The Effects of Sleeve Gastrectomy on the Appetitive Domain of Taste Using the Progressive Ratio Task.

INTRODUCTION: Sleeve gastrectomy (SG) is an effective treatment for obesity in adolescents. The underlying weight loss mechanism may impact the peripheral and central gustatory system along with reward circuits in the brain. This study aims to assess changes in appetitive behavior in short-, medium-, and long-term follow-up. METHODS: In this prospective observational study, a total of 8 adolescents with obesity who underwent SG and 9 comparator unoperated participants were studied. Appetitive behaviour towards fat and sweet taste stimuli was assessed using the Progressive Ratio Task (PRT) over a 6 year period. RESULTS: Mean body mass index (BMI) of the surgical patients dropped from 51.5 ± 2.8 kg/m2 to 31.4 ± 1.9 and 30.9 ± 2.3 kg/m2 at 1 and 6 years follow-up, respectively. (p < 0.001). The median (interquartile range) total rewards earned during the PRT was 6 (5-7) pre-surgery, 5 (3-6) after one year and 4 (2-4) after six years from surgery (p = 0.007). CONCLUSION: SG reduced appetitive behaviour at 1 year with maintained the benefit over 6 years as measured by the progressive ratio task.

Bariatric Evaluation Through AI: a Survey of Expert Opinions Versus ChatGPT-4 (BETA-SEOV).

BACKGROUND: Recent advancements in artificial intelligence, such as OpenAI's ChatGPT-4, are revolutionizing various sectors, including healthcare. This study investigates the use of ChatGPT-4 in identifying suitable candidates for bariatric surgery and providing surgical recommendations to improve decision-making in obesity treatment amid the global obesity epidemic. METHODS: We devised ten patient scenarios, thoughtfully encompassing a spectrum that spans from uncomplicated cases to more complex ones. Our objective was to delve into the decision-making process regarding the recommendation of bariatric surgery. From July 29th to August 10th, 2023, we conducted a voluntary online survey involving thirty prominent bariatric surgeons, ensuring that there was no predetermined bias in the selection of a specific type of bariatric surgery. This survey was designed to collect their insights on these scenarios and gain a deeper understanding of their professional experience and background in the field of bariatric surgery. Additionally, we consulted ChatGPT-4 in two separate conversations to evaluate its alignment with expert opinions on bariatric surgery options. RESULTS: In 40% of the scenarios, disparities were identified between the two conversations with ChatGPT-4. It matched expert opinions in 30% of cases. Differences were noted in cases like gastrointestinal metaplasia and gastric adenocarcinoma, but there was alignment with conditions like endometriosis and GERD. CONCLUSION: The evaluation of ChatGPT-4's role in determining bariatric surgery suitability uncovered both potential and shortcomings. Its alignment with experts was inconsistent, and it often overlooked key factors, emphasizing human expertise's value. Its current use requires caution, and further refinement is needed for clinical application.

Endoscopic Sleeve Gastroplasty in Those With a Body Mass Index of 27-30.

INTRODUCTION: Endoscopic sleeve gastroplasty (ESG) is safe and effective in patients with a body mass index (BMI) more than 30, with few cases reported in patients with overweight (BMI 27-30). However, evidence is lacking in the overweight group because the procedure is not currently performed routinely for such patients. In this study, we aim to evaluate the safety and efficacy of ESG in patients with a BMI between 27 and 30 who failed other weight loss modalities and/or had weight-related comorbidities. METHODS: This was a subgroup analysis of data pertaining to adults with a BMI between 27 and 30 who underwent ESG as a primary weight loss intervention. Data were abstracted from our longitudinal, prospective single-center registry. We analyzed weight loss, comorbidity resolution, adverse events, revisions, and quality of life using the Bariatric Analysis and Reporting Outcome System. RESULTS: Of 3,797 ESG procedures, 656 patients (17%) had a BMI of 27-30. The mean age was 33 ± 9 years and women comprised 94% (n = 616) of the sample. The mean % total weight loss at 6, 12, 24, and 36 months after ESG was 11.0 ± 7.2, 15.5 ± 6.3, 15.1 ± 8.3%, and 13.3 ± 9.9%, respectively. Eight of 22 patients with diabetes (36%) and 9 of 51 patients (18%) with hypertension experienced complete remission. Two patients were hospitalized with bleeding. Twenty-three patients (3.5%) underwent revision to laparoscopic sleeve gastrectomy or repeat ESG. Six more patients underwent suture removal. A total of 214 of 261 patients (82%) rated quality of life after ESG as good or better. DISCUSSION: ESG seems to be well tolerated, safe, and effective in patients with a BMI of 27-30.

