Disclosures I have nothing to disclose Outline Growing obesity - PDF document

 5/18/13 Disclosures I have nothing to disclose Outline  Growing obesity epidemic  Not just about weight loss: treating metabolic disease and reducing mortality.  RY gastric bypass, gastric band, sleeve gastrectomy: what is the difference?  Current AAP recommendations  1

 5/18/13 Outline Obesity Trends* Among U.S. Adults BRFSS, 1990, 2000, 2010 (*BMI ≥ 30, or about 30 lbs. overweight for 5’4” person)  Growing obesity epidemic 1990 2000 2010 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥ 30% Obesity reduces life expectancy For young men, BMI >45 took off 13 years of life expectancy For young women, BMI >45 took off 8 years of life expectancy  2

 5/18/13 Outline Age 1976-80 2003-04  Growing obesity epidemic 2-5 years 5.0% 13.9%  Not just about weight loss: treating 6-11 years 6.5% 18.8% 12-19 years 5.0% 17.4% metabolic disease and reducing mortality. Metabolic benefits of bariatric surgery in children and adolescents? Metabolic benefits of bariatric surgery UNKNOWN courtesy of ASMBS  3

 5/18/13 Resolution of Medical Outline Comorbidities  Growing obesity epidemic  Not just about weight loss: treating metabolic disease and reducing mortality.  RY gastric bypass, gastric band, sleeve gastrectomy: what is the difference? Treadwell et al, Ann Surg, 2008  Gold Standard – Long-term weight loss  Increased mortality and operative morbidity  Permanently alters GI anatomy - Not Reversible  Requires lifelong nutritional supplementation  ? osteoporosis, short stature, gastric CA, fetal anomalies, infertility?  4

 5/18/13  No in-hospital deaths Connection with the - 1 death at 9 months postop (C diff colitis, subcutaneous Gastric hypovolemia, MOF) reservoir pouch - 3 additional unrelated deaths  Reported postop complications - shock - PE - severe malnutrition and micronutrient deficiency (most common) - bleeding - GI obstruction Treadwell et al, Ann Surg, 2008  Slower weight loss – less long-term data 84/151 patients who underwent gastric banding from 1994-1997  Reduced mortality and operative morbidity 39% experienced major complications (28% had erosions) 49% of the bands were removed  Reversible 17% required conversion to a gastric bypass  Not associated with nutritional deficiencies  ? sustainability   5

 5/18/13  No in-hospital or postoperative deaths  Reoperations 28/352 (8%) band slippage 12/352 (3%) gastric dilation intragastric band migration psychologic intolerance of band hiatal hernia cholecystitis tubing crack  8 cases of Fe deficiency  5 cases of hair loss Kelleher et al, JAMA Pediatrics, 2013 Treadwell et al, Ann Surg, 2008 Treadwell et al, Ann Surg, 2008  6

 5/18/13 band sleeve bypass Change in BMI after bariatric surgery So what about kids?…. NO PUBLISHED DATA FOR CHILDREN  7

 5/18/13 Surgery for the Severely Outline Obese NIH Consensus Panel –  Growing obesity epidemic March 25-27, 1991  Not just about weight loss: treating metabolic disease and reducing mortality.  RY gastric bypass, gastric band, sleeve gastrectomy: what is the difference?  Current AAP recommendations Am J Clin Nutr 1992; 55: 615-619 Severely obese adolescents: completed linear growth & been 
 unsuccessful at organized attempts at weight management. � BMI ≥ 40 � BMI ≥ 50 Continue behavioral Severe Severe or less Continue behavioral approaches Comorbidity? severe comorbidity?* approaches Any contraindications to surgery?** Consider specific bariatric surgical options  8

 5/18/13 Table 2: Obesity-related Conditions � Table 3: Contraindications  Serious comorbities: �  Presence of medically correctable cause of obesity  Type 2 diabetes mellitus �  Patient or family is unable or unwilling to participate in long-term  Obstructive sleep apnea � follow-up  Pseudotumor cerebri �  Absence of decision capacity on the part of patient  Less serious comorbities: �  Hypertension � � � ��  Existence of medical, psychiatric, or cognitive condition that  Non-alcoholic steatohepatitis � � may impair patient’s ability to assent to surgery or adhere to  Significant impairment in activities of daily living � post-op dietary and medication regimen  Intertriginous soft tissue infections �  Existence of substance abuse in preceding year Stress urinary incontinence �  Gastroesophageal reflux disease �  Current lactation, pregnancy, or plans for pregnancy in  Weight-related arthorpathies that impair physical activity � upcoming 2 yrs  Obesity-related psychosocial distress �  Dyslipidemias �  Venous stasis disease �  Summary Points Bariatric Surgery  Children not immune to the growing obesity Why? Why Not? epidemic.  Metabolic benefits of bariatric surgery for children Obesity in childhood = 20-30% of children who are unknown. Long-term studies needed.   obesity in adulthood do not become obese in  Current recommendations: gastric restrictive Better weight loss adulthood  procedures (gastric band, possibly sleeve Reduction of long-term No long-term studies of gastrectomy) to avoid the nutrient deficiency seen   metabolic disease and metabolic benefits in gastric bypass procedures. mortality? Concern for nutritional   Importance of preoperative psychological Improved quality of life complications  evaluation and long-term medical surveillance in Unknown perioperative  the setting of a multidisciplinary team approach. morbidity and mortality  9

 5/18/13 References  Treadwell et al, Systemic Review and Meta-Analysis of Bariatric Surgery for Pediatric Obesity, Ann Surg 2008; 248: 763-776.  Kelleher et al, Recent National Trends in the Use of Adolescent Inpatient Bariatric Surgery, JAMA Pediatr 2013; 167(2): 126-132.  Inge et al, Bariatric Surgery for Severely Overweight Adolescents: Concerns and Recommendations, Pediatrics 2004; 114-217.  10