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Bariatric surgery in morbidly obese adolescents
International Journal of Surgery 36 (2016) 330e331
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Letter to the Editor
Bariatric surgery in morbidly obese adolescents
Keywords: Bariatric surgery Cardiorespiratory fitness Functional capacity Children
Gastric bypasses and Laparoscopic Sleeve Gastrectomies are standardized procedures. Bariatric Surgery in adolescents remains a controversial topic with lack of consensus among experts. The few published studies present conflicting results. Most of the studies do not focus on the other aspects of the surgery, such as psychosocial and interpersonal effects [1]. When taking these last elements into consideration, bariatric surgery might be more beneficial on vital functions in adolescents compared to adults. In medical literature, studies about monitoring VO2max in post bariatric surgery adults are scarce. The lack of clinical data keeps us from comparing the efficiency of bariatric surgery in the adult and adolescent population. In a recent study by Brissman and al followed 41 adolescents who underwent Roux-en-Y Gastric Bypasses (RYGB) [2]. Cardiorespiratory fitness, body composition and functional capacity were measured and analysed. The authors identified a 62% VO2max improvement per kilogram of body mass and 21% per kilogram of fat free mass. The enhancement in VO2max reinforces the hypothesis of a more efficient bariatric surgery in adolescents than in adults. However, if sufficient data were made available on these elements, we could recommend bariatric surgery in adolescents. Up until now, undergoing bariatric surgery in adolescence was a real challenge due to the lack of literature on post-surgery complications [3e5], more so in RYGB surgery. Recently, a study of 77 patients in a children's hospital setting with a baseline BMI (Body Mass Index) of 59 kg/m2, showed that intraoperative complications were seen in two (3%), perioperative complications were seen in 22% of patients within 30 days, whereas 13% showed a complication between 31 and 90 days. The most common types of postoperative complications included gastrojejunal anastomotic stricture (17%), anastomotic leak (7%), dehydration (7% [6]) and reoperation (13%). The Teen-LABS (Teen-Longitudinal Assessment of Bariatric Surgery) study, a multicenter prospective investigation of postoperative complications in 161 adolescents who underwent RYGB [7], recently published its findings. Data was collected at day 30 and between 1 month until 3 years post-surgery. The most
common complications requiring surgery was cholecystectomy in 15 of the adolescent patients, gastrojejunal anastomotic stricture occurred in 6 patients, anastomotic leak in 3 patients, bleeding in 4 patients requiring transfusion, gastrostomy in 4 patients and another 4 patients required exploratory laparotomy. “The most significant long-term complications of adolescent bariatric surgery are nutritional deficiencies, which have been associated with all three types of bariatric surgery procedures” [8]. Other contributors to postoperative nutritional deficiencies in the adolescent group included: reduced food intake, poor adherence with supplement regimens, and altered digestion and absorption. One adolescent study found that the mean rate of treatment adherence during the 6-month study was 30%, which is a specific challenge within the adolescent group [9]. Also, Teen-LABS data showed that 37% of patients were vitamin D deficient at baseline and 43% of RYGB and VSG patients remained deficient for 3 years. However, on the contrary, Vitamin B12 deficiency had a statistically significant increase 3 years after the surgery, 1% at baseline versus 8% after 3 years (P < 0.005). Additionally, low ferritin levels were seen in 5% of patients at baseline compared with 57% 3 years after surgery (P < 0.001). Also, there was an 8% increase in vitamin A deficiency 3 years post-surgery (6% vs.13%) [6]. All these findings require further investigation of bariatric surgery in adolescents. Ethical approval None. Sources of funding None. Author contribution Olivier TIffet. François Varlet. Rani Kassir. Manuel Lopez. Radwan Kassir. All Authors contributed equally to the preparation, writing and review of this manuscript. Declaration of interest The authors have no conflicts of interests to declare in relation to this article.
http://dx.doi.org/10.1016/j.ijsu.2016.11.087 1743-9191/© 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
Letter to the Editor / International Journal of Surgery 36 (2016) 330e331
Talal Alamri, Olivier Tiffet Department of General Surgery, CHU Hospital, Jean Monnet University, Saint Etienne, France
Guarantor Radwan Kassir.
