Bone mineral density in young adults 5 to 11 years after adolescent metabolic and bariatric surgery for severe obesity compared to peers.

OBJECTIVE: Metabolic and bariatric surgery (MBS) is associated with decreased bone mineral density (BMD) in adults. The long-term impact of MBS during adolescence on BMD is unknown. We report bone health status 5 to 11 years after Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG) from the Teen-LABS study cohort. METHODS: Between 2016 and 2022, BMD was measured by dual energy x-ray absorptiometry (DXA) in 106 young adults who had undergone MBS as adolescents. Volumetric BMD by peripheral quantitative computed tomography was measured on a subset. Ninety-one controls who had not undergone MBS were recruited for comparison. RESULTS: In cases (RYGB: mean age 26.8 ± 1.9 years, mean BMI 42.1 ± 9.9 kg/m2, VSG: mean age 25.1 ± 2.1 years, mean BMI 37.1 ± 8.4 kg/m2), compared to controls (mean age 26.5 ± 2.7 years, mean BMI 40.2 ± 8.7 kg/m2) (age p < 0.001, BMI p = 0.02), adjusted mean DXA-BMD (g/cm2) of the RYGB (n = 58) and VSG (n = 48) groups were lower at the hip (-10.0% and -6.3%), femoral neck (-9.6% and -5.7%) and ultra-distal radius (-7.9% and -7.0%; all p < 0.001), respectively. DXA-BMD did not differ between RYGB and VSG groups. Trabecular volumetric BMD at the radius and tibia were lower in the RYGB (-30% and -26%) and VSG (-15% and -14%) groups compared to the control group (p < 0.001). Greater time since MBS was associated with lower BMD Z-scores at the hip (p = 0.05) and femoral neck (p = 0.045). Percent change in body mass index (BMI) from baseline or in the first year after MBS were not associated with bone measures at a median of 9.3 years post MBS. CONCLUSION: BMD, especially of the hip and femoral neck, was lower in young adults who underwent MBS during adolescence compared to matched peers who had not undergone MBS. BMD Z-scores of the femoral neck were inversely associated with time since MBS but were not associated with BMI change.

Five-Year Outcomes of Gastric Bypass in Adolescents as Compared with Adults.

BACKGROUND: Bariatric surgery results in weight loss and health improvements in adults and adolescents. However, whether outcomes differ according to the age of the patient at the time of surgery is unclear. METHODS: We evaluated the health effects of Roux-en-Y gastric bypass in a cohort of adolescents (161 patients enrolled from 2006 through 2012) and a cohort of adults (396 patients enrolled from 2006 through 2009). The two cohorts were participants in two related but independent studies. Linear mixed and Poisson mixed models were used to compare outcomes with regard to weight and coexisting conditions between the cohorts 5 years after surgery. The rates of death and subsequent abdominal operations and selected micronutrient levels (up to 2 years after surgery) were also compared between the cohorts. RESULTS: There was no significant difference in percent weight change between adolescents (-26%; 95% confidence interval [CI], -29 to -23) and adults (-29%; 95% CI, -31 to -27) 5 years after surgery (P = 0.08). After surgery, adolescents were significantly more likely than adults to have remission of type 2 diabetes (86% vs. 53%; risk ratio, 1.27; 95% CI, 1.03 to 1.57) and of hypertension (68% vs. 41%; risk ratio, 1.51; 95% CI, 1.21 to 1.88). Three adolescents (1.9%) and seven adults (1.8%) died in the 5 years after surgery. The rate of abdominal reoperations was significantly higher among adolescents than among adults (19 vs. 10 reoperations per 500 person-years, P = 0.003). More adolescents than adults had low ferritin levels (72 of 132 patients [48%] vs. 54 of 179 patients [29%], P = 0.004). CONCLUSIONS: Adolescents and adults who underwent gastric bypass had marked weight loss that was similar in magnitude 5 years after surgery. Adolescents had remission of diabetes and hypertension more often than adults. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases; ClinicalTrials.gov number, NCT00474318.).

Gastroblastoma with a novel EWSR1-CTBP1 fusion presenting in adolescence.

Gastroblastomas are rare tumors with a biphasic epithelioid/spindle cell morphology that typically present in early adulthood and have recurrent MALAT1-GLI1 fusions. We describe an adolescent patient with Wiskott-Aldrich syndrome who presented with a large submucosal gastric tumor with biphasic morphology. Despite histologic features consistent with gastroblastoma, a MALAT1-GLI1 fusion was not found in this patient's tumor; instead, comprehensive molecular profiling identified a novel EWSR1-CTBP1 fusion and no other significant genetic alterations. The tumor also overexpressed NOTCH and FGFR by RNA profiling. The novel fusion and expression profile suggest a role for epithelial-mesenchymal transition in this tumor, with potential implications for the pathogenesis of biphasic gastric tumors such as gastroblastoma.

