 35 + Comorbidities BMI > 40 + Comorbidities
ComorbiditiesHypertension PanniculitisDiabetes Venous Stasis DiseaseHyperlipidemia Urinary IncontinenceSleep apnea Impaired Quality of LifeSevere arthrosis NAFLD
Inge et al. Pediatrics 2004: 114: 217-223. IPEG Guidelines: JLAST 2009.
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Rationale for Early InterventionPre-Op Weight Influences Post-Op Weight
Duration of Diabetes Predicts Failure to Achieve Full Remission Post-Surgery (Beta-Islet-Cell Burnout)
Early Stages of Fatty Liver Disease Respond Better.
Improved Pregnancy and Neonatal Outcomes
Lower Operative Risk (Less Advanced Comorbidities)
Improvement in Life Expectancy & Quality of Life
Decreased Need for Abdominoplasty
Cost Savings?
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Study DesignStudy DesignProspective, Randomized, (Not Blinded) Controlled
Gastric-banding (Free)Optimal Lifestyle Program (Free)
Population: 50 Adolescents with BMI>35Location: Melbourne, AustraliaPeriod: May 2005 – September 2008
Hypothesis: Gastric banding would induce more weight loss and provide greater health benefits and better improvement in quality of life of obese adolescents than optimal application of currently available lifestyle approaches.
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CriteriaCriteriaAge 14-18
BMI>35
Medical Complications
Attempts to lose weight by lifestyle >3years
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Preparation & RandomizationPreparation & RandomizationVisit 1 - Patient Information Session
2-Week Food Diary and Activity Log + Pedometer
Several Questionnaires
Visit 2 – Consultation (<4 weeks later)
Clinical assessment
History / Labs
2-Month Program
Best practice recommendations (eating and physical activity)
Visit 3 – Consent
Follow Up (7 days later) – Confirmation and Randomization
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Lifestyle Program SurgeryIndividual Diet Plan Diet instructions.Increased Activity Encouragement Activity 30 min/dayStructured Exercise SchedulePersonal Trainer for 6-weeksCompliance Monitoring Band adjustments prn.
Food Diaries Based on weight loss, satiety,Step Counts eating pattern, and symptoms.
Q 6 week F/U with: Q 6 Week F/UAdolescent MD Experienced Medical StaffDietitian or Exercise ConsultantStudy Nurse CoordinatorSports Medicine Physician
Family InvolvementGroup Outings / Outdoor ReunionsInvitation for Educational Programs
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Statistical Analysis
Powered using Intention-to-treat Analysis
>50% Excess Weight Loss at 2 Years
Surgery: >60%
Lifestyle: <10%
17 patients in each group for 80% power & two-sided p<0.05.
Assumed 30% drop-out after randomization (n=25).
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Outcomes
Weight loss, % Weight Loss, BMI Change, BMI Z-scores
Neck, Waist, Hip Circumference
Health: Metabolic Syndrome, Hypertension, HOMA
QOL: Child Health Questionnaire (CHQ CF-50)
Adverse Events
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Participant Flowchart
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Baseline Characteristics
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BMI
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% Weight Loss
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Individual Weight Change
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QOL
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Changes in Cardiovascular Risk
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Adverse EventsBAND - 7 patients required 8 (33%) revisional procedures.
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StrengthsStrengthsRandomized Controlled Trials can be performed in surgery!
Lifestyle interventions may have some health benefits despite unimpressive weight loss.
Level 1 evidence to support bariatric surgery.
Adverse events in adolescents undergoing bands are high (especially for an experienced center).
Conflicts of interest disclosed.
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CriticismsCriticismsUnbelievable Data:
Failure to Disclose by Lead AuthorLow attrition rate in both groups.
Incentives for follow up?Free treatment may have influenced study population.
% EWL 79% for band and % EWL 13% for lifestyle.% EWL >50%: 84% band and 12% for lifestyle.
Reproducibility?Preparation, Intervention, Attrition (4% and 28%), and Results.Adverse eventsBAND: 20.4 visits / 9.5 adjustments of band.LIFESTYLE: 15.5 visits; 5 phone consultations; 6 personal trainer sessions
Durability?
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RealReal--World Outcomes:World Outcomes: Band vs. BypassBand vs. Bypass
Birkmeyer et al. Abstract. Journal of Surgical Research 2010.
Michigan Bariatric Surgery Collaborative Prospective Clinical Registry 2006-2008 – 1 Year Follow Up
Band Bypass
% of Cases 35% 54% Serious Complications 0.7% 3.4% Death 0.04% 0.1%
EBWL 40% 67% Diabetes Resolved 47% 77% Hypertension Resolved 25% 55% Hyperlipidemia Resolved 30% 66%
% Very Satisfied 64% 90%
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LifestyleLifestyleMeta-analysis of 17 RCTs in lifestyle interventions to treat obesity in
children.
Results:
Modest weight reduction for up to 12 months.
Weight regain.
Luttkhuis et al. Interventions for treating obesity in children. Cochrane Database Syst Rev 2009(1);cd14001872.
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BariatricBariatric Surgery OptionsSurgery Options
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Adolescents Adolescents -- DiabetesDiabetesNumber of Patients = 11 Adolescents
10 Oral Hypoglycemic Agents -> Off
1 Insulin & Oral Agents -> Decreased Insulin Requirements
Mean age = 16 years
Mean Weight & BMI = 149 kg and BMI 50
Mean Follow Up = 1 year
Weight Loss = 33 to 99 kg
Mean BMI Drop: 34%
Post-Op BMI%ile: Still >85%ile
Inge et al. Reversal of Type 2 Diabetes Mellitus and Improvements in Cardiovascular Risk Factors After Surgical Weight Loss in Adolescents. Pediatrics 2009;123;214-222.
