OBES SURG DOI 10.1007/s11695-013-1169-7
ORIGINAL CONTRIBUTIONS
Mid-term Results of Laparoscopic Sleeve Gastrectomy and Roux-en-Y Gastric Bypass in Adolescent Patients Yaniv Cozacov & Mayank Roy & Savannah Moon & Pablo Marin & Emanuele Lo Menzo & Samuel Szomstein & Raul Rosenthal
# Springer Science+Business Media New York 2014
Abstract The prevalence and severity of obesity in children and adolescents has been increasing in recent years at an unprecedented rate. Morbidly obese children will almost certainly develop severe comorbidities as they progress to adulthood, and bariatric surgery may provide the only alternative for achieving a healthy weight. The aim of this study was to assess the long-term outcomes and safety of laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB) as new treatment modalities for morbidly obese adolescents. We conducted a retrospective review of a prospectively collected database of all adolescent patients who underwent LSG and RYGB under IRB protocol at the Bariatric and Metabolic Institute in Cleveland Clinic Florida between 2002 and 2011. Patients were also contacted by phone, adhering to HIPAA regulations, and were asked to answer a survey. Eighteen adolescents had a bariatric procedure performed at this institution. The mean age was 17.5 years, the average weight was 293.1 lbs, and the average BMI was 47.2 kg/m 2 . The mean follow-up period consisted of 55.2 months. The postoperative weight at 55 months followup was 188.4 lbs and average BMI was 30.1 kg/m2. Fifteen of the patients were available for follow-up. Thirteen out of 16 (81 %) comorbidities in patients available for follow-up were in remission following rapid weight loss. The long-term follow-up and perioperative morbidity shown in this study suggest that LSG and LRYGB appear to be safe and effective operations in morbidly obese adolescents.
Y. Cozacov : M. Roy : S. Moon : P. Marin : E. L. Menzo : S. Szomstein : R. Rosenthal (*) Department of General Surgery, Bariatric and Metabolic Institute and Section of Minimally Invasive Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL 33331, USA e-mail: [email protected]
Keywords Laparoscopic Roux-en-Y gastric bypass . Laparoscopic sleeve gastrectomy . Weight loss surgery . Bariatric surgery . Adolescents
Introduction The prevalence and severity of obesity in children and adolescents has been increasing at a parallel rate of adult obesity [1]. Overweight (defined as BMI>95 % percentile for age and gender) doubled for children ages 6 to 11 years and tripled for adolescents ages 12 to 19 years over the last three decades [1]. In 2008, obesity among 6-to-11-year olds was 19.6 % and between 12 and 19 years of age the rate was 18.1 % [2]. Morbidly obese adolescents are increasingly being diagnosed with medical complications such as cardiovascular disease [3], non-insulin-dependent diabetes [4], obstructive sleep apnea [5], skeletal disorders [6], polycystic ovarian disease [7], non-alcoholic liver fatty disease [8], and gynecological cancer [9]. Severe obesity is also associated with a reduced quality of life in adolescents [10] and negative self-esteem that may persist into adulthood [11]. Given the natural history of obesity, these children will almost certainly develop severe comorbidities as they progress to adulthood and portend a further increase in the prevalence and severity of the obesity epidemic in the next generation of adults. In fact, obese teenagers are far more likely to carry obesity into adulthood than to outgrow obesity [12, 13]. The risk factors for adolescent obesity and its persistence into adulthood offer insight into the phenotypes of those individuals who may be least likely to succeed with nonsurgical management versus those who may obtain substantial benefit from early application of surgical therapy. Despite massive healthcare initiatives, including lifestyle changes, increase in physical activity, and dietary modifications, non-operative therapy for morbid obesity has produced poor results [14]. For severely overweight
OBES SURG
adolescents with serious or life threatening conditions who have failed conventional non-operative approaches, bariatric surgery may provide the only practical alternative for achieving a healthy weight and for escaping physical and psychological effects of obesity [15]. The American Society for Metabolic and Bariatric Surgery (ASMBS) has emphasized the need to prevent comorbidities by offering surgery earlier rather than waiting for them to develop in this patient population [16-18]. Since the ASMBS supports using the same criteria for bariatric surgery in adolescents as those set forth by the 1991 National Institute of Health (NIH) Consensus Conference for morbidly obese adults, bariatric surgery is increasingly being considered as an adjunct treatment tool. RYGB and LSG are rapidly growing in popularity as bariatric procedures being used for the management of morbid obesity in this population. In contrast to numerous published reports investigating the outcome of bariatric surgery in adults, there is a relative paucity of published data comparing the efficacy and safety of various bariatric procedures among adolescents [16]. The safety and effectiveness of LSG in morbidly obese adolescents is not yet clear and reported outcomes show it could be an alternative treatment modality. The aim of this study was to assess the long-term outcomes of RYGB and LSG as treatment modalities for morbidly obese adolescents.
