Bariatric Surgery in the Pediatric Patient

Stay Current is a multimedia publication designed to keep healthcare professionals up to date with standards of care and new emerging ideas. This chapter is created and edited by Todd Ponsky, Sophia Abdulhai, Abdulruf Lamoshi, and Rajavendra Rao and is recorded and produced at Akron Children's Hospital in Akron, Ohio. Welcome to State Current in Pediatric Surgery. This is Todd Ponske recording from Akron Children's Hospital, and today we are going to be talking about bariatric surgery. This is something that has recently become very popular and more common in the pediatric world, and more and more we find that this is something that we need to know about in pediatric surgery. And with us today we have two real experts in the field, and this is a unique podcast that we actually have two experts. Talking to us. And so first I'd like to introduce Dr. Thomas Inge. Dr. Inge is the Acres Endowed Chair in Pediatric Surgery, Director of Division of Pediatric Surgery, director of adolescent metabolic and bariatric Surgery at Children's Hospital of Colorado. Tom, thanks for joining us. Hey Todd, thanks for having me. It's our other co-expert, Dr. Mack Harmon. Dr. Harmon is the professor of surgery at the University of Buffalo SUNY and surgeon in chief at the. Children's Hospital. Mack, thanks for joining us. Thanks, Todd. Well, let's, let's dive right into this topic. I have to tell you I'm very eager to hear a lot about this because this is something that I am not so familiar with. So Mack, why are we seeing a need for weight loss surgery in teenagers in 2017? Well, the problem is with the increasing prevalence of obesity in children, we're seeing more and more complications of the obesity. Comorbidities related to childhood obesity. So you may recall that in the old days it was called adult onset diabetes, but now we're seeing type 2 diabetes in children and teenagers as complications of obesity, along with obstructive sleep apnea and hypertension and dyslipidemias and cardiovascular risk factors. So the consideration really is driven by these medical problems that we used to not. See in children very much at all. Yeah, so Mac, I agree entirely. The other thing too we're seeing is, is really this emergence of a great deal of literature showing us the benefits of bariatric surgery in adults. And so, in part, you know, these parents that are getting surgery or, you know, pediatricians are reading the literature are asking, well, what are we going to do about the adolescents that are developing these similar problems? Do we think surgery will have similarly good Results and improve health and improve the weight of teenagers, and I think that that's driving this as well. And just to follow up, I'll say that in my practice, about half of the teenagers that present interested in bariatric surgery have had a parent who've had weight loss surgery. Oh, that's interesting and not surprising though. So Tom, let me ask you, we're surgeons and so we think about surgery, but what is the effectiveness of not Non-operative therapy for obesity. Sure, so you know we certainly don't recommend weight loss surgery as the first option for treating obesity. In fact, we do believe that some patients, you know, some patients, particularly with the lower age groups, preteens, those that maybe only have 20 or 30 pounds to lose, probably are going to be best served by non-operative. Weight loss measures, but you know when you get to talking about teenagers in particular, and it's it's really kind of interesting to see the rate of success with non-operative weight loss falls dramatically and linearly when you're talking about going from, you know, 6 years old to 10 years old to 14, you know, 16 years old, it just plummets, the successfulness of lifestyle interventions. Couple that also with it falling dramatically. As you get into these upper weight classes, if you will, when you start getting into really the severely obese range, you know, a teenager in particular might have a 1% chance of losing any major amount of weight with non-operative measures, and so that kind of taints one's opinion about how much you should focus on lifestyle interventions for teenagers with severe obesity and why you really need to be starting to think about surgery pretty early in this process. So Matt, do you have any comments about that? The lifestyle management research really has declared success when a patient may lose 5 to 10% of their total body weight, and I would agree with that. However, in our bariatric surgery teenage cohort, we're seeing weight losses, at least at the, at the 345 year mark of about 30%, which is much more significant. And successful. So I actually have a question that you may not have an answer for. When you look at the measures like diet or exercise or lifestyle interventions, which of those are more effective? Is it the diet? Is it the exercise, or is it hard to tell? Yes, so it's pretty well established that to really lose weight, you have to really take in less in the way of calories. Most people would agree that, you know, exercise and really, you know, paying attention to physical activity, which, you know, ostensibly burns calories, it really is not a good mechanism for weight loss, but rather maintaining that weight loss once it's been achieved. I think that the best non-surgical methods for weight loss today are any number of drugs now that are on the market that weren't on the market. Just, you know, a half dozen years ago. And so when you're talking about, you know, the best way to get in front of a weight problem, it's surgery for sure, but non-operatively, it would be, you know, and it's actually gratifying to see more drugs that are coming on the market as well. But for weight loss, it's, it's definitely caloric restriction. For weight loss maintenance, it's going to be exercise and some form of drug therapy. So regarding those drugs, are any of those drugs that are for the adults, can you give those to the children? Do