Bariatric Partial Gastrectomy Technique: Adolescent Obesity 2013
hosted by Dr. Todd Ponsky · StayCurrentMD
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
OptiView trocar with 5mm zero-degree scope used for left upper quadrant access in obese patients undergoing any intraabdominal surgery, avoiding umbilical entry
Resection starts 5-6 cm from pylorus to spare antrum and avoid intrinsic factor deficiency and anemia
For patients with BMI >60, surgeon stands between the legs; for BMI 41, surgeon stands on patient's left side
Three of four ports placed to the left of patient's midline, only one port on the right
Patient is 17 years 9 months old, BMI 41, with polycystic ovarian syndrome and insulin resistance on metformin
Patient in multidisciplinary weight management clinic for approximately one year, physically active as softball team captain, family initially resistant to surgery
Indications for adolescent bariatric surgery: BMI ≥35 with major comorbidities (diabetes, sleep apnea, steatohepatitis, pseudotumor cerebri) or BMI ≥40 with any weight-responsive comorbidity
No strict age criterion recommended; preteens can develop comorbidities and may have sufficient maturity for surgery consideration
Youngest patient operated was 13 years old at UAB program
Adult surgeons leaving 2-3 cm of antrum; pediatric surgeon leaves 6 cm conservatively
B12 levels typically at low end of normal postoperatively, some in abnormal range, but no megaloblastic anemia observed
First staple firing performed without bougie; second stapler loaded but not fired, then bougie passed to save 30 minutes
In 108 sleeve gastrectomy cases, 30% developed vitamin B12 deficiency during postoperative follow-up (some deficient preoperatively)
Volume studies show the antrum expands more than the sleeve tube; leaving large antrum may lead to weight regain
Patients with severe sleep apnea (hypoxia to 50% during sleep), pulmonary hypertension, and risk of cardiac arrest from hypoxia are candidates for surgery regardless of young age
80-90% cure rate for diabetes in patients undergoing bariatric surgery
71% of pediatric bariatric surgery patients are compliant with follow-up and protocol, better than adults
Pediatric bariatric patients grow normally based on growth parameters, hormones, and bone age evaluation; no significant micronutrient deficiency problems
If fundal pouch not retracted laterally, can leave large remnant that may regrow, twist, or impact weight regain
Completely mobilizing left crus to visualize angle of His helps straighten stomach and prevent firing on folded/double stomach layer
Intraoperative leak test performed with 60cc methylene blue stained saline via OG tube while occluding duodenum; never detected a leak with this method
Most leaks occur 7-10 days postoperatively, not during initial hospitalization; postoperative contrast studies are not predictive and have been abandoned
Leak rate less than 5% in adults
Postoperative contrast studies abandoned after 75 cases as non-predictive; leaks typically occur days 3-7
34 French bougie used; resultant stomach width typically one vertebral body or narrower on upper GI
Buttresses used after first stapler firing (not on first firing with green stapler due to thick antrum); used on all subsequent firings
In 200 pediatric sleeve gastrectomy cases, zero leaks observed; leak is technical problem
Leaks occur at uppermost portion of sleeve in adult studies; requires careful attention at GE junction
Some high-volume adult surgeons place prophylactic reinforcement stitch at GE junction and suspend to crus to recreate angle of His and reduce reflux
Reflux reported in up to one-third of sleeve gastrectomy patients in longer-term follow-up
Tachycardia and fever are 60% predictive for leak; CT scan with oral and IV contrast is 90%+ predictive