Janey Pratt, MD and David Lanning, MD - 2024 Pediatric Bariatric Surgery Update Course

OK. Welcome back to the 2024 pediatric bariatric Update course. Uh, and there we have, I'm here with my two lovely co-hosts, Stephanie Walsh and Tom Inge. Uh, thanks to our, uh, sponsors, Medtronics and Teleflex. Um, and I think Tom, you're gonna introduce the next session. Yes, Mark, thank you. I'm really excited about this next session because it gets into territories that we, uh, we don't usually talk about. And so, um, David Lanning from, uh, my alma mater at Virginia Commonwealth University is here to talk to us about alternative procedures. And, uh, Janie Pratt, who we've come to love and adore, is an honorary pediatric surgeon because she's been doing Um, pediatric, bariatric cases for a very long time and has been a thought leader in this space. So, she's gonna talk to us about what happens later on, maybe years and years from now in terms of revision of procedures. So, really, I appreciate you guys being here. Take it away. Thank you. Um, I think I'm going to talk first, so let me just share my screen. So I'm going to talk about revisional procedures in children following metabolic and bariatric surgery, and I guess in children is a, is a, in quotes, I should have it because perhaps it's not going to be during childhood. Um, so what are the primary procedures we use in children? The 2022 MBSAQIP database says 90% of the time we're using sleeve gastrectomies, and then 9% of the time we're using laparoscopic gastric bypass, and then some biliopancreatic diversions. So what is the first revisional surgery that most people think about, and really the most common revisional procedure is going to be a sleeve to a bypass, and that's going to be done for sometimes inadequate weight loss and sometimes for bile reflux, but that's usually the most common procedure that we see. However, there are a lot of alternatives, and these are also not always the primary procedure done in childhood. So in the US it's 90% of cases are sleeve gastrectomies, but that's not necessarily true around the world. So what are the reasons for revisional surgery? The top reason in the sleeve is inadequate weight loss, followed by bile reflux and then stenosis or kinking. And you can see that you're going to do different operations depending on what the problem is. So if you have inadequate weight loss, you could try to re-sleeve the patient if they happen to have an unusually shaped sleeve. That's also true for some bile reflux, but most of them you're going to want to do either a gastric bypass is the best one for bile reflux or OAGP, and I'm going to talk about those, show those procedures in a second, is also a possibility for bile reflux. For the bypass, if you've done a bypass, um, inadequate weight loss, there really is not, there's not, revision is ineffective. You can lengthen limbs, you can make the pouch smaller, doesn't work. There's, there's no evidence that that works. I did it for years, doesn't work. You can try to convert it to a BPD, but that's extremely difficult, and you'll see the anatomy in a second why I say that. And then, but you do often revise bypasses for ulcer disease. So if kids do start to shake up smoking as they get to adults, they can develop gastrogenital ulcers. They get stenosis, they get ulcers, they get pain and bleeding and, and food intolerance, and that you can redo the gastrojugeneral anastomosis. You could also dilate if it's a stenosis initially, or you can redo the anastomosis. I'm going to show you each of those operations. So let's say you're going to re-sleeve someone. You have a patient who either has a large antrum, inadequate weight loss, and they're having, or they're having a lot of reflux, which can happen, nonbile reflux, because food sort of gathers in in a. What we call a retained fundus. In that case, you can revise to, you can re-sleeve them. So you just take a stapler and you, you put your bougie in and you re-sleeve them. And this is actually fairly effective, um, in, uh, in a moderate number of patients. There is no data. I cannot give you data. I cannot give you numbers. So, um, just take it as it as it is from my experience. Um, there is data in adults. There's no data in children. The gastroduodenal anastomosis revision is also fairly simple, uh, although it's, it's a longer operation. I prefer to use a robot for this one. you will, um, basically just resect, uh, the small intestine, the whole anastomosis, uh, with a stapler, staple here, staple here, and sew it back together. Um, pretty straightforward. What are the conversional preparations you could use for inadequate weight loss? Um, uh, one is the one anastomosis gastric bypass. This shows it as a primary procedure, but if you happen to have a sleeve there, you simply cut in the same place. It's about 15 centimeters from the GE junction. You make an, uh, you cut, and then you, you measure your small