Trends in robotic surgery utilization across tertiary children's hospitals in the United States.

BACKGROUND: A growing number of tertiary children's hospitals are utilizing robotic surgical technology. We sought to characterize national trends in pediatric surgical robotic case utilization and related drivers. METHODS: Pediatric urology and pediatric surgery (abdominal and thoracic) procedures, performed from January 2010 to December 2019 across 19 U.S. tertiary care children's hospitals, were identified using the Pediatric Health Information System (PHIS). Trends in robot utilization were evaluated by surgical subspecialty, procedure type, and number of individual operating surgeons. RESULTS: Increases were noted in the overall numbers of pediatric surgery (1.3% per quarter, p = 0.005) and urology robotic procedures (2.0% per quarter, p < 0.001), as well as the numbers of pediatric surgeons (7.5% per year, p < 0.001) and pediatric urologists (7.8% per year, p < 0.001) operating robotically. Biliary system and spleen surgery were the most common robotic pediatric surgery procedures (45.5%) and had stable utilization over time (- 0.8% per quarter, 95% CI - 2.3-0.8). Robotic foregut surgery showed the most rapid growth in utilization (2.1% per quarter, 95% CI 0.7-3.6, p = 0.004) in pediatric surgery, while mediastinal/thoracic surgery demonstrated a decrease in utilization (- 4.6%, 95% CI - 7.9-1.2, p = 0.008). Renal pelvis/ureter surgery was the most common robotic urologic procedure (55.8%) and also demonstrated the fastest growth utilization (2.2% per quarter, 95% CI 1.5-2.9, p < 0.001) in urology. CONCLUSIONS: Utilization of robotic-assisted surgery in pediatric surgery and pediatric urology has increased both in case volume and the number of operating surgeons, with foregut and renal pelvis/ureter surgery responsible for the areas of greatest growth.

Nutritional Risks in Adolescents After Bariatric Surgery.

BACKGROUND & AIMS: Little is known about prevalence and risk factors for nutritional deficiencies in adolescents after metabolic bariatric surgery. We performed a 5-year prospective cohort study of these. METHODS: Adolescents who had Roux-en-Y gastric bypass (RYGB, n = 161) or vertical sleeve gastrectomy (VSG, n = 67) were enrolled at 5 tertiary-care centers from March 2007 through February 2012. The final analysis cohort included 226 participants (161 who had RYGB and 65 who had VSG). We measured serum levels of ferritin; red blood cell folate; vitamins A, D, B1, B12; and parathyroid hormone at baseline and annually for 5 years. General linear mixed models were used to examine changes over time and identify factors associated with nutritional deficiencies. RESULTS: The participants were 75% female and 72% white, with a mean age of 16.5 ± 1.6 years and mean body mass index of 52.7 ± 9.4 kg/m2 at surgery. Mean body mass index decreased 23% at 5 years, and did not differ significantly between procedures. After RYGB, but not VSG, serum concentrations of vitamin B12 significantly decreased whereas serum levels of transferrin and parathyroid hormone increased. Ferritin levels decreased significantly after both procedures. Hypo-ferritinemia was observed in 2.5% of patients before RYGB and 71% at 5 y after RYGB (P < .0001), and 11% of patients before VSG and 45% 5 y after VSG (P = .002). No significant changes in serum levels of folate or vitamins A, B1, or D were found between baseline and 5 y after either procedure. By 5 y, 59% of RYGB and 27% of VSG recipients had 2 or more nutritional deficiencies. Risk factors associated with specific deficiencies included surgery type, female sex, black race, supplementation intake, weight regain, and for females, pregnancy. CONCLUSIONS: In a prospective study of adolescents who underwent RYGB or VSG, we observed nutritional deficiencies by 5 y after the procedures-particularly in iron and B12 after RYGB. Ongoing nutrient monitoring and supplementation are recommended for all patients, but surgery type, supplementation intake, sex, and race might affect risk. (Clinical trial registration: Adolescent Bariatrics: Assessing Health Benefits and Risk [also known as Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS)], NCT00474318.).

Weight Loss and Health Status 3 Years after Bariatric Surgery in Adolescents.