Long-term outcomes of laparoscopic sleeve gastrectomy in those with class I obesity: safety, efficacy, and quality of life.

BACKGROUND: Class I obesity carries significant morbidity and mortality risk similar to higher grades of obesity, and persons with class I obesity have a high risk of progression to class II and III obesity. While bariatric surgery has made strides in safety and efficacy, it remains inaccessible for persons with class I obesity (body mass index [BMI] of 30-35 kg/m2). OBJECTIVES: To assess safety, weight loss durability, co-morbidity resolution, and quality of life after laparoscopic sleeve gastrectomy (LSG) in persons with class I obesity. SETTING: Multidisciplinary medical center that specializes in obesity management. METHODS: A longitudinal prospective single-surgeon registry was queried for data pertaining to persons with class I obesity who underwent primary LSG. Primary endpoint was weight loss. Secondary endpoints included change in obesity-related co-morbidities, adverse events, and post hoc analysis of symptoms of gastroesophageal reflux disease (GERD) and Bariatric Analysis and Reporting Outcome System results. Follow-up was divided into short- (1-3 yr), intermediate- (4-7 yr), and long-term (8-12 yr). We evaluated percent excess weight loss (%EWL) using linear mixed models adjusting for age, sex, years since operation, and baseline BMI. Least-squares means estimates and 95% confidence intervals (CI) were generated. RESULTS: Of 13,863 bariatric procedures, a total of 1851 patients were included. Mean baseline BMI, age, and male:female ratio were 32.6 ± 2.1 kg/m2, 33.7 ± 9.2 years, and 1:5, respectively. Adjusted mean %EWL (95% CI) at short-, intermediate-, and long-term follow-up were 111% (95% CI, 91%-131%), 110% (95% CI, 89%-131%), and 141% (95% CI, 57%-225%), respectively. Of 195 patients with type 2 diabetes, 59% experienced complete remission, and of 168 patients with hypertension, 43% experienced complete remission. Being on oral antidiabetes medication was a significant predictor of sustained remission compared with being on insulin or combination therapy (P < .001). Sixty-nine patients had symptoms of GERD before surgery, which improved in 55 (79.7%). Thirty-three patients developed de novo symptoms of GERD. The average Bariatric Analysis and Reporting Outcome System score was 4.5 ± 1.7, with 83% of participants rating their quality of life after surgery as good, very good, or excellent. CONCLUSION: Those with class I obesity who undergo LSG experience normalization of weight, sustained remission of co-morbidity, and good quality of life without significant risk of morbidity or mortality.

Laparoscopic sleeve gastrectomy as day-case surgery versus conventional hospitalization: results of the DAYSLEEVE randomized clinical trial.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is an effective bariatric intervention with short operative time and low morbidity and mortality. However, ambulatory sleeve gastrectomy is underutilized. OBJECTIVE: This clinical trial compares feasibility, perioperative outcomes, and weight loss of patients undergoing ambulatory LSG with same-day discharge versus conventional hospitalization with next-day discharge. SETTING: Hospital and ambulatory surgery center. METHODS: Patients who satisfied low-acuity criteria were randomized to undergo day-case LSG in the ambulatory surgery center with same-day discharge (DC LSG) or LSG with conventional hospitalization and next-day discharge (CH LSG) between December 2018 and December 2020. The primary outcomes were 30-day adverse events, hospitalizations, reoperations, and readmissions, and the secondary outcome was weight loss during the first year. RESULTS: Of 2541 screened patients, 1544 patients were randomized in the study. Mean age and body mass index were 31.7 ± 9.1 years versus 31.8 ± 9.2 years and 39.6 ± 5.8 kg/m2 versus 40.0 ± 5.7 kg/m2 in the DC LSG group (n = 777) and in the CH LSG group (n = 777), respectively. Eighteen patients (2.3%) in the DC LSG were transferred to the hospital for overnight stay. Additionally, 13 patients (1.7%) requested additional stay without a medical indication for a total overnight stay rate of 4%. One DC LSG patient (.1%) was readmitted, and 2 CH LSG patients (.3%) stayed for an extra day. Seventeen percent of DC LSG patients had unscheduled consultations during the first postoperative week compared with 6% of CH LSG patients (P < .001). Those 2 groups were similar in baseline characteristics. There were no reoperations or mortality in either group, and weight loss results were similar; At 1-year follow-up, DC LSG percent excess weight loss was 87% ± 17% compared with 85% ± 17% in the CH LSG group. The follow-up rate was 100%. CONCLUSION: LSG is feasible as a day-case procedure with comparable outcomes to conventional hospitalization.