intestine. And in the OAGB you measure from the ligament of trites, uh, and you, you measure usually about 150 to 200 centimeters, and you want to leave at least 300 centimeters in your common channel. In the biliopancreatic diversion, traditionally, you're going to, um, you're gonna leave about 100 centimeters actually from this point to this point, so it's the terminal ileum. And then you split the the intestinal length between the other two limbs, and then the CAD, which is the single anastomosis biliopancreatic diversion, essentially, is similar except you're going to measure from the ileocecal valve 300 centimeters and you're going to make an anastomosis there. You can see that these operations are easily done after a sleeve. All of them incorporate the prior sleeve into the procedure. So, um, this is just the limb lengths I already talked about, and that's it. Fantastic, David. OK. Good morning, everyone. Can you hear me OK? You're good. OK, perfect. So I'm gonna touch um on alternative procedures and uh really focus mostly on our experience with placation. It's a small experience, but I think interesting one. So, this is uh in reference to a greater curvature of placation in the stomach, um, as was deemed early on to be better than anterior placation. Some of the potential or uh purported advantages, um, may be that may be more widely accepted, um, particularly in younger patients, given that it's really not a resective uh resection. Um, it's thought to have some not only restrictive component of it, but also probably some metabolic, uh, uh, uh, benefit as well. Uh, it's also purported to be reversible. Certainly, that's, uh, the case early on and, uh, becomes more difficult, of course, further out from the time of surgery. There's some suggestion that maybe there's, uh, less risk of a leak and, um, certainly can be progressive in terms of, uh, as was just kind of highlighted, progressing to a, uh, a full sleeve or even other uh procedures as was alluded to just recently. That being said, there are certainly limited studies. A number of them have been done in the adults. There's just really one other, uh, study outside of ours, um, and that was, uh, overseas with a dozen adolescent patients. So we did a pilot study, actually it started 10 years ago, IRB approved. Um, unfortunately, we only had 4 patients enrolled. We really never suggested this is better than a sleeve. It was just a trial we did and try to get a hand, a small handful of patients. Uh, the 4 that were enrolled, um, as you can see, were either 16 or 17 years of age, had a couple comorbidities. Their average weight, um, 139 kg with an average BMI of 48. Ranging from 41.7 to 53.7. Unfortunately, uh, two of the patients, um, uh, both of which lived over an hour outside of Richmond, uh, withdrew from the study after the ninety-day period and only had two patients that went the full length at, uh, 3 years. Some of the technical details, um, real briefly, rogastrics were taken down. We had either etelbo or prolene sutures to sort of start the imbrication of the greater curvature, and then we run a 2 a prolene from the angle of fist down to close to the uh pyloris, probably about 67 centimeters away. Then did a gastroscopy, flexible gastroscopy to sort of see how things looked, and then almost always did another running to a prolene to imbricate the stomach even further. And, uh, a final gastroscopy to make sure we felt like the uh placation was adequate. This is sort of just a general picture. It's, it shows interrupted stitches. That's the first kind of layer was, but the second, uh, two layers are really running, but you can see kind of the idea what we're left with, uh, at the end on the bottom right. And our results, um, we took our time, uh, took an average of 202 minutes, certainly got, uh, better and more efficient with the last one we did. Minimal blood loss. Um, we did keep our patients for a couple of days, 2 to 3 days. Um, weight loss at 90 days was on average at 17.7 kg and at 3 years for the two that were in the study, uh, for the duration was 45.7 kg, but a little bit of disparity there. We had one that lost up to 70 kg. Uh, one that lost some weight but gained a little bit back, and you can see the percent change of BMI of 17.5% and 39.7% at 36 month period. The nice thing is, is that the patients reported early satiety and good hunger control for the duration of, of the, the time we follow them and limited nausea. We're pretty aggressive about um our antiemetic uh treatment from the beginning. uh, there was, uh, two patients that were in long term, did have mild reflux symptoms, but resolved without um any significant, uh, long-term intervention. Uh, one patient had a little bit of abdominal pain, but, uh, resolved on its own. And, uh, we did do some other, um, uh, measurements, uh, including psychological, um, evaluations and so forth, and uh did demonstrate some, some minor improvements in those. Again, our