Surgical Endoscopy

, Volume 26, Issue 11, pp 3094–3100

Laparoscopic sleeve gastrectomy in adult and pediatric obese patients: a comparative study

Authors

    • Department of Surgery, College of MedicineKing Saud University, Obesity Chair
  • Hussam Alamri
    • Department of Surgery, College of MedicineKing Saud University
  • Mohamed Elahmedi
    • Department of Surgery, College of MedicineKing Saud University
  • Rafiuddin Mohammed
    • Department of Surgery, College of MedicineKing Saud University
Article

DOI: 10.1007/s00464-012-2345-x

Cite this article as:
Alqahtani, A., Alamri, H., Elahmedi, M. et al. Surg Endosc (2012) 26: 3094. doi:10.1007/s00464-012-2345-x

Abstract

Background

Laparoscopic sleeve gastrectomy (LSG) is a recent bariatric procedure that has gained widespread popularity in morbidly obese adults. However, pediatric bariatric surgery is controversial, and the type(s) of bariatric surgery that are suitable for children and adolescents is under debate. No studies exit that compare LSG outcomes in adult and pediatric patients. We reviewed our experience to assess the safety, efficacy, and complications of LSG in adult and pediatric morbidly obese patients.

Methods

A retrospective review of all patients who underwent LSG by a single surgeon between March 2008 and February 2011 was performed. The 222 patients included 108 pediatric patients aged 21 years or younger and 114 adult patients older than 21 years. Baseline, operative, perioperative, and available follow-up data were abstracted.

Results

Pediatric patients had a mean age of 13.9 ± 4.3 years and a mean baseline body mass index (BMI) of 49.6 kg/m2, whereas adults had a mean age of 32.2 ± 9.4 years and a mean baseline BMI of 48.3 kg/m2. Our pediatric group achieved a mean percent of excess weight loss (%EWL) of 32.4, 52.1, 65.8, and 64.9 % at 3, 6, 12, and 24 months postoperative, respectively, compared with a mean %EWL of 30.9, 55.2, 68.5, and 69.7 %, respectively, in our adult group (p > 0.05). During the 24-month follow-up period, pediatric patients attended 71.7 % of follow-up visits, whereas adults attended 61.2 % of follow-up visits (p = 0.01). Postoperative complications occurred in six (5.6 %) and eight (7 %) pediatric and adult patients, respectively.

Conclusions

Laparoscopic sleeve gastrectomy in the pediatric age group is of similar safety and effectiveness compared with adults. Pediatric patients had fewer major complications and were more compliant with follow-up than adults. Nevertheless, long-term results are required to further clarify the safety and effectiveness of LSG in pediatric patients.

Keywords

BariatricPediatricsAdultSleeve gastrectomyLaparoscopic

The global obesity epidemic has become one of the major health problems facing the world today. Obesity among children and adolescents is increasing dramatically; for example, the prevalence of obesity in children in the United States increased from 4 to 13 % between 1965 and 1999. Prevalence in adolescents nearly tripled from 5 to 14 % between 1970 and 1999 [1]. Furthermore, in the United States 32 % of children and adolescents aged 2 through 19 years were either overweight or obese, of whom 17 % were obese [1].

Many studies have demonstrated the immediate and long-term health effects of obesity in children and adolescents [2]. Multiple life-threatening conditions are associated with obesity in this age group, including insulin resistance and diabetes, obstructive sleep apnea (OSA), nonalcoholic fatty liver disease, dyslipidemia, and metabolic syndrome [35]. As the prevalence of childhood obesity increases, the prevalence of obesity-related comorbidities also increases. For example, the incidence of type 2 diabetes in children increased nearly tenfold from 1982–1994 [6].

Obese children carry this risk into adulthood, and it is estimated that 42–64 % of obese school-age children will become obese adults [7]. In addition, obese children suffer from reduced quality of life compared with their nonobese peers [8].

Importantly, adolescents who were overweight between the ages of 14 and 19 years had increased mortality after the age of 30 years compared with normal-weight adolescents [9]. Therefore, it is extremely important to recognize and treat childhood obesity. Obesity treatment comprises a multidisciplinary approach that intends to reduce weight, resolve or improve medical comorbidities, and improve quality of life.

However, nonsurgical treatments typically have poor results [1013]. Bariatric surgery is now considered the most effective treatment for morbidly obese adults and is proven to be superior to nonsurgical treatments [14]. Pediatric bariatric surgery remains controversial, however, due to concerns about safety, effectiveness, the ability of this age group to comply with postoperative monitoring visits, and the possibility for long-term complications and adverse effects on growth and maturation that may be associated with bariatric surgery. In addition, the type(s) of bariatric surgery that is suitable for children and adolescents is under debate.

