Bariatric surgical management of adolescents with morbid obesity.

PURPOSE OF REVIEW: Adolescent obesity continues to be a significant public health issue. To date, there are no medical therapies that provide significant, durable weight loss. Bariatric surgery has been shown in the adult and now the adolescent population to provide a reasonable alternative for weight loss. RECENT FINDINGS: Recent publications have focused on the revision of the current guidelines for bariatric surgery in adolescents to more closely align with their well-established adult counterparts. These guidelines now introduce the establishment of multidisciplinary teams for the care of this subset of adolescent surgical patients. Numerous manuscripts in the past 2-3 years have demonstrated the overall effectiveness of Roux-en-Y gastric bypass, adjustable gastric banding, and most recently sleeve gastrectomy for both significant weight loss and comorbidity reduction with safety profiles similar to those found in adults. Despite these data, a recently published study showed that the trend for adolescent bariatric surgery has been stagnant over a 6-year period. There is also an ongoing shift in the type of procedure performed for morbid obesity in the United States toward sleeve gastrectomy and away from the adjustable gastric band. SUMMARY: With the growing number of morbidly obese adolescents in the United States coupled with the relative ineffectiveness of medical therapy in this group of patients, bariatric surgery consistently provides a means for significant weight loss and the resolution of substantial comorbidities. Its approval is slowly increasing, and the growing fund of knowledge in regard to complication rates and the efficacy of bariatric surgery will ultimately result in its more widespread acceptance.

Contemporary surgical management of the obese adolescent.

PURPOSE OF REVIEW: Adolescent obesity is rapidly becoming a significant public health issue. To date, there are no medical therapies that provide significant and durable weight loss. The surgical treatment of adolescent obesity is a rapidly evolving field. RECENT FINDINGS: Recent publications have focused on the increase in the morbidity and mortality of adolescent obesity into adulthood. There have been significant findings that overweight children and adolescents progress towards severe obesity as adults. Firm guidelines for bariatric surgery in adults have been established for over 15 years, but there have been insufficient data in regards to guidelines for adolescents. The trend has always been to be more conservative, but a recent paper reviews the available literature to establish new guidelines. Adolescents can see a significant amount of weight loss in the first year after bariatric surgery with a resolution of diabetes and other cardiovascular risk factors. Bariatric surgery is well tolerated and effective, but carries with it long-term nutritional deficiencies, which need to be assessed and supplemented. SUMMARY: Given the recent rise in obesity seen in this population, the surgical management of the adolescent has increased in popularity. Bariatric surgery is well tolerated and provides significant weight loss in those who are severely obese.

Crohn's disease limited to the appendix: a case report in a pediatric patient.

In the original description of Crohn's disease, the appendix was not believed to be involved in the inflammatory process. Later on, case reports started to appear in publications demonstrating that the appendix could be involved in the inflammatory changes of Crohn's disease, and it could also be the primary or the sole manifestation of the disease. Being that appendectomies are one of the most common procedures performed by pediatric surgeons, the knowledge about this diagnosis, all be it rare, is important. Our aim was to report a case and discuss the results of our literature review in order to elucidate the probability of a pediatric patient subsequently developing full Crohn's disease and the follow up that is indicated in such patients. A 12-year-old male patient presented with a history of chronic abdominal pain (3-4 times per week) for 1 year, crampy in nature, localized in the left lower quadrant, and associated with diarrhea (2 episodes per day). There were no extraintestinal manifestations of Crohn's, such as arthralgia or uveitis. Important family history included two paternal uncles with ulcerative colitis both of whom currently have stomas. The only abnormal laboratory value in our patient was an elevated fecal calprotectin level. An esophagogastroduodenoscopy and colonoscopy were performed and found to be unremarkable except for the cecum where it appeared that an exudate was emanating from the appendiceal orifice. A magnetic resonance enterography was ordered and showed an enlarged enhancing appendix. An exploratory laparoscopy identified an appendix with macroscopic cobblestone or lymphoid reaction that histologically was consistent with Crohn's disease. It appears that the Crohn's appendix is more indolent than Crohn's disease of the ileum or colon, with a recurrence rate in the largest series of 8%. The interval time from diagnosis to recurrence varied from 1 to 48 months with an average of 19 months. Some authors debate the need of follow up at all in those patients, believing that the appendectomy alone is curative in the majority of patients. Others recommend follow up for up to 5 years.

