BTK Pediatric Bariatrics Surgery Episode (Martin_Dan_Cironi)

Welcome everyone out in behind the knife world. This is Matt Martin with the bariatric surgery team for behind the knife. And this will be our first episode of 2025. We're going to be talking about a really interesting and important topic, pediatric and adolescent bariatric surgery. But let's start with introductions.

I'm Matt Martin. I'm a bariatric surgeon currently at university of Southern California. Yeah. Where we've also started a pediatric adolescent program at our children's hospital over the past year that I've been involved with so This is a topic that is now near and dear to my heart and back again with my wonderful partner as usual, Adrian.

And I'm Adrian Dan. I am first and foremost a bariatric surgeon. I am also program director of the Bariatric MIS and Foregut Surgery Fellowship at a place called Summa Health Northeast Ohio Medical University in Akron,

Ohio. And we also help out with the Akron Children's Hospital, where they have a wonderful adolescent bariatric surgical program that we've been a part of and helped to get going.

And it's also a topic that's near and dear to my heart. All right. And joining us for our first episode is our new resident. Who's a, one of our great surgery residents here with me at USC. Katie, you want to introduce yourself? Hey guys, my name is Katie Cerrone. I'm one of the general surgery residents at USC.

I'm excited to join the team. And you're interested in MIS and bariatrics? Very. All right. Why don't we get started? All right. To start things off. Let's briefly review some of the general indications for bariatric surgery in the pediatric population. Dr. Martin, do you mind breaking that down for us? Sure.

And there's, there's two good recent sources for this. The ASMBS has a specific set of guidelines for pediatric and

adolescent bariatric surgery. And they also came out with a more recent 2022 update to their overall guidelines. bariatric surgery guidelines. It also touches on pediatric patients. I generally think about it.

It's, it's very similar to our classic NIH criteria for adults. BMI of greater than 35 with a weight related comorbidity or a BMI greater than 40 is an indication. Of course, in kids, we often talk about their percentile on their height weight charts. So the corresponding numbers there are If they're greater than 120 percent of the 95th percentile for their height and weight, that corresponds to a BMI of 35.

So if they have that with a comorbidity, or if they have greater than 140 percent of the 95th percentile, that corresponds to class 3 obesity, and that is an indication in and of itself. Now, Dr. Dan, what are some of the comorbidities we often see in this pediatric population? Well,

Katie, there are a few major ones that we often see.

You know, the usual suspects that we see in adults, type 2 diabetes, hypertension, obstructive sleep apnea. But for the adolescent population, there are some broader ones that include Metabolic dysfunction associated fatty liver disease, MAFLD, idiopathic intracranial hypertension, which can lead to pseudo tumor cerebri, headaches, and all kinds of neurological and visual problems.

Orthopedic issues like slipped capital femoral epiphysis, we love to call it SCFI for short, and that's where the femoral head slips off the bone there. Blount's disease, tibia vera, which is an outbowing of the tibia that occurs due to the sheer amount of weight that the bones have to sustain prior to full maturity and development.

And also gastric reflux, even mental health factors, and by no means is that an exhaustive list. There's a

few other ones also. Right. So there are quite a few factors to consider in this population. Now with some of that background in mind, let's dive into our first paper. So for the first paper, we're talking about a study that discusses the five year outcomes of gastric bypass in adolescents as compared to the adult population.

So this was a retrospective observational study that uses data from the Teens Longitudinal Assessment of Bariatric Surgery Database, also called Teen Labs, and they compared this database To an adult labs database that they already had, and they use these two to compare the outcomes of adolescents and adults who underwent a route and why gastric bypass between 2006 and 2009.

Yeah. And teen labs data as well as the adult labs is a really valuable resource. And, and even though this is a retrospective review, these are both very well done prospective. data sets that were collected. So it's very good data.

And this was a longitudinal study that looks at the risks and benefits. of bariatric surgery for adolescents, and it's a multi institutional sample.

This particular study compared outcomes of adolescents with adults who experienced sustained obesity since childhood. And additionally, both groups were undergoing their first bariatric surgery, and this was at about the same time period. Yeah, it's important to note that this study focuses solely on gastric bypass.

That's what they had at the time when this was starting. When the sleeve wasn't really, Standardized operation, it was in its infancy, and there are other options today, such as the gastric sleeve. They're also available to both adolescents and adults. Right, so Dr. Dan, in your practice, do you find that gastric bypass is typically favored over the sleeve in adolescents, like these studies?

