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INTRODUCTION: Glucagon-like peptide-1 receptor agonist (GLP-1A) medications are gaining widespread popularity for the treatment of obesity. The optimal use of these drugs in pediatric bariatric populations, and especially in those considering metabolic and bariatric surgery (MBS), is yet to be established. We sought to characterize current practice patterns of GLP-1A use at major pediatric bariatric centers across the United States. MATERIALS AND METHODS: We administered an online survey to a purposive sample of 46 surgeons who perform MBS on children and adolescents. Survey questions explored practices prescribing GLP-1As in patients considering MBS, holding them prior to elective operations, and restarting them postoperatively following MBS. Responses were summarized with descriptive statistics and inductive content analysis. RESULTS: There were 22 responses (48% response rate) representing 19 institutions. Most (86%) respondents do sometimes prescribe GLP-1As for patients considering MBS, but the specific indications vary. Practices for holding GLP-1As preoperatively also vary, from not at all to holding for 2 wk. Over half (55%) of respondents sometimes restart GLP-1As after MBS. Free-response themes included still-evolving preoperative utilization patterns, difficulty with access and insurance coverage, and a lack of data informing GLP-1A use in the pre and postoperative periods. CONCLUSIONS: Given the increasing use of these medications for weight loss purposes, this substantial variation in practice highlights a need for further research to examine the safest and most effective use of GLP-1As in the pre and postoperative periods and for practice guidelines to standardize care pathways in pediatric bariatric contexts.
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INTRODUCTION: Obesity is a significant public health concern in children. The American Academy of Pediatrics recommends the use of metabolic and bariatric surgery (MBS) in children with severe obesity, however; MBS remains underutilized in part due to lack of access. This study aims to characterize the prevalence of pediatric obesity and compare this to regional pediatric MBS provider availability. METHODS: State-specific prevalence rates of childhood obesity in children aged 10-17 were obtained from the National Survey of Children's Health. The member directory provided by the American Society for Metabolic and Bariatric Surgeons was used to identify all pediatric MBS providers and used to calculate the prevalence of MBS providers by state. RESULTS: The five states with the highest prevalence rates of childhood obesity were Kentucky, Mississippi, Louisiana, West Virginia, and Alabama. The five states with the highest prevalence (per 100,000 children with obesity) of MBS providers doing pediatric cases were North Dakota, New Jersey, Kansas, New York, and Utah. Notably, there was a negative correlation between the states with the lowest prevalence of pediatric MBS providers and states with the highest prevalence of childhood obesity (r -0.40, ∗P = 0.002). CONCLUSIONS: Our study demonstrates significant state-to-state variation in the prevalence of pediatric obesity and MBS provider availability by state as a proxy for access to surgical care for pediatric obesity. Further work to establish accessible multidisciplinary pediatric weight loss centers is needed to ensure that children and adolescents with obesity receive thorough evaluation and have access to MBS.