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Adolescents Adolescents -- DiabetesDiabetesSurgery Medical Cohort
Weight -34% -0.3%BMI -34% -1.6%SBP -7.4% 1.0%DBP -19.5% -1.1%
HR -19.3%
HgA1C -2% (7.3 -> 5.6) -0.8% (7.8->7.1)
Glucose -41% (143->85) diet changes
Insulin -81% (44 -> 9) meds - minimal change
TGs -61% (213->83)
Chol -29% (202->143)
HDL +14% (38.9->44.2)
LDL -31% (120->79)
ALT -51% (61->26)
AST -37% (45->28)
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Adolescent Gastric BandAdolescent Gastric BandRandomized Trial from Australia.Mean Follow Up = 2 years
Band LifestyleCompleted Study 24/25 18/25>50% EWL 84% 12%% Pre Met Sx 36% 40%% Post Met Sx 0% 22% p=0.03HOMA Ins Sensitivity 89 14.6 p=0.001Waist circumference -28.2 -3.5 p<0.001
Reoperations: 8 (33%) in 7 of 24 patients completing study for pouch dilation (6) and tubing injury (2).
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Diet / Medications / TherapyAdults
$32-40 billion industry.Relatively small amount of weight loss (10 to 40 lbs)95% fail to maintain weight loss.Drug therapy can have side effects.
ChildrenHigh dropout rates (29-35%).Minimal BMI Drop (0.55 to 3.2 units) after 1-year.(Chanoine – Orlistat JAMA 2005; Savoye – Weight Management Porgram JAMA 2007; Berkowitz – Behavior Therapy and sibutramine JAMA 2003). Starting BMI was 35.6 to 37.5.
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Surgical OutcomesSurgical OutcomesWeight Loss: 60% Excess Body-Weight in 1 to 2 Years
5’4” Female with BMI of 43
Preoperative Body Weight: 250 lbs
Ideal Body Weight: 125 lb (85%ile is 139 lbs for a 15 year old)
Excess Body Weight: 125 lbs
60% of Excess Body Weight: 75 lbs
Average Expected Postoperative Weight After 2 Years: 175 lbs
Postoperative BMI: 30
Reduction of Comorbidities75% - Resolution of Diabetes Type 2
80% - Improvement in Blood Pressure & Sleep Apnea
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Adolescent Adolescent -- Gastric BypassGastric BypassNumber of Patients = 11 Adolescents
Mean age = 16 years
Mean BMI = 50
Mean Follow Up = 1 year
Excess Weight Loss = 60%
Improvement in Comorbidities = 70%
Marked improvement:
Quality of life Social functioning
Self-esteem Productivity
Collins J et al. Initial outcomes of laparoscopic Roux-en-Y gastric bypass in morbidly obese adolescents. Surgery for Obesity and Related Diseases 3 (2007): 147-152.
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Adolescent Gastric BandAdolescent Gastric BandMean Follow Up = 2 years
Excess Body Weight Loss = 61%
Number of Band Adjustments 1st Year = 6
Complication Rate: 15%
Band Migration Requiring Repositioning
Development of Symptomatic Hiatal Hernias
Wound Infection / Port Leak
Nutritional Deficiencies (Fe 17%; Asymptomatic Vitamin D 5%)
Nadler EP et al. An update on 73 US obese pediatric patients treated with laparoscopic adjustable gastric banding: comorbidity resolution and compliance data. J Ped Surg 2008;43:141-146.
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LaparoscopicLaparoscopic Surgical OptionsSurgical Options
Sleeve GastrectomyRoux en-Y Gastric BypassBiliopancreatic Diversion
Gastric Band
RestrictiveRestrictive
MalabsorptiveMalabsorptive
DysphagiaDysphagia
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Gastric Gastric Band (Not FDA-approved if <18yrs)Band Slippage / Infection / Gastric Erosion Megaesophagus / Esophagitis Compliance with Port Management Long-Term Efficacy Complicates Revisional (RYGB) Surgery Potential Long-Term Consequences (Esophageal Dysfunction)
47% Complication Rate & 29% Reoperation Rate Age <25 years. Follow Up – 9 Years. Mittermair et al. High Complication Rate after Swedish Adjustable Gastric Banding in Younger Patients ≤25 Years. Obesity Surgery 2008.
52% Complications -> Reoperation 40% BAROS Failure Rate Age < 25 years. Median Follow Up – 7 Years. Lanthaler et al. Disappointing mid-term results after lap gastric banding in young patients (Austrias). SOARD 2009.
33% Reoperation Rate at 2 Years Follow Up – 2 Years. 6 or 24 for pouch enlargement and 2 for tubing injury. Less consistent % weight loss (>SD than RYGB). (Dixon – Australian Randomized Control Study – JAMA 2010)
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Sleeve GastrectomyMetabolic Surgery (Decreased Ghrelin Levels & Reduces Appetite) Similar Excess Weight Loss and Resolution of Diabetes to RYGB Reduced Complication and ER Admission Rate Avoids Malabsorption – Decreased Supplements Post-Op Avoids Anastomosis (Leak, Stricture, Anastomosis, Intussusception) Avoids Impaired Medication Absorption (e.g. Seizure Medications) Avoids Implantation of Foreign Bodies (No Adjustment) Allows for Endoscopic Surveillance of Distal Stomach & Biliary Tree ‘Easy’ and ‘Safe’ Conversion to RYGB or Biliary Pancreatic Diversion (BPD)
75cc Volume in
Gastric Tube
Antrum is Preserved