Endoscopic gastroplasty versus laparoscopic sleeve gastrectomy: a noninferiority propensity score-matched comparative study.

BACKGROUND AND AIMS: Endoscopic bariatric therapies are less-invasive alternatives to bariatric surgery, and endoscopic gastroplasty (ESG) represents the latest evolution. This study aims to compare weight loss, safety, and comorbidity resolution of ESG compared with laparoscopic sleeve gastrectomy (LSG). METHODS: This was a propensity score-matched study of patients who underwent ESG or LSG. Primary outcome was weight loss at 6, 12, 24, and 36 months. A noninferiority margin of 10% total weight loss (%TWL) was used. Secondary outcomes were safety and comorbidity resolution. RESULTS: A 1:1 propensity score match yielded 3018 patient pairs. Average age and body mass index (BMI) were 34 ± 10 years and 33 ± 3 kg/m2, respectively, and 89% were women. Mean percentage of excess weight loss at 1, 2, and 3 years after ESG was 77.1% ± 24.6%, 75.2% ± 47.9%, and 59.7% ± 57.1%, respectively. Mean percentage of excess weight loss at 1, 2, and 3 years after LSG was 95.1% ± 20.5%, 93.6% ± 31.3%, and 74.3% ± 35.2%, respectively. The mean difference in %TWL was 9.7% (95% confidence interval [CI], 6.9-11.8; P < .001), 6.0% (95% CI, -2.0 to 9.4; P < .001), and 4.8% (95% CI, -1.5 to 8.7; P < .001) at 1, 2, and 3 years, respectively. Noninferiority was demonstrated at all follow-up visits. Fourteen ESG patients developed adverse events (.5%) versus 10 LSG patients (.3%). Comorbidity remission rates after ESG versus LSG were 64% versus 82% for diabetes, 66% versus 64% for dyslipidemia, and 51% versus 46% for hypertension, respectively. Eighty ESG patients (2.7%) underwent revision to LSG for insufficient weight loss or weight regain, and 28 had resuturing after primary ESG (.9%). CONCLUSIONS: ESG induces noninferior weight loss to LSG with similar comorbidity resolution and safety profiles.

Religious Fasting of Muslim Patients After Metabolic and Bariatric Surgery: a Modified Delphi Consensus.

BACKGROUND: Fasting during Ramadan is one of the five pillars of the Muslim faith. Despite the positive effects of fasting on health, there are no guidelines or clear recommendations regarding fasting after metabolic/bariatric surgery (MBS). The current study reports the result of a modified Delphi consensus among expert metabolic/bariatric surgeons with experience in managing patients who fast after MBS. METHODS: A committee of 61 well-known metabolic and bariatric surgeons from 24 countries was created to participate in the Delphi consensus. The committee voted on 45 statements regarding recommendations and controversies around fasting after MBS. An agreement/disagreement ≥ of 70.0% was regarded as consensus. RESULTS: The experts reached a consensus on 40 out of 45 statements after two rounds of voting. One hundred percent of the experts believed that fasting needs special nutritional support in patients who underwent MBS. The decision regarding fasting must be coordinated among the surgeon, the nutritionist and the patient. At any time after MBS, 96.7% advised stopping fasting in the presence of persistent symptoms of intolerance. Seventy percent of the experts recommended delaying fasting after MBS for 6 to 12 months after combined and malabsorptive procedures according to the patient's situation and surgeon's experience, and 90.1% felt that proton pump inhibitors should be continued in patients who start fasting less than 6 months after MBS. There was consensus that fasting may help in weight loss, improvement/remission of non-alcoholic fatty liver disease, dyslipidemia, hypertension and type 2 diabetes mellitus among 88.5%, 90.2%, 88.5%, 85.2% and 85.2% of experts, respectively. CONCLUSION: Experts voted and reached a consensus on 40 statements covering various aspects of fasting after MBS.

