Nine years follow up of the 1st Adolescent Bariatric Surgery in Spain

Case Report

Nine years follow up of the 1st Adolescent Bariatric Surgery in Spain

Corresponding author Dr. Aniceto Baltasar, Tel: +34 675.070.195; Email: alejandro.ros12@gmail.com

Abstract
This is an update of the 1st Adolescents Bariatric Surgery (ABS) done in Spain in a 10-year-old boy with BMI-42 Kg/m2. A Sleeve-forming Laparoscopic Gastrectomy (SFLG) was performed. Nine years later, his BMI is 25 and his % Expected BMI loss (PBMIL) is 127% better than expected.
Keywords: Adolescent Bariatric Surgery; Children Bariatrics; Sleeve-Forming Gastrectomy 
Introduction

Adolescent Bariatric Surgery (ABS) is a new concept of bariatric surgery in full evolution. As in adults, the epidemic of obesity affects also children, with an incidence that is now increasing. Over the past 20 years, the prevalence of overweight in the US has tripled, reaching more than 15% of the child and adolescent population [1].
Pediatric obesity is considered from the 95th percentile for age and gender [2]. It has also been seen that between 70-80% of children with childhood obesity will present obesity in adulthood [3].
Although dietary treatment and lifestyle changes are the basis for managing childhood obesity, ABS is becoming more important in younger patients who cannot control excess weight and present complications.
This is because conservative treatments are often ineffective, especially in cases of severe obesity (BMI ≥40 Kg/m²) and that a substantial benefits have been demonstrated in obese adult patients undergoing bariatric surgery [2].
At present, bariatric surgery in children and adolescents may play an important role in the treatment of obesity, but today however clinical guidelines to guide us have not been standardized. In 2008 [3] we published the case of a child 147 cm in height and 88 Kg of weight, with severe obesity (BMI-42, 99th percentile) with associated co morbidities that hindered his quality of life. Now, 9 years after surgery, the case is reviewed.
Clinical Case
A 10-year-old boy, BMI – 42 Kg/m2, has severe Blount disease with fractures of both knees (tibia vara) due to obesity (Figure 3). He was riding a wheelchair.
Both parents also had Morbid Obesity. His mother BMI-64 (Figure 1) come also riding a wheelchair and had an open duodenal switch (ODS) surgery in 2002.
obesity fig 29.1
Figure 1. BMI-64 and then BMI-33 at 5 years.
Then his father with BMI-46 had a ODS in 2004
obesity fig 29.2
Figure 2. BMI-46 and then BMI-29.
In March 2007, after the evaluation of all the cognitive aspects of the patient and the consent of the patient and family, surgical intervention was decided. A Sleeve-forming laparoscopic vertical gastrectomy (SFVG) was performed [4] with a 34F  probe, with antral resection starting at the pylorus and lesser omentum patch to prevent rotation of the sleeve [5]. Surgery and the postoperative course were uneventful. At that time he was the 1st child to have this surgery in Spain and one of the earliest and youngest published cases undergoing ADS.
obesity fig 29.3
Figure 3. IMC-42 pre-op.
Results
The patient is now age 19, his BMI is 25.7, with a height of 1.57 m. and 64 kg. He has grown 1o cm. (Figure 4). The patient is currently with an excellent quality of life and adequate physical activity. %EWL-83%, %EBMIL-100% and the % of the expected BMI lost (PExBMIL) is 126%, much better than expected! [6].
obesity fig 29.4
BMI-25; Expected BMI-28 y %EBMII- 127%
In the short term, his BMI dropped from 42 to 27 in 9 months and the Excess of BMI lost (%EBMIL) was 79%. Subsequently, Blount disease correction surgery was performed on both knees with good results and ability to roam favorably.
Discussion
Bariatric surgery in adults is usually performed in patients with a BMI ≥ 35 Kg/m² with associated co morbidities or ≥ 40 kg / m² with or without co morbidities. However, in children and adolescents surgery is more conservative: they must present at least BMI ≥ 40 Kg/m2 with associated obesity related co-morbidities that could improve with weight loss (like type 2 diabetes mellitus, obstructive sleep apnea) or BMI ≥ 50 Kg/ m² with or without co morbidities. In addition, according to clinical guidelines, they must have developed pubertal development of Tanner 4-5 and at least 95% of adult height based on bone age, as well as having demonstrated psychological maturity [7].

Our patient did not meet the established requirements, however, the clinical judgment of the bariatric team should finally determine the option of surgery in an individualized way, since the effectiveness of bariatric surgery in the weight loss of the patients and decreased co-morbidities when long-term conservative treatment is not sufficient [8].There are several publications currently on bariatric surgery performed on children who do not meet the criteria, with good initial results. Dan et al. [9] reported the case of a 6-year-old girl with morbid obesity (BMI 53.18 Kg/m²) with associated Blount disease as described in our patient. LSAFG was performed without complications and with good short-term results: BMI of 33.33 Kg/m² with %EWL-37% and 50% of %EBMIL.

