Seminars in Pediatric Surgery 23 (2014) 21–23
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Seminars in Pediatric Surgery journal homepage: www.elsevier.com/locate/sempedsurg
Laparoscopic vertical sleeve gastrectomy for adolescents with morbid obesity Margaret M. McGuire, MD, Evan P. Nadler, MD, Faisal G. Qureshi, MDn Department of Surgery, Children's National Medical Center, WW 4200, 111 Michigan Ave, Washington, DC 20010
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Keywords: Laparoscopic sleeve gastrectomy Morbid obesity Adolescent Bariatric surgery
Obesity is a worldwide epidemic, and surgical weight loss operations have been performed for over 20 years. Laparoscopic sleeve gastrectomy was ﬁrst performed as part of the biliopancreatic diversion over 30 years ago. Recently, laparoscopic sleeve gastrectomy has led to excellent excess weight loss with limited morbidity, especially compared to Roux-en-Y gastric bypass. In adolescents, laparoscopic sleeve gastrectomy is an excellent option to provide excess weight loss and remission of comorbid conditions without long-term malabsorptive risks. & 2014 Elsevier Inc. All rights reserved.
Roux-en-Y gastric bypass
In a contemporary review of RYGB in obese pediatric patients, Treadwell et al.5 cited 6 studies reporting complications, which included pulmonary embolism, shock, malnutrition, gastrointestinal obstruction, and post-operative bleeding. Of these, malnutrition is the most common complication after RYGB and it requires lifelong vitamin and mineral replacement (vitamin D and B-12).6 In women who have undergone RYGB, malnutrition has been linked to the development of neural tube defects in their children.7 RYGB requires long-term follow-up with monitoring for malnutrition, especially if the patient is of reproductive age. RYGB is also associated with marginal ulcer formation, and El-Hayek et al.8 published a 34% overall rate of marginal ulceration with 47% presenting 1 year after bypass. Marginal ulceration has been described in pediatric patients as well.5 This risk of marginal ulceration and potential perforation should be explained to surgical candidates and they need counseling on the warning signs for which they should seek emergent medical attention. Additional complications include the development of an internal hernia at the transverse colon or behind the roux limb. As an undetected internal hernia can lead to life-threatening bowel ischemia, any patient must always be carefully evaluated post-RYGB for newonset severe abdominal pain. Treadwell et al. reported a 2.5% rate of internal hernia with RYGB in pediatric patients.9 All patients who present with abdominal symptoms after RYGB should be evaluated for marginal ulceration or internal hernia, and workup often includes an abdominal CT scan and possible endoscopy or laparoscopy.
RYGB is a restrictive and malabsorptive procedure. The operation is a permanent alteration of anatomy and has lifelong risks.
Laparoscopic adjustable gastric banding
Introduction Obesity is a worldwide epidemic and affects 35% of the adult population and about 15% of the pediatric population in the United States.1 Obesity in childhood is associated with many of the same physical and psychosocial conditions that are seen in adults who are obese.2 Obese children and adolescents are all but destined to become obese adults. While lifestyle modiﬁcation and patient education are important components of any weight management program, they have failed to demonstrate consistent durable weight loss.3 Bariatric surgery, on the other hand, has been performed with sustainable weight loss for over 20 years in adults. In addition, weight loss surgery in adults has lead to reduction in comorbid conditions such as diabetes, obstructive sleep apnea, and hyperlipidemia.
Weight loss surgery in pediatric patients Weight loss surgery in adolescents has been controversial and has been limited in the past to either laparoscopic gastric bypass (RYGB) or laparoscopic adjustable gastric band (LAGB).4 These topics are covered in more detail elsewhere, but below is a brief description to provide context to the foregoing discussion of sleeve gastrectomy results.
Corresponding author. E-mail address: [email protected]
1055-8586/$ - see front matter & 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1053/j.sempedsurg.2013.10.021
Laparoscopic adjustable gastric banding (LAGB) is considered to have fewer perioperative complications than RYGB and a shorter
M.M. McGuire et al. / Seminars in Pediatric Surgery 23 (2014) 21–23
operative time.10 It is considered solely a restrictive operation. LAGB is not approved by the Federal Drug Administration for use in patients under the age of 18 years. Yet, it has been used in the pediatric population for several years. Nadler et al.11 published a series of 73 adolescent patients who underwent LAGB at an average age of 15.8 years. Excess weight loss (EWL) was 57% and 61% at 1 and 2 years, respectively.11 The most common complications reported were hair loss, iron or vitamin D deﬁciency, band slipping, hiatal hernia, and gastro-esophageal reﬂux.11 There was 1 gastric perforation in this group, which required emergent reoperation.11 The reoperation rate was 12% and 5 had slipped bands. Of those with slipped bands, 4 had laparoscopic repositioning.11 Treadwell et al.5 also reported an 8% reoperation rate most commonly for band slippage. Postoperatively, patients undergoing LAGB are required to return for ofﬁce visits, usually monthly, for the ﬁrst post-operative year. During these visits, the volume of the band is adjusted to increase or decrease the restrictive effect. In addition, patients need constant monitoring and education regarding symptoms suggestive of band slippage, as this can lead to gastric perforation.