Ten-Year Outcomes of Children and Adolescents Who Underwent Sleeve Gastrectomy: Weight Loss, Comorbidity Resolution, Adverse Events, and Growth Velocity.

BACKGROUND: To date, there are insufficient data on long-term outcomes of weight loss surgery in children and adolescents with obesity beyond 5 years of follow-up. This study aimed to analyze durability of weight loss and comorbidity resolution, growth velocity, and adverse events associated with laparoscopic sleeve gastrectomy (LSG) in children and adolescents with severe obesity. STUDY DESIGN: In this prospective cohort study, 2,504 children and adolescents with class II/III obesity who were enrolled in a multidisciplinary, family-based pediatric obesity management program underwent LSG between 2008 and 2021. Weight loss, growth, comorbidity resolution, and adverse event data during the first 10 years after LSG were analyzed. RESULTS: The cohort age was 5 to 21 years at the time of operation, and 55% were female. Mean ± SD percentage of excess weight lost during short- (1 to 3 years; n = 2,051), medium- (4 to 6 years; n = 1,268), and long-term (7 to 10 years; n = 632) follow-up was 82.3% ± 20.5%, 76.3% ± 29.1%, and 71.1% ± 26.9%, respectively. Complete comorbidity remission at long-term follow-up was observed in 74%, 59%, and 64% of type 2 diabetes, dyslipidemia, and hypertension cases, respectively. Mean ± SD height z-score change at short-, medium-, and long-term follow-up was 0.1 ± 0.5, 0.1 ± 1.2, and 0.0 ± 0.8, respectively, representing no significant change in growth velocity. There were 27 adverse events (1%) with no procedure-related mortality. CONCLUSIONS: Long-term follow-up after LSG in children and adolescents demonstrates durable weight loss, maintained comorbidity resolution, and unaltered growth.

Revisional endoscopic sleeve gastroplasty of laparoscopic sleeve gastrectomy: an international, multicenter study.

BACKGROUND AND AIMS: Laparoscopic sleeve gastrectomy (LSG) facilitates significant and durable weight loss; however, weight recidivism and need for revisional surgery occur in a subset of patients. Reduction of a dilated LSG using the revisional endoscopic sleeve gastroplasty (R-ESG) approach is an appealing and minimally invasive alternative to surgical revision that is congruent with obesity as a chronic relapsing disease model. In this study, we examine the safety and efficacy of the technique in a large multicenter international cohort. METHODS: Prospectively collected data from 9 centers for 82 consecutive adults who underwent R-ESG for weight regain after LSG using the OverStitch device (Apollo Endosurgery, Austin, Tex, USA) from March 2014 to November 2019 were reviewed. Total body weight loss (TBWL) and adverse events were reported up to 12 months. Univariable logistic regression was used to identify predictors of response at 12 months. RESULTS: Eighty-two adults (92.7% female) experienced 27.9 ± 20.7 kg weight regain from post-LSG nadir weight, prompting R-ESG (mean age, 42.8 ± 10.4 years) at a mean weight of 128.2 ± 57.5 kg. Mean R-ESG procedure duration was 48.3 ± 20.5 minutes, and the median number of sutures used was 4 (interquartile range, 3-4). After R-ESG, TBWL (follow-up %) was 6.6% ± 3.2% at 1 month (81.7%), 10.6% ± 4.4% at 3 months (74.4%), 13.2% ± 10.1% at 6 months (63.4%), and 15.7% ± 7.6% at 12 months (51.2%). In a per-protocol analysis, ≥10% TBWL was achieved by 37 of 51 patients (72.5%) at 6 months and 34 of 42 patients (81.0%) at 12 months; ≥15% TBWL was achieved by 20 of 46 patients (43.5%) at 6 months and 22 of 42 patients (52.4%) at 12 months. Only 1 moderate adverse event occurred in the form of a narrowed gastroesophageal junction, which resolved after a single endoscopic dilation. CONCLUSIONS: R-ESG is a safe and effective means of facilitating weight loss for weight recidivism after LSG, with sustained results at 1 year. R-ESG should be considered before pursuing more-invasive surgical revisional options.