regimens. All patients were counseled in the presence of their parents on the specific risks associated with RYGB and LSG and with abdominal operations in general. Additionally, we discussed the lack of information on long-term effects of the procedure in adolescence, the possibility of long-term weight gain, post-surgery dietary requirements, and nutritional and vitamin supplement recommendations. The comorbidities analyzed were hypertension (HTN), hyperlipidemia, diabetes mellitus (DM), gastroesophageal reflux disease (GERD), depression, and sleep apnea. The presence of each condition was defined as being documented in a physician consultation note. Improvement of DM was defined as fasting blood glucose less than or equal to 126 without medication. Improvement of HTN was defined as systolic blood pressure less than or equal to 140 without medication. Improvement of hyperlipidemia was defined as absence of medication. Improvement of sleep apnea was defined as normal sleep pattern without the use of continuous positive airway pressure (CPAP) machine. Routine postoperative polysomnography was not performed. All procedures were performed at a single institution using a similar technique for RYGB, as well as for LSG [19]. The standard criteria, as described by the Consensus Development Panel of the National Institutes of Health (NIH), were used to determine the eligibility for surgery [20]. All the adolescent patients undergoing RYGB or LSG were enrolled in an IRB-approved study.
Methods Following Institutional Review Board approval and HIPAA guidelines, we conducted a retrospective review of a prospectively collected database of all adolescent patients (ages 11– 19 years old) who underwent RYGB and LSG as a primary procedure at the Bariatric and Metabolic Institute in Cleveland Clinic Florida between 2002 and 2011. Only those patients who had completed 12 months follow-up at the time of the study were analyzed. Data collected from medical records included patient demographics, preoperative body mass index (BMI), initial weight, comorbid conditions, postoperative body mass index (BMI), postoperative weight, and postoperative complications. The subjects were also contacted by phone, adhering to HIPAA regulations, and were questioned upon current health and weight, symptoms and medications, whether they had to undergo a secondary bariatric procedure, surgical complications, and quality of life. Patients were selected for RYGB or LSG on the basis of the following: (1) patient’s preference, (2) high risk, (3) BMI >40 or >35 kg/m2 with an associated comorbidity, (4) failure to lose weight after participation in formal weight management program, (5) written informed consent, and (6) psychological evaluation to confirm motivation for surgery and commitment for compliance with follow-up visits and lifestyle and dietary
Results Eighteen adolescents had a bariatric procedure performed at our institution, from January 2002 to January 2011, inclusive of 13 females and 5 males (Table 1). Mean operative time was 85 min (range 65–170). All the operations were completed laparoscopically with no postoperative complications or mortality in this series. Preoperatively, the mean age was 17.5 years, the mean weight was 293.1 lbs, and the mean BMI was 47.2. The mean length of postoperative stay (LOS) was 3.1 days, and the mean follow-up period was 55.2 months. The mean postoperative weight at latest follow-up was 188.4 lbs, and the mean BMI was 30.1. Of the 18 patients, 15 (83 %) were available for a follow-up period of over 1 year (Table 2), 13 (72 %) patients available for over 2 years, 10 (56 %) patients available for over 3 years, 7 (39 %) patients were available for over 4 years, 6 (33 %) patients available for over 6 years, and 3 (17 %) patients available for over 7 years. Comorbidity resolution for patients is described as follows (Table 3): Of two patients diagnosed with HTN preoperatively, both cases reported resolved. Of six patients diagnosed with sleep apnea, three were lost to follow-up and the other three had their condition resolved. One patient with type 2 DM had resolution of his condition. For gastroesophageal
OBES SURG Table 1 Details of the 18 adolescent patients
Table 3 Comorbidity resolution
Preoperative Age Gender Weight BMI LOS
17.5 13 females, 5 males 293.1 47.2 3.1
Postoperative n Follow-up months Weight BMI
15 55.2 188.4 30.1
Preoperative comorbidity (n) Hypertension (2) Sleep apnea (6) Type 2 DM (1) GERD (4) Depression (4)
Follow-up 4.5 years All resolved 3 resolved, 3 lost to FU Resolved 3 of 4 resolved 3 of 4 resolveda
Asthma (1) Hypercholesterolemia (1)