BACKGROUND: Bariatric surgery is increasingly considered for the treatment of adolescents with severe obesity, but few prospective adolescent-specific studies examining the efficacy and safety of weight-loss surgery are available to support clinical decision making. METHODS: We prospectively enrolled 242 adolescents undergoing weight-loss surgery at five U.S. centers. Patients undergoing Roux-en-Y gastric bypass (161 participants) or sleeve gastrectomy (67) were included in the analysis. Changes in body weight, coexisting conditions, cardiometabolic risk factors, and weight-related quality of life and postoperative complications were evaluated through 3 years after the procedure. RESULTS: The mean (±SD) baseline age of the participants was 17±1.6 years, and the mean body-mass index (the weight in kilograms divided by the square of the height in meters) was 53; 75% of the participants were female, and 72% were white. At 3 years after the procedure, the mean weight had decreased by 27% (95% confidence interval [CI], 25 to 29) in the total cohort, by 28% (95% CI, 25 to 30) among participants who underwent gastric bypass, and by 26% (95% CI, 22 to 30) among those who underwent sleeve gastrectomy. By 3 years after the procedure, remission of type 2 diabetes occurred in 95% (95% CI, 85 to 100) of participants who had had the condition at baseline, remission of abnormal kidney function occurred in 86% (95% CI, 72 to 100), remission of prediabetes in 76% (95% CI, 56 to 97), remission of elevated blood pressure in 74% (95% CI, 64 to 84), and remission of dyslipidemia in 66% (95% CI, 57 to 74). Weight-related quality of life also improved significantly. However, at 3 years after the bariatric procedure, hypoferritinemia was found in 57% (95% CI, 50 to 65) of the participants, and 13% (95% CI, 9 to 18) of the participants had undergone one or more additional intraabdominal procedures. CONCLUSIONS: In this multicenter, prospective study of bariatric surgery in adolescents, we found significant improvements in weight, cardiometabolic health, and weight-related quality of life at 3 years after the procedure. Risks associated with surgery included specific micronutrient deficiencies and the need for additional abdominal procedures. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and others; Teen-LABS ClinicalTrials.gov number, NCT00474318.).

Acetaminophen pharmacokinetics in severely obese adolescents and young adults.

BACKGROUND: Intravenous acetaminophen is commonly administered as an adjunctive to opioids during major surgical procedures, but neither the correct pharmacokinetic size descriptor nor the dose is certain in severely obese adolescents undergoing bariatric surgery. METHODS: Adolescents, 14-20 years of age, with a body mass index (BMI) ≥95th percentile for age and sex or BMI ≥40 kg·m-2 , presenting for laparoscopic or robotic assisted or vertical sleeve gastrectomy were administered intravenous acetaminophen (1000 mg) following completion of the surgical procedure. Venous blood was drawn for acetaminophen assay at eight time points, starting 15 minutes after completion of the infusion and up to 12 hours afterward. Time-concentration data profiles were analyzed using nonlinear mixed effects models. Parameter estimates were scaled to a 70-kg person using allometry. Normal fat mass was used to assess the impact of obesity on pharmacokinetic parameters. RESULTS: The study cohort comprised 11 female patients, age 17 SD 2 years with a weight of 125 SD 19 kg and a mean BMI of 46 SD 5 kg·m-2 . The plasma acetaminophen serum concentration was 17 (SD 4) µg·mL-1 at 10-20 minutes after completion of the infusion and 5 (SD 6) µg·mL-1 at 80-100 minutes. A two-compartment model, used to investigate pharmacokinetics, estimated clearance 10.6 (CV 72%) L·h·70 kg-1 , intercompartment clearance 37.3 (CV 63%) L·h·70 kg-1 , central volume of distribution 20.4 (CV 46%) L·70 kg-1 , and peripheral volume of distribution 16.8 (CV 42%) L·70 kg-1 . Clearance was best described using total body weight. Normal fat mass with a parameter that accounts for fat mass contribution (Ffat) of 0.88 best described volumes. CONCLUSION: Current recommendations of acetaminophen to a maximum dose of 1000 mg resulted in serum concentrations below detection limits in all patients within 2 hours after administration. Dose is better predicted using total body mass with allometric scaling.

High Prevalence of Nonalcoholic Fatty Liver Disease in Adolescents Undergoing Bariatric Surgery.