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Cirugía Bariátrica , Obesidad Mórbida , Obesidad Infantil , Cirujanos , Adolescente , Estados Unidos/epidemiología , Humanos , Niño , Obesidad Infantil/epidemiología , Obesidad Infantil/cirugía , Obesidad Mórbida/cirugía , AlabamaRESUMEN
OBJECTIVE: The American Academy of Pediatrics (AAP) recently released clinical guidelines for the treatment of childhood obesity, including surgery being appropriate for children 13 years of age and older. The use of this age cut-off was due to a lack of data for children younger than 13. To address this knowledge gap, the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was queried to compare outcomes in preteens to teens after bariatric surgery hypothesizing that there would be no difference in outcomes between the two groups. METHODS: Patients from the MSAQIP database (2016-2021) were identified and divided into groups <13 years and 13-18 years and were matched using propensity scores based on race, sex, and preoperative BMI. Outcomes were compared including change in BMI, complication rates, 30-day readmission or reoperation, and mortality. Additionally, the centers responsible for the bulk of the preteen patient entries queried their center-specific databases to evaluate weight loss over time. RESULTS: A total of 4755 patients were identified, 47 of whom were <13 years of age. Preteens had similar sex distribution (66% vs. 75% female), were more likely to be Black (27.7% vs. 18.3%) or Hispanic (21.3% vs. 7.6%) race, and weighed less (274 ± 58 vs. 293 ± 85 lb, p = 0.01), but they had similar BMI (46.9 ± 7 vs. 47 ± 13 kg/m2 ) as their teen counterparts. Preteens were more likely to suffer from sleep apnea (34% vs. 19%, p < 0.01) and insulin-dependent type 2 diabetes (10.6% vs. 1.8%, p < 0.01). There were no complications in the preteens compared to teens (0% vs. 0.5%), and they did not undergo any unplanned readmissions (0% vs. 2.9%) or reoperations (0% vs. 0.8%) within 30 days of surgery. There were also no mortalities reported in preteens (0% vs. 0.1%). The risk-adjusted decrease in BMI between preteens and teens was also comparable at 30 days (4.2 [95% CI: 3.0-5.4] vs. 4.6 [95% CI: 4.4-4.7], p = 0.6). Decrease in BMI in preteens was 7 ± 3 kg/m2 at 3 months and 9 ± 4 kg/m2 at 12 months after surgery, which represented a percentage BMI change of 16 ± 7 and 20 ± 8, respectively. CONCLUSIONS: This study demonstrates that bariatric surgery in preteens is safe and efficacious when performed at specialized centers, and that age criteria may not be required. The AAP and others are encouraged to include age cut-offs in their guidelines for children with obesity and bariatric surgery only when data are available to support their inclusion.
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Cirugía Bariátrica , Diabetes Mellitus Tipo 2 , Derivación Gástrica , Obesidad Mórbida , Obesidad Infantil , Humanos , Adolescente , Femenino , Niño , Masculino , Obesidad Mórbida/cirugía , Obesidad Mórbida/complicaciones , Diabetes Mellitus Tipo 2/complicaciones , Mejoramiento de la Calidad , Complicaciones Posoperatorias , Obesidad Infantil/cirugía , Obesidad Infantil/complicaciones , Cirugía Bariátrica/efectos adversos , Acreditación , Resultado del Tratamiento , Estudios Retrospectivos , Derivación Gástrica/efectos adversos , Gastrectomía/efectos adversosRESUMEN
BACKGROUND: Sleeve gastrectomy (SG) induces weight reduction and improves metabolic co-morbidities in children with severe obesity but remains underutilized, especially for young adolescents and preadolescents. OBJECTIVE: We hypothesized there would be no differences in weight loss or co-morbidity resolution at 1 year post-SG in children who underwent SG at 13 years or younger compared to children who underwent SG at 17-18 years old. SETTING: Academic medical center, United States. METHODS: Medical records of children who underwent laparoscopic SG at a quaternary academic center from September 2014 to October 2022 were reviewed. A cohort of 15 patients, ≤13 years of age, was compared to a matched cohort of 15 older adolescent patients. Preoperative characteristics and postoperative outcomes were collected. RESULTS: Both cohorts had similar baseline characteristics. Median preoperative body mass index (BMI) was 51.8 kg/m2 for the ≤13 cohort compared to 50.9 kg/m2 in the older cohort (P = .87). Time to postoperative enteral feeds and length of stay were similar between both groups, and there were no 30-day readmissions or immediate postoperative complications. Median percentage excess BMI loss at 1 year postoperation was 54% (IQR, 25.5%-94.5%) for the ≤13 cohort compared with 44% (IQR, 34.0%-51.0%) for the older cohort (P = .34). Two of 11 patients were lost to follow-up in the younger group compared to 4 of 15 in the older group (P = .61). Both groups demonstrated significant improvement in metabolic syndrome co-morbidities after SG. CONCLUSION: SG in younger children is associated with successful postsurgical outcomes compared with adolescents, with effective weight loss and improvement of obesity-related metabolic co-morbidities.