Laparoscopic sleeve gastrectomy Sleeve gastrectomy was ﬁrst described as part of biliopancreatic diversion by Scopinaro in 1979.12 In mid-2000, centers started to perform laparoscopic sleeve gastrectomy (LSG) as the ﬁrst-stage weight loss operation for the super obese patients, i.e., BMI 460 and high-risk patients, to help them become better candidates for the second-stage RYGB. Cottam et al.13 demonstrated a 46% excess weight loss after laparoscopic sleeve gastrectomy at 1 year as a ﬁrst-stage procedure. Since then, the use of LSG as the primary procedure has increased, as data have shown that LSG alone results in signiﬁcant excess weight loss.14,15 Nguyen et al.16 published a dramatic increase in the incidence of LSG, which represented 36.3% of all bariatric procedures in 2012 with comparable morbidity and mortality compared to gastric bypass. During this same time laparoscopic gastric bypass decreased from 66.8% to 56.4% and laparoscopic gastric banding also decreased from 23.8% to 4.1%.16 Complications associated with LSG are similar to those associated with laparoscopic gastric bypass and laparoscopic gastric banding. These include leak, hemorrhage, venous thromboembolism, and infection. Carlin et al.10 found a lower overall complication rate with LSG compared to RYGB (6.3% vs 10%) but a higher rate when compared to LAGB (2.4%). They also found a signiﬁcantly lower rate of hemorrhage and obstruction after LSG compared to RYGB but a similar length of stay.10 Carlin et al.10 reported lower excess weight loss at 1 year for LSG vs RYGB but higher than LAGB (60%, 69%, and 34%, respectively). Average operative times for LSG reported range from 69 to 84 min.17,18 As LSG has gained popularity in recent years for use in adults, it has also become an option for obese adolescents with fewer perioperative and long-term complications. In addition, LSG does not alter the small bowel anatomy or include the use of a foreign body. Thus, we have adopted its use primarily in our adolescent weight loss surgery program.
Procedure Laparoscopic sleeve gastrectomy is performed with the patient supine, with or without stirrups, depending on the patient's size (we prefer putting the patient in the split leg position at the highest end of the BMI spectrum). Patients are given pre-operative antibiotics and low-molecular weight heparin for deep vein thrombosis prophylaxis. Patients are checked and padded at any
pressure points and sequential compression devices are also applied. A 5-mm optical port is used in the left upper quadrant just below the costal margin laterally to access the abdomen, and 4 other port incisions are placed. Our current preference is to use a 12- or 15-mm port above the umbilicus and to the left of midline; this is our only port of greater diameter than 5 mm, and it is used for all of the stapler ﬁrings. The remaining 3 ports are a 5-mm port in mid-left epigastrium, a 5-mm port in right mid-abdomen, and an epigastric incision for 5-mm port, which is then removed and used elsewhere. A Nathanson liver retractor (Mediﬂex, Islandia, NY) is placed through the epigastric incision and used to retract the left lateral segment of the liver to provide exposure to the gastro–esophageal junction. Local anesthesia is used liberally. The stomach is inspected and the pylorus is identiﬁed. A window is created in the gastrocolic ligament 4–6 cm from the pylorus using a harmonic scalpel (or other energy device as is the surgeon's preference). The gastro-splenic ligament and short gastric vessels are mobilized off the greater curve using the same energy source; hemostasis is crucial. The short gastric vessels are carefully dissected off the spleen, and the fundus of the stomach and angle of His are clearly identiﬁed. Using an endoscopic stapler [Ethicon Echelon ﬂex Endopath, 60, green load (4.1 mm open/2 mm closed; Ethicon, Cincinnati, OH)] with a butress (Gore, Seamguard, Flagstaff, AZ), the stomach is divided over a 40 Fr bougie dilator that is snug against the lesser curve. There is debate regarding the need for buttressing, but it is our current preference to do so. Multiple ﬁrings of the stapler are used to march along the stomach, up to the angle of His. Here, a gold load (Ethicon, Cincinnati, OH, 3.8 mm open/1.8 mm closed) is used and the gastrectomy is completed. The bougie is removed; a nasogastric tube is placed into the antrum, the duodenum is obstructed with a blunt grasper and 60 ml of saline stained with methylene blue (American Regent, Shirley, NY) is injected in 30-ml aliquots into the residual stomach. The staple line is inspected for leak and the methylene blue is aspirated prior to the duodenum being released. The nasogastric tube is then removed. The resected stomach is withdrawn through the 15-mm port site. We originally placed the stomach in a 15-mm Endocatch bag (Covidien, Mansﬁeld, MA) and expanded the port site. However, we have recently modiﬁed our technique instead, placing a small Alexis wound retractor (Applied Medical, Rancho San Margarita, CA) into the 15-mm port site and bringing the stomach through this opening. Once the stomach is retrieved, we close the 15-mm wound using the Carter Thomason device and 0 vicryl sutures. Laparoscopy is reinitiated and the left upper quadrant inspected for bleeding or any delayed leak. Once these issues are conﬁrmed absent, the Nathanson retractor is removed under laparoscopic vision and then the laparoscopy is terminated, the air is evacuated, all the ports are removed and the skin is closed with monocryl (Ethicon, Cincinnati, OH). Steri-strips or Dermabond are used for skin dressing (Ethicon, Cincinnati, OH).