Neonatal Intestinal Anastomosis Using a 5 mm Laparoscopic Stapler.

Recently, a 5 mm laparoscopic stapler entered the market and is currently used for a wide variety of pediatric applications. The aim of this article is to be the first report of the use of this 5 mm laparoscopic stapler for open neonatal intestinal anastomosis in humans. We used JustRight (Justright Surgical) 5 mm laparoscopic stapler® in 5 patients, with a total of six anastomoses being constructed. Enteroenterostomies after bowel resection were performed in these neonates with diagnoses of closed gastroschisis with ileal atresia, multiple intestinal atresia, ileal atresia, and jejunal atresia. Side-to-side, functional end-to-end, stapled anastomoses were performed in the standard antimesenteric manner. Using 2.5 cm long staple loads, the anastomoses approximated 1.5 cm. Minimal staple line overlap was incurred. Enteral feedings were initiated, and nutritional goals met, on postoperative days 8 and 15.2, respectively (means). Postoperative recovery was uneventful, notably without anastomotic complications of leak or stenosis. No long-term follow-up was done. The 5 mm laparoscopic stapler offers an attractive alternative in open neonatal intestinal anastomosis, particularly in both ease and time of anastomosis. Its more generalized use in neonatal intestinal reconstruction awaits further scientific investigation.

Concurrent testicular torsion and acute incarcerated inguinal hernia in an adolescent boy.

Testicular torsion and acute incarcerated inguinal hernia are both common surgical emergencies in the paediatric population. We present the unusual case of a 16-year-old adolescent boy who presented with both of these conditions concurrently. He had a history of a right inguinal hernia, but ultrasound confirmed a testicular torsion and we employed manual detorsion in the emergency department prior to taking him to the operating room. We successfully salvaged the testicle in addition to performing inguinal hernia reduction and repair. The goal of this report is to emphasise the importance of maintaining a broad differential and early utilisation of ultrasound in the patient with acute groin pain.

Spine Growth Modulation in Early Adolescent Idiopathic Scoliosis: Two-Year Results of Prospective US FDA IDE Pilot Clinical Safety Study of Titanium Clip-Screw Implant.

STUDY DESIGN: Prospective pilot clinical safety study of novel treatment, consecutive case series from first human use in patients with early adolescent idiopathic scoliosis (AIS). OBJECTIVE: The primary purpose was to determine the initial safety of a titanium clip-screw implant system for spine growth modulation. The secondary aim was to document curvatures to 2 years postoperatively. SUMMARY OF BACKGROUND DATA: Spinal growth modulation was documented in preclinical studies. A prospective pilot clinical safety study was then performed under a Food and Drug Administration (FDA) Investigational Device Exemption (IDE) (www.clinicaltrials.gov Identifier: NCT01465295). METHODS: Six subjects with early AIS underwent thoracoscopic placement of titanium clip-screw devices. Eligibility criteria included only patients at high risk for progression to 50°: single major thoracic curve 25°-40°, age ≥10 years, skeletally immature (Risser 0 plus open triradiate cartilages), and if female, premenarchal. Adverse events (AEs), clinical outcomes, and radiographic measures were documented using Good Clinical Practices. RESULTS: Six consecutive subjects were enrolled, three females and three males aged 12.1 years (±1.7). AEs included one that was device related-mild device migration at 18 months in the most rapidly progressive curve. Procedure-related AEs were mostly pulmonary. A chylous effusion that met the clinical protocol definition of a serious AE resolved after minimally invasive interventions. Major thoracic curves were 34° (±3°) preoperatively and 38° (±18°) at two years (intrasubject change, 4° ± 18°). At 24 months, curves in 3 patients were >45° and 3 were <40°. CONCLUSIONS: A spine growth modulation system undergoing study under an FDA IDE was determined to be safe. Variability in curve response to the implant was high, ranging from progression to correction. Investigational approval was granted by the US FDA for the next cohort of 30 subjects.

Rat intubation and ventilation for surgical research.