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Laparoscopía , Obesidad Mórbida , Obesidad Infantil , Niño , Humanos , Adolescente , Estudios Retrospectivos , Obesidad Infantil/cirugía , Obesidad Infantil/complicaciones , Resultado del Tratamiento , Obesidad Mórbida/complicaciones , Obesidad Mórbida/cirugía , Índice de Masa Corporal , Gastrectomía , Pérdida de PesoRESUMEN
MAJOR UPDATES TO 1991 NATIONAL INSTITUTES OF HEALTH GUIDELINES FOR BARIATRIC SURGERY: Metabolic and bariatric surgery (MBS) is recommended for individuals with a body mass index (BMI) >35 kg/m2, regardless of presence, absence, or severity of co-morbidities.MBS should be considered for individuals with metabolic disease and BMI of 30-34.9 kg/m2.BMI thresholds should be adjusted in the Asian population such that a BMI >25 kg/m2 suggests clinical obesity, and individuals with BMI >27.5 kg/m2 should be offered MBS.Long-term results of MBS consistently demonstrate safety and efficacy.Appropriately selected children and adolescents should be considered for MBS.(Surg Obes Relat Dis 2022; https://doi.org/10.1016/j.soard.2022.08.013 ) © 2022 American Society for Metabolic and Bariatric Surgery. All rights reserved.
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Cirugía Bariátrica , Enfermedades Metabólicas , Obesidad Mórbida , Adolescente , Niño , Humanos , Estados Unidos/epidemiología , Obesidad Mórbida/cirugía , Obesidad/complicaciones , Obesidad/cirugía , Cirugía Bariátrica/métodos , Enfermedades Metabólicas/cirugía , Índice de Masa CorporalRESUMEN
Background: Obesity is a chronic disease which frequently begins in childhood and requires a life-long multidisciplinary approach. Metabolic-bariatric surgery (MBS) is a key component of the treatment of severe obesity in children, adolescents and adults. Children and adolescents who have class II obesity and a complication of obesity or have class III obesity should be considered for MBS, regardless of age, race, sex, or gender. Children and adolescents with cognitive disabilities, a history of mental illness, a treated eating disorder, immature bone growth, or low Tanner Stage should not be denied treatment. Early intervention can reduce the risk of persistent obesity, end organ damage, and sequelae from long-standing complications of obesity. Methods: This roundtable discussion includes three pediatric obesity specialists with experience in the medical and surgical management of children and adolescents with obesity. Included are citations regarding metabolic-bariatric surgery in children and adolescents. Results: MBS in pediatric patients is increasingly recognized as an essential part of managing the disease of obesity in combination with medication, nutrition, behavioral training, and physical activity. Vertical sleeve gastrectomy or Roux-en-Y gastric bypass in patients meeting criteria for severe obesity should be considered, especially when children have complications such as poor quality of life, orthopedic disease, idiopathic intracranial hypertension, type 2 diabetes mellitus, obstructive sleep apnea, or cardiovascular risk. Children and adolescents with autism, developmental delay, or syndromic obesity should be considered for MBS on a case-by-case basis. Early intervention may result in improved long-term outcomes, and referral for MBS should not be conditional based on stage of pubertal development (Tanner Staging), bone age, or prior weight loss attempts. Conclusions: Children and adolescents who suffer from severe obesity need the entire spectrum of treatment modalities available to achieve a healthy weight and control obesity-related complications. This treatment spectrum should include MBS. These children and adolescents should be cared for by a pediatric weight management team prepared to care for them until they transition to adult care.