BACKGROUND & AIMS: Little is known about the prevalence of nonalcoholic fatty liver disease (NAFLD) among severely obese adolescents or factors that determine its development. We investigated the prevalence of NAFLD in a multicenter cohort of adolescents undergoing bariatric surgery and the factors associated with it. METHODS: We enrolled 242 adolescents undergoing bariatric surgery between March 2007 and February 2012 at 5 tertiary care centers into a multicenter, prospective observational cohort study. Intraoperative core liver biopsies were collected from 165 subjects; 17 were excluded because of insufficient liver tissue or use of hepatotoxic medications, so 148 remained in the study (mean age, 16.8 ± 1.6 years; median body mass index = 52 kg/m(2)). Liver tissues were analyzed by histology using validated criteria. Hepatic gene expression was analyzed in 67 samples. RESULTS: NAFLD was present in 59% of this predominantly female (72%), white (68%), non-Hispanic (91%) cohort. Of subjects with NAFLD, 24% had borderline and 10% had definite nonalcoholic steatohepatitis (NASH). Mild fibrosis (stage 2 or lower) was observed in 18% of liver biopsies and stage 3 was observed in 0.7%, but cirrhosis was not detected. Dyslipidemia was present in 78% of subjects, hypertension in 44%, and diabetes in 14%. More severe NAFLD was associated with increasing levels of alanine aminotransferase, fasting glucose level, hypertension (each P < .01), and white blood cell count (P = .04). Only diabetes was associated with detection of fibrosis (odds ratio = 3.56; 95% confidence interval: 1.93-6.56). Microarray analysis associated presence of NASH with altered expression of genes that regulate macrophage chemotaxis, cholesterol absorption, and fatty acid binding. CONCLUSIONS: More than half of adolescents undergoing bariatric surgery in this cohort had NAFLD, yet the prevalence of severe or fibrotic NASH was low. Increasing severity of NAFLD was associated with level of alanine aminotransferase and cardiometabolic risk factors, but not body mass index. Based on gene expression analysis, borderline and definite NASH were associated with abnormal immune function, intestinal cholesterol absorption, and lipid metabolism.

Severe obesity and comorbid condition impact on the weight-related quality of life of the adolescent patient.

OBJECTIVES: To assess links between comorbid health status, severe excess weight, and weight-related quality of life (WRQOL) in adolescents with severe obesity and undergoing weight-loss surgery (WLS) to inform clinical care. STUDY DESIGN: Baseline (preoperative) data from Teen Longitudinal Assessment of Bariatric Surgery, a prospective multicenter observational study of 242 adolescents with severe obesity (MedianBMI = 50.5 kg/m(2); Meanage = 17.1; 75.6% female; 71.9% white) undergoing WLS, were used to examine the impact of demographics, body mass index (BMI), presence/absence of 16 comorbid conditions, and a cumulative comorbidity load (CLoad) index on WRQOL scores (Impact of Weight on Quality of Life-Kids). RESULTS: WRQOL was significantly lower than reference samples of healthy weight, overweight, and obese samples. Of 16 comorbid conditions, the most prevalent were dyslipidemia (74.4%), chronic pain (58.3%), and obstructive sleep apnea (56.6%). Male subjects had a greater CLoad (P = .01) and BMI (P = .01), yet less impairment in total WRQOL (P < .01) than females. CLoad was a significant predictor of male WRQOL. For females, psychosocial (vs physical) comorbidities, BMI, and white race were significant predictors of WRQOL impairment. Less prevalent conditions (eg, stress urinary incontinence) also emerged as contributors to lower WRQOL. CONCLUSIONS: WRQOL impairment is substantial for adolescents with severe obesity undergoing WLS, with predictors varying by sex. These patient-data highlight targets for education, support, and adjunctive care referrals before WLS. Furthermore, they provide a comprehensive empirical base for understanding heterogeneity in adolescent WRQOL outcomes after WLS, as weight and comorbidity profiles change over time.

Update on bariatric surgery in adolescence.

PURPOSE OF REVIEW: Recent evidence highlighting the prevalence of severe obesity in the pediatric population, coupled with disappointing outcomes related to medical weight loss interventions, has led to increased interest in bariatric surgery. This article focuses on recent additions to the literature regarding the current indications and outcomes of adolescent bariatric surgery, emerging guidelines on the development of surgical weight loss programs and the status of access to bariatric surgical care for adolescents in the United States. RECENT FINDINGS: Current data have shown a steady rise in the use of bariatric surgery among adolescents and serve to highlight the prevalence of several important obesity-related comorbidities. In addition to reports showing the safety and efficacy of adolescent bariatric surgery, a number of investigators have demonstrated significant improvement in key physiological and metabolic parameters (i.e., glucose metabolism, elevated blood pressure, dyslipidemia, etc.), offering updated consensus-driven guidelines for the indications for surgical intervention, as well as the development of multidisciplinary adolescent-specific care. Despite favorable outcomes, a disparity exists between the pediatric and adult populations related to access to such care. SUMMARY: In contrast to previous small and mostly retrospective series, contemporary studies have shown that adolescent bariatric surgery is well tolerated and effective. Despite these findings and the emergence of a national consensus regarding multidisciplinary care, skepticism among primary care providers, as well as significant challenges related to healthcare access, remain. Longitudinal studies and open dialogue within the medical community are needed.