François Varlet Department of Pediatric Surgery, CHU Hospital, Jean Monnet University, Saint Etienne, France
References [1] K. Willcox, N. Warren, P. O'Brien, et al., Patient and parent perspectives of adolescent laparoscopic adjustable gastric banding (LAGB), Obes. Surg. (2016), http://dx.doi.org/10.1007/s11695-016-2156-6. [2] M. Brissman, K. Ekbom, E. Hagman, et al., Physical fitness and body composition two years after roux-en-Y gastric bypass in adolescents, Obes. Surg. (2016), http://dx.doi.org/10.1007/s11695-016-2282-1. [3] Update on adolescent bariatric surgery, Endocrinol. Metab. Clin. N. Am., Volume 45, Issue 3,Pages 667e676, Nirav K. Desai, Mark L. Wulkan, Thomas H. Inge. [4] J.E. Varela, M.W. Hinojosa, N.T. Nguyen, Perioperative outcomes of bariatric surgery in adolescents compared with adults at academic medical centers, Surg. Obes. Relat. Dis. 3 (5) (2007) 537e540. [5] G.F. Paulus, L.E.G. de Vaan, F.J. Verdam, et al., Bariatric surgery in morbidly obese adolescents: a systematic review and meta-analysis, Obes. Surg. 2 (5) (2015) 860e878. [6] G. Miyano, T.M. Jenkins, S.A. Xanthakos, et al., Perioperative outcome of laparoscopic Roux-en-Y gastric bypass: a children's hospital experience, J. Pediatr. Surg. 48 (10) (2013) 2092e2098. [7] T.H. Inge, M.H. Zeller, T.M. Jenkins, et al., Perioperative outcomes of adolescents undergoing bariatric surgery: the teen-longitudinal assessment of bariatric surgery (Teen-LABS) study, JAMA Pediatr. 168 (1) (2014) 47e53. [8] N.K. Desai, M.L. Wulkan, T.H. Inge, Update on adolescent bariatric surgery, Endocrinol. Metab. Clin. North Am. 45 (3) (2016 Sep) 667e676. [9] A.C. Modi, M.H. Zeller, S.A. Xanthakos, et al., Adherence to vitamin supplementation following adolescent bariatric surgery, Obes. (Silver Spring) 21 (3) (2013) E190eE195.
331
Rani Kassir Department of General Surgery, CHU Hospital, Jean Monnet University, Saint Etienne, France Manuel Lopez Department of Pediatric Surgery, CHU Hospital, Jean Monnet University, Saint Etienne, France Radwan Kassir* Department of General Surgery, CHU Hospital, Jean Monnet University, Saint Etienne, France *
Corresponding author. Department of Bariatric Surgery, CHU Hospital, Jean Monnet University, Avenue Albert Raimond, 42270, Saint Etienne, France. E-mail address: [email protected] (R. Kassir). 10 November 2016 Available online 17 November 2016
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Letter to the Editor
Bariatric surgery in morbidly obese adolescents
Keywords: Bariatric surgery Cardiorespiratory fitness Functional capacity Children
Gastric bypasses and Laparoscopic Sleeve Gastrectomies are standardized procedures. Bariatric Surgery in adolescents remains a controversial topic with lack of consensus among experts. The few published studies present conflicting results. Most of the studies do not focus on the other aspects of the surgery, such as psychosocial and interpersonal effects [1]. When taking these last elements into consideration, bariatric surgery might be more beneficial on vital functions in adolescents compared to adults. In medical literature, studies about monitoring VO2max in post bariatric surgery adults are scarce. The lack of clinical data keeps us from comparing the efficiency of bariatric surgery in the adult and adolescent population. In a recent study by Brissman and al followed 41 adolescents who underwent Roux-en-Y Gastric Bypasses (RYGB) [2]. Cardiorespiratory fitness, body composition and functional capacity were measured and analysed. The authors identified a 62% VO2max improvement per kilogram of body mass and 21% per kilogram of fat free mass. The enhancement in VO2max reinforces the hypothesis of a more efficient bariatric surgery in adolescents than in adults. However, if sufficient data were made available on these elements, we could recommend bariatric surgery in adolescents. Up until now, undergoing bariatric surgery in adolescence was a real challenge due to the lack of literature on post-surgery complications [3e5], more so in RYGB surgery. Recently, a study of 77 patients in a children's hospital setting with a baseline BMI (Body Mass Index) of 59 kg/m2, showed that intraoperative complications were seen in two (3%), perioperative complications were seen in 22% of patients within 30 days, whereas 13% showed a complication between 31 and 90 days. The most common types of postoperative complications included gastrojejunal anastomotic stricture (17%), anastomotic leak (7%), dehydration (7% [6]) and reoperation (13%). The Teen-LABS (Teen-Longitudinal Assessment of Bariatric Surgery) study, a multicenter prospective investigation of postoperative complications in 161 adolescents who underwent RYGB [7], recently published its findings. Data was collected at day 30 and between 1 month until 3 years post-surgery. The most