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BACKGROUND: Pediatric severe obesity is a worldwide health concern. Treatment with metabolic and bariatric surgery can reduce morbidity and mortality. The COVID-19 pandemic not only has had a significant effect on rates of pediatric obesity but also has necessitated a rapid transition to virtual medicine. OBJECTIVE: We aimed to identify and examine adolescent metabolic and bariatric surgery patient participation rates through our program's virtual telehealth programming as compared with prepandemic traditional in-person clinic appointments. SETTING: This study took place at an academic pediatric quaternary care center. METHODS: We evaluated 92 adolescent patients with a total of 2442 unique encounters between January 2018 and July 2021. RESULTS: The rate of attendance was found to be greater for telehealth visits (83.1%) than for in-person appointments (70.5%) for all clinics regardless of appointment type (preoperative versus postoperative). Cancellation rates were lower for telehealth visits (9.9%) than for in-person appointments (22.5%). CONCLUSION: This study provides evidence that telehealth can be implemented successfully in an adolescent metabolic and bariatric surgery program and can improve attendance rates for all provider and appointment subtypes.
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Cirugía Bariátrica , COVID-19 , Obesidad Mórbida , Telemedicina , Adolescente , COVID-19/epidemiología , Niño , Humanos , Obesidad Mórbida/cirugía , PandemiasRESUMEN
Major updates to 1991 National Institutes of Health guidelines for bariatric surgery.
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Cirugía Bariátrica , Enfermedades Metabólicas , Obesidad Mórbida , Estados Unidos , Humanos , Obesidad/complicaciones , Obesidad/cirugía , Enfermedades Metabólicas/cirugía , Obesidad Mórbida/complicaciones , Obesidad Mórbida/cirugíaRESUMEN
Childhood obesity can lead to comorbidities that cause significant decrease in health-related quality of life and early mortality. Recognition of obesity as a disease of polygenic etiology can help deter implicit bias. Current guidelines for treating severe obesity in children recommend referral to a multidisciplinary treatment center that offers metabolic and bariatric surgery at any age when a child develops a body mass index that is greater than 120% of the 95th percentile. Obesity medications and lifestyle counseling about diet and exercise are not adequate treatment for severe childhood obesity. Early referral can significantly improve quality and quantity of life.
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Cirugía Bariátrica/métodos , Índice de Masa Corporal , Laparoscopía/métodos , Obesidad Infantil/cirugía , Calidad de Vida , Niño , HumanosRESUMEN
OBJECTIVES: In this report, we compare weight loss, comorbidity resolution, nutritional abnormalities, and quality of life between younger and older adolescents after metabolic and bariatric surgery. METHODS: From March 2007 to December 2011, 242 adolescents (≤19 years of age) who underwent bariatric surgery at 5 clinical centers in the United States were enrolled in the prospective, multicenter, long-term outcome study Teen-Longitudinal Assessment of Bariatric Surgery. Outcome data from younger (13-15 years; n = 66) and older (16-19 years; n = 162) study participants were compared. Outcomes included percent BMI change, comorbidity outcomes (hypertension, dyslipidemia, and type 2 diabetes mellitus), nutritional abnormalities, and quality of life over 5 years post surgery. RESULTS: Baseline characteristics, except for age, between the 2 cohorts were similar. No significant differences in frequency of remission of hypertension (P = .84) or dyslipidemia (P = .74) were observed between age groups. Remission of type 2 diabetes mellitus was high in both groups, although statistically higher in older adolescents (relative risk 0.86; P = .046). Weight loss and quality of life were similar in the 2 age groups. Younger adolescents were less likely to develop elevated transferrin (prevalence ratio 0.52; P = .048) and low vitamin D levels (prevalence ratio 0.8; P = .034). CONCLUSIONS: The differences in outcome of metabolic and bariatric surgery between younger and older adolescents were few. These data suggest that younger adolescents with severe obesity should not be denied consideration for surgical therapy on the basis of age alone and that providers should consider adolescents of all ages for surgical therapy for obesity when clinically indicated.
