Dr Sunita Goel
Consultant Anesthesiologist
Mumbai
Obesity is reaching epidemic proportions in the pediatric and adolescent populations. The prevalence of adolescent obesity has tripled over the last 3 decades, and the consequences of pediatric and adolescent obesity are becoming clearer. Aside from the fact that obese adolescents have a substantial risk of becoming obese adults, they also have an increased risk of co-morbidities commonly associated with adult-onset obesity including hypertension, hyperlipidemia and glucose intolerance. Additionally, obese children and adolescents experience significant psychosocial consequences. There is little evidence that dietary or pharmacologic treatments will effectively reverse morbid obesity in adolescence. Because of this epidemic, adolescents are increasingly seeking bariatric surgery as a realistic and effective treatment for their morbid obesity
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Patient Evaluation |
Body mass index BMI (weight in kilograms divided by the height in meter squared) is a useful screening tool for assessing and tracking the degree of obesity among adolescence. Medical evaluation should include investigations into causes of obesity that may be amenable to treatment and identification of any obesity related health complications.
The most important ethical issues when considering an adolescent for a bariatric procedure are whether the patients health is being compromised by severe obesity, whether the patient has failed more conservative options to meet that health need and whether the patient has decisional capacity.
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Criteria for bariatric surgery |
- Has failed > 6 months of available, organized attempts at weight management.
- Has attained or nearly attained physiologic maturity.
- Severely obese BMI>40kg/m2 with severe obesity related co-morbidities or BMI>50kg/m2 with less severe co-morbidities.
- Avoid pregnancy for atleast 1-year post surgery.
- Capable and willing to adhere to nutritional guidelines.
- Informed consent to surgical treatment.
- Decisional capacity.
- Supportive family environment
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Surgical treatment |
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Optimal timing
Neuroendocrine, skeletal and psychosocial maturation are accelerated during adolescence. The rapid somatic growth observed in early adolescence requires adequate nutrition. Therefore, bariatric procedures performed before the growth spurt could potentially compromise linear growth.
Physical examination should include evaluations of sexual maturation. Overweight children experience an early onset of puberty and are likely to achieve skeletal maturity earlier in adolescence compared with age matched non-over weight children.
If an individual has attained > 95% of adult stature then there is little concern that a bariatric procedure may significantly impair completion of linear growth.
Informed Consent
Should be obtained from the adolescent patient. Although bariatric procedures can result in substantial weight loss, the long term metabolic, nutritional and psychosocial effects among adolescents are unknown.
Laboratory and radiologic examinations
- Fasting Glucose
- HbA1C Measurements
- Liver Function Tests
- Lipid Profile Tests
- Complete Blood Count
- Thyroid Function Test
- Pregnancy Test for Female Patients
- Surgery for micronutrients deficiency
- Polysomnography for Sleep apnea
- Bone Age assessment for skeletal maturity
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Choice of procedure |
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Adjustable Gastric Banding (AGB): AGB consists of Laparoscopic placement of a silicone band that encircles the most proximal stomach, just beyond the gastro esophageal junction. The band is adjustable with injection of saline into a peripherally placed reservoir. The band is removable if necessary. Major advantage of AGB includes the ease and safety of minimally invasive placement, adjustability and reduced potential for adverse nutritional consequences.
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Roux-en-y- Gastric Bypass
Gastric Bypass currently seems to be the most approved surgical option for most adolescents who are candidates for bariatric surgeries.
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Post- Operative concerns |
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Patients must adhere to guidelines regarding diet and vitamin/ mineral supplementation.
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Gastric Bypass results in significantly enforced very low caloric, low carbohydrate dietary intake, requiring attention to adequate (0.5gm/kg) daily protein intake.
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Micronutrients, including calcium, Vit B12, folate, multivitamins thiamine and iron must be supplemented after gastric bypass.
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NSAID’s medication should be avoided, to reduce the risk of intestinal ulceration and bleeding.
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Pregnancies can be safely supported after bariatric surgery, reliable contraception should be used for atleast 1st year after the operatio
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Long Term follow up
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Meticulous, life long, medical supervision of adolescent patients who undergo bariatric surgery is essential. Early hematologic or metabolic complications can be detected with periodic assessments of blood counts, blood chemistry profile and body composition.
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Side Effects
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Compromise linear growth
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Early Complications: Wound Infections
Pulmonary Embolism
Stomal Stenosis dilatation)
Dehydration
Ulcers
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Late Complications:
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Gastric Bypass
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Intestinal Leak
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Thromboembolic Disease
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Small bowel Obstruction
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Incisional hernia
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Symptomatic cholelithiasis
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Protein Caloric Malnutrition
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Micro Nutrient Deficiency- Iron, calcium and Vit B12
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Much Later Complications:
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AGB related Complications
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Port Malposition/ Malfunction
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Tubing Leaks
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Band Slippage leading to gastric prolapse
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Foreign body infection
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Band erosion into stomach or esophagus
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Last created on 23-02-2001
Last updated on 01-11-2005
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How to cite this url |
Goel S.Bariatric Surgery For The Adolescence.Pediatric Oncall [serial online] 2005 [cited 2005 November 1];2. Available from:
http://www.pediatriconcall.com/fordoctor/diseasesandcondition/
PEDIATRIC_ANAESTHESIA/bariatric_surgery.asp
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