Post-operative management The patient is admitted overnight and monitored for clinical evidence of leak. Until very recently we performed a limited UGI the next day to evaluate for leak and determine the size of the residual stomach. We have forgone this study in our most recent patients. A liquid diet is started after the UGI, or ﬁrst thing in the morning without UGI more recently, and patients are discharged home on post-operative day 1 or 2, depending on their ability to tolerate enough oral liquid to keep themselves hydrated and the adequacy of their pain control. Follow-up occurs at 1, 3, 6, and 12 months, and then every 6 months thereafter. Patients continue on a clear liquid diet for
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conditions and that the sleeve gastrectomy is a reasonable option for surgical weight loss.
Table 1. Demographics and results. Total number of patients Sex Ethnicity Average Average Average Average Average
pre-operative BMI EWL 3 months delta BMI 3 months EWL 6 months delta BMI 6 months
59 81% Women 56% African American, 22% Caucasian, and22% Hispanic 50.6 32.4% 8.8 (17.8%) 38.6% 11.2 (21.6%)
2–3 days and are then advanced to a full liquid diet for 2–3 weeks. They are given a target of 50–60 g of protein and 64–90 ﬂuid ounces per day. At 3 weeks, they are advanced to a pureed diet and then textures are gradually increased during the ensuing weeks. Patients are asked to separate their liquid and solid consumption until 3 months after surgery. No carbonated beverages are allowed. Exercise programs are highly encouraged. They are started on a multivitamin postoperatively to ensure appropriate vitamin levels while on the restricted diet. Extensive educational materials are provided to the patient and their family that help with each diet stage and focus on healthy food choices. Women are counseled on the risks of pregnancy in the ﬁrst year after LSG, given the reported association with birth defects.7
Results of laparoscopic sleeve gastrectomy We have now performed 59 LSG procedures in adolescents with morbid obesity. The average age is 17.2 years, 81% are women, average pre-operative weight is 144 kg, and average BMI is approximately 51. The average length of stay is 1.7 days. All patients were started on a pre-operative protein-sparing modiﬁed fast for 2 weeks prior to LSG. We previously reported 1 complication in our ﬁrst 23 patients and 40% excess weight loss (EWL) at 1 year.19 In our 59 procedures to date, at 3 months there is an average 32.4% EWL and 17.8% decrease in BMI. At 6 months, an average 21.6% decrease in BMI is achieved, which increased to 24.9% at 12 months. Table shows the demographics and weight loss results in our cohort of patients. Our results are comparable to others using LSG in adolescents. Alqahtani et al.17 published data on 108 patients aged 5–21 years. They found median excess weight loss of 61.3% and 62.3% at 12 and 24 months, respectively.17 There were no major complications and 4.3% rate of minor complications including reﬂux and wound infections.17 Boza et al.18 reported a series of 51 patients aged 15–19 years, who had EWL of 94.6%, 96.2%, and 92.9% at 6 months, 1 year, and 2 years postoperatively, respectively. While the metabolic changes after LSG in adolescents have not been widely published, LSG has been demonstrated to lead to normalization of glucose metabolism in adults.20 Ramon et al.20 reported similar levels of insulin and glucose in patients after LSG and RYGB but lower fasting ghrelin levels in patients who had undergone LSG. Alqahtani et al.17 reported in his adolescent cohort a resolution rate of comorbid conditions of 70–100%. Further studies are certainly needed in the adolescent population; however, it appears that in the short term LSG compares favorably with RYGB in terms of weight loss and resolution of comorbid