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Cirugía Bariátrica , Diabetes Mellitus Tipo 2/terapia , Dislipidemias/terapia , Hipertensión/terapia , Obesidad Infantil/cirugía , Adolescente , Factores de Edad , Índice de Masa Corporal , Comorbilidad , Dislipidemias/epidemiología , Femenino , Humanos , Hipertensión/epidemiología , Masculino , Trastornos Nutricionales/terapia , Obesidad Mórbida/epidemiología , Obesidad Mórbida/cirugía , Prevalencia , Estudios Prospectivos , Calidad de Vida , Inducción de Remisión/métodos , Factores de Tiempo , Transferrina/metabolismo , Resultado del Tratamiento , Estados Unidos/epidemiología , Deficiencia de Vitamina D/epidemiología , Pérdida de Peso , Adulto JovenRESUMEN
BACKGROUND: Studies of patients who have undergone surgery while infected with COVID-19 have shown increased risks for adverse outcomes in both pulmonary complications and mortality. It has become clear that the risk of complications from perioperative COVID-19 infection must be weighed against the risk from delayed surgical treatment. Studies have also shown that prior bariatric surgery conveys protection against mortality from COVID-19 and that obesity is the biggest risk factor for mortality from COVID-19 infection in adults under 45 years of age. Studies in patients who have fully recovered from COVID-19 and underwent elective surgery have not become widely available yet. OBJECTIVES: This multi-institutional case series is presented to highlight patients who developed COVID-19, fully recovered, and subsequently underwent elective bariatric surgery with 30-day outcomes available. SETTING: Nine bariatric surgery centers located across the United States. METHODS: This multicenter case series is a retrospective chart review of patients who developed COVID-19, recovered, and subsequently underwent bariatric surgery. Fifty-three patients are included, and 30-day morbidity and mortality were analyzed. RESULTS: Thirty-day complications included esophageal spasm, dehydration, and ileus. There were no cardiovascular, venous thromboembolism (VTE) or respiratory events reported. There were no 30- day mortalities. CONCLUSIONS: Bariatric surgery has been safely performed in patients who made a full recovery from COVID-19 without increased complications due to cardiovascular, pulmonary, venous thromboembolism, or increased mortality rates.
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Cirugía Bariátrica , COVID-19 , Obesidad Mórbida , Tromboembolia Venosa , Adulto , Cirugía Bariátrica/efectos adversos , Humanos , Obesidad Mórbida/cirugía , Complicaciones Posoperatorias , Estudios Retrospectivos , SARS-CoV-2 , Estados Unidos , Tromboembolia Venosa/etiología , Tromboembolia Venosa/prevención & controlRESUMEN
To ensure successful outcomes in pediatric patients with severe obesity who undergo metabolic and bariatric surgery (MBS), a number of pre-operative patient management options should be considered. This manuscript will review the indications and contraindications of MBS and special considerations for youth who might benefit from MBS. The treatment team conducts a thorough pre-operative evaluation, assessing risks and benefits of surgical intervention, and prepares patients and families to be successful with MBS by providing education about the surgical intervention and lifestyle changes that will be necessary. This article reviews the pre-operative considerations for adolescents with severe obesity who are being considered for MBS, based upon recent clinical practice guidelines.