Efficacy and Safety of Endoscopic Sleeve Gastroplasty: A Systematic Review and Meta-Analysis.

BACKGROUND & AIMS: Bariatric surgery is the most successful treatment for obesity. However, many patients avoid surgery due to its perceived invasive nature and fear of complications. Endoscopic sleeve gastroplasty (ESG) is a seemingly less invasive option for patients with obesity. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of ESG in adults. METHODS: We searched MEDLINE, Embase, Web of Science, and Cochrane Library through July 2019. Investigated outcomes included the percent total body weight loss (TBWL), body mass index reduction, percent excess weight loss (EWL), and adverse events. RESULTS: We extracted data from 8 original studies, published from 2016 through 2019, which included a total of 1772 patients. At 6 months, mean TBWL was 15.1% (95% CI, 14.3-16.0), mean decrease in body mass index was 5.65 kg/m2 (95% CI, 5.07-6.22), and mean excess weight loss was 57.7% (95% CI, 52.0-63.4). Weight loss was sustained at 12 months and 18-24 months with a TBWL of 16.5% (95% CI, 15.2-17.8) and 17.2% (95% CI, 14.6-19.7), respectively. The pooled post-ESG rate of severe adverse events was 2.2% (95% CI, 1.6%-3.1%), including pain or nausea requiring hospitalization (n = 18, 1.08%), upper gastrointestinal bleeding (n=9, 0.56%), and peri-gastric leak or fluid collection (n = 8, 0.48%). CONCLUSIONS: In a systematic review and meta-analysis, we found ESG to produce clinically significant weight loss that was reproducible among independent centers and to have a low rate of severe adverse events. ESG appears to be an effective intervention for patients with obesity, although comparative studies and randomized controlled trials are necessary. PROSPERO Identifier: CRD42019121921.

Laparoscopic Sleeve Gastrectomy After Endoscopic Sleeve Gastroplasty: Technical Aspects and Short-Term Outcomes.

BACKGROUND: Endoscopic sleeve gastroplasty (ESG) utilizes full-thickness sutures to plicate the greater curvature of the stomach. As with other weight loss interventions, some patients end up requiring revision to another procedure for insufficient weight loss or weight regain, discomfort, and procedure-related adverse events. OBJECTIVES: In this paper, we report our technique and short-term outcomes of revisional sleeve gastrectomy (LSG) after ESG. SETTING: Specialized medical center with standardized multidisciplinary protocols for medical, surgical, and endoscopic management of obesity. METHODS: A combined laparoscopic-endoscopic technique that identifies plication orientation and the location of anchors and sutures was employed. This prepares the stomach for safe stapling, excluding sutures and anchors from the staple line and the retained sleeve. Hereby, we report this technique with its short-term safety and efficacy outcomes. RESULTS: Twenty patients (16 female; mean age 40 ± 6 years) underwent revisional LSG from a total of 1665 (1.2%) who underwent primary ESG. Mean body mass index at the time of primary and revision procedures were 35.0 ± 4.0 and 35.2 ± 3.8 kg/m2, respectively. Nadir % total weight loss (%TWL) after primary ESG was 7.7 ± 3.5%. %TWL at 6 and 12 months after LSG was 21.0 ± 2.7 (n = 11) and 25.6 ± 4.1 (n = 8), respectively. There were no missed follow-up visits. Additionally, there was no mortality, prolonged hospital stay, adverse events, reoperations, or readmissions. CONCLUSIONS: Based on this combined laparoscopic-endoscopic technique, laparoscopic sleeve gastrectomy is a safe and feasible revision option for patients who fail ESG.

Vertical sleeve gastrectomy in adolescents reduces the appetitive reward value of a sweet and fatty reinforcer in a progressive ratio task.