Not at all, Katie. According to the ASMBS guidelines that are based on the available literature, the sleeve is often the preferred

option for adolescents because it tends to provide weight loss results similar to gastric bypass, but with fewer problems and complications. There's better iron absorption, which is very important in this population, and similar improvements in comorbidities and sometimes better remission rates.

With that said, we will need more long term data comparing the various procedures, specifically in adolescents. Okay, great. So now let's dive into this study a little bit more. So for this first study, the authors looked at about 160 adolescents that range in age from 13 to 19. They all had a BMI over 35.

And then they compared this population with about 400 adults that ranged in age from 25 to 50. And all of these adults have been obese since their adolescence, like Dr. Martin had mentioned. Both groups were unadjusted with similar demographics, but the BMI was notably slightly higher on average in adolescence to be about a BMI of 54 compared to an adult BMI average of

51.

And they had a very good detailed data, as I mentioned earlier, they did both unadjusted analyses, but then they also did linear mixed and Poisson mixed models to analyze patient's weight and changes in their coexisting conditions and to adjust for some of those differences at baseline. Right. So one key finding that this study found was adolescents were significantly more likely to experience remission of their type 2 diabetes and hypertension as compared to adults, showing that possibly earlier we intervene, the better the outcomes.

Between both groups, about 60 to 75 percent of patients had a weight reduction of 20 percent or more at the five year mark. And then both groups had similar improvements in lipid profiles, both with reduced hypertriglyceridemia and higher HDL levels. Yeah, and that's actually not too surprising, particularly for the diabetes.

We know now probably the strongest predictor of the chance of remission of diabetes

is how long the patient has had diabetes. So obviously that'll tend to be a shorter duration. In kids than adults. So I just think that highlights why it's important to get them early, especially if we're talking about intervening for diabetes and similar findings for hypertension, where the kids had a significantly higher remission or resolution rate compared to the adults in this population.

Plus, the adolescents tend to be on fewer medications, have better baseline insulin function, like increased baseline C peptide levels. Exactly, but one thing to note in the study is that the rate of abdominal reoperations was higher in adolescents at about 20 percent versus 16 percent in adults, though it's worth mentioning that the study may be underpowered for a finding to be considered significant.

In addition, many more adults, Actually entered the study, having already had a colostomy, which was the most common reason for re intervention compared to the adolescent group. And the

threshold for diagnostic laparoscopy also have been a bit lower in the younger cohort. Right. It is interesting that the most common intra abdominal re operation in both groups over this five year period was a colostomy.

About a half of the patients who needed a re operation in this five year period had a colostomy. Dr. Dan, in your experience, do you ever consider doing a cholecystectomy during that initial bariatric surgery, especially considering that risk of cholelithiasis with rapid weight loss? That's a great question, Katie.

I don't like doing it at the same time, but many times we have to, and it still remains somewhat controversial. It's not a yes or no answer in my practice, I tend to perform a cholecystectomy if a patient has cosis and is undergoing a diversional procedure where ERCP is no longer an easy go-to option and has to be done either transgastric or retrograde trans juvenile, those are difficult things to do that your GI colleagues don't appreciate.

For the management of Chodo Cosis, of course, if anyone is symptomatic, I'll also do a cholecystectomy, but in some centers, a chole cystectomy is only performed if the cosis is symptomatic. Although the rate of cholecystectomy after gastric bypass is slightly higher compared to sleeve, the overall need for cholecystectomy in the first six months is relatively low.

Less than 5 percent and can be decreased and kept low and prevented with medication. As you all know, yeah, I think it's also important to note since, you know, I guess one of their findings that could be quote unquote scary was the higher reoperation rate. And as you mentioned, half of those were cold cystectomies.

The other half. We're small bowel obstruction or explorations for internal hernias, which since we've now shift to primarily sleeves and kids, those are much less of an issue. So I think you would not have this same finding in a series of

sleeve comparisons, pediatric patients versus adults. But it's also worth noting that at baseline, obese adults tend to have more comorbidities preoperatively compared to adolescents.

And this study showed that with 31 percent of the adults having diabetes prior to surgery, compared to only 14 percent of the adolescents. And while a third of the adolescents had hypertension, nearly two third of the adults in this study did as well. And they had a similar less need for medication in the pediatric sample.

So Adrian, to sum it up, what are your, what are your key take home points from this article? Well, to me, Matt, this article shows us that metabolic and bariatric surgery is safe, it's feasible, it's quite effective in the adolescent population, and likely, as is the case with the adults, very underutilized.

Teens tend to have weight loss that is quite similar to that of adults, and resolution of comorbidities and conditions that are associated with obesity that is actually quite better. As the diseases,

including type two diabetes, have not progressed as much. They've not had the time to progress as much as they have had in adults.