they work? Very good question, Todd. I mean, as you know, in pediatrics we we have this unique situation of having patients to take care of that have really significant diseases and not a lot of drugs that are actually labeled for pediatrics, but we use them anyway, and that's really much the same. When it comes to drugs, we really only have one on the market now that's Orlistat that gives you greasy stools and really only about a 2% weight loss. So that is the reality. The other drugs that are approved for adults certainly do work in teenagers, and we use them routinely, things like topiramate and phentermine that affect our Appetite and satiety pathways in teenagers very much the same or identical ways as they do in adults. Matt, do you have any comments on that? That sums it up nicely. OK, so we've talked about all these non-operative measures. How do you know when it's time or reasonable to operate on these patients? Well, this has been another point of great debate and controversy. Todd. Tom and I have been discussing this since. Oh, at least 2003, 2004, and early on felt that perhaps with adolescents we needed to be cautious and set the bar fairly high and choose an age where the patients were physiologically mature, so that may be 1415, the bottom end, to make sure weight loss surgery didn't harm further development. And so in the United States, most of us in this business have limited the operation. To teenagers, the youngest patient I've operated on is 13. However, this has been an area of controversy, and Tom and I have a close friend and colleague in Saudi Arabia who's done weight loss surgery on kids down to at least 6 or 7 and has reported good long-term results. And there are always some exceptions to the rules, so to speak. So currently, most of the surgeons would recommend teenage years, and most of the time we recommend that we're treating a comorbidity and not just The weight itself. So Tom, do you have any thoughts on that? I do. I think that, you know, certainly we have this time-honored tradition of really putting the comorbidities up there as the prime reason why, why we're operating, and I think that that is, you know, done for good reason. You know, we really do want to make an impact that's long lasting. We want to prevent comorbidities from developing, and I think surgery does that, say, in the adolescent. That has a slightly elevated blood sugar. It is not a diabetic yet. I think surgery absolutely has a role in prevention of diabetes when when that kiddo would would go on to develop diabetes. But certainly, you know, we face, you know, life in the real world where insurance companies really do play a strong role in partnering with us to get kids healthier and sometimes, you know, being more conservative. So the guidelines for use. Of surgery really do, I think, take into account what's reasonable given these facts, the fact that these operations do have risks, you know, risks of major complications of general surgery. I think we do want to have a, you know, a very real health benefit in mind that is here and now in addition to this health benefit later on and quite honestly from the adult studies, a longevity benefit for having undergone surgery for morbid obesity or severe obesity. So Tom, let me ask you, when do you start seeing these patients? How do they decide? Is it when they think they're a candidate for surgery, or do they send them to you earlier than that and you follow them for a while before? And then once you see the patient, what is the usual process that they have to go through before you'd be willing to operate on them? Sure, so just to kind of take it in order, you know, they come in through a variety of different doors, as Mac alluded to earlier, some of them come in, you know, because a successful bariatric parent of theirs, that is, you know, mom had bariatric surgery, lost 100, 125 pounds, and realizes that this may be a good choice for, you know, the 16-year-old son or daughter that has a similar. Weight problem. So some of them are self-referred and then have a pediatrician, for instance, that is in agreement, and they get them in to see us. Some of them are kids with diabetes that are being managed by a switched on endocrinologist that realizes, you know, surgery will reverse this diabetes, you know, 90% of the time, and the drug therapy, you know, may reverse. At 5% of the time, so these patients certainly both have come to see us. In terms of the process, we see that again, most of the plans that cover bariatric surgery do require a six month period of what's termed medically supervised weight loss, and you know we don't have any real weight loss demands that we put on patients during that period. We figure, you know, they Generally demanded weight loss of themselves and their parents have for sometimes a lot of years before they come to see us and so we think it's reasonable to encourage them to lose weight during that period while we are, you know, putting them through surgery school, meaning, you know, we teach them what surgery is all about, we teach them what nutrition is all about, and we make sure that they enter into this decision to undergo surgery. You know, not coerced by, you know, a family member, but because they truly understand the meaning of of what this is from a risk standpoint. They understand how surgery is going to benefit them from the research that we can show them, and we feel like we have a much better patient in a much better position to be successful with the surgery and partnering with us and really knowing what this is all about. So Mac, you know, a lot of people listening here may be considering starting a bariatric program on their own. Before we get into how they would learn the technical part of surgery, can you describe your multidisciplinary team that sees these patients? Who else other than the surgeon is involved in working these patients up and taking care of them? Yeah, so there are a couple of different models, I think, Todd. I'm not sure that Tom and