RATIONALE FOR BARIATRIC RATIONALE FOR BARIATRIC SURGERY IN ADOLESCENTSSURGERY IN ADOLESCENTS

SCOPE OF THE OBESITY SCOPE OF THE OBESITY PROBLEMPROBLEM

26% of children and adolescents aged 2 to 17 26% of children and adolescents aged 2 to 17 years were overweight (18%) or obese (8%) - years were overweight (18%) or obese (8%) - Canadian Community Health Survey 2004Canadian Community Health Survey 2004

For adolescents 12 to 17 yrs - overweight rate For adolescents 12 to 17 yrs - overweight rate more than doubled and obesity rate tripled over more than doubled and obesity rate tripled over past 25 yrspast 25 yrs

SCOPE OF THE OBESITY SCOPE OF THE OBESITY PROBLEMPROBLEM

SCOPE OF THE OBESITY SCOPE OF THE OBESITY PROBLEMPROBLEM

26% of children and adolescents aged 2 to 17 26% of children and adolescents aged 2 to 17 years were overweight (18%) or obese (8%) - years were overweight (18%) or obese (8%) - Canadian Community Health Survey 2004Canadian Community Health Survey 2004

For adolescents 12 to 17 yrs - overweight rate For adolescents 12 to 17 yrs - overweight rate more than doubled and obesity rate tripled over more than doubled and obesity rate tripled over past 25 yrspast 25 yrs

Obesity during adolescence is the single best Obesity during adolescence is the single best predictor for adult obesitypredictor for adult obesity

WHY WOULD WE EVEN WHY WOULD WE EVEN THINKTHINK ABOUT ABOUT DOING SURGERY FOR OBESITY IN DOING SURGERY FOR OBESITY IN

CHILDREN?CHILDREN?

Because diets, pills, lifestyle Because diets, pills, lifestyle changes, and prevention strategies changes, and prevention strategies

don’t seem to be working…don’t seem to be working…

What’s the best kind of bariatric What’s the best kind of bariatric procedure for children?procedure for children?

What’s the best kind of bariatric What’s the best kind of bariatric procedure for children?procedure for children?

MalabsorptiveMalabsorptive

RestrictiveRestrictive

What’s the best kind of bariatric What’s the best kind of bariatric procedure for children?procedure for children?

MalabsorptiveMalabsorptive

RestrictiveRestrictive– Laparoscopic bandLaparoscopic band– Roux-en-Y gastric bypassRoux-en-Y gastric bypass– Sleeve gastrectomySleeve gastrectomy

OUTCOMES: ADOLESCENTSOUTCOMES: ADOLESCENTS

O’Brien et al. O’Brien et al. JAMA.JAMA. 2010; 2010; 303(6):519-526

OUTCOMES: ADOLESCENTSOUTCOMES: ADOLESCENTS

Treadwell et al. Treadwell et al. Ann Surg.Ann Surg. 2008; 248(5) 2008; 248(5)

OUTCOMES: ADOLESCENTSOUTCOMES: ADOLESCENTS

OUTCOMES: ADOLESCENTSOUTCOMES: ADOLESCENTS

OUTCOMES: ADOLESCENTSOUTCOMES: ADOLESCENTS

0

5

10

15

20

25

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Year

An

nu

al c

ases

Bypass

Sleeve

CCHMC Bariatric Case Volume(n=144 total over 10 years)

ADOLESCENT BARIATRIC ADOLESCENT BARIATRIC SURGERY IN ONTARIOSURGERY IN ONTARIO

Who should be doing it, and in what Who should be doing it, and in what kind of environment?kind of environment?

ADOLESCENT BARIATRIC ADOLESCENT BARIATRIC SURGERY IN ONTARIOSURGERY IN ONTARIO

Children are not just small adults…

ADOLESCENT BARIATRIC ADOLESCENT BARIATRIC SURGERY IN ONTARIOSURGERY IN ONTARIO

Integrated multidisciplinary pediatric-Integrated multidisciplinary pediatric-oriented medical programoriented medical program

– Pediatric medical specialtiesPediatric medical specialties– Psychosocial support for child and familyPsychosocial support for child and family

Surgical expertiseSurgical expertise

Academic environment as part of overall Academic environment as part of overall pediatric obesity strategypediatric obesity strategy