That's why there tends to be less relapse than in adults and improved remission rates. The ability to improve hemoglobin A1C and increase insulin sensitivity is also remarkable and likely to impart tremendous long term healthcare benefits and prevention of cardiometabolic diseases while improving the quality of life, but those things still need to be studied in longer periods of time.

Perfect. Now our next paper is the same kind of study, but it builds off the first study, and it discusses 10 year outcomes of bariatric surgery in only adolescents. This group uses the same teen labs database as well. That's right, this study focuses on 260 adolescents, they're 13 to 19 years in age. They underwent either gastric bypass or sleeve

gastrectomy.

161 had the bypass, 99 had the sleeve, about a 60 to 40 split, again favoring the gastric bypass. So this paper utilized propensity score adjusted linear and generalized mixed models to depict the outcomes. Honestly, after 10 years, the results were very impressive. For one, about 83 percent of their patients completed their post operative visit at 10 years.

Furthermore, between both surgery groups, the patients had an average of 20 percent reduction in BMI total. Also, more than half of patients who had diabetes, hypertension, and or dyslipidemia to start saw remission of these conditions. Thanks. Yeah. And those are particularly striking findings. Right. And, and I think this highlights the, the story of metabolic and bariatric surgery should be told in terms of decades.

Especially for pediatric patients and not months to a few years, which unfortunately is the majority of the literature we get just

because of the difficulty of having long term follow up like this. So, so this was a major publication looking at this and long term tenure outcomes. But of course, it's important to note the relatively small sample size here at 260 patients.

So we have to keep that in mind when weighing the outcomes. Yeah, small sample size. These are tough studies to do, and I agree, Matt, that it underscores the durability of the operations. Another important point to mention is that these studies are observational, so there's no comparison to the best available medical management.

Hopefully we'll have that in the future, as with the advent of newer weight loss drugs such as the GLP 1s, we're seeing a need to study medical management versus therapy. Early studies on GLP1s show promise for weight loss, and as more studies are published, we'll have a better understanding of the role of these various treatment modalities and how we can use them together.

Yeah, and I think it's also going to be important, as again,

remember the teen labs is relatively old. As evidenced by how many gastric bypasses they performed in comparison in the past year of the program at Children's Hospital We've done one bypass and everyone else has had a sleeve and I'm guessing it's similar at your pediatric program Adrian, yes, it's it's mostly sleeve gastrectomies.

We started Fairly recently, about four or five years ago, it's been mostly sleeves and at the Children's Hospital there, they always say, you know, if we need you to do a bypass, you can get emergency privileges in five minutes and we'll have you come out and help us out if the, if the need arises. Going back to GLP 1s and similar medications, now it's definitely a growing area of interest.

For now, the studies discussed show that bariatric surgery is effective, it's safe, it's highly beneficial compared to untreated obesity, especially in terms of the long term improvements in comorbidities like diabetes, hypertension,

dyslipidemias, and what this can mean to these patients over the long term is yet to be determined.

But it's likely to be tremendous. Like you said, man, the success and the outcomes of bariatric surgery should be measured in decades. Yeah, and I think it's important to not only think of it as a GLP 1 versus surgery, but certainly a lot of emerging data about the synergistic effects of integrating GLP 1s preoperatively and postoperatively.

And I think that'll be particularly striking in the pediatric patients. You bet. I mean, what's the take home point from this article from your standpoint? How do you summarize it for our listeners? Well, like I said, and this is a very short read if anyone wants to pull it up in the New England Journal.

It's a couple page correspondence. I think the big key points are. 10 year data, especially in adolescents, is rare, and this shows significant durability of the procedures. It's also interesting that it shows very similar results

between the bypass and sleeve cohorts. So, you know, there were some concerns that the sleeve would be significantly inferior, but at least in this patient population, it appears to have similar outcomes.

Although, they did actually show, they divided up and they showed four different trajectory patterns. of weight loss and some weight regain, and there still is a small cohort. Of these patients that did not achieve significant weight loss or had significant weight regain. And that will again be the challenge I think we're facing as we do this more in pediatric patients of they, they have had a suboptimal outcome and what do you do next?

And if I may, Matt, I think that brings up a very important point is, in my opinion, another area where the sleeve is beneficial is that there is a lot more you can do than with a bypass. So, the patient is a non responder to operations that seem to have bypassed. Very similar metabolic impact in, in the,

in the adolescent population.

