RATIONALE FOR BARIATRIC SURGERY IN ADOLESCENTS

1
RATIONALE FOR BARIATRIC SURGERY IN ADOLESCENTS
2
SCOPE OF THE OBESITY PROBLEM

• 26 of children and adolescents aged 2 to 17
  years were overweight (18) or obese (8) -
  Canadian Community Health Survey 2004
• For adolescents 12 to 17 yrs - overweight rate
  more than doubled and obesity rate tripled over
  past 25 yrs

3
SCOPE OF THE OBESITY PROBLEM
4
SCOPE OF THE OBESITY PROBLEM

• 26 of children and adolescents aged 2 to 17
  years were overweight (18) or obese (8) -
  Canadian Community Health Survey 2004
• For adolescents 12 to 17 yrs - overweight rate
  more than doubled and obesity rate tripled over
  past 25 yrs
• Obesity during adolescence is the single best
  predictor for adult obesity

5
(No Transcript)
6
WHY WOULD WE EVEN THINK ABOUT DOING SURGERY FOR
OBESITY IN CHILDREN?
7
Whats the best kind of bariatric procedure for
children?
8
Whats the best kind of bariatric procedure for
children?

• Malabsorptive
• Restrictive

9
Whats the best kind of bariatric procedure for
children?

• Malabsorptive
• Restrictive
• Laparoscopic band
• Roux-en-Y gastric bypass
• Sleeve gastrectomy

10
OUTCOMES ADOLESCENTS
OBrien et al. JAMA. 2010 303(6)519-526
11
OUTCOMES ADOLESCENTS
Treadwell et al. Ann Surg. 2008 248(5)
12
OUTCOMES ADOLESCENTS
13
OUTCOMES ADOLESCENTS
14
OUTCOMES ADOLESCENTS
CCHMC Bariatric Case Volume(n144 total over 10
years)
15
ADOLESCENT BARIATRIC SURGERY IN ONTARIO

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

16
ADOLESCENT BARIATRIC SURGERY IN ONTARIO
Children are not just small adults
17
ADOLESCENT BARIATRIC SURGERY IN ONTARIO

• Integrated multidisciplinary pediatric-oriented
  medical program
• Pediatric medical specialties
• Psychosocial support for child and family
• Surgical expertise
• Academic environment as part of overall pediatric
  obesity strategy

18
SICKKIDS TEAM OBESITY MANAGEMENT PROGRAM (STOMP)

• Multidisciplinary medical/psychosocial program
  funded through MOHLTC Diabetes Strategy
• Bariatric surgery funded by MOHLTC through
  University of Toronto Bariatric Surgery
  Collaboration
• High Impact Strategies Toward Obesity Reduction
  in Youth (HISTORY) multidisciplinary grant funded
  by CIHR
• Province-wide initiative for obesity prevention
  and management

19
Intake/Initial Assessment
20
Intake/Initial Assessment
Parent Group Support
Adolescent Group Support
Adolescent Individual Appointments Diet/Behaviour/
Exercise
21
Intake/Initial Assessment
Parent Group Support
Adolescent Group Support
Adolescent Individual Appointments Diet/Behaviour/
Exercise
3-6 Months
Team Re-Assessment
Ongoing support and treatment
Bariatric surgery
22
SICKKIDS EXPERIENCE SO FAR

• Pre-STOMP
• Seven cases
• 4 craniopharyngioma
• 3 morbid obesity
• First two Roux-en-Y bypass
• Excellent weight loss
• Last five laparoscopic band
• All inflated with good initial weight loss
• Two required reoperation
• One removed at 2.5 years - converted to Roux-en-Y
  bypass
• One removed at 2.0 years - converted to Roux-en-Y
  bypass
• Weight loss results mixed

23
SICKKIDS EXPERIENCE SO FAR

• Post-STOMP
• Nine cases
• 1 craniopharyngioma
• 8 morbid obesity
• First three laparoscopic band
• Excellent weight loss in 1, poor weight loss in 2
• One removed after 10 months - converted to sleeve
  gastrectomy
• No complications
• Last six
• 3 Roux-en-Y bypass and 3 sleeve gastrectomy
• Excellent early weight loss
• No complications

24
SICKKIDS EXPERIENCE SO FAR
25
ONGOING ISSUES
?

• What is the best operation for adolescents?
• Laparoscopic band
• Potentially reversible and lower mortality
• Higher complication and reoperation rate
• Lower efficacy
• Roux-en-Y bypass
• Gold standard
• Long term issues with vitamin deficiencies and
  compliance in adolescents
• Sleeve gastrectomy

26
ONGOING ISSUES

• How many funded pediatric centres should there be
  in Ontario?
• For complex medical care
• For bariatric surgery
• Which model is better?
• Pediatric centre with help from adult surgeons
• Adult centre with help from pediatric medical
  specialists
• Transitioning to adult centres

27
THANKS FOR YOUR ATTENTION!