Child Maltreatment and the Adolescent Patient With Severe Obesity: Implications for Clinical Care.

OBJECTIVE: To characterize prevalence and correlates of child maltreatment (CM) in a clinical sample of adolescents with severe obesity. METHOD: Multicenter baseline data from 139 adolescents undergoing weight loss surgery (Mage = 16.9; 79.9% female, 66.2% White; Mbody mass index [BMI] = 51.5 kg/m(2)) and 83 nonsurgical comparisons (Mage = 16.1; 81.9% female, 54.2% White; MBMI = 46.9 kg/m(2)) documented self-reported CM (Childhood Trauma Questionnaire) and associations with psychopathology, quality of life, self-esteem and body image, high-risk behaviors, and family dysfunction. RESULTS: CM prevalence (females: 29%; males: 12%) was similar to national adolescent base rates. Emotional abuse was most prevalent. One in 10 females reported sexual abuse. For females, CM rates were higher in comparisons, yet correlates were similar for both cohorts: greater psychopathology, substance use, and family dysfunction, and lower quality of life. CONCLUSION: While a minority of adolescents with severe obesity reported a CM history, they carry greater psychosocial burden into the clinical setting.

Carbon dioxide monitoring during laparoscopic-assisted bariatric surgery in severely obese patients: transcutaneous versus end-tidal techniques.

Various factors including severe obesity or increases in intra-abdominal pressure during laparoscopy can lead to inaccuracies in end-tidal carbon dioxide (PETCO2) monitoring. The current study prospectively compares ET and transcutaneous (TC) CO2 monitoring in severely obese adolescents and young adults during laparoscopic-assisted bariatric surgery. Carbon dioxide was measured with both ET and TC devices during insufflation and laparoscopic bariatric surgery. The differences between each measure (PETCO2 and TC-CO2) and the PaCO2 were compared using a non-paired t test, Fisher's exact test, and a Bland-Altman analysis. The study cohort included 25 adolescents with a mean body mass index of 50.2 kg/m2 undergoing laparoscopic bariatric surgery. There was no difference in the absolute difference between the TC-CO2 and PaCO2 (3.2±3.0 mmHg) and the absolute difference between the PETCO2 and PaCO2 (3.7±2.5 mmHg). The bias and precision were 0.3 and 4.3 mmHg for TC monitoring versus PaCO2 and 3.2 and 3.2 mmHg for ET monitoring versus PaCO2. In the young severely obese population both TC and PETCO2 monitoring can be used to effectively estimate PaCO2. The correlation of PaCO2 to TC-CO2 is good, and similar to the correlation of PaCO2 to PETCO2. In this population, both of these non-invasive measures of PaCO2 can be used to monitor ventilation and minimize arterial blood gas sampling.

Accuracy of the CNAP™ monitor, a noninvasive continuous blood pressure device, in providing beat-to-beat blood pressure measurements during bariatric surgery in severely obese adolescents and young adults.