I have the same model, both in Alabama when I was there and now in Buffalo. I've used a model where the surgical patients are embedded in the larger obesity program that includes the behavior modification, lifestyle modification piece. So, all of the patients come to the same clinic. And so I get to start getting to know the patients very early, and a patient may be in the, in the medical. Program for 3 years before they decide they want to consider surgery, and I've actually had a chance to meet the families and meet the kids early on. And so in our program, we have the medical directors, a pediatric endocrinologist. We have a pediatric gastroenterologist embedded in the program. We have 2 pediatric psychologists, we have 2 exercise physiologists and 2 nutritionists, and a patient comes into our program and is seen by all those people every time. And if they're Interested in surgery, they're seen by me. So the process may be a little different, but I agree with Tom. Not only do the insurance companies oftentimes demand the 6 month trial, I think it takes us 6 months or so to really get to know the families, for them to get to know us and the team. And post op, I have the patients followed up by that same group of people very, very closely to ensure the best results. That's great. And Tom, is there any major differences that you have at your place? No, in fact, you know, this multidisciplinary team is, is a point that we highlight because I think that is the best way to take care of patients, to have experts that can help with a lot of the complexities that these kids present with right here either on the team or nearby and cooperating and collaborating with the team. I'd like to add one more thing about the timing of surgery. Early on, for fear of complications in these teenagers, again, like I said, we set the bar high, but Tom in particular noticed that whether your BMI started out at 40 at the time of surgery or 60 or 70 or 80, in the first year or so, you lose about 30% of your weight. So we, we learned that we didn't really want the kids to delay and get to 60 or. 70 because they were still going to lose 30% of the weight versus an earlier time point. So I'd be interested in Tom's comments, but certainly over the years I've pushed the surgery up rather than deferring for more complications. Tom, right, and I, I, I do think that that's an important concept to bring up, Mac. I mean, it's so true that, you know, we are attempting to turn back the hands of time in a sense. With the surgery and get them back to a healthy weight, but the sad reality is that, you know, if you have, you know, gotten to 600 pounds, you know, getting back to 400 pounds is a, is a major improvement, but that's still quite a burden to bear for many more decades to come, you know, starting at 300 pounds and getting down to 200 is really where we want to be, and I think that, you know, when it comes to Our joints when it comes to, you know, quality of life, when it comes to, you know, risk of more disease in the future, and you know, having achieved that healthier weight that represents 33% less weight is, is what we'd like to do. So I do agree that, you know, starting this process, exploring surgical options earlier in this weight gain makes a lot more sense. Great. And just a question, do you You know about how many patients that enter into these bariatric multidisciplinary centers, how many of them end up moving on to surgery? Do you have any idea? I mean, is it a small percentage? Is it a minority? Is it a majority? Yeah, I'd say it's a majority of patients that come to us that are trying to get through the program and do get through the program. You know, the reality is, and Todd, this may be going too deep into the weeds, you know, but the reality. Is that most of the patients that need surgery probably don't have that as a covered benefit on their insurance plan, and that's, that's kind of an artifact of our, of our system here that a lot of countries don't have, where, you know, the services are more need-based. Here, you may need a gastric bypass or a sleeve gastrectomy, and your insurance company says, yes, we agree with you, that is certainly indicated medically, but the policy. Doesn't permit it, it's an exclusion, and you need a policy that permits it. So it's kind of hard to say, you know, how many, but when I say that most of them get the surgery, I think we can prepare most of the patients that come to see us for these procedures, but we only see those that have insurance benefits for surgery because it's, it's a real problem for some that need surgery, but yet it's not going to happen because Don't have insurance coverage. The other point on that topic is that when they do actually come to us, don't have benefits, there are certainly ways that we advocate for them, and we, we do press hard for, you know, those that the insurance company is pushing back a bit, but it's not an absolute exclusion, and I think that that is a major role that we play in advocating for the patients that truly need these services. So Tom, you've talked about the indications for surgery, but are there teens that you might see that meet criteria but should not undergo surgery? So that's a, that's an interesting question. I think that there are teens that we see that have absolutely ironclad, you know, indications for surgery and who present with, you know, a very chaotic life. They present with other, you know, existing medical problems that may or may not be weight related, that are not in control. Some of them, you know, come to us with untreated. Psychiatric illness, untreated and sometimes undiagnosed. So I absolutely think that these are the things that make the multidisciplinary team a necessity because you know we really do want to do everything in our power to take the patients to surgery that have the greatest opportunity for success and benefit from that surgery, and the lowest risk point of, you know, they're just not ready for this. Type of intervention in their lives right now. Our obligation, of course, is to get those patients ready for surgery and use, you know, the full resources of the team and of the hospital to say, you know, what can we do to prepare you for surgery, and if this is not right, you know, now, you know, what are the steps to take that we need to help this family through to get them ready for surgery. So Really do appreciate that question, Todd. Great. And Matt, do you have any comments about that? The other group that I think is challenging for us is the syndromic obesity group or the monogenic obesity group, where they have a mutation and a single gene that really is driving the out of control appetite. There are case reports about successes and failures with weight loss surgery in that group that is about. 