BACKGROUND: Adolescent obesity is challenging to treat even if good multidisciplinary approaches are started early. Vertical sleeve gastrectomy (VSG) is an effective intervention for long-term weight loss, but the underlying mechanisms that result in reduced calorie intake are controversial. Anecdotal evidence from the clinic and evidence in rodents after VSG suggest a decrease in the reward value of high-calorie dense foods. OBJECTIVES: To determine changes in appetitive behavior of candies (high in sugar and fat) after VSG in adolescents with obesity. SETTING: University hospital. METHODS: Sixteen adolescents with obesity (age 15.3 ± .5 yr) who had VSG and 10 control patients (age 13.8 ± .6 yr) who had not undergone surgery were studied. Both groups completed a progressive ratio task by clicking a computer mouse on a progressive ratio schedule to receive a candy high in sugar and fat. In the task, patients were required to expend an increasing amount of effort to obtain the reinforcer until they reach a breakpoint (measure of the reward value of the reinforcer). The task was performed before VSG and 12 and 52 weeks after VSG. RESULTS: The VSG group's bodyweight decreased from the baseline 136.6 ± 5.1 to 110.9 ± 5.2 to 87.4 ± 3.7 kg after 12 and 52 weeks, respectively (P < .001). The median breakpoint for candies decreased after VSG from the baseline 320 (160-640) to 80 (50-320) to 160 (80-560) after 12 and 52 weeks, respectively (P = .01). Breakpoints for the control patients did not change (480 [160-640] versus 640 [280-640], P = .17). CONCLUSION: VSG resulted in a reduction in the reward value of a candy, as suggested by the reduced amount of effort adolescents were prepared to expend to obtain the high-sugar and high-fat candy. The effect was most pronounced 12 weeks after surgery but was largely maintained at 1 year. Long-term attenuation of appetitive behavior may be the key to weight loss and weight loss maintenance after VSG in adolescents.

Evidence Base for Multidisciplinary Care of Pediatric/Adolescent Bariatric Surgery Patients.

PURPOSE OF REVIEW: Severe childhood obesity, defined as having a body mass index (BMI) greater than the 99th percentile for age and gender, is rising in most countries and is associated with early morbidity and mortality. Optimal management of the health of the child with obesity requires a multidisciplinary approach that identifies and treats associated derangements. RECENT FINDINGS: Lifestyle interventions such as diet, exercise, and behavioral therapy for the severely obese pediatric patient are generally not effective. Few centers worldwide offer bariatric surgery for adolescents in a multidisciplinary setting, and we are the only center that offers a multidisciplinary approach that incorporates bariatric surgery for severely obese children and adolescents across all age groups. In this paper, we review up-to-date evidence in this subject including ours, and provide details on the multidisciplinary approach to pediatric obesity that accommodates bariatric surgery for children across all age groups.

5-year outcomes of 1-stage gastric band removal and sleeve gastrectomy.

BACKGROUND: No verdict has been reached on single-stage removal of gastric banding with sleeve gastrectomy. OBJECTIVES: To report 5-year outcomes of 1-stage gastric band removal and sleeve gastrectomy (Conversion-LSG) compared with primary laparoscopic sleeve gastrectomy (Prim-LSG). SETTING: Large single-surgeon prospective database. METHODS: Two patient groups were included: Conversion-LSG as the study group and Prim-LSG for comparison. Preconversion characteristics, conversion indication, weight loss, and complications were compared. The surgical protocol was reviewed, focusing on key technical recommendations. RESULTS: A total of 209 Conversion-LSG and 3268 Prim-LSG patients, aged 32.9±9.8 and 31.8±10.7 years respectively (P = .2), were studied. No significant differences in age, body mass index (BMI), or gender distribution existed. Conversion-LSG Baseline BMI was 47±12 kg/m2. Patients spent 6.2±2.6 years with the band before Conversion-LSG. BMI at 1, 2, 3, 4, and 5 years was 37±8, 31±9, 29±11, 30±9, and 30±11 kg/m2, respectively. No significant difference in BMI change between the 2 groups existed. In the Conversion-LSG group, 1 patient had a successfully stented leak but developed a gastrobronchial fistula 1 year later. In the Prim-LSG group, 3 leak cases were reported and managed successfully through endoscopic stenting, 1 patient had pulmonary embolism that responded to standard treatment, and 3 patients had postoperative bleeding. No other major complications occurred, and there was no mortality in either group. Additionally, no Conversion-LSG patients required further bariatric intervention. CONCLUSION: Employing the surgical technique described in this paper, conversion-LSG is as well tolerated and effective as primary sleeve gastrectomy.