No change Resolved
FU follow-up, GERD gastroesophageal reflux disease, DM diabetes mellitus a
One patient has depression, related to death in family
BMI body mass index, LOS length of stay
reflux disease (GERD), three of four patients reported the comorbidity resolved. For depression, three of four patients did not need medication, except one patient who assigns his depression to death of an immediate family member. One patient with hypercholesterolemia has his lipid profile currently within normal range, without the use of medication. One patient with asthma still requires medication. Summed together, of a total 16 comorbidities of patients available for followup, 13 (81 %) have been reported to be resolved. Questionnaire Results Of 18 patients, 11 (61 %) patients could be reached by phone for answering a questionnaire, involving several aspects of health and lifestyle. On average, patients reported a maximum weight loss of 147.5 lbs. Eight of the 11 patients had reported to regain weight, averaging 45.4 lbs. Of the eight, three females reported to regain weight during pregnancies. Two female patients (one RYGB, one LSG) had been pregnant twice, and one patient (RYGB) had been pregnant three times. All patients reported healthy newborns and a non-complicated pregnancy, except for one patient reporting cholelithiasis during her second pregnancy. The latter three women gained on average 55.0 lbs. Two of the eight patients, one female and one male, Table 2 Details of follow-up cohort Postoperative follow-up (years) >1 >2 >3 >4 >6 >7
LSG (n)
LRYGB (n)
Total (n)
9 8 6 5 4 1
6 5 4 2 2 2
15 13 10 7 6 3
LSG laparoscopic sleeve gastrectomy, LRYGB laparoscopic Roux-en-Y gastric bypass
regained 80 and 50 lbs., respectively. Both had a second bariatric procedure performed, in which their LSG was converted to a RYGB. The female patient had her LSG at the age of 17 and RYGB at age 24, and the male patient had his first bariatric procedure at the age of 12 and the second at the age of 17. The female patient currently weighs 179 lbs with a BMI of 33.8 and the male patient weighs 236 lbs with BMI of 41.8 kg/m2. The last three of eight patients regained on an average 22.7 lbs. Of 11 patients, three reported iron deficiency anemia, two of which were pregnant as reported above. Of the 11 patients answering the questionnaire, nine (82 %) are taking dietary supplements, such as vitamin D, vitamin B complex, iron, and calcium. For gastrointestinal (GI) symptoms, of 11 patients, one patient (LSG) complains of heartburn, and one patient (RYGB) describes nausea following overeating. One LSG female patient complains of diarrhea and occasional abdominal discomfort or pain. Ten (91 %) patients reported no complaints regarding difficulty swallowing, heartburn, or any other upper GI discomfort or motility dysfunction. None of the 11 patients reported currently having the following comorbidities: HTN, obstructive sleep apnea, DM, insulin resistance, or any kind of joint disease (osteoarthritis). Only one patient reported psychiatric illness, relating to depression mentioned above. This patient is prescribed trazadone and is the only patient to report smoking (1 PPD). One patient continues on asthma medication, and except for OCP, none of the patients receive any other medications. One female patient (LSG) had her gallbladder removed and another (LSG) reported cholelithiasis during her second pregnancy (as mentioned above). When asked for quality of life and satisfaction, patients reported on four different fields, ranging from 1 to 7, with 7 being the most satisfied. The results (Table 4) average 4.8 for physical activity, 5.9 for sexual activity, 5.8 for self-esteem, and 6.6 when ranking their social relationships satisfaction. The lowest average for all four indicators in a single patient is
OBES SURG Table 4 Lifestyle satisfaction Patient
Physical activity
Sexual activity
Self esteem
Social relationships
Average
1 2 3 4
7 4 5 4
7 7 5
7 7 5 6
7 7 6 6
7.00 6.25 5.75 5.25
5 6 7 8 9 10 11 (n=11)
1 6 4 5 7 3 7 4.82
4 6 5 5 7 6 7 5.90
2 7 5 6 7 5 7 5.82
7 6 7 6 7 6 7 6.55
3.50 6.25 5.25 5.50 7.00 5.00 7.00 Average
3.5 points. All other patients (10 of 11) reported an average of >5 points. As far as comparing RYGB patients with LSG patients (Table 5), we have found no statistically significant difference (p>0.05) for all preoperative and postoperative outcomes, including age, LOS, weight, BMI, maximum weight loss, or follow-up period. Data for two patients who converted from LSG to RYGB were deduced prior to the second bariatric procedure, where the follow-up period was 79 and 30 months for each.