6 to 7% of severely obese kids by the age of 10 fall into that category, and I think we still are trying to figure out how surgery might play a role or not in that group. Great. All right, Mac, we've been talking about bariatric surgery, but can you school us up exactly what that means? What are the different operations available, and what are the ones that we do for which, which patients? So the gastric bypass, Roin Yi gastric bypass is what has been around the longest in the adult world, and it's what we know the most about in adults and I would say teenagers at this point. I will say that when the adjustable gastric band. Came on the scene. A lot of the pediatrics community thought that that would be a good option for children. They had the notion that we would put this band in, they would lose weight, and we'd take it out and everything would be OK. That option has not turned out to be so successful in teenagers or adults for that matter, with a high reoperation rate. And so in my view, that is not on the menu to a large degree these days. And then more recently, the vertical. Sleeve gastrectomy, originally designed to help super, super obese initially so they could then have a gastric bypass, has now been shown in adults and in our teenagers, at least at the 34 year mark to do a good job of initial weight loss as well as resolution of comorbidity. So I'm interested in Todd's comments, but my impression is that for the most part, currently adolescents are being offered sleeve gastrectomy as a first line choice. That certainly has been what I've done in Buffalo, unlike my initial experience in Alabama where I did gastric bypass. Tom, yeah, and I, I certainly echo that. In fact, I was part of a Pkori project. The Pkori bariatric Project had adult and adolescent aims, and you know, we showed with, you know, 500 cases over the last several years that the prevalent use. Of sleeve gastrectomy has just continued to climb. I think the last year that the data set included was 2015 in that and in 2015, sleeve gastrectomies were done about 80% of the time in teenagers with the numbers of of gastric bypasses, about 20% and really virtually no bands being done in teenagers. So, you know, I think that this is a sleeve bypass. Type of sport right now and we are seeing the benefits and charting the benefits for the sleeve gastrectomy in our patients and we're seeing very, very comparable results with these two operations. Does the size of the patient or any other factors lean you towards doing a gastric bypass? I'd say so. You know, the big driver for me for bypass these days is what Mac alluded to, which is the special form. Of obesity, you know, these are patients that are rarely taken care of at all in adult years, even though they exist as adults, but they're more complicated than most adult bariatric surgeons, you know, want to get into. And these are the patients that have had a brain tumor, for instance, and that's left them with, you know, pan hypopituitarism where, you know, they're on hydrocortisone, they're on thyroid hormone, they're on, you know, DDAVP for diabetes insipiditus. And you know, rightfully so, you know, adding on to patients of this medical complexity, a bariatric procedure, perioperative care, as well as postoperative care beyond the perioperative period is a bit more complicated. So I think this is the patient group too though, where sleeve gastrectomy and banding has not shown us as good weight loss results, and the bypass has been what I consider, you know. A more high potency operation for this group of patients, whereas you know the patients with your, shall we say just exogenous obesity are patients that don't have this biologically driven obesity seem to be served quite well with a sleeve gastrectomy or a gastric bypass, and most of us believe that, you know, theoretical risks as well as measured risks of sleeve seem to be lower than gastric bypass in teenagers and adults. Mac, can you take us through the basic steps of what is a sleeve gastrectomy and what is a Rou Yi gastric bypass? Sure, so first of all, let me say that both of the operations we're talking about are done laparoscopically and are successful that way most of the time. A sleeve gastrectomy operation starts with retracting the left lateral segment of the liver up so you can examine the entire surface of the stomach. In the adult world, hiatal hernias are fairly. Prevalent and so there's an effort to look and see if there's a hiatal hernia that may be something you want to fix at the time of the sleeve gastrectomy. And then typically most surgeons measure back from the pylorus 4 to 6 centimeters and start taking the greater omentum off the greater curvature of the stomach, and they continue that dissection all the way up the greater curvature and across the short gastrics and all the way up to the diaphragm to free up the stomach from the omentum. And attachments, then typically a bougie is passed down the esophagus and along the lesser curve of the stomach with the tip pointing to or into the pylorus, and what size bougie should be used is a debate amongst weight loss surgeons and I'm sure in the pediatric world as well, but somewhere between a 36 and a 40 or 42 French bougie is typical. And then