BACKGROUND: During perioperative care, the continuous measurement of blood pressure (BP) provides superior physiological monitoring compared to intermittent techniques, especially for patients with comorbid conditions such as severe obesity. The current study prospectively assesses the accuracy of a continuous, noninvasive BP device in severely obese adolescents and young adults. METHODS: The technology evaluated was the CNAP Monitor 500, developed by CNSystems AG (Graz, Austria). The study cohort was composed of severely obese adolescents (body mass index ≥ 35 kg/m(2)) undergoing a surgical weight loss procedure (robotically assisted or laparoscopic vertical sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass). Systolic (sBP), diastolic (dBP), and mean arterial (MAP) blood pressure readings were captured from an intraoperatively placed radial arterial cannula (AC) and the CNAP device at regular intervals (once per minute) during anesthetic care. RESULTS: The study cohort consisted of 18 severely obese subjects undergoing weight loss surgery. A total of 2,159 pairs each of sBP, dBP, and MAP values obtained. The correlation coefficient between the AC and the CNAP device was 0.655, 0.667, and 0.783 for the sBP, dBP, and MAP, respectively. The CNAP values (sBP, dBP, MAP) were ≤5 mmHg from the AC values in 33, 40, and 41% of the values, respectively. The difference was more than 10 mmHg (sBP, dBP, MAP) in 39, 28, and 25% of the values, respectively. Using a Bland-Altman analysis, the precision and bias for the sBP, dBP, and MAP were 0.3 ± 14.2, -1.3 ± 9.5, and -0.6 ± 8.6 mmHg, respectively. CONCLUSION: When compared to previous studies in the adult population, the accuracy of the CNAP device in a cohort of severely obese adolescents undergoing weight loss surgery was slightly less than previously reported. The current data demonstrate a clinically useful trend of the CNAP device with arterial values in this challenging patient population in whom an arterial cannula may at times be difficult.

Associations between marital status and weight loss trajectories entering into early adulthood: a Teen-LABS study.

BACKGROUND: Among adolescents who underwent metabolic and bariatric surgery (MBS), it is unclear how relationships and specifically marital status (MS) may be associated with long-term weight loss. OBJECTIVE: In this analysis, we tested for associations between the MS of adolescents who underwent MBS and the MS of their primary caregiver and weight loss trajectory over 8 years. SETTING: Teen-LABS participating sites. METHODS: This sample included 231 participants (75.3% female, 71.4% White, 68.0% Roux-en-Y gastric bypass, 27.7% vertical sleeve gastrectomy, 4.3% laparoscopic adjustable gastric band). A linear mixed model was conducted with the dependent variable percent body mass index (BMI) change from preoperatively through 8 years with between-participant factors (1) participant MS, (2) caregiver MS, and (3) interaction between caregiver and participant MS. RESULTS: One third of participants and 87% of caregivers were ever married (EM). Compared with never-married (NM) participants and caregivers (-14.6%), EM participants and caregivers (-20.6%), EM participants and NM caregivers (-25.9%), and NM participants and EM caregivers (-19.8%), each had significantly greater BMI loss at 8 years (each P < .05). No other group comparisons achieved statistical significance. CONCLUSIONS: NM participants with NM caregivers had less favorable long-term BMI. Additional research is needed to better understand how relationships affect behavior change and weight loss after MBS.

Robotic-Assisted Surgery in Patients Less than 15 kg: A Single Center Review.

Introduction: Robotic-assisted surgery (RAS) is an increasingly utilized tool in children. However, utilization of RAS among infants and small children has not been well established. The purpose of this study was to review and characterize RAS procedures for children ≤15 kg. Methods: We performed a single institution retrospective descriptive analysis including all patients ≤15 kg undergoing RAS between January 2013 and July 2021. Data collection included procedure type, age, weight, gender, and surgical complications. Cases were further categorized according to surgical specialty: pediatric urology (PU), pediatric surgery (PS), and multiple specialties (MS). t-Tests were used for statistical analyses. Results: Since 2013, a total of 976 RAS were identified: 492 (50.4%) were performed by PU, 466 (47.8%) by PS, and 18 (1.8%) by MS. One hundred eighteen (12.1%) were performed on children ≤15 kg, consisting of 110 (93.2%) PU cases, 6 (5.1%) PS cases, and 2 (1.7%) MS cases. Procedures were significantly more common in the PU subgroup, mean of 12 cases/year, compared to PS subgroup, mean of 0.63 cases/year, (P < .01). The mean weight of PU patients (10.5 kg) was significantly less than PS patients (13.9 kg) (P < .01). Mean age was also significantly lower among PU patients (18.6 months) compared to PS (34.2 months) (P < .01). Conclusion: RAS among patients ≤15 kg is safe and feasible across pediatric surgical subspecialties. RAS was performed significantly more frequently by pediatric urologists in younger and smaller patients compared to pediatric surgeons. Further refinement of robotic technology and instrumentation should enhance the applicability of these procedures in this young group.

Robotic-assisted Pediatric Thoracic and Abdominal Tumor Resection: An Initial Multi-center Review.