Laparoscopic sleeve gastrectomy in children and adolescents with Prader-Willi syndrome: a matched-control study.

BACKGROUND: Obesity is a leading cause of mortality and morbidity in Prader-Willi syndrome (PWS). OBJECTIVES: To study weight loss and growth after laparoscopic sleeve gastrectomy (LSG) in pediatric patients with PWS compared with those without the syndrome. SETTING: Academic center with a standardized care pathway for pediatric bariatric surgery as a part of a prospective clinical outcome study on children and adolescents undergoing weight loss surgery. METHODS: Clinical data of all PWS patients who underwent LSG were abstracted from our prospective database, which included all pediatric patients who underwent bariatric surgery. These data were then compared with a 1:3 non-PWS group matched for age, gender, and body mass index (BMI). Data for up to 5 years follow-up were analyzed. RESULTS: The 24 PWS patients (mean age 10.7; 6<8 yr old, range 4.9-18) had a preoperative BMI of 46.2 ± 12.2 kg/m(2). All PWS patients had obstructive sleep apnea (OSA), 62% had dyslipidemia, 43% had hypertension, and 29% had diabetes mellitus. BMI change at the first, second, third, fourth, and fifth annual visits was -14.7 (n = 22 patients), -15.0 (n = 18), 12.2 (n = 13), -12.7 (n = 11), and -10.7 (n = 7), respectively, in the PWS group, whereas the non-PWS group had a BMI change of -15.9 (n = 67), -18.0 (n = 50), -18.4 (n = 47), -18.9 (n = 26), and -19.0 (n = 20), respectively. No significant difference was observed in postoperative BMI change (P = .2-.7) or growth (postoperative height z-score P value at each annual visit = .2-.8); 95% of co-morbidities in both groups were in remission or improved, with no significant difference in the rate of co-morbidity resolution after surgery (P = .73). One PWS patient was readmitted 5 years after surgery with recurrence of OSA and heart failure. No other readmissions occurred, and there were no reoperations, postoperative leaks, or other complications. No mortality or major morbidity was observed during the 5 years of follow-up. Among the PWS patients who reached their follow-up visit time points the total follow-up rate was 94.1%, whereas in the non-PWS group it was 97%. All patients who missed a follow-up visit were subsequently seen in future follow-ups, and no patient was lost to follow-up in either group. CONCLUSIONS: PWS children and adolescents underwent effective weight loss and resolution of co-morbidities after LSG, without mortality, significant morbidity, or slowing of growth. LSG should be offered to obese PWS patients with heightened mortality particularly because no other effective alternative therapy is available.

Pediatric bariatric surgery: the clinical pathway.

PURPOSE: Despite the rising interest in bariatric surgery (BS) for children and adolescents, algorithms that incorporate BS in weight management (WM) programs are lacking. This study presents the results of the pediatric bariatric surgery clinical pathway employed in our institution. MATERIALS AND METHODS: Starting March 2008, we enrolled obese children and adolescents in a standardized multidisciplinary obesity management program. Weight loss, complications, comorbidities, and growth results of those who eventually underwent BS were compared with a matched (age, gender, and height z-score) group of patients on non-surgical WM only. RESULTS: Up to July 2014, a total of 659 patients received care through the pathway, of whom 291 patients underwent laparoscopic sleeve gastrectomy (LSG). Mean age and pre-LSG body mass index (BMI) were 14.4 ± 4.0 years (range; 5 to 21 years) and 48.3 ± 10.0 (range; 31.8-109.6). Mean BMI change (% excess weight loss) at 1, 2, 3, and 4 postoperative years was -16.9 ± 4.9 (56.6 ± 22.6), -17.5 ± 5.2 (69.8 ± 22.5), -18.9 ± 4.3 (75.1 ± 26.8), and -19.6 ± 6.4 (73.6 ± 24.3), respectively. Postoperatively, complications occurred in 12 patients (4.1%), with no leaks or mortality, and more than 90% of comorbidities were resolved or improved without recurrence. Additionally, LSG patients exhibited significantly higher postoperative growth velocity compared to WM patients. CONCLUSIONS: Applying this standardized clinical pathway with its BS component results in safe and successful weight loss for pediatric patients, with low complication rates, maximum comorbidity resolution, and minimum morbidity.