using sequential stapling and. You then staple along and cut along the bougie all the way up to the cardia and the angle of hiss to resect the larger remnant of the stomach, which is then extracted through one of the trochar sites which has to be made a little bit bigger, and there are all kinds of variations on that in terms of whether you reinforce the staple line with pledgets or suturing, whether you do endoscopy at the end of the operation to inspect the staple. Line, but those are the essential steps of a sleeve gastrectomy. So Mac, when you start the gastrectomy, is that right at the level of the pylorus at the trim? No, it's about 56 centimeters proximal to the pylorus. OK, all right, Tom, do you have anything to add about that? So yes, so the only thing that I have to add is the difference in the way that I do this, you know, over the years, and I started doing sleeve gastrectomies in 2008, but over the years, I've seen a lot of variability in how to do the operation and a lot of the patients with, you know, particular anatomic limitations or challenges, you know, we may not get the exact same sleeve every time, and I'd like to see the exact same sleeve operation every time. So I actually use a 25 centimeter clamp that wasn't on the market until we kind of envisioned it. And so now we have such a clamp, and so I'll do the dissection and completely free up the. The greater curve in the under surface of the stomach in the lesser sac area and free up the fundus from the left crew completely just like we were going to do a fundal placation and then place this very long clamp on the stomach, apply it, and I can see instantly then exactly where my staple line is going to be. There's no zigzagging, there's no twisting and turning, and firing that stapler then gives me a really nice product that's really quite Comparable patient to patient. So in terms of, you know, our current goal of standardizing patient care pathways, you know, after a post-op appendectomy and trying to achieve, you know, similar results and, you know, measurable deviations so that we can improve our craft, I really see this as, as a benefit. And so that's the only major difference that when I do the sleeve gastrectomy, we try to make that sleeve, you know, similar every time. So it's hard for me to envision exactly what the clamp is like. Do you have a video that demonstrates how you do the operation that we could post here with the podcast? Yeah, absolutely. I think that that would be helpful because, you know, it is something that also not just standardize the operation, but I'll confess, you know, when, when you do this operation and it is easy to leave a little bit of the fundus maybe attached to the, the crews, and I've Certainly seen in my own practice and in the practice of others, a bit more fundus than you want left there, and sometimes that can lead to pretty significant reflux. And so I think being able to use this technique, you know, really allows me to, to make sure that that fundus is completely mobilized, or else, you know, it just doesn't, it just, the, the clamp just doesn't go on very well. And on the other hand, you have to be. Concerned about that upper spinal firing of the stapler getting too close to the esophagus or across the esophagus on that lateral side, because if you have a leak there, that's a tough problem to solve. Yeah, and that leak at the fundus is, you know, at the cardia, the GE junction angle, hiss area is, you know, the most common place to have a leak, and, you know, as Matt mentioned, that's where this operation is the, that's the. Achilles' heel, at least in the early perioperative period where you worry the most. That's the thinnest part of the stomach when you kind of look at cadaveric stomachs and measure thickness from caudal to rostral, it's it's where it's the thinnest up there. So Mac, what are some tricks to try to minimize the risk of a leak there? Well, I think paying close attention to being, as Tom suggested, close to the esophagus, but not too close. And I think it's oftentimes the final firing of the stapler that dictates this, and I think it's just very close attention to the details. And again, sort of a technical point that's a little bit deep is it's the posterior wall of the stomach that tends to want to slip up and create too much fundus, so you really have to have good counter traction on the posterior wall of the stomach with the final firing to be sure you don't leave too much stomach but are not too close to the esophagus. It's one of those surgical judgment moments. And you also want to take a really close look, you know, use that, you know, it's typically a 10:30 scope that you're using at that point, really use that magnifying aspect of that scope to inspect that staple line and really make sure that your staples are uniform, they're formed, you know, completely, and you don't have any bleeding up there that might be an indication, well, you might have a malformed staple, and it's not, you know, you're getting a little hemostasis issue there. You see something that looks weird or that is bleeding, I think that you're going to be doing yourself and your patient a whole lot of good by just putting a simple figure of 8 or a couple of figure of eights in that and laying the issue to rest. That's a great point, Tom. What about the gastric bypass? What are the main points of the gastric bypass? So here again, we're obviously operating minimally invasively, laparoscopically, and you know, getting the liver up with either a Grasper attached to the diaphragm just like a fundoplication or using this instrument called a Nathanson retractor, particularly if you've got a massive left lateral segment, you'll want to think about. There are a lot of techniques you can use, you know, we arrived at a circularly stapled technique for the gastrojaiannostomy. So basically you go in and you and you dissect out your stomach pouch by really just getting around the lesser curve, typically just below the left gastric. Artery, getting