INTRODUCTION: Robotic-assisted minimally invasive surgery (RA-MIS) for tumor resection is an emerging technology in the pediatric population with significant promise but unproven safety and feasibility. METHODS: A multi-center retrospective review of patients ≤18 years undergoing RA-MIS tumor resection from December 2015-March 2023 was performed. Patient demographics, perioperative variables, and complication rates were analyzed. RESULTS: Thirty-nine procedures were performed on 38 patients (17 thoracic, 22 abdominal); 37% female and 68% non-Hispanic White. Median age at surgery was 8.3 years (IQR 5.7, 15.7); the youngest was 1.7 years-old. Thoracic operations included resections of neuroblastic tumors (n = 16) and a single paraganglioma. The most common abdominal operations included resections of neuroblastic tumors (n = 5), pheochromocytomas (n = 3), and angiomyolipomas (n = 3). Six patients underwent retroperitoneal lymph node dissection (RPLND) for paratesticular tumors. Median operating time for the cohort was 2:52 h (IQR 2:04, 4:31). Two thoracic cases required open conversion due to poor visualization and lack of working domain. All patients underwent complete tumor resection; one had tumor spillage from a positive margin (Wilms tumor). Median LOS was 1.5 days (IQR 1.1, 3.0). Postoperatively, one patient developed a chyle leak requiring interventional radiology drainage, but none required a return to the operating room. CONCLUSIONS: Robotic-assisted surgery is safe and feasible for tumor resection in carefully selected pediatric patients, achieving complete resection with minimal morbidity and short LOS. Resection should be performed by those with robotic expertise for optimal outcomes. LEVEL OF EVIDENCE: IV. TYPE OF STUDY: Original Clinical Research.

Bone mineral density 5 to 11 years after metabolic and bariatric surgery in adolescents with severe obesity compared to peers.

Objective: Metabolic and bariatric surgery (MBS) is associated with decreased bone mineral density (BMD) in adults. The long-term impact of MBS during adolescence on BMD is unknown. We report bone health status 5 to 11 years after Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG) from the Teen-LABS study cohort. Methods: Between 2016 and 2022, BMD was measured by dual energy x-ray absorptiometry (DXA) in 106 young adults who had undergone MBS as adolescents. Volumetric BMD by peripheral quantitative computed tomography was measured on a subset. Ninety-one controls who had not undergone MBS were recruited for comparison. Results: Compared to controls, adjusted mean DXA-BMD of the RYGB (n = 58) and VSG (n = 48) groups were lower at the hip (-10.0% and - 6.3%), femoral neck (-9.6% and - 5.7%) and ultra-distal radius (-7.9% and - 7.0%; all p < 0.001), respectively. DXA-BMD did not differ between RYGB and VSG groups. Trabecular volumetric BMD at the radius and tibia were lower in the RYGB (-30% and - 26%) and VSG (-15% and - 14%) groups compared to the control group (p < 0.001). Greater time since MBS was associated with lower BMD Z-scores at the hip (p = 0.05) and femoral neck (p = 0.045). Percent change in body mass index (BMI) from baseline or in the first year after MSB were not associated with bone measures at a median of 9.3 years post MSB. Conclusion: BMD, especially of the hip and femoral neck, was lower in young adults who underwent MBS during adolescence compared to matched peers who had not undergone MBS. BMD Z-scores of the femoral neck decreased with time since MBS but were not associated with BMI change.

Utilization of an Enhanced Recovery After Surgery (ERAS) protocol for pediatric metabolic and bariatric surgery.

INTRODUCTION: Enhanced recovery after surgery (ERAS) protocols for pediatric metabolic and bariatric surgery are limited. In 2018, an ERAS protocol for patients undergoing robotically assisted vertical sleeve gastrectomy (r-VSG) was instituted. This study's aim was to compare outcomes before and after ERAS initiation. METHODS: A single institution retrospective review of patients undergoing r-VSG from July 2015 to July 2021 was performed. The multimodal ERAS protocol focused on limiting post-operative nausea and narcotic utilization. Subjects were categorized into non-ERAS (July 2015-July 2018) and ERAS (August 2018-July 2021) groups. In-hospital and 30-day outcomes were compared. RESULTS: 110 subjects (94 females) with a median age of 17.6 years (range 12.5-22.0 years) were included (60 non-ERAS, 50 ERAS). Demographics were similar except for a higher proportion of females in the non-ERAS group (97% vs 72%, p < 0.001). A significant decrease in narcotic use (p < 0.001) and higher utilization of acetaminophen (p < 0.001) and ketorolac (p < 0.001) was observed in the ERAS group. Additionally, median time to oral intake, a proxy for postoperative nausea and vomiting [2:00 h (1:15, 2:30) vs. 3:22 h (2:03, 6:15), p < 0.001] and hospital length of stay (LOS) [1.25 days (1.14, 1.34) vs. 2.16 days (1.48, 2.42), p < 0.001] were shorter in the ERAS group. Eleven subjects (10%; ERAS = 5, non-ERAS = 6) experienced post-discharge dehydration, prompting readmission 8 times for 7 (6%) individuals. CONCLUSION: Utilization of ERAS led to a significant decrease narcotic utilization, time to first oral intake, and hospital LOS with no change in adverse events following pediatric metabolic and bariatric surgery. Larger studies, including comparative analysis of health care utilization, should be carried out. LEVEL OF EVIDENCE: III. TYPE OF STUDY: Treatment Study.