Effective outcomes in cardiothoracic surgical research using rodents are dependent upon adequate techniques for intubation and mechanical ventilation. Multiple methods are available for intubation of the rat; however, not all techniques are appropriate for survival studies. This article presents a refinement of intubation techniques and a simplified mechanical ventilation setup necessary for intrathoracic surgical procedures using volatile anesthetics. The procedure is defined and complications of the procedure are elucidated that provide a justification for animal numbers needed for initiating new studies. Lewis rats weighing 178-400 g (287 +/- 44) were anesthetized using Enflurane and intubated with a 16-G angiocatheter using transillumination. Mechanical ventilation (85 bpm, 2.5 mL TV, enflurane 1.5-2%) maintained adequate sedation for completion of an intrathoracic procedure. Complications of the intubation and ventilation included mortality from anesthetic overdose, intubation difficulty, pneumothorax, traumatic extubation, and ventilation disconnection. Anesthetic agents and their related effects on the rat heart and reflexes are compared. This article also underscores the importance of refinement, reduction, and replacement in the context of cardiothoracic surgery using rodent models.

Long-term follow-up and the role of surgery in adolescents with morbid obesity.

PURPOSE: Obesity has become a health-care crisis in the United States. Adolescent obesity is now one of the most common childhood disorders, with 4.7 million American adolescents having a body mass index (BMI) greater than the 95th percentile. Most patients do not respond to diet modification or exercise programs and attention is now turning toward surgery as a source of weight loss in adolescents. Few studies have looked at the overall morbidity and mortality of weight loss surgery in this patient population. METHODS: This is a retrospective study of medical charts of 15 bariatric surgical procedures performed on 14 adolescents without known genetic syndromes associated with severe childhood obesity from 1971 to 2001 at the University of Minnesota. Procedures performed on these patients included vertical banded gastroplasty (n = 7), Roux-en-Y gastric bypass (n = 5), and jejunoileal bypass (n = 3). Jejunoileal bypass procedures were performed from 1971 to 1977, after which time this procedure was abandoned. Patient age ranged from 13 to 17 years (mean, 15.7 years). Mean follow-up time was 6 years, with 9 patients available for long-term follow-up. RESULTS: All procedures were performed using an open technique by 1 surgeon. There were no perioperative deaths; complications included 1 case of wound infection, 2 episodes of dumping syndrome that resolved without revision, 1 episode of hypoglycemia, and 1 case of short-term electrolyte imbalance in a patient who underwent jejunoileal bypass. The average BMI dropped from 58.5 +/- 13.7 to 32.1 +/- 9.7 kg/m(2) (P < .01)--a 45% reduction. CONCLUSIONS: Surgery for morbid obesity is safe and results in significant weight loss in adolescents who fail medical therapy.

Patients as partners in innovation.

As the culture of medical practice has evolved, so has the relationship between the physician and patient. This is decidedly true with regards to the introduction of innovative therapies, especially in the surgical arena. A critical challenge is identifying and defining innovative therapy. Is the proposed treatment an incremental change, a research proposal, or more commonly someplace in between? This gray area creates a transition zone commonly referred to as innovative therapy. Given the complexities of the current landscape of innovation, innovation therapy committees may provide a mechanism to help to guide both physicians and patients through such difficult topics as the process of informed consent, managing conflicts of interest, and how to evaluate the outcomes of innovative therapies. As surgical innovation remains critical to the advancement of care, it must occur in a transparent partnership with patients, under the eye of guiding entities, aimed at ultimately improving outcomes and care.

Octreotide does not prevent postoperative pancreatic fistula or mortality following Pancreaticoduodenectomy.

The role of octreotide in preventing pancreatic fistula following pancreaticoduodenectomy (PD) remains controversial. The purpose of our study was to report our experience with octreotide in 266 patients undergoing PD from 1995 to 2002. There were 150 males and 116 females. Patients were divided into two groups. Group 1 did not receive octreotide (N = 61). Group 2 received octreotide (N = 205). The average patient age was 66.2 years in the control group and 63.6 years in the octreotide group. One hundred fifty patients were male and 116 were female. Thirty-day mortality for both groups was 1.9 per cent. The incidence of pancreatic fistula was 12 per cent. Fistula occurrence in the octreotide group was 13 per cent and in the no-octreotide group 8 per cent (P = 0.34). Common complications in the no-octreotide group were pancreatic leak (10%), pancreatic fistula (8%), and delayed gastric emptying (8%). Common complications in the octreotide group were pancreatic leak (18%), pancreatic fistula (13%), intra-abdominal abscess (7%), and arrhythmia or myocardial infarction (7%). The only statistically different variable was the incidence of arrhythmia or myocardial infarction (P = 0.026). Octreotide did not reduce pancreatic fistula, other complications, or mortality. Octreotide may contribute cardiac morbidity. Octreotide cannot be recommended to prevent mortality or postoperative complications after PD.