into that space and then passing a stapler first from right to left across the lesser curve and then dissecting up to the angle of hiss with a harmonic and then progressively, you know, firing a couple of stapler loads usually up to the angle of hiss to complete that lesser curve, you know, kind of narrow gastric pouch. So once that's done, and some people will invariably go do the small intestine part first. For the gastric part, but you know, you certainly do have to come down, usually about 50 centimeters from the ligament of trites, divide the bowel with a linear stapler, and measure off, you know, depending on, you know, your school of thought in your practice, measure off about 100 centimeters of rou limb and then use a stapled, again, the linear staple technique to do a jejun or jejunostomy there, and then just elevate that rou limb up toward the Gastric pouch using a 25 millimeters is what we use circular stapler placed in the left upper quadrant. Go ahead and insert the stapler into the end of the roar limb, and you've deployed already your anvil in your pouch when you're creating that pouch. What you want to do is make those two up and fire that stapler, and you've got a nice reconstruction there with a large enough stoma to not have to worry about stricture. Formation typically we certainly remind the listeners that we want to close up hernial defects and internal hernias are really one of the long term risks of these operations. So you certainly close your degeno degenostomy defect with a non-absorbable suture, and you do close that Peterson's defect as well between the mesentery of the roe limb, and the transverse mesocolon. Great, Mac, anything you do different? Yes, I don't know if Tom mentioned this, but there's a debate about whether it's retrocolic or anticholic, and I started off doing retrocolic and found anticholic to work just fine. You still have a space there you need to close. Absolutely. And then the second thing is just a comment about the gastroginostomy. I'm happy with a linear stapler, a 2.5 centimeter firing of a of a straight linear stapler to create the gastroginostomy and then closure of the defect for putting in the stapler. Find that to be a very satisfactory approach as well. Tom, what's your, your usual postoperative routine? Right, so we start patients off, you know, taking sips of, of water, really, room temperature water, the same day of the operation, and, and then advance them up to, you know, 4 ounces an hour. By the next day, they're usually able to do that and, and get them on up to, you know, 66 ounces per hour. On the following day, again, clear liquids and Try to get them out of the hospital when they are, you know, achieving 64 to 96 ounces a day. What we see them do then at home and recommend is getting to hit the protein pretty hard once they get home. What we want to see is, of course, their fat mass being really beta oxidized and consumed with an energy deficit, but we don't want to see their lean mass consumed. So lean mass preservation by giving them a good Source of protein every day in their diet, 60 to 80 g a day is recommended for muscle preservation during this rapid phase of weight loss, so they will gradually over the course of the next few weeks, you know, be on a very soft mechanical diet as their GI tract is getting used to food and solids, but really by the end of the first month they're really on a much less restricted type of diet. They're eating very little. In the way of calories, still though, maybe 5 or 600 calories a day would be a good day, and you know 3 or 400 calories a day with very small meals. So you know that's at least the early postoperative look at the dietary advancement. Great. So you know, Mac, things don't always go as planned. Talk to us about the complications that you see with this operation. I know you alluded to the leak right at the gastroesophageal junction. Tell me about what you see some. in these patients, so complications related to the sleeve gastrectomy fall into a couple of categories. The one that we worry the most about is a leak at the staple line. We've discussed that a bit. I'm still in the habit of, though I allow sips of water on the day of surgery, I still get an upper GI on the first post-op day to make me feel better, I guess, about the possibility of a leak. Then I agree with Tom in terms of the advancement of the diet. The other complication is bleeding. Again, at the staple line, some surgeons automatically do an endoscopy at the end of the gastric resection to look for bleeding. Fortunately, it's not too common, but that can be an issue enough for someone to be transfused or have to get an early endoscopy with some sort of intervention. The site that you pull the stomach out of is at risk for a hernia because you have to make the hole in the rectus abdominus larger to do that. I put a stitch in that one particular trochar site using an endo. Type stitch to try to decrease that particular problem. In the long term, the gastric bypass has more complications, but the sleeve gastrectomy certainly can have problems with anemia down the road and concerns about vitamin deficiencies. The gastric bypass has more complications. You have the internal hernias that Tom mentioned. You can have a fairly high rate of stricture at the gastrojejunal anastomosis. You can have very bad marginal ulcers at the gastrojejunalas. Stomosis as well and so higher rate of serious complications with gastric bypass. Yes, and I think that the only other thing to mention there, and you may have mentioned it, but you know the adults, anymore you're talking to them and they're really worried about up to a third of the adult patients undergoing sleeve gastrectomy developing some form of, you know, a significant reflux requiring treatment. And of course the treatment that is most commonly successful is, you know, just acid. Suppression, but I think that this is a concern because, you know, what is our go to operation, of course, for reflux, it's a fundoplication, and