common complications requiring surgery was cholecystectomy in 15 of the adolescent patients, gastrojejunal anastomotic stricture occurred in 6 patients, anastomotic leak in 3 patients, bleeding in 4 patients requiring transfusion, gastrostomy in 4 patients and another 4 patients required exploratory laparotomy. “The most significant long-term complications of adolescent bariatric surgery are nutritional deficiencies, which have been associated with all three types of bariatric surgery procedures” [8]. Other contributors to postoperative nutritional deficiencies in the adolescent group included: reduced food intake, poor adherence with supplement regimens, and altered digestion and absorption. One adolescent study found that the mean rate of treatment adherence during the 6-month study was 30%, which is a specific challenge within the adolescent group [9]. Also, Teen-LABS data showed that 37% of patients were vitamin D deficient at baseline and 43% of RYGB and VSG patients remained deficient for 3 years. However, on the contrary, Vitamin B12 deficiency had a statistically significant increase 3 years after the surgery, 1% at baseline versus 8% after 3 years (P < 0.005). Additionally, low ferritin levels were seen in 5% of patients at baseline compared with 57% 3 years after surgery (P < 0.001). Also, there was an 8% increase in vitamin A deficiency 3 years post-surgery (6% vs.13%) [6]. All these findings require further investigation of bariatric surgery in adolescents. Ethical approval None. Sources of funding None. Author contribution Olivier TIffet. François Varlet. Rani Kassir. Manuel Lopez. Radwan Kassir. All Authors contributed equally to the preparation, writing and review of this manuscript. Declaration of interest The authors have no conflicts of interests to declare in relation to this article.
http://dx.doi.org/10.1016/j.ijsu.2016.11.087 1743-9191/© 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
Letter to the Editor / International Journal of Surgery 36 (2016) 330e331
Talal Alamri, Olivier Tiffet Department of General Surgery, CHU Hospital, Jean Monnet University, Saint Etienne, France
Guarantor Radwan Kassir.
François Varlet Department of Pediatric Surgery, CHU Hospital, Jean Monnet University, Saint Etienne, France
References [1] K. Willcox, N. Warren, P. O'Brien, et al., Patient and parent perspectives of adolescent laparoscopic adjustable gastric banding (LAGB), Obes. Surg. (2016), http://dx.doi.org/10.1007/s11695-016-2156-6. [2] M. Brissman, K. Ekbom, E. Hagman, et al., Physical fitness and body composition two years after roux-en-Y gastric bypass in adolescents, Obes. Surg. (2016), http://dx.doi.org/10.1007/s11695-016-2282-1. [3] Update on adolescent bariatric surgery, Endocrinol. Metab. Clin. N. Am., Volume 45, Issue 3,Pages 667e676, Nirav K. Desai, Mark L. Wulkan, Thomas H. Inge. [4] J.E. Varela, M.W. Hinojosa, N.T. Nguyen, Perioperative outcomes of bariatric surgery in adolescents compared with adults at academic medical centers, Surg. Obes. Relat. Dis. 3 (5) (2007) 537e540. [5] G.F. Paulus, L.E.G. de Vaan, F.J. Verdam, et al., Bariatric surgery in morbidly obese adolescents: a systematic review and meta-analysis, Obes. Surg. 2 (5) (2015) 860e878. [6] G. Miyano, T.M. Jenkins, S.A. Xanthakos, et al., Perioperative outcome of laparoscopic Roux-en-Y gastric bypass: a children's hospital experience, J. Pediatr. Surg. 48 (10) (2013) 2092e2098. [7] T.H. Inge, M.H. Zeller, T.M. Jenkins, et al., Perioperative outcomes of adolescents undergoing bariatric surgery: the teen-longitudinal assessment of bariatric surgery (Teen-LABS) study, JAMA Pediatr. 168 (1) (2014) 47e53. [8] N.K. Desai, M.L. Wulkan, T.H. Inge, Update on adolescent bariatric surgery, Endocrinol. Metab. Clin. North Am. 45 (3) (2016 Sep) 667e676. [9] A.C. Modi, M.H. Zeller, S.A. Xanthakos, et al., Adherence to vitamin supplementation following adolescent bariatric surgery, Obes. (Silver Spring) 21 (3) (2013) E190eE195.
331
Rani Kassir Department of General Surgery, CHU Hospital, Jean Monnet University, Saint Etienne, France Manuel Lopez Department of Pediatric Surgery, CHU Hospital, Jean Monnet University, Saint Etienne, France Radwan Kassir* Department of General Surgery, CHU Hospital, Jean Monnet University, Saint Etienne, France *
Corresponding author. Department of Bariatric Surgery, CHU Hospital, Jean Monnet University, Avenue Albert Raimond, 42270, Saint Etienne, France. E-mail address: [email protected] (R. Kassir). 10 November 2016 Available online 17 November 2016