Perioperative outcomes of adolescents undergoing bariatric surgery: the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study.

IMPORTANCE: Severe obesity in childhood is a major health problem with few effective treatments. Weight-loss surgery (WLS) is being used to treat severely obese adolescents, although with very limited data regarding surgical safety for currently used, minimally invasive procedures. OBJECTIVE: To assess the preoperative clinical characteristics and perioperative safety outcomes of severely obese adolescents undergoing WLS. DESIGN, SETTING, AND PARTICIPANTS: This prospective, multisite observational study enrolled patients from February 28, 2007, through December 30, 2011. Consecutive patients aged 19 years or younger who were approved to undergo WLS (n = 277) were offered enrollment into the study at 5 academic referral centers in the United States; 13 declined participation and 22 did not undergo surgery after enrollment, thus the final analysis cohort consisted of 242 individuals. There were no withdrawals. MAIN OUTCOMES AND MEASURES: This analysis examined preoperative anthropometrics, comorbid conditions, and major and minor complications occurring within 30 days of operation. All data were collected in a standardized fashion. Reoperations and hospital readmissions were adjudicated by independent reviewers to assess relatedness to the WLS procedure. RESULTS: The mean (SD) age of participants was 17.1 (1.6) years and the median body mass index (calculated as weight in kilograms divided by height in meters squared) was 50.5. Fifty-one percent demonstrated 4 or more major comorbid conditions. Laparoscopic Roux-en-Y gastric bypass, vertical sleeve gastrectomy, and adjustable gastric banding were performed in 66%, 28%, and 6% of patients, respectively. There were no deaths during the initial hospitalization or within 30 days of operation; major complications (eg, reoperation) were seen in 19 patients (8%). Minor complications (eg, readmission for dehydration) were noted in 36 patients (15%). All reoperations and 85% of readmissions were related to WLS. CONCLUSIONS AND RELEVANCE: In this series, adolescents with severe obesity presented with abundant comorbid conditions. We observed a favorable short-term complication profile, supporting the early postoperative safety of WLS in select adolescents. Further longitudinal study of this cohort will permit accurate assessment of long-term outcomes for adolescents undergoing bariatric surgery. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00474318.

Pediatric hernia repair: 1-stop shopping.

PURPOSE: Multiple visits for the evaluation, treatment, and follow-up of straightforward surgical problems are inconvenient, can result in lost work for the parents, and missed school for the child. We hypothesized that with proper previsit screening, patients with select diagnoses can be evaluated in an outpatient clinic setting and undergo operation the same day. METHODS: Criteria were developed to identify straightforward referrals to our surgical practice for umbilical, epigastric, or inguinal hernias. Scripting was created to offer families the option of consultation and, if indicated, surgical treatment on the same day. Data collected included number of patients, cases performed, insurance status, and consultation reimbursement and surgical fees. Families were surveyed postoperatively. RESULTS: Sixty-one patient candidates participated. The diagnosis and indication for surgery were confirmed in 56 (92%), of which 50 underwent repair the day of their consultation. Seventy-two percent of patients had commercial insurance, whereas 28% had Medicaid. The preoperative consultation fee was reimbursed in 39 (78%) of 50 encounters (57% Medicaid, 86% commercial). All surgical cases were reimbursed. Patient and family satisfaction was high. CONCLUSIONS: We conclude that it is feasible to provide same-day evaluation and service for straightforward pediatric hernias with acceptable financial reimbursement and high parent satisfaction.

Distance to clinic and follow-up visit compliance in adolescent gastric bypass cohort.

BACKGROUND: Regular follow-up after bariatric surgery is important to assess the clinical status. Various factors could influence retention (i.e., compliance with clinical follow-up). The present analysis tested the hypothesis that the distance from the center will influence clinical retention for adolescent bariatric surgery patients. Our aim was to determine whether the distance to the clinic, and other patient characteristics, would predict clinical follow-up compliance. The present study was conducted at a tertiary care, free-standing children's hospital. METHODS: The Follow-up of Adolescent Bariatric Surgery (FABS) study is a single-center cohort study collecting demographic and clinical information. The subjects' addresses were geocoded, and the distance to the clinic was calculated. A generalized estimating equations model was used to examine follow-up visit compliance. RESULTS: A total of 71 subjects underwent Roux-en-Y gastric bypass surgery (RYGB), with a mean body mass index of 59 kg/m(2). The average distance to the clinic was 98 miles. Retention declined over time (6 mo, 94%; 1 yr, 89%; 2 yr, 69%; P < .01); however, distance was not associated with retention (P = .68). Age at surgery was inversely related to retention (P = .04). CONCLUSION: Compliance with clinical follow-up decreased 1 and 2 years after RYGB in adolescents. The distance from the center was not associated with follow-up regimen compliance. However, increasing age was associated with decreased retention. Additional research should focus on determining the modifiable factors that influence retention.