Summary Pediatric obesity is a worldwide problem with alarming rates in children and adolescents. Without intervention this will lead to even more obese adults. While laparoscopic gastric bypass has been established as the most successful weight loss surgery for adults, it is associated with signiﬁcant nutrition alternations and possible serious long-term complications. Laparoscopic sleeve gastrectomy has gained favor in recent years after starting as a ﬁrst-stage operation. It is associated with excess weight loss of over 60% at 1 year and normalization of glucose and insulin levels. For adolescents, LSG is an excellent option to allow excess weight loss and lifestyle modiﬁcations that will lead to a healthier adult. References 1. Central for Disease Control. National health and nutrition examination survey; 2009–2010. 2. Vanhala M, Vanhala P, Kumpusalo E, et al. Relation between obesity from childhood to adulthood and the metabolic syndrome: population based study. Br Med J. 1998;317:319. 3. Dansinger ML, Tatsioni A, Wong JB, et al. Meta-analysis: the effect of dietary counseling for weight loss. Ann Intern Med. 2007;147:41–50. 4. August GP, Caprio S, Fennoy I, et al. Prevention and treatment of pediatric obesity: an endocrine society clinical practice guideline based on expert opinion. J Clin Endocrinol Metab. 2008;93:4576–4599. 5. Treadwell JR, Sun F, Schoelles K. Systematic review and meta-analysis of bariatric surgery for pediatric obesity. Ann Surg. 2008;248:763–776. 6. Gletsu-Miller N, Wright BN. Mineral malnutrition following bariatric surgery. Adv Nutr. 2013;4:506–517. 7. Saﬁ J, Joyeux L, Chalouhi GE. Periconceptional folate deﬁciency and implications in neural tube defects. J Pregnancy. 2012;2012:295083. 8. El-Hayek K, Timratana P, Shimizu H, et al. Marginal ulcer after Roux-en-Y gastric bypass: what have we really learned? Surg Endosc. 2012;26:2789–2796. 9. Iannelli A, Facchiano E, Gugenheim J. Internal hernia after laparoscopic Rouxen-Y gastric bypass for morbid obesity. Obes Surg. 2006;16:1265–1271. 10. Carlin AM, Zeni TM, English WJ, et al. The comparative effectiveness of sleeve gastrectomy, gastric bypass, and adjustable gastric banding procedures for the treatment of morbid obesity. Ann Surg. 2013;257:791–797. 11. Nadler EP, Youn HA, Ren CJ, et al. An update on 73 US obese pediatric patients treated with laparoscopic adjustable gastric banding: comorbidity resolution and compliance data. J Pediatr Surg. 2008;43:141–146. 12. Scopinaro N, Gianetta E, Civalleri D, et al. The bilio-pancreatic bypass for functional surgical treatment of obesity. Minerva Med. 1979;70:3537–3547. 13. Cottam D, Qureshi FG, Mattar SG, et al. Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity. Surg Endosc. 2006;20:859–863. 14. Regan JP, Inabnet WB, Gagner M, et al. Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient. Obes Surg. 2003;13:861–864. 15. Eid GM, Brethauer S, Mattar SG, et al. Laparoscopic sleeve gastrectomy for super obese patients: forty-eight percent excess weight loss after 6 to 8 years with 93% follow-up. Ann Surg. 2012;256:262–265. 16. Nguyen NT, Nguyen B, Gebhart A, et al. Changes in the makeup of bariatric surgery: a national increase in use of laparoscopic sleeve gastrectomy. J Am Coll Surg. 2013;216:252–257. 17. Alqahtani AR, Antonisamy B, Alamri H, et al. Laparoscopic sleeve gastrectomy in 108 obese children and adolescents aged 5 to 21 years. Ann Surg. 2012;256: 266–273. 18. Boza C, Viscido G, Salinas J, et al. Laparoscopic sleeve gastrectomy in obese adolescents: results in 51 patients. Surg Obes Relat Dis. 2012;8:133–137 [discussion 137–139]. 19. Nadler EP, Barefoot LC, Qureshi FG. Early results after laparoscopic sleeve gastrectomy in adolescents with morbid obesity. Surgery. 2012;152:212–217. 20. Ramón JM, Salvans S, Crous X, et al. Effect of Roux-en-Y gastric bypass vs sleeve gastrectomy on glucose and gut hormones: a prospective randomised trial. J Gastrointest Surg. 2012;16:1116–1122.