Mohaidly et al. [10] have published a case of a 2-and-a-halfyear- old child with LSG due to morbid obesity (BMI 41 Kg/m²) and significant co morbidities (sleep apnea and tibia vara). After surgery, short-term results were also very satisfactory, with weight reduction (BMI 24 Kg/m²) and resolution of co morbidities.Villalonga [11] presented in his Initial Approach to Childhood Obesity [8], conducted by a multidisciplinary group of experts, that there was no agreement on variability inclusion criteria in bariatric surgery in children and adolescents.

Regarding the type of surgery, this same study suggests that there is currently no consensus, the two most prevalent options being LSG and Roux-en-Y gastric bypass (RYGBP). Biliopancreatic diversion (BPD) is not recommended due to the greater risk of complications after surgery and the possibility of malabsorptive complications, given the short age of the patients. As for the adjustable gastric band (BGA), although it is less invasive and with a lower rate of complications, its longterm results in adult patients are lower than in other techniques. In addition, gastric banding has not been approved by the “US Food and Drug Administration” in children under 18 years [8].

The RYGBP has good long-term weight loss results, but since it consists of a mixed technique (restrictive and malabsorptive), there is a risk of developing metabolic and nutritional alterations that can compromise the growth of the child. In addition, they are not exempt from major complications such as leakage, pulmonary thromboembolism, intestinal obstruction, internal hernias.

As for the LSG, it is the most commonly used technique at present and its use is increasing. The technique is simpler, has fewer risks in terms of surgical and malabsorptive complications and can always be converted to a RYGBP if surgery is not effective. However, we lack long-term studies to confirm their effectiveness.

Conclusion

Bariatric surgery in children and adolescents is an effective tool when dietary and lifestyle change measures are not helpful. The co morbidities that can be generated after obesity in the long term will significantly affect the quality of life of these patients, so it is necessary to avoid these complications early.

There is no consensus at present on which type of surgery is most effective, although it is suggested that LSG and RYGBP are adequate for these patients. Although it has been shown that its efficacy with respect to conservative measures is greater [11], there are still not enough studies comparing which of them is more favorable in this type of patients.

It is necessary to review the inclusion criteria in the ABS since there are cases of patients who do not meet these requirements but will benefit greatly from the surgery; And above all individualize each case according to the BMI and their co morbidities.

References

1. Inge TH, Lawson L. Treatment considerations for severe adolescent obesity. Surg Obes Relat Dis. 2005, 1(2): 133–139.

2. Tsai WS, Inge TH, Burd RS. Recent National Trends in Use and In-Hospital Outcome. Bariatric Surgery in Adolescents. Arch Pediatr Adolesc Med. 2007, 161(3): 217-221.

3. Baltasar A, Serra C, Bou R, Bengochea M, Andreo L. Sleeve gastrectomy in a 10-year-old child. Obes Surg. 2008, 18(6): 733–736.

4. Baltasar A, Serra C, Pérez N, Bou R, Bengochea M et al. Laparoscopic Sleeve Gastrectomy: A Multi-purpose Bariatric Operation. Obes Surg. 2005, 15(8): 1124-1128.

5. Baltasar A, Bou R, Bengochea M, Serra C, Pérez N. Laparoscopic Gastric Sleeve, Subtotal Antrectomy and Omentoplasty. Obes Surg. 2015, 25(1): 195–196.

6. Baltasar A, Perez N, Serra C, Bou R, Bengochea M et al. Weight Loss Reporting: Predicted Body Mass Index After Bariatric Surgery. Obes Surg. 2011, 21(3): 367–372.

7. Serdula MK, Ivery D, Coates RJ, Freedman DS, Williamson DF et al. Do obese children become obese adults? A review of the literature. Prev Med. 1993, 22(2): 167–177.

8. Inge TH, Krebs NF, Garcia VF, Skelton JA, Guice KS et al. Bariatric Surgery for Severely Overweight Adolescents: Concerns and Recommendations. Pediatrics. 2004, 114(1): 217-223.

9. Dan D, Harnanan D, Seetahal S, Naraynsingh V, Teelucksingh S. Bariatric Surgery in the Management of Childhood Obesity: Should There be an Age Limit? Obes Surg. 2010, 20(1): 114– 117.

10. Mohaidly M, Suliman A, Malawi H. Laparoscopic sleeve gastrectomy for a two-and half year old morbidly obese child. Int J Surg Case Rep. 2013, 4(11): 1057–1060.

11. Vilallonga R, Moreno JM, Yeste D, Sánchez Santos R, Casanueva Freijo F et al. Initial Approach to Childhood Obesity in Spain. A multi society expert panel assessment. Obes Surg. 2016, 27(4): 997-1006.

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