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Cirugía Bariátrica/normas , Toma de Decisiones Clínicas , Obesidad Mórbida/cirugía , Grupo de Atención al Paciente/normas , Obesidad Infantil/cirugía , Cuidados Preoperatorios/normas , Adolescente , HumanosRESUMEN
A growing number of youth suffer from obesity and in particular severe obesity for which intensive lifestyle intervention does not adequately reduce excess adiposity. A treatment gap exists wherein effective treatment options for an adolescent with severe obesity include intensive lifestyle modification or metabolic and bariatric surgery while the application of obesity pharmacotherapy remains largely underutilized. These youth often present with numerous obesity-related comorbid diseases, including hypertension, dyslipidemia, prediabetes/type 2 diabetes, obstructive sleep apnea, nonalcoholic fatty liver disease, musculoskeletal problems, and psychosocial issues such as depression, anxiety, and social stigmatization. Current pediatric obesity treatment algorithms for pediatric primary care providers focus primarily on intensive lifestyle intervention with escalation of treatment intensity through four stages of intervention. Although a recent surge in the number of Food and Drug Administration-approved medications for obesity treatment has emerged in adults, pharmacotherapy options for youth remain limited. Recognizing treatment and knowledge gaps related to pharmacological agents and the urgent need for more effective treatment strategies in this population, discussed here are the efficacy, safety, and clinical application of obesity pharmacotherapy in youth with obesity based on current literature. Legal ramifications, informed consent regulations, and appropriate off-label use of these medications in pediatrics are included, focusing on prescribing practices and prescriber limits.
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Obesidad Infantil/tratamiento farmacológico , Adolescente , Niño , Humanos , Obesidad Infantil/epidemiología , Resultado del TratamientoRESUMEN
This cross-sectional study compares trends in use of robotic surgery for general surgical procedures among the Veterans Health Administration (VHA), community practice, and academic health centers from 2013 to 2021.
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Procedimientos Quirúrgicos Robotizados , Veteranos , Humanos , Estados Unidos , Salud de los Veteranos , United States Department of Veterans Affairs , Hospitales de Veteranos , Servicios de Salud ComunitariaRESUMEN
The American Society for Metabolic and Bariatric Surgery Pediatric Committee updated their evidence-based guidelines published in 2012, performing a comprehensive literature search (2009-2017) with 1387 articles and other supporting evidence through February 2018. The significant increase in data supporting the use of metabolic and bariatric surgery (MBS) in adolescents since 2012 strengthens these guidelines from prior reports. Obesity is recognized as a disease; treatment of severe obesity requires a life-long multidisciplinary approach with combinations of lifestyle changes, nutrition, medications, and MBS. We recommend using modern definitions of severe obesity in children with the Centers for Disease Control and Prevention age- and sex-matched growth charts defining class II obesity as 120% of the 95th percentile and class III obesity as 140% of the 95th percentile. Adolescents with class II obesity and a co-morbidity (listed in the guidelines), or with class III obesity should be considered for MBS. Adolescents with cognitive disabilities, a history of mental illness or eating disorders that are treated, immature bone growth, or low Tanner stage should not be denied treatment. MBS is safe and effective in adolescents; given the higher risk of adult obesity that develops in childhood, MBS should not be withheld from adolescents when severe co-morbidities, such as depressed health-related quality of life score, type 2 diabetes, obstructive sleep apnea, and nonalcoholic steatohepatitis exist. Early intervention can reduce the risk of persistent obesity as well as end organ damage from long standing co-morbidities.
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Cirugía Bariátrica/normas , Síndrome Metabólico/cirugía , Obesidad Mórbida/cirugía , Obesidad Infantil/epidemiología , Obesidad Infantil/cirugía , Sociedades Médicas/normas , Humanos , Síndrome Metabólico/diagnóstico , Síndrome Metabólico/epidemiología , Obesidad Mórbida/diagnóstico , Obesidad Mórbida/epidemiología , Obesidad Infantil/diagnóstico , Guías de Práctica Clínica como Asunto , Pronóstico , Medición de Riesgo , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
Known complications of Roux-en-Y gastric bypass causing abdominal pain and obstructive symptoms include biliary colic, anastomotic ulcer, anastomotic stenosis, or internal hernia. This case report describes a new complication in a patient 15 months post-bypass: a bezoar at the gastrojejunal anastomosis, the nidus of which was a length of permanent suture material which had eroded through the gastric wall. We include endoscopic images of the bezoar, a review of the related gastric bypass literature, and describe the changes made in our practice as a result of this complication.