Marijuana, e-cigarette, and tobacco product use in young adults who underwent pediatric bariatric surgery.

BACKGROUND: The postoperative course after pediatric metabolic and bariatric surgery (MBS) cuts across a developmental phase when substance-use behaviors emerge as significant public health concerns. OBJECTIVE: We examined use of marijuana, conventional cigarettes, and alternate tobacco products/devices (e.g., e-cigarettes, hookah, smokeless, dissolvable) in young adults (YA) to 6 years postsurgery. SETTING: Five academic medical centers. METHODS: In a prospective observational cohort series, 139 surgical (Mage = 16.9, Mbody mass index [BMI] = 51.5, 80% female, 66% white) and 83 nonsurgical comparisons (Mage = 16.1, MBMI = 44.9, 82% female, 54% white) completed assessments at presurgery/baseline and postsurgery years 2, 4, and 6 (year 6 [2014-2018]: surgical n = 123 [89%], Mage = 23.0, MBMI = 39.8; nonsurgical n = 63 [76%], Mage = 22.4, MBMI = 53.6). Lifetime and current (past 30 days) use were reported. RESULTS: Consistent with national YA trends (2014-2018), the most commonly used were (1) conventional cigarettes (30% surgical, 41% nonsurgical, nonsignificant [ns]); (2) marijuana (25% surgical, 27% nonsurgical, ns); and (3) e-cigarettes (12% surgical, 10% nonsurgical). A sizable minority (26% surgical, 18% nonsurgical) used one or more alternate tobacco product/device. Many YA reported persistent and/or heavy use (e.g., >50% marijuana at year 6 and year 2 or 4; ≈50% ≥.5 pack/d of cigarettes), suggesting more established (versus intermittent) health risk behaviors. For the surgical group at year 6, current tobacco product/device use was associated with lower BMI (P < .001) and greater percent weight loss (P = .002). CONCLUSIONS: Pediatric MBS demonstrates promise in lowering risks for adult chronic disease, which may be diminished by age-typical health risk behaviors. Developmentally salient and holistic pediatric postoperative care guidelines are needed.

Trends and Economic Implications of Disparities in Postoperative Pneumonia.

BACKGROUND: Postoperative pneumonia is the third most common surgical complication and can seriously impair surgical rehabilitation and lead to related morbidity and mortality. We evaluated the temporal trends in racial and ethnic disparities in postoperative pneumonia and quantified the economic burden resulting from these inequalities in the United States. METHODS: This population-based study includes 195 028 children (weighted to 964 679) admitted for elective surgery across 5340 US hospitals reporting to the Nationwide Inpatient Sample between 2010 and 2018. We estimated the risk-adjusted incidence of postoperative pneumonia, comparing racial and ethnic groups. We also quantified the inflation-adjusted hospital costs attributable to racial and ethnic disparities in postoperative pneumonia. RESULTS: The risk-adjusted rates of pneumonia declined across all racial and ethnic categories, with Black children having the lowest annual rate of decline (Black: 0.03 percentage points, Hispanic: 0.05 percentage points, white: 0.05 percentage points). The risk-adjusted rates of pneumonia trended consistently higher for Black and Hispanic children, relative to white children, throughout the study period (Black versus white: relative risk, 1.31 (95% confidence interval, 1.14-1.51), P < .01; Hispanic versus white: relative risk, 1.16 (95% confidence interval, 1.02-1.32), P = .02). These disparities did not narrow significantly over time. During the study period, the excess hospitalization cost attributable to racial and ethnic disparities in postoperative pneumonia was $24 533 458 for Black children and $26 200 783 for Hispanic children (total, $50 734 241). CONCLUSIONS: Against the backdrop of decreasing postoperative pneumonia, Black and Hispanic children continue to experience higher rates compared with white children. These persistent disparities in postoperative pneumonia were associated with considerable excess cost of surgical care.