Discussion No consensus exists regarding the definitive treatment for morbidly obese children and adolescents who failed nonsurgical multidisciplinary therapy regimes. In studying the RYGB versus behavioral pediatric weight management, Lawson and colleagues found a 37 % decrease in pediatric BMI with surgery compared to behaviorally
managed group; Inge and colleagues demonstrated that RYGB has been to shown to cause remission in type 2 diabetes in the pediatric population [21, 22]. Brethauer and colleagues’ literature review reported short and long-term outcomes of LSG, with excess weight loss averaging 55 % and the majority of patients experiencing improvement or resolution of comorbidities [23]. Laparoscopic sleeve gastrectomy has shown a complication rate ranging from 2 to 5 % in adults, with excess weight loss and a resolution of comorbid conditions in over 90 % of subjects over 12 months. Langer et al. refuted the theory that LSG may result in the long-term dilation of the remaining stomach in a follow-up of 20 months [24]. Varela et al. [25] have reviewed the University Health System Consortium (UHC) database in search of perioperative morbidity surrounding bariatric surgery in adolescents compared to the adult population. Adolescents were defined as patients
ORIGINAL CONTRIBUTIONS
Mid-term Results of Laparoscopic Sleeve Gastrectomy and Roux-en-Y Gastric Bypass in Adolescent Patients Yaniv Cozacov & Mayank Roy & Savannah Moon & Pablo Marin & Emanuele Lo Menzo & Samuel Szomstein & Raul Rosenthal
# Springer Science+Business Media New York 2014
Abstract The prevalence and severity of obesity in children and adolescents has been increasing in recent years at an unprecedented rate. Morbidly obese children will almost certainly develop severe comorbidities as they progress to adulthood, and bariatric surgery may provide the only alternative for achieving a healthy weight. The aim of this study was to assess the long-term outcomes and safety of laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB) as new treatment modalities for morbidly obese adolescents. We conducted a retrospective review of a prospectively collected database of all adolescent patients who underwent LSG and RYGB under IRB protocol at the Bariatric and Metabolic Institute in Cleveland Clinic Florida between 2002 and 2011. Patients were also contacted by phone, adhering to HIPAA regulations, and were asked to answer a survey. Eighteen adolescents had a bariatric procedure performed at this institution. The mean age was 17.5 years, the average weight was 293.1 lbs, and the average BMI was 47.2 kg/m 2 . The mean follow-up period consisted of 55.2 months. The postoperative weight at 55 months followup was 188.4 lbs and average BMI was 30.1 kg/m2. Fifteen of the patients were available for follow-up. Thirteen out of 16 (81 %) comorbidities in patients available for follow-up were in remission following rapid weight loss. The long-term follow-up and perioperative morbidity shown in this study suggest that LSG and LRYGB appear to be safe and effective operations in morbidly obese adolescents.