Bariatric surgery has been performed in adolescents for more than 40 years and was initially considered only for extreme cases. However, with the rising obesity epidemic in this age group, and successful outcomes following bariatric surgery in adults, the annual volume of bariatric surgery in adolescents increased threefold between 2000 and 2003 [15]. Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic adjustable gastric banding (LAGB) have both been reported as achieving a clinically significant and sustained weight loss in morbidly obese adolescents, in addition to producing clinically significant resolution of comorbidities [16]. Laparoscopic sleeve gastrectomy (LSG) is a recent bariatric procedure that has gained widespread popularity in adults and is reported to result in significant weight loss, resolution of comorbidities, and a low complication rate [17]. To date and apart from our personal experience [18], the use of LSG in children and adolescents has been limited to few case reports [1923].

The increased use of LSG in children and adolescents warrants a comparison of LSG outcomes in adult and pediatric patients. Accordingly, we performed a retrospective review of the safety and effectiveness of LSG in adult and pediatric morbidly obese patients during up to 24 months of follow-up.

Methods

A retrospective review of clinical data from adult patients ≥22 years of age and pediatric patients <22 years of age who underwent LSG by a single surgeon at King Saud University (KSU) Hospitals in Riyadh, Saudi Arabia, between March 2008 and February 2011, was performed. Baseline, operative, perioperative, and available follow-up data were abstracted.

A multidisciplinary team, including nurses, pediatricians or bariatric medicine, dieticians, health educators, psychologists, and surgeons, assessed patient eligibility. Patient requirements included: (1) body mass index (BMI) of at least 40 kg/m2, or 35 kg/m2 with an associated comorbidity, or BMI for age and gender ≥99 percentile in patients younger than aged 20 years; (2) failure to achieve clinically significant weight loss (10 % of baseline body weight) despite participation for at least 6 months in a formal weight management program; (3) written, informed, assent/consent, with concomitant parental consent for patients younger than aged <17 years, after being thoroughly counseled on the surgical procedure, its investigational nature, which includes lack of information on long-term effects, the possibility of long-term weight gain, mechanisms of weight loss, potential complications and risks, postsurgery dietary requirements, and nutritional and vitamin supplement recommendations; and (4) positive results from a psychological evaluation of motivation for surgery and commitment to and potential for compliance with follow-up visits and lifestyle and dietary regimens.

Surgical technique

The LSG procedure as previously described was followed, which includes a standardized perioperative protocol [24, 25]. Patients were positioned in the reverse Trendelenburg French position and a five-trocar approach was used. The abdominal cavity is insufflated with carbon dioxide to a pressure of 15 mmHg using a 10-mm optic port placed at or within a variable distance above the umbilicus based on patient’s age. This port serves as the camera trocar. Four additional trocars are placed under laparoscopic view. The greater curvature is freed close to the stomach wall beginning approximately 2 cm proximal to the pylorus to the angle of His using a Ligasure device (Valleylab, USA) The left crus is then dissected and the angle of His is delineated. Posterior adhesions to the pancreas are lysed. A 36-Fr Calibrating tube (34-Fr for patients younger than age 12 years) is placed transorally and carefully advanced through the pylorus to the duodenum. At 3–4 cm of from the pylorus, the stomach is divided by using a linear stapler (Echelon 60 Disposable, Ethicon, Endo-Surgery, Inc., Cincinnati, OH). A green load (4.1 mm) followed by gold (3.8 mm) and blue loads (3.5 mm) are used for all patients, except for those younger than age 12 years with thinner stomach in whom only gold and blue loads are used. There is no routine staple line reinforcement or routine drain placement. The resected stomach is then extracted through the 12-mm port site.

Hypertension, diabetes, and dyslipidemia were diagnosed by using standard definitions [2630]. Baseline studies included fasting serum lipid profile, standard oral glucose tolerance test (OGTT), or fasting plasma glucose (FPG) and hemoglobin A1C. Sleep studies were performed for all pediatric patients and for all symptomatic adult patients. Outcomes regarding OSA were related to symptom resolution rather than objective results of repeated sleep studies. At each follow-up visit, blood pressure measurements, OGTT, fasting plasma glucose, hemoglobin A1C levels, and fasting lipid profiles were acquired as indicated to monitor status of comorbid conditions.

Follow-up visits were scheduled for 3, 6, and 12 months postoperatively, and annually thereafter. Each visit included evaluation of weight loss, resolution of comorbidities, and development of complications. The study received approval of the KSU Institutional Review Board.