SICKKIDS TEAM OBESITY MANAGEMENT SICKKIDS TEAM OBESITY MANAGEMENT PROGRAM (STOMP)PROGRAM (STOMP)

Multidisciplinary medical/psychosocial program funded Multidisciplinary medical/psychosocial program funded through MOHLTC Diabetes Strategythrough MOHLTC Diabetes Strategy

Bariatric surgery funded by MOHLTC through Bariatric surgery funded by MOHLTC through University of Toronto Bariatric Surgery CollaborationUniversity of Toronto Bariatric Surgery Collaboration

High Impact Strategies Toward Obesity Reduction in High Impact Strategies Toward Obesity Reduction in Youth (HISTORY) multidisciplinary grant funded by Youth (HISTORY) multidisciplinary grant funded by CIHRCIHR

Province-wide initiative for obesity prevention and Province-wide initiative for obesity prevention and managementmanagement

Intake/Initial Assessment

Intake/Initial Assessment

Parent Group SupportAdolescent Group

Support

Adolescent Individual Appointments

Diet/Behaviour/Exercise

Intake/Initial Assessment

Parent Group SupportAdolescent Group

Support

Adolescent Individual Appointments

Diet/Behaviour/Exercise

Team Re-Assessment

3-6 Months

Ongoing support and treatment

Bariatric surgery

SICKKIDS EXPERIENCE SO FARSICKKIDS EXPERIENCE SO FAR

Pre-STOMPPre-STOMP

Seven casesSeven cases– 4 craniopharyngioma4 craniopharyngioma– 3 morbid obesity3 morbid obesity

First two: Roux-en-Y bypassFirst two: Roux-en-Y bypass– Excellent weight lossExcellent weight loss

Last five: laparoscopic bandLast five: laparoscopic band– All inflated with good initial weight lossAll inflated with good initial weight loss– Two required reoperationTwo required reoperation– One removed at 2.5 years - converted to Roux-en-Y bypassOne removed at 2.5 years - converted to Roux-en-Y bypass– One removed at 2.0 yearsOne removed at 2.0 years - - converted to Roux-en-Y bypassconverted to Roux-en-Y bypass– Weight loss results mixedWeight loss results mixed

SICKKIDS EXPERIENCE SO FARSICKKIDS EXPERIENCE SO FARPost-STOMPPost-STOMP

Nine casesNine cases– 1 craniopharyngioma1 craniopharyngioma– 8 morbid obesity8 morbid obesity

First three: laparoscopic bandFirst three: laparoscopic band– Excellent weight loss in 1, poor weight loss in 2Excellent weight loss in 1, poor weight loss in 2– One removed after 10 months One removed after 10 months - - converted to sleeve gastrectomyconverted to sleeve gastrectomy– No complicationsNo complications

Last six:Last six:– 3 Roux-en-Y bypass and 3 sleeve gastrectomy3 Roux-en-Y bypass and 3 sleeve gastrectomy– Excellent early weight lossExcellent early weight loss– No complicationsNo complications

SICKKIDS EXPERIENCE SO FARSICKKIDS EXPERIENCE SO FAR

ONGOING ISSUESONGOING ISSUESWhat is the best operation for adolescents?What is the best operation for adolescents?

Laparoscopic bandLaparoscopic band – Potentially reversible and lower mortalityPotentially reversible and lower mortality– Higher complication and reoperation rateHigher complication and reoperation rate– Lower efficacyLower efficacy

Roux-en-Y bypassRoux-en-Y bypass– ““Gold standard”Gold standard”– Long term issues with vitamin deficiencies and compliance in adolescentsLong term issues with vitamin deficiencies and compliance in adolescents

Sleeve gastrectomySleeve gastrectomy?

ONGOING ISSUESONGOING ISSUES

How many funded pediatric centres should there be in Ontario?How many funded pediatric centres should there be in Ontario?– For complex medical careFor complex medical care– For bariatric surgeryFor bariatric surgery

Which model is better?Which model is better?– Pediatric centre with help from adult surgeonsPediatric centre with help from adult surgeons– Adult centre with help from pediatric medical specialistsAdult centre with help from pediatric medical specialists

Transitioning to adult centresTransitioning to adult centres

THANKS FOR YOUR THANKS FOR YOUR ATTENTION!ATTENTION!