Safety and immunogenicity of Salmonella typhimurium expressing C-terminal truncated human IL-2 in a murine model.

Salmonella enterica serovar Typhimurium preferentially colonizes tumors in vivo and has proven to be an effective biologic vector. The attenuated S. enterica Typhimurium strain chi4550 was engineered to express truncated human interleukin-2 and renamed SalpIL2. Previously, we observed that a single oral administration of SalpIL2 reduced tumor number and volume, while significantly increasing local and systemic natural killer (NK) cell populations in an experimental metastasis model. Here we report that in nontumor-bearing mice, a single oral dose of SalpIL2 resulted in increased splenic cytotoxic T and NK cell populations that returned to control levels by 4 weeks post oral administration. Though SalpIL2 was detected in mouse tissues for up to 10 weeks, no prolonged alterations in peripheral blood serum chemistry or complete blood cell counts were observed. Similarly, comparative histopathological analysis of tissues revealed no significant increase in pyogranulomas in SalpIL2-treated animals with respect to saline controls. In Rag-1 knockout mice, which have severely impaired B and T cell function, SalpIL2 reduced growth of hepatic metastases. Furthermore, SalpIL2 altered expression of several proinflammatory cytokines and chemokines in the serum of mice with pulmonary osteosarcoma metastases. These data further suggest that SalpIL2 is avirulent and induces a cell-mediated antitumor response.

Decompressive abdominal laparotomy for abdominal compartment syndrome in an unengrafted bone marrow recipient with septic shock.

Objective. To describe a profoundly immunocompromised (panleukopenia) child with septic shock who developed abdominal compartment syndrome (ACS) and was successfully treated with surgical decompression. Design. Individual case report. Setting. Pediatric intensive care unit of a tertiary children's hospital. Patient. A 32-month-old male with Fanconi anemia who underwent bone marrow transplantation (BMT) 5 days prior to developing septic shock secondary to Streptococcus viridans and Escherichia coli ACS developed after massive fluid resuscitation, leading to cardiopulmonary instability. Interventions. Emergent surgical bedside laparotomy and silo placement. Measurements and Main Results. The patient's cardiopulmonary status stabilized after decompressive laparotomy. The abdomen was closed and the patient survived to hospital discharge without cardiac, respiratory, or renal dysfunction. Conclusions. The use of laparotomy and silo placement in an unengrafted BMT patient with ACS and septic shock did not result in additional complications. Surgical intervention for ACS is a reasonable option for high risk, profoundly immunocompromised patients.

Preserved vision without growth retardation after laparoscopic Roux-en-Y gastric bypass in a morbidly obese child with pseudotumor cerebri: 36-month follow-up.

A 12-year-old boy presented with a weight of 136 kg and a history of progressive vision loss associated with unremitting pseudotumor cerebri requiring bilateral optic nerve sheath decompression. He underwent laparoscopic Roux-en-Y gastric bypass (RYGBP) without complication. At 36 months post-RYGBP, he has grown 5 cm since the time of surgery, his weight is 6.8 kg above his postoperative nadir weight of 68.2 kg, and his visual acuity has improved with OD 20/100 (preoperative, 20/200) and OS 20/70 (preoperative, 20/100). This case suggests that RYGBP can be performed safely and without stopping linear growth in carefully selected children.

Pulmonary embolism associated with a vacuum-induced arm compartment syndrome: a setting for increased vigilance.

Vacuum injuries, otherwise known as negative pressure injuries, are unique mechanisms of traumatic injury. There are few reports of this mechanism in the literature and, although rare, familiarity with the presentation and management is essential to be life and limb saving. In addition, because of the severe inflammatory process, the potential is increased for life-threatening thrombosis and embolism. This is a case of a circumferential vacuum injury to the arm requiring fasciotomy complicated by development of pulmonary embolism. We describe treatment, postoperative management and a review of the relevant literature.