numbers are, are quite small. No major complications, and again, one, only one readmission of which um was due to some uh nausea and, um, it was just a 23 hour stay. Uh, let's see here. Uh Next slide. Um, There we go. Thank you. Um, interestingly, I did have the opportunity to, uh, reach back out to, to the, uh, our patients. I did get a hold of two patients that were 9 years out from their application. Um, the first patient, uh, as you can see, the highest weight was 142 143 kg, has lost about 40 kg to date with the BMI going from 55.8 down to 40.4. She have some pre-diabetes, um, uh, when she initially had the surgery, and that's resolved. And interestingly, the second patient, uh, went from 175 down to 100 kg. He's actually pretty tall, 5'11, so, uh, his BMI went from 53.8 down to 30.7 and had resolution of his severe, uh, sleep apnea. Uh, that did require a CPAP. Uh, he had it, uh, he, he had it retested and, and his score was normal. He, he stopped, didn't have to use CPAP anymore. And interestingly, both patients continue to have really good early satiety and hunger control, um, to date, uh, 9 years out from their surgery. So, in, in closing, um, again, as mentioned, uh, it's nice to hear they have good early satiety hunger control. Um, it can be performed again, a very small handful of patients in some severely obese patients with minimal morbidity and, and modest efficacy. Um, and it certainly may have a role in these patients, um, whose care providers are reluctant to have an operation where you're removing 80% of the stomach, particularly those that are, uh, on the younger side. And, uh, as has been sort of proposed in some um of the studies that have been out in adult patients, it does seem to tend to do a little bit better in those that have BMI is less than 40, um, and that's probably a general, a good statement anyway, um, and, and maybe has a bit more of a role possibly in, in younger patients. So, um, and there are some other uh operations and procedures that are out and about with some um limited. Uh, certainly, uh, so, David, let's just do a quick pause for time here. I know that this is an area we want to really talk about a little bit, and we're just have 3 minutes for the discussion, um, and I, I, I, I, I just, I just know that people really wanna talk. So, um, questions from the group. Two great talks so far. I'd like to ask Janie her thoughts on, uh, Sadie versus, um, sleeve to Sadie versus sleeve to. Ruin why, because I, you know, as I've been out of clinical practice for 7 months or so, I've been going around the country asking a lot of adult surgeons what their preference between those two, strategies. Yeah, so the, the, the, the issue is, um, kids respond differently to revisional surgery. So when I do, when I do revision surgery on the 20-year-olds who I've done sleeves on, I do bypasses, they lose a ton of weight. So I don't know the answer to that because in general in the adult population, if they have a BMI over 50 or if they have childhood onset obesity, you're going to do a sleeve to Sadie. Kids are different, need more research. Kids are different, need more research. That's yes, that's my answer. David, kudos to you for bringing forward 9-year data. Unfortunately, 2 out of 4, but, but it's very, very interesting to me. Did you do any GI hormone collection analysis? Not, not yet, but we actually have blood samples and, and we, we may go back and look at that. Um, excellent, yeah, I'd be curious, I'd be curious what happens to their ghrelin levels because, yes, it's, it's not like a sleeve, right, because you left the stomach there, right? Yeah, some limited studies on, on the metabolic changes. There are some changes in, in the hormone levels. It's not been really characterized completely, but there is some suggestion, there's some metabolic, uh, you know, changes, uh, from just in the cation. Is anyone, is anyone on the panel doing endoscopic, uh, placation or any endoscopic procedures at all? I just saw a lecture on it like a couple of days ago and I was really impressed actually at the data that's coming out on endoscopic sleeve, and I think we, we can start, we can argue about robot versus lap all we want. They're going to take over. So, um, I think, you know, we should consider endoscopic sleeve. In kids, I'm not, I, I, you know, I'm not convinced yet because I've always said, oh, it's impossible to revise them afterwards, etc. etc. but the presentation I saw was very convincing and the data was really good. We were, yeah, yeah, we were looking at that to potentially start that in Richmond, but I saw a video one time where there's a lab assisted endoscopic placation and the needles are going full thickness through the stomach. And you know, you got to wonder how many have complications or problems, but it never comes, and it's never part of a publication, so we kind of shied away from it. I have the same. I think catching the liver seems obvious, but