# Presentation: 560042

## 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
- 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 

- 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:

- 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

## OBESITY PROGRAM:  Key Players

**Primary care MD**
**Nutrition specialist**
**Psychologist/psychiatrist**
**Gastroenterologist**
**Endocrinologist**
**Anesthesiologist**
**Exercise physiologist**
**Nurse Clinician**
**Surgeon**

## SURGICAL ELIGIBILITY

- 	A multidisciplinary team with expertise in adolescent weight management and bariatric surgery should carefully consider the indications, contraindications, risks, and benefits of bariatric surgery for individual patients.
- This team must agree that surgical approach is the best alternative for the patient
- Adolescent bariatric surgery should be performed only at facilities capable of treating adolescents with complications of severe obesity, where detailed clinical data collection can occur.

## SURGICAL OPTIONS FOR SEVERELY OBESE PATIENTS

- Jejunoileal bypass
- Pancreaticobiliary diversion
- Gastroplasty
- Horizontal
- Vertical
**Lap-band**
**Laparoscopic Gastric Bypass**

## LAP-BAND

## 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

- 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

- Technically easier
- Reversible
- No aspects of malabsorption

## LAP BAND COMPLICATIONS

- Band erosion
- Infection
- Slippage
- Gastric obstruction
- Port migration
- Esophageal dilation

## LAP BAND SUCCESS

- Needs serial close follow-up
- Needs serial band adjustment
- Will FAIL  if patient likes sweets, high carbohydrate liquids

## 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

- 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

## 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.