you know, with a sleeve gastrectomy, you're, you're sort of burned that bridge and that fundus is long gone. So I do think that it's a topic that we spend some time on when counseling families and teenagers. I privately think that the teenagers probably have a lower risk of this particular complication. Only because their physiologic anti-reflux barriers are a bit more secure as a teenager than a, you know, a 40-year-old, and I think that we're going to probably have these kids enjoying a more commonly a reflux-free experience after the sleeve. But you know, this is a matter of controversy and data collection right now. I agree. I do put my patients on a proton pump inhibitor after the operation. What kind of weight loss do you tell the family to expect? Well, in the Teen lab study, which is a study that Mac and I have been involved with now for what, nearly a decade, you know, we are finding that at 3 years, the gastric bypass, as well as the sleeve patients are losing, you know, 28 to 30% of their weight, and so I know from my personal experience with patients. Going beyond that, that the weight loss maintained in the vast majority of these patients at about that level, so between 25 and 30% weight loss on the longer term as well. And so I think that, you know, depending on what weight you start at, that could be 80 pounds, it could be 100 pounds, it could be 150 pounds. So we try to, you know, really clue the family into what is expected so that we don't have unrealistic expectations going in. OK. I would just add that in most patients after bypass or sleeve gastrectomy, most of our typical teenagers lose between 80 and 100 pounds in that first year as a number we oftentimes communicate with them. OK. Tom, do you want to talk about health benefits? Well, I think that we could, you know, we could talk about a few different things. You know, one of the most common reasons why we're operating tends to be obstructive sleep apnea, and it's a fascinating study that one of the pulmonologists in Cincinnati did, bringing in teenagers before and 3 weeks and 5 weeks after surgery and finding that the sleep apnea went away essentially by 3 weeks. Which is, you know, a timetable which is not congruent with weight loss. I mean they're losing some weight but not a major amount of weight in that period. And so it looks as though sleep apnea might be one of those conditions that like diabetes, really responds rapidly and may be more of a neurohormonal response to surgery rather than just a weight loss response. So I'm forever, you know, quite amazed with the results of these procedures that you know sometimes. Are related to weight. I mean, for instance, if you've got somebody that's complaining of a lot of joint pain because of their weight, you know, get the weight off and the joint pain gets better. But you know some outcomes are really totally independent of the weight loss and have to do with the fact that we have, you know, we've really done an operation that's changed the signaling from the GI tract to other parts of the body, including the brain. That's really interesting about the sleep apnea. That's shocking to me. And the other example, Todd. diabetes again, certainly in the adult research literature and what we've learned in teenagers as well is type 2 diabetes and glucose metabolism issues improve within days of the surgery. So again, not related to the weight loss. Yes, certainly with the bypass. Wow, that's fascinating. Have we been doing this long enough that we know anything about long term outcomes in doing this in teenagers? Well, Tom has followed his group preteen labs the longest and the Thoroughly, so he should speak to this, right, so we had a group of 70 some teenagers that we operated on before the, you know, the big teen lab study started, and these were all bypass patients, and you know we were fortunate enough to have an industry sponsor to fund an investigator initiated study to bring in those patients after an average of 8 years. So some of them were only 5 years out, some of them were up to 12 years out, and And I think that the really positive part of this study is that we were able to get about 80% of them to come back, and you know that is one of the real knocks on long-term bariatric research that you might have 20% or 30% of the folks eligible for a study based on the, you know, long term nature of it. Only a fraction of them are locatable or come back in, and so, you know, that represents a big bias, but if you have 80% of them, you can feel pretty comfortable. That your bias is minimized in that, and so we found these folks that were in all different walks of life, you know, in their twenties after having undergone the surgery in their teenage years and were quite reassured by the fact that they may have lost, you know, 32, 33% of their weight in the first year and by on average 8 years, they were still maintaining a weight loss of 28 or 30%, which, you know, to me, is an expected amount of weight gain on the average because we see that no matter what form of weight loss therapy we use, be it dieting or drug therapy, we see some weight loss after the intervention. This was a very gentle amount of weight loss, and when we looked at their comorbidity resolution and the durability of that, again, quite reassured by the fact that in those with diabetes, the diabetes went away initially and it stayed away, and So when we look at a comparable population of teenagers in that study that were severely obese and underwent lifestyle intervention as teenagers and we caught up to them six years later, you know, they had developed, you know, in an expected frequency, they'd developed diabetes, they'd put on 66% more weight than they had in the beginning, and, and so I think that that study, which, you know, we were fortunate enough to get published in The Lancet. endocrinology really did, I think, offer families today and pediatricians today a glimpse, you know, with granted only 50 some patients in the end, but a very real glimpse at what the long term durability of gastric bypass is when done at teenagers, and people, people have had legitimate concerns about, you know, is this just an early result and then, you know, they're going to put the weight all back on. I think that, you know, with 50 patients at least we can, you know, make some. Reassuring statements that no, that's not the case. Tom, what research is going on in this arena, and you've been, I've heard you mention teen labs. Can you talk to us about the research in this area? Yeah, absolutely. Certainly Mac has been a big part of this as well, and you know, the collaborators in the five sites around the country that have participated in this study called Teen Labs, or it stands for Teen Longitudinal Assessment of Bariatric Surgery, we recruited 2. 