A multidisciplinary approach to laparoscopic sleeve gastrectomy among multiethnic adolescents in the United States

Five-Year Physical and Psychosocial Outcomes in Obese Adolescents With and Without Metabolic Bariatric Surgery

PURPOSE

Metabolic bariatric surgery (MBS) is increasingly accepted as a treatment for severely obese adolescents. However, its long-term efficacy and safety are not well characterized, particularly in the Eastern Asian population. We aimed to explore the long-term effects of MBS on Chinese adolescents with severe obesity.

METHODS

A total of 44 obese adolescents (≤18 years old) underwent MBS at our institution from May 2011 to May 2017. A matched nonsurgical control group, including 43 patients, was recruited from lifestyle modification programs in the same period. All patients completed assessments at presurgery/baseline and five years after surgery. The data were collected and analyzed using the χ2 test and an independent sample t-test.

RESULTS

Comparing the surgical and control groups revealed that the surgical patients showed significant weight loss and improvement in comorbidities, while the nonsurgical patients showed a trend of weight gain and increased comorbidities (p < .05). Furthermore, the surgical patients had a higher composite physical quality of life (as determined by the Short Form-36 questionnaire). On the other hand, the patients who underwent MBS had a higher risk of malnutrition.

DISCUSSION

Compared with nonsurgical patients, severely obese adolescents who undergo MBS exhibit more effective long-term weight loss, remission of comorbidities, and improved quality of life. Furthermore, more attention should be paid to helping adolescents avoid malnutrition after they undergo MBS.

Laparoscopic sleeve gastrectomy for obesity treatment in adolescents and young adults: a systematic review and meta-analysis

BACKGROUND

The incidence of obesity has been increasing in younger population, posing a significant impact on adolescents' life and health care system worldwide.

METHODS

We critically analyzed the existing literature on the use of laparoscopic sleeve gastrectomy (LSG) for the treatment of obesity. We performed an in-depth evaluation of 37 studies and analyzed the effect of LSG in 2300 patients, aged ≤ 22 years.

RESULTS

Mean body mass index (BMI) loss after LSG was 17.81 kg/m2. Gastroesophageal reflux was the most common complication. Most of the patients showed remission of comorbidities including hypertension, diabetes, and obstructive sleep apnea after LSG.

CONCLUSIONS

These findings suggest that surgical intervention is highly beneficial for reducing BMI in appropriately selected adolescents and young adults suffering from obesity and comorbidities such as life-threatening obstructive sleep apnea.

Management of Pediatric Obstructive Sleep Apnea After Failed Tonsillectomy and Adenoidectomy

Pediatric obstructive sleep apnea (OSA) represents a different entity from its adult counterpart and therefore requires a different therapeutic approach. Adenotonsillectomy (AT) is the primary treatment of pediatric OSA, and evidence shows it is very effective. However, there is a growing understanding that residual OSA is common, and next steps for patients who fail primary AT are less certain. This article reviews current methods of evaluating and treating these complex patients.

Innovations in the Treatment of Pediatric Obstructive Sleep Apnea

Obstructive sleep apnea affects a large proportion of otherwise healthy children in the context of interactions between craniofacial elements, adenotonsillar hypertrophy and other anatomical factors, and neuromuscular reflexes of the upper airway. In light of the adverse consequences of sleep apnea, it is important not only to proceed with early diagnosis but also to implement adequate treatment that is guided by the pathophysiological determinants of the disease in each child. Here, we will describe the current standard of care approaches to the treatment of pediatric obstructive sleep apnea, and will also explore novel management strategies that should enable more personalized therapy in the near future.

Durability of Cardiometabolic Outcomes Among Adolescents After Sleeve Gastrectomy: First Study with 9-Year Follow-up

BACKGROUND

Long-term durability of weight loss and comorbidity resolution beyond 7 years after laparoscopic sleeve gastrectomy (LSG) among adolescents is completely lacking.