Calculations and summary statistics

Weight loss in both groups is expressed as the actual weight loss, the percentage of weight loss, the percentage of excess weight loss (%EWL; (preoperative weight − follow-up weight)/(preoperative weight − ideal weight) × 100), and the percentage of excess BMI loss (%EBL; (preoperative BMI − follow-up BMI)/(preoperative BMI − ideal BMI) × 100). In the adult group, the ideal weight was calculated according to the Metropolitan Height and Weight Tables, and ideal BMI was defined as a BMI of 25 kg/m2 [31]. In the pediatric group, ideal weight and ideal BMI were calculated from BMI corresponding to 85 percentile for age and gender using CDC growth charts [32]. Groups were compared using Student’s t test for continuous variables and Chi-square or Fisher’s exact test for categorical variables, with p < 0.05 achieving statistical significance.

Results

LSG was performed on 108 pediatric patients aged 5–21 years (mean 13.9 ± 4.3) and 114 adult patients aged 22–55 years (mean 32.2 ± 9.4; Table 1). There were significantly more female patients in the adult group (65.8 %) compared with the pediatric group (50.9 %; p = 0.03). Mean preoperative BMI was 49.6 ± 11.5 in the pediatric group and 48.3 ± 8.8 in the adult group (not significant). Comorbidity prevalences were similar between groups. In the pediatric group, 13 patients had cognitive disabilities: Prader–Willi syndrome (n = 7), Bradet–Biedl syndrome (n = 2), mental retardation (n = 3), and Down’s syndrome (n = 1).
Table 1

Baseline demographics and characteristics of adult and pediatric patients undergoing laparoscopic sleeve gastrectomy

 

Pediatric (n = 108)

Adult (n = 114)

P value

Age (year)

13.9 ± 4.3 (5–21)

32.2 ± 9.4 (22–55)

<0.001

Female (%)

50.9

65.8

0.03

BMI (kg/m2)

49.6 ± 11.5

48.3 ± 8.8

NS

Diabetes (%)a

16 (16.2)

18 (21.2)

NS

Hypertension (%)a

36 (36.4)

27 (31.8)

NS

Dyslipidemia (%)a

30 (30.3)

38 (44.7)

NS

Symptoms of obstructive sleep apnea (%)a

22 (22.2)

16 (18.8)

NS

BMI body mass index, NS no statistical difference between groups (p > 0.05)

aPatients with condition at baseline who have preoperative and at least one postoperative visit with clinical and laboratory data available

Ninety-nine pediatric patients (91.7 %; 9 patients were lost to follow-up) and 85 adult patients (74.6 %; 13 had surgery less than 3 months at the time of analysis; 16 had insufficient follow-up records) with available postoperative data were included in our analysis.

Weight-loss outcome measures are listed in Table 2. At 6 months, 32 of 76 (42 %) pediatric patients achieved %EWL ≥ 50 %, compared with 23 of 43 (53 %) adult patients (p > 0.05), which increased to 73 and 84 %, respectively, at 12 months (p > 0.05). At 6 and 12 months, seven pediatric and three adult patients failed to achieve %EWL of 25 %. Thirteen patients with Prader–Willi syndrome, Bradet–Biedl syndrome, mental retardation, and Down’s syndrome had %EBL of 37.0 ± 11.3, 46.2 ± 17.3, 58.2 ± 16.5, and 21.1 at 3 (n = 10), 6 (n = 6), 12 (n = 5), and 24 (n = 1) months, respectively, with no statistical significant differences in weight loss outcome measures compared with the adult group at 3, 6, and 12 months. In 41 pediatric patients and 44 adults patients with 12 months follow-up, our pediatric patients had a BMI of 50.65 ± 12.06 and 32.42 ± 8.46 at baseline and 12 months respectively compared with 48.8 ± 8.59 and 31.81 ± 6.99 in our adult group with no statistical significant differences in weight loss outcome measures.
Table 2

Weight loss outcome measures in adult and pediatric patients undergoing laparoscopic sleeve gastrectomy

 

Pediatric

Adult

Baseline

 n

108

114

 Weight

123.9 ± 41.3

128.3 ± 28.5

 BMI

49.6 ± 11.5

48.3 ± 8.8

3 months

 n

88

61

 BMI (kg/m2)

40.6 ± 9.6

41.9 ± 8.7

 Weight loss (kg)

20.8 ± 12.3

21.9 ± 11.9

 % Weight loss

16.1 ± 8