The sleeve leaves you a lot more options for a more powerful metabolic malabsorptive procedure that you can do down the road than the gastric bypass does. Agreed. Alright, so now shifting gears a little bit, this next paper discusses an ethical framework that we can use when evaluating patients, specifically adolescent patients, before offering bariatric surgery.

It explores some of the big questions we need to ask ourselves as providers when considering surgery for these younger patients. Yeah, and and even though it's it's not a paper looking at we did the surgery and had this weight loss I think of the three this is probably the most important of the papers to read if you're gonna dip your toes in the waters of pediatric and analysts and bariatric surgery because you run into a lot of these ethical and challenging issues that maybe you haven't given a whole lot of thought to doing adult bariatric surgery.

So this paper discusses four main ethical questions that are crucial in some of these scenarios. And these were number one, should any patient be automatically excluded from bariatric surgery consideration? Two, how do we determine if the benefits outweigh the risks? Three, how do we ensure that the patient fully understands and is capable of cooperating with the surgery and follow up care?

And four, how do we make sure the decision to have surgery is truly voluntary and not coerced by family members or other caregivers? Gosh, this adds a whole different level of complexity in this patient population. These are incredibly important questions, especially when you're talking about adolescence.

They're still developing their sense of self, their decision making capabilities. The paper also gets into an interesting discussion about when it's more appropriate to involve the parents versus the adolescent patient alone on making the final decision, particularly if the patient is

cognitive, intellectual, and developmental disabilities, which, as you all know, can be associated with many of the monogenetic and the syndromic causes of childhood obesity.

Yeah, and calling back to our original discussion about indications in this patient population. One of the things we didn't mention is that there used to be a practice of you should only do this in order adolescence or you need it or you should wait for bone density development or Tanner stage or post puberty.

And those guidelines have essentially gone away. They should not be used to exclude patients for surgery, which means we're looking at doing this in younger and younger patients. So the ASMBS guidelines also make it clear that adolescents with cognitive disabilities or mental challenges should not automatically be excluded from surgery.

But it's particularly critical in these patients. that

they're able to adhere to dietary and medical requirements post operatively, and if they're unable to meet these, then surgery may not be appropriate or safe. Yeah, and mentioning the older adolescents, there's actually a subgroup analysis, one paper by the same group that did teen labs that shows that younger teens do just as well as older teens in terms of weight loss.

But exactly as you mentioned, it's all about the patient's ability to understand and follow through the treatment plan while making sure that we're not excluding those with more limited decision making capabilities. But now let's dive into a couple of cases that highlight how this framework can be useful in actual practice.

Katie. Perfect. So the first case they discussed is a 17 year old male with a BMI of 42 and a history of autism spectrum disorder, pre diabetes, depression, behavioral challenges, hypertension, and dyslipidemia. At school, he reads at a 4th grade level. And then at

home, unfortunately, his mom struggles with food insecurity, which makes it hard for her to manage his diet at home.

So Dr. Martin, do we operate? What are some of the considerations we should think of when evaluating this patient? Yeah, and I think going back to that framework we talked about with those four questions, the first one is, should this patient be excluded? And I think the easy answer there is no. In fact, in my mind, nobody should be excluded from at least evaluation, right?

And you take these on a case by case basis. But this is a tough case because there's consent and understanding issues. There's socioeconomic issues. So these cases, even much more than in adults, require a multidisciplinary approach. which involves the parents, the patient, the bariatric surgery team, the pediatric team, a pediatric psychologist, and often an ethics team for some of these really difficult questions.

In this case, one of the things they did was interview the patient

and his mother separately, and then together to assess if the patient understood what the surgery would involve, and also to see if the patient truly wanted the operation. Right, this can get very complex. Everybody's entitled to an evaluation, but when they're excluded from surgery, sometimes for the right reason, it can get very, very difficult to, to get everybody on the same page.

You really have to get a sense of whether the patient can form their own independent decision and understand the risks and benefits of the operation. You also need to ensure that the parents or guardians are fully supportive and capable of helping the adolescent patient through the entire process, the pre operative preparation, the perioperative phase, and of course, the long term post operative period.

As Matt mentioned, psychologists will often conduct interviews of the patient and the parents separately to ensure that there's no evidence of coercion and that the patient has some kind of autonomous motivation to undergo the surgery, as well as willingness

to follow the recommendations. Yeah, exactly.

And if necessary, it's a great idea to try to bring in some additional support for the immediate family. to help with care, especially in cases like this, where the family is already facing some financial challenges, has food insecurity issues. If they can bring in additional assets like trusted friends or family members who can help with the post operative care.