METHODS

Retrospective review of adolescents aged ≤ 18 years who underwent primary LSG at our institution between 2011 and 2015 (N = 146). We assessed anthropometric and cardiometabolic outcomes at 1, 3, 5, 7, and 9 years.

RESULTS

Follow-up rates were 57.53%, 82.87%, 85.24%, 83.92%, and 83.33% at the five time points. The preoperative mean body mass index (BMI) (45.60 ± 6.50 kg/m2) decreased at year 1 (30.04 ± 4.96 kg/m2, P=0.001) and was maintained up to 9 years (30.20 ± 3.92 kg/m2, P = 0.001). Remission rates were triglycerides, 100% (11/11) at 5 years, and 100% (1/1) at 9 years; high density lipoprotein, 89.4% (17/19) at 5 years, and 100% (3/3) at 7 years; low density lipoprotein, 71.4% (11/14) and 100% (3/3) at 5 and 7 years; total cholesterol, 70% (7/10) at 5 years, and 100% (2/2) at 9 years; uric acid, 100% (3/3) at 5 years. Remission of liver enzymes was 84.6-100% (22/26-2/2) at 5-9 years. Prediabetes remission was 87.5% (14/16 and 7/8) at 5 and 7 years and 100% (3/3) at year 9. Type 2 diabetes complete remission was 50% (3/6, 1/2) at years 5 and 7, with all cases resolved at 9 years. The only case of hypertension completely resolved.

CONCLUSIONS

LSG achieved substantial weight loss and remission of cardiometabolic risk factors that were sustained on the long term. This is the first study among adolescents to assess such outcomes beyond 7 years.

Pediatric Metabolic and Bariatric Surgery

Childhood obesity can lead to comorbidities that cause significant decrease in health-related quality of life and early mortality. Recognition of obesity as a disease of polygenic etiology can help deter implicit bias. Current guidelines for treating severe obesity in children recommend referral to a multidisciplinary treatment center that offers metabolic and bariatric surgery at any age when a child develops a body mass index that is greater than 120% of the 95th percentile. Obesity medications and lifestyle counseling about diet and exercise are not adequate treatment for severe childhood obesity. Early referral can significantly improve quality and quantity of life.

Obstructive sleep apnea in pediatric obesity and the effects of sleeve gastrectomy

The prevalence of severe pediatric obesity is rising and poses many adverse health risks. Children with obesity are at increased risk of several cardiovascular and metabolic diseases. They are also more likely to have obstructive sleep apnea (OSA), which increases the risk of cardiovascular and metabolic problems. In this review, we examine the relationship between OSA and obesity, improvements in OSA after non-surgical and surgical weight loss, and explore potential directions for future research.

Length of stay by uncomplicated diabetes bariatric surgery patients: A laparoscopic adjustable banding versus laparoscopic sleeve gastrectomy

RATIONALE, AIMS, AND OBJECTIVE

Bariatric surgery is an effective procedure for morbidly obese patients when all else fails. The purpose of this study was to compare the hospital length of stay (LOS) for two surgical procedures, laparoscopic adjustable gastric banding (LAGB) and laparoscopic sleeve gastrectomy (LSG).

METHODS

This study was a retrospective cross-sectional analysis of the Nationwide Inpatient Sample (NIS) from 2009 to 2014. Patients who received bariatric surgery as indicated by International Classification of Diseases, Ninth Revision (ICD-9) procedure codes were selected (N = 4001). Cases were limited to uncomplicated diabetic patients. Differences in the odds of long vs short (2< and ≥2) stay for a patient receiving LSG were compared with LAGB while adjusting for hospital volume, hospital size, patient age, gender, ethnicity, season, and year using logistic regression analysis.