Y. Cozacov : M. Roy : S. Moon : P. Marin : E. L. Menzo : S. Szomstein : R. Rosenthal (*) Department of General Surgery, Bariatric and Metabolic Institute and Section of Minimally Invasive Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL 33331, USA e-mail: [email protected]
Keywords Laparoscopic Roux-en-Y gastric bypass . Laparoscopic sleeve gastrectomy . Weight loss surgery . Bariatric surgery . Adolescents
Introduction The prevalence and severity of obesity in children and adolescents has been increasing at a parallel rate of adult obesity [1]. Overweight (defined as BMI>95 % percentile for age and gender) doubled for children ages 6 to 11 years and tripled for adolescents ages 12 to 19 years over the last three decades [1]. In 2008, obesity among 6-to-11-year olds was 19.6 % and between 12 and 19 years of age the rate was 18.1 % [2]. Morbidly obese adolescents are increasingly being diagnosed with medical complications such as cardiovascular disease [3], non-insulin-dependent diabetes [4], obstructive sleep apnea [5], skeletal disorders [6], polycystic ovarian disease [7], non-alcoholic liver fatty disease [8], and gynecological cancer [9]. Severe obesity is also associated with a reduced quality of life in adolescents [10] and negative self-esteem that may persist into adulthood [11]. Given the natural history of obesity, these children will almost certainly develop severe comorbidities as they progress to adulthood and portend a further increase in the prevalence and severity of the obesity epidemic in the next generation of adults. In fact, obese teenagers are far more likely to carry obesity into adulthood than to outgrow obesity [12, 13]. The risk factors for adolescent obesity and its persistence into adulthood offer insight into the phenotypes of those individuals who may be least likely to succeed with nonsurgical management versus those who may obtain substantial benefit from early application of surgical therapy. Despite massive healthcare initiatives, including lifestyle changes, increase in physical activity, and dietary modifications, non-operative therapy for morbid obesity has produced poor results [14]. For severely overweight
OBES SURG
adolescents with serious or life threatening conditions who have failed conventional non-operative approaches, bariatric surgery may provide the only practical alternative for achieving a healthy weight and for escaping physical and psychological effects of obesity [15]. The American Society for Metabolic and Bariatric Surgery (ASMBS) has emphasized the need to prevent comorbidities by offering surgery earlier rather than waiting for them to develop in this patient population [16-18]. Since the ASMBS supports using the same criteria for bariatric surgery in adolescents as those set forth by the 1991 National Institute of Health (NIH) Consensus Conference for morbidly obese adults, bariatric surgery is increasingly being considered as an adjunct treatment tool. RYGB and LSG are rapidly growing in popularity as bariatric procedures being used for the management of morbid obesity in this population. In contrast to numerous published reports investigating the outcome of bariatric surgery in adults, there is a relative paucity of published data comparing the efficacy and safety of various bariatric procedures among adolescents [16]. The safety and effectiveness of LSG in morbidly obese adolescents is not yet clear and reported outcomes show it could be an alternative treatment modality. The aim of this study was to assess the long-term outcomes of RYGB and LSG as treatment modalities for morbidly obese adolescents.
regimens. All patients were counseled in the presence of their parents on the specific risks associated with RYGB and LSG and with abdominal operations in general. Additionally, we discussed the lack of information on long-term effects of the procedure in adolescence, the possibility of long-term weight gain, post-surgery dietary requirements, and nutritional and vitamin supplement recommendations. The comorbidities analyzed were hypertension (HTN), hyperlipidemia, diabetes mellitus (DM), gastroesophageal reflux disease (GERD), depression, and sleep apnea. The presence of each condition was defined as being documented in a physician consultation note. Improvement of DM was defined as fasting blood glucose less than or equal to 126 without medication. Improvement of HTN was defined as systolic blood pressure less than or equal to 140 without medication. Improvement of hyperlipidemia was defined as absence of medication. Improvement of sleep apnea was defined as normal sleep pattern without the use of continuous positive airway pressure (CPAP) machine. Routine postoperative polysomnography was not performed. All procedures were performed at a single institution using a similar technique for RYGB, as well as for LSG [19]. The standard criteria, as described by the Consensus Development Panel of the National Institutes of Health (NIH), were used to determine the eligibility for surgery [20]. All the adolescent patients undergoing RYGB or LSG were enrolled in an IRB-approved study.
Methods Following Institutional Review Board approval and HIPAA guidelines, we conducted a retrospective review of a prospectively collected database of all adolescent patients (ages 11– 19 years old) who underwent RYGB and LSG as a primary procedure at the Bariatric and Metabolic Institute in Cleveland Clinic Florida between 2002 and 2011. Only those patients who had completed 12 months follow-up at the time of the study were analyzed. Data collected from medical records included patient demographics, preoperative body mass index (BMI), initial weight, comorbid conditions, postoperative body mass index (BMI), postoperative weight, and postoperative complications. The subjects were also contacted by phone, adhering to HIPAA regulations, and were questioned upon current health and weight, symptoms and medications, whether they had to undergo a secondary bariatric procedure, surgical complications, and quality of life. Patients were selected for RYGB or LSG on the basis of the following: (1) patient’s preference, (2) high risk, (3) BMI >40 or >35 kg/m2 with an associated comorbidity, (4) failure to lose weight after participation in formal weight management program, (5) written informed consent, and (6) psychological evaluation to confirm motivation for surgery and commitment for compliance with follow-up visits and lifestyle and dietary
Results Eighteen adolescents had a bariatric procedure performed at our institution, from January 2002 to January 2011, inclusive of 13 females and 5 males (Table 1). Mean operative time was 85 min (range 65–170). All the operations were completed laparoscopically with no postoperative complications or mortality in this series. Preoperatively, the mean age was 17.5 years, the mean weight was 293.1 lbs, and the mean BMI was 47.2. The mean length of postoperative stay (LOS) was 3.1 days, and the mean follow-up period was 55.2 months. The mean postoperative weight at latest follow-up was 188.4 lbs, and the mean BMI was 30.1. Of the 18 patients, 15 (83 %) were available for a follow-up period of over 1 year (Table 2), 13 (72 %) patients available for over 2 years, 10 (56 %) patients available for over 3 years, 7 (39 %) patients were available for over 4 years, 6 (33 %) patients available for over 6 years, and 3 (17 %) patients available for over 7 years. Comorbidity resolution for patients is described as follows (Table 3): Of two patients diagnosed with HTN preoperatively, both cases reported resolved. Of six patients diagnosed with sleep apnea, three were lost to follow-up and the other three had their condition resolved. One patient with type 2 DM had resolution of his condition. For gastroesophageal
OBES SURG Table 1 Details of the 18 adolescent patients
Table 3 Comorbidity resolution
Preoperative Age Gender Weight BMI LOS
17.5 13 females, 5 males 293.1 47.2 3.1
Postoperative n Follow-up months Weight BMI
15 55.2 188.4 30.1
Preoperative comorbidity (n) Hypertension (2) Sleep apnea (6) Type 2 DM (1) GERD (4) Depression (4)
Follow-up 4.5 years All resolved 3 resolved, 3 lost to FU Resolved 3 of 4 resolved 3 of 4 resolveda
Asthma (1) Hypercholesterolemia (1)
No change Resolved
FU follow-up, GERD gastroesophageal reflux disease, DM diabetes mellitus a
One patient has depression, related to death in family
BMI body mass index, LOS length of stay
reflux disease (GERD), three of four patients reported the comorbidity resolved. For depression, three of four patients did not need medication, except one patient who assigns his depression to death of an immediate family member. One patient with hypercholesterolemia has his lipid profile currently within normal range, without the use of medication. One patient with asthma still requires medication. Summed together, of a total 16 comorbidities of patients available for followup, 13 (81 %) have been reported to be resolved. Questionnaire Results Of 18 patients, 11 (61 %) patients could be reached by phone for answering a questionnaire, involving several aspects of health and lifestyle. On average, patients reported a maximum weight loss of 147.5 lbs. Eight of the 11 patients had reported to regain weight, averaging 45.4 lbs. Of the eight, three females reported to regain weight during pregnancies. Two female patients (one RYGB, one LSG) had been pregnant twice, and one patient (RYGB) had been pregnant three times. All patients reported healthy newborns and a non-complicated pregnancy, except for one patient reporting cholelithiasis during her second pregnancy. The latter three women gained on average 55.0 lbs. Two of the eight patients, one female and one male, Table 2 Details of follow-up cohort Postoperative follow-up (years) >1 >2 >3 >4 >6 >7
LSG (n)
LRYGB (n)
Total (n)
9 8 6 5 4 1
6 5 4 2 2 2
15 13 10 7 6 3
LSG laparoscopic sleeve gastrectomy, LRYGB laparoscopic Roux-en-Y gastric bypass
regained 80 and 50 lbs., respectively. Both had a second bariatric procedure performed, in which their LSG was converted to a RYGB. The female patient had her LSG at the age of 17 and RYGB at age 24, and the male patient had his first bariatric procedure at the age of 12 and the second at the age of 17. The female patient currently weighs 179 lbs with a BMI of 33.8 and the male patient weighs 236 lbs with BMI of 41.8 kg/m2. The last three of eight patients regained on an average 22.7 lbs. Of 11 patients, three reported iron deficiency anemia, two of which were pregnant as reported above. Of the 11 patients answering the questionnaire, nine (82 %) are taking dietary supplements, such as vitamin D, vitamin B complex, iron, and calcium. For gastrointestinal (GI) symptoms, of 11 patients, one patient (LSG) complains of heartburn, and one patient (RYGB) describes nausea following overeating. One LSG female patient complains of diarrhea and occasional abdominal discomfort or pain. Ten (91 %) patients reported no complaints regarding difficulty swallowing, heartburn, or any other upper GI discomfort or motility dysfunction. None of the 11 patients reported currently having the following comorbidities: HTN, obstructive sleep apnea, DM, insulin resistance, or any kind of joint disease (osteoarthritis). Only one patient reported psychiatric illness, relating to depression mentioned above. This patient is prescribed trazadone and is the only patient to report smoking (1 PPD). One patient continues on asthma medication, and except for OCP, none of the patients receive any other medications. One female patient (LSG) had her gallbladder removed and another (LSG) reported cholelithiasis during her second pregnancy (as mentioned above). When asked for quality of life and satisfaction, patients reported on four different fields, ranging from 1 to 7, with 7 being the most satisfied. The results (Table 4) average 4.8 for physical activity, 5.9 for sexual activity, 5.8 for self-esteem, and 6.6 when ranking their social relationships satisfaction. The lowest average for all four indicators in a single patient is
OBES SURG Table 4 Lifestyle satisfaction Patient
Physical activity
Sexual activity
Self esteem
Social relationships
Average
1 2 3 4
7 4 5 4
7 7 5
7 7 5 6
7 7 6 6
7.00 6.25 5.75 5.25
5 6 7 8 9 10 11 (n=11)
1 6 4 5 7 3 7 4.82
4 6 5 5 7 6 7 5.90
2 7 5 6 7 5 7 5.82
7 6 7 6 7 6 7 6.55
3.50 6.25 5.25 5.50 7.00 5.00 7.00 Average
3.5 points. All other patients (10 of 11) reported an average of >5 points. As far as comparing RYGB patients with LSG patients (Table 5), we have found no statistically significant difference (p>0.05) for all preoperative and postoperative outcomes, including age, LOS, weight, BMI, maximum weight loss, or follow-up period. Data for two patients who converted from LSG to RYGB were deduced prior to the second bariatric procedure, where the follow-up period was 79 and 30 months for each.
Discussion No consensus exists regarding the definitive treatment for morbidly obese children and adolescents who failed nonsurgical multidisciplinary therapy regimes. In studying the RYGB versus behavioral pediatric weight management, Lawson and colleagues found a 37 % decrease in pediatric BMI with surgery compared to behaviorally
managed group; Inge and colleagues demonstrated that RYGB has been to shown to cause remission in type 2 diabetes in the pediatric population [21, 22]. Brethauer and colleagues’ literature review reported short and long-term outcomes of LSG, with excess weight loss averaging 55 % and the majority of patients experiencing improvement or resolution of comorbidities [23]. Laparoscopic sleeve gastrectomy has shown a complication rate ranging from 2 to 5 % in adults, with excess weight loss and a resolution of comorbid conditions in over 90 % of subjects over 12 months. Langer et al. refuted the theory that LSG may result in the long-term dilation of the remaining stomach in a follow-up of 20 months [24]. Varela et al. [25] have reviewed the University Health System Consortium (UHC) database in search of perioperative morbidity surrounding bariatric surgery in adolescents compared to the adult population. Adolescents were defined as patients