That will always tip the scale in favor of a better outcome. Right. Great points, especially on bringing a multidisciplinary team, both medically and socially, to provide full support to these adolescent patients. For this case, the child was able to show an independent desire for surgery when interviewed separately from his family, and the family found additional support systems from their extended family, so the surgical team did end up moving forward with operating.

Yeah, and I'll make two quick

comments, and maybe Adrian, you can chime in too. So one is, although they use an ethics consult, an ethics consult still should be relatively uncommon. Most of this doesn't require an ethics team, and the other Misconception is that you're calling in the ethics team to make the decision.

They're just there to offer advice. This should really be reserved for particularly difficult cases, maybe where your team has disagreements. Most of these cases, though, can be resolved within your team. multidisciplinary team. The other issue here is, you know, can this patient truly consent? And I think what we talk about now in pediatric and adolescence is you want to have consent of the parent or legal guardian, but also assent of the patient.

So they at least agree to the surgery. And that's been a hard line in the sand for me. In our pediatric program of we've had several kids who they say they do not want the surgery. They're scared

and their parents are dead set on. And I just I will not operate on a kid who understands it and will not give a cent.

I agree with all that, Matt, and I also want to add that it can get also complicated when one parent wishes to have the surgery while the other parent is opposed. Really difficult situations and something that we don't have to deal with to the same degree with the adult population. All right, well, moving on to the next case.

This was an 8 year old female with a history of obstructive sleep apnea. Ann Skiffy. The slipped capital femoral epiphysis that we never see in adults, fortunately. So this patient was referred for bariatric surgery by her parents. And in this scenario, the mom had actually had a prior sleeve gastrectomy, which is very common in this patient population.

We see this all the time. Now, here we're dealing with an eight year old, so that can be a lot more controversial. And according to the ASMBS guidelines, adolescent is defined

as 10 to 19 years old, but they report younger patients can and should still be considered for surgery if they meet the criteria and if the benefits outweigh the risks.

Yeah, especially with some syndromic obesity. In this particular case, it's really important to make sure that all non surgical options were explored and that they were unsuccessful prior to jumping into surgery. For example, was the patient part of a structured weight management program? In the world of pediatric weight management, there's actually tier systems that are defined based upon the resources that are available, including physician support, dieticians, counseling, and of course Metabolic and bariatric surgery for the highest tiers.

Plus we have to assess whether the child is capable of understanding the decision, especially at such a young age. Yeah, right. And in this case, the team did a thorough assessment as they should. They had a pediatric psychologist who again interviewed the

child alone, and then the mother or father alone, and then the family together.

And they really wanted to make sure the child at least understood what undergoing surgery meant and whether it was truly her decision to move forward. Right. So for this case, the younger girl was a little bit more reluctant to undergo surgery. So the team ended up choosing more conservative treatment measures.

And her reluctance to undergo surgery really outweighed the medical necessity, at least at this time, for her to have surgery. Yeah, and obviously it's always a balance. The model they provide in this paper is, is a great guide, but it's not without its limitations. For example, not every bariatric center has access to a pediatric psychologist or a pediatric specific ethics team.

Especially if you're at a at an adult center that is doing adolescent bariatric surgery which can make these cases more challenging to navigate. And of course there can be some bias when

it's a surgery team deciding whether or not to consult an ethics team, but hopefully in most cases it's not necessarily needed.

Overall, this framework discussed in this paper provides some valuable bariatric surgery should be considered for our adolescent patients. So, what's the main takeaway for our listeners, Katie? So, some of the big takeaways that our ASMBS guidelines give us a lot of good direction on who qualifies for surgery, and they emphasize some of the importance of interdisciplinary approach to decision making.

The decision to pursue surgery should always weigh the benefits and risks and should always be made collaboratively with the patient, family, and care team combined. Absolutely, and I want to thank you all a lot for diving into this with us today. It's a really important topic. It's clear that bariatric surgery can be an incredibly beneficial option for pediatric and adolescent patients who have a lot of years of life left

to live and that can be done without obesity related comorbidities with the right planning and support system in place.

Yes, and metabolic plasticity, ability to go into remission for many conditions. Definitely, we're going to see more pediatric and adolescent bariatric surgery in the future. We'll see more studies comparing the outcomes of surgery to GLP 1s and best medical therapy. And we'll find out when surgery or medicine is the right choice for the right patient.

It could truly be life changing. All right. And with that, we want to thank everyone again for listening. for listening. And tuning into this episode of the bariatric team behind the knife. We hope you all enjoyed the discussion until next time. And, and as always, we will end it with our usual. All right.

That's the best we can do.