RESULTS

The odds for LSG (odds ratio [OR] = 0.100, 0.066-0.150, P < 0.001) patients for long LOS are lower when compared with LAGB. In the stratified logistic regression model, both male (OR = 0.157, 0.074-0.333, P < 0.001) and female (OR = 0.077, 0.046-0.127, P < 0.001) had reduced odds of extended LOS for LSG. Discharged patients in the year 2012 (OR = 0.660, 0.536-0.813, P < 0.001) had decreased odds of having a longer LOS when compared with the year 2014. Both government, nonfederal (OR = 0.452, 0.251-0.816, P = 0.008), and private investor-owned (OR = 0.421, 0.244-0.726, P < 0.001) patients had similar odds for long duration of stay when compared with government or private. Urban non-teaching (OR = 1.954, 1.653-2.310, P < 0.001) patients had higher odds for long LOS in comparison with urban teaching. New England patients' (OR = 0.365, 0.232-0.576, P < 0.001) odds for extended LOS were lower when compared with pacific. Both patients who received care in low (OR = 1.330, 1.109-1.595, P = 0.002) and medium (OR = 1.639, 1.130-2.377, P = 0.009) volume hospital had increased odds for long duration of stay. Female patients in the stratified logistic regression model with high (OR = 1.330, 1.109-1.595, P < 0.002) volume had elevated odds of extended LOS when compared with very low volume hospital.

CONCLUSION

Among the uncomplicated diabetic patients, LSG provides a substantially low odds of extended LOS after adjusting for covariates when compared with LAGB. The finding of the relative reduction in LOS for LSG suggests opportunities for improvement both for cost reduction for third party insurance payers and greater efficacy and outcomes for patients.

Evolution and Outcomes of a Canadian Pediatric Bariatric Surgery Program

PURPOSE

An interdisciplinary obesity management program was established in 2007 at our quaternary hospital, including bariatric surgery for selected adolescent patients. We report the evolution of surgical management within the program and outcomes following bariatric surgery.

METHODS

This was a retrospective review of adolescents who underwent bariatric surgery between 2007 and 2017. All cases were performed by a pediatric surgeon and an adult bariatric surgeon. Baseline demographics, BMI, co-morbidities, and post-operative outcomes were recorded.

RESULTS

Thirty-eight patients underwent bariatric surgery. Median age at entrance into the program was 16.5 (range, 12.1-17.4) years and at time of surgery was 17.4 (range, 13.6-18.8) years. Eight patients had laparoscopic adjustable gastric banding (LAGB) from 2007 to 10. Between 2011 and 2017, 18 had laparoscopic sleeve gastrectomy (LSG), and 12 had laparoscopic Roux-en-Y gastric bypass (RYGB). There were no intraoperative complications or conversions. Postoperative complications included wound infection, bleeding requiring transfusion and re-exploration, and internal hernia. Of patients who had LAGB, 2 required surgical revision, and 3 underwent subsequent removal.

CONCLUSIONS

Adolescent bariatric surgery in the context of a multidisciplinary obesity management program is safe and effective. RYGB and sleeve gastrectomy are associated with superior weight loss in the immediate post-operative period and at most recent follow-up and lower reoperation rates than gastric banding.

LEVEL OF EVIDENCE

III.

Weight Loss in Adolescents After Bariatric Surgery: A Systematic Review

INTRODUCTION

Bariatric surgery is a treatment option for the obese adolescent. There are three primary surgical procedures: the bypass, sleeve gastrectomy, and lap band. The most recent literature was reviewed to examine changes in weight, comorbidities, and complications after bariatric surgery in the adolescent.

METHOD

A systematic search was performed to identify original research articles published in the United States between the years of 2000 and 2017 with patients between the ages of 11 and 21 years that provided greater than 30 days of results.

RESULTS

A total of 23 articles were identified. Weight loss, improvement in comorbidities, and complications after all procedures were reported.

DISCUSSION

Outcomes were not reported in a standardized fashion, creating much difficulty in interpreting and comparing results. The sleeve gastrectomy is increasing in incidence, whereas the lap band is decreasing. Further research is needed to draw more definitive conclusions regarding long-term results in the adolescent undergoing bariatric surgery.