42 teenagers from 2007 to 2012 in this NIH sponsored study that's now in its third 5-year cycle of funding actually, and we really did look at broad outcomes, not just weight loss, but you know, important aspects of their health at baseline and follow up. We collected bios specimens, blood, urine, DNA, that sort of thing, and banked them for use in the laboratory, but we have been, you know, quite pleased to see. The level of participation, you know, 80-90% of these patients are following up every year with us and are really painting a picture of, you know, health and well-being after these operations. Now we're also collecting, you know, risks of surgery and nutritional risks as well. And so I think that, you know, what we're, our goal is to be fair and balanced about it is to show what nutritional problems these kids have over the long haul as well. And teen labs is not the only thing that's Going on, you know, the Swedes are also doing some very good high quality long term research after gastric bypass and have published 5 year results that are really quite comparable to the results that we're seeing in the US with long-term maintenance of weight loss. There are a lot of pockets of research going on out there with very good, very good people behind it. So I think that the future is, is really going to be quite enlightening with outcome results that are coming to us about these interventions. Well, that's, I mean, it's exciting not only that bariatric surgery is coming into the arena of pediatric surgery, but that both of you are being so proactive with studying it to look at the outcomes. And just to finish this off, I wanted to ask AC and then Tom, both of you, what do we expect to see in the future? Is there anything new coming out on the horizon? Well, there are a number of innovative research projects, I'll call them, trying to decide about perhaps Less invasive ways to succeed weight loss procedures. The adult world has a moderate experience with a balloon that you inflate in the stomach to make your stomach feel full all the time and restrict what you can eat. And there's also an endoscopic gastric placation experience where you try to essentially create a small stomach like a sleeve gastrectomy, but doing an endoluminal placation. And, and there are a number of teenagers. that have been tested with that procedure as well in Richmond, Virginia. So, so those are two things on the list that again has more experience in adults than children, but may be things to explore. And I'm certainly interested in Tom's perspective as well. Well, so I'm going to take this in a slightly different direction, you know, I, I certainly do appreciate potential device therapies as well as the potential for novel non-device related. Surgical treatment, but what has become, you know, quite obvious in adult circles now, and I'm in Denver at the Children's Hospital of Colorado now, and really do appreciate my medical colleagues who are in this, you know, in this lifestyle medicine group that we've joined forces with. I think that one of the things that we are obligated to do is to try to identify those kids that are going to have suboptimal results with surgery. And it is a fraction of them that have suboptimal results, either going to gain a lot of weight back or going to have a primary failure and not lose very much weight in the first place for potentially a variety of reasons, but I think we're obligated to look at these pharmacologic interventions that are being used successfully for adults now and say, you know, what is the role of multimodal therapy postoperatively for these patients. Where, you know, you might actually see some synergism between surgery and medical therapy for weight loss, and I really do think that a trial is going to be, you know, in order as we go forward with this to, you know, to see, well, what can we do to really optimize the results and treating them with medications that definitely affect appetite. You know, personally, I think that bariatric surgery is a form of medical therapy, to be honest. Surgeons operate on the stomach and the intestines sometimes, but what's happening at the molecular level, I think, is quite a, a medical type of intervention. And so the relationship between the gut and the brain is certainly a physiologic and neural relationship, and I think that these drugs that we are using in many ways mimic what's going on with bariatric surgery and can be used to extend the results of bariatric surgery. And so I'm I'm actually Quite intrigued and excited about the possibilities of combining therapies postoperatively. I think that's a great look at the future and a great summary of where we're at now. So this has been great for me. I know a whole lot more than I did an hour ago. So I want to thank both of you, real true experts in the field, to take time out of your day to create this audio chapter. Tom and Mac, thanks again so much, and we appreciate your time. Happy to be here, Todd. We hope you enjoyed this episode of Stay Current in Pediatric Surgery. You can listen, watch, or read all content by downloading the Stay Current and Surgery app. Please send questions or comments to us at staycurrent podcast@gmail.com. We'll see you next time.