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By Prof Aayed Alqahtani, MD, FRCSC, FACS, Professor and Consultant of Obesity & MIS Surgery Obesity Chair, Department of Surgery,College of Medicine, King Saud University
Weight loss surgery is now an accepted solution for morbid obesity and obesity with uncontrolled type 2 diabetes. While these are not diseases that are restricted to adults, severely obese children and adolescents are often denied bariatric surgery because of unproven fears. Historically, these included concerns over the growth of children, the nutritional impact, unforeseeable long-term complications, as well as their ability to consent to have tissue removed or re-arranged.
While such concerns are debated, children with severe obesity continue to suffer from this crippling disease. Proceeding unhindered, it induces major irreversible consequences. The long-term effects of paediatric obesity have been well-documented in many longitudinal studies, such as the Bogalusa Heart Study and national data from several countries around the world. These effects include the development of type 2 diabetes, renal impairment, non-alcoholic fatty liver disease, obstructive sleep apnea, early onset of atherosclerosis, and many other obesity-related diseases. Moreover, studies have found that childhood obesity is associated with a quality of life that is similar to that of children with cancer. In short, severe childhood obesity has serious life-threatening pathologic and psychologic consequences.
Specialists classically opt for lifestyle and nutritional recommendations when treating severe childhood obesity. However, these methods have been repeatedly proven to cause insignificant weight loss at best, and no programme has been shown to cure diabetes or the metabolic syndrome. On the other hand, bariatric surgery is a proven cure for morbid obesity and related diseases. However, it is not widely adopted for children and adolescents.
In our center, we realised the profound consequences of childhood obesity and started to offer weight loss surgery for children and adolescents whose health fails to improve otherwise. We established a comprehensive multidisciplinary programme that involves paediatric endocrinologists, a bariatric surgeon, nutritionists, behavioural therapists, physical therapists, bariatric nurses, and coordinators who counsel each patient and monitor their progress. Every month, we hold a family-focused workshop for new patients and their families where the endocrinologist, the senior nutritionist, the behavioural therapist and a health educator give talks and host interactive sessions (Figure 1). We provide examples of poor practices, substitutes of common unhealthy choices, hands-on training on preparing healthy meals, and physical education lessons are also conducted. Each patient is then regularly seen in the clinic according to their health category.
We follow specific criteria for recommending bariatric surgery to a patient (Figure 2). We started offering laparoscopic adjustable gastric banding (LAGB) in 2005 owing to the fact that this is a minimally invasive, completely reversible procedure. However, long-term results with this procedure were not acceptable. Studies have shown that up to 60% of patients with gastric bands develop complications necessitating revision. Our centre’s studies on gastric band conversion to sleeve gastrectomy (LSG) showed that weight regain and poor weight loss account for more than 70% of reasons for conversion, with the remaining patients having band slippage, erosion, or device failure. Consequently, we gradually dropped gastric banding in favor of LSG as a recommended option for children and adolescents with severe obesity.
LSG rapidly gained preference worldwide because it offered superior weight loss to gastric banding, but with morbidity risks and surgical complexity compared to Roux-en-Y Gastric Bypass. Additionally, gastric bypass complicates abdominal anatomy, posing a challenge during future revisions, abdominal surgery, and endoscopy.
For LSG, patients are positioned in the reverse Trendelenburg French position and a five-trocar approach is used. The abdominal cavity is insufflated with to a pressure of 15 mmHg using a 10 mm optic port placed at or within a variable distance above the umbilicus based on the patient’s age. Two 5mm trocars are inserted on the right side, one 5mm trocar is inserted in the midline few cm below the xiphisternum to assist in liver retraction, and one 12mm trocar is inserted on the left side. A nasogastric tube is inserted to deflate the stomach. The greater curvature is then freed close to the gastric wall, beginning from approximately 2 cm proximal to the pylorus and extending to the angle of His using a Ligasure TM (Covidien, Medtronic, USA) or Enseal TM (Ethicon, Johnson & Johnson, USA) device. The left crus is then dissected and the angle of His is delineated. Posterior adhesions to the pancreas are lysed. A 36-Fr calibrating tube (34-Fr for patients below the age of 12) is placed transorally and carefully advanced through the pylorus to the duodenum. At 2-3 cm from the pylorus, the stomach is divided using a linear stapler (Echelon 60 TM). A green load (4.1mm) followed by gold (3.8mm) and blue loads (3.5mm) are used for all patients except for those younger than 12 years with thinner stomachs, where only gold and blue loads are used. There is no routine staple line reinforcement or routine testing for leak or drain placement. The left 12mm port is slightly enlarged using a Kelly clamp. The resected stomach is extracted through this port site and the site is closed using the Endo Close device (US Surgical TM). Wound sites are sutured and patients are extubated while awake. Children and adolescents with pre- booked ICU beds are sent to the ICU depending on their breathing effort and oxygenation during and after extubation.
The children and adolescents who undergo bariatric surgery spend an average of 19 months on the standardised nonsurgical weight management protocol before undergoing LSG at our center. Our latest statistics show that 1,341 children and adolescents underwent LSG. The mean age of those who had surgery was 16.2 ± 3.9 years, and 187 patients (12.5%) had type 2 diabetes.
When we aimed to identify whether there were any valid concerns against offering bariatric surgery to young children with severe obesity, we analysed outcomes of up to 5 years of follow-
up from 724 children and adolescents. About 40% (n= 302) of those patients underwent LSG at our center, and the remaining patients maintained non-surgical weight management. We divided the cohort according to baseline
age and whether or not the patient had surgery. We compared growth, weight loss, co-morbidity resolution, and compliance to follow-up in surgical
children and adolescents, and a
matched group of children who did
not undergo surgery. There was no significant difference in weight loss,
co-morbidity resolution and
complication rates after LSG
comparing children with
adolescents. Strikingly, the children who underwent LSG experience a significantly higher growth rate compared to those who did not (Figure 3). This led us to conclude that severely obese children who undergo LSG might experience an improvement in growth, contrary to the opinion that bariatric surgery may stunt the growth of children.
Our previous studies include our assessment of co-morbidity resolution after LSG in children and adolescents. In a study published in 2014, we documented the remission and improvement of type 2 diabetes, dyslipidemia, obstructive sleep apnea, and hypertension in more than 90% of cases (Figure 4).
We previously compared the outcomes of LSG in 108 paediatric patients with 114 adults who had the procedure under a standardised protocol. The paediatric arm had a 30-day complication rate of 5.6% with no major complications. The adult arm had a complication rate of 7% with three major complications. At the end of two years of follow-up, the paediatric and adult arms achieved similar average excess weight loss results (64.9% for children and 69.7% for adults). Additionally, the paediatric patients showed significantly better compliance to follow-up, possibly owing to the fact that the multidisciplinary programme in our center is family-based, and stresses on the importance of having a caretaker from the child’s family.
As for bariatric surgery in children and adolescents with syndromic forms of obesity. We previously published results on LSG in patients with Prader-Willi, Bardet-Biedl, Kleinfelter and Alstrom syndromes. Results confirmed that those patients lose significant weight loss and resolution of comorbidities with no mortality or significant morbidity. Moreover, we closely reviewed our data on 25 children and adolescents with Prader-Willi syndrome. No mortality or excess morbidity after LSG was observed, and the children had significant weight loss and resolution of co-morbidities for the five years of study.
We believe that LSG is the most suitable bariatric procedure for severely obese children and adolescents. Our studies have shown that it is safe and effective in patients from all age groups including paediatric patients as young as five years old.
While bariatric surgery is slowly being adopted worldwide for severely obese adolescent patients, children younger than 14 years of age are still denied this option. We hope that current and future evidence convinces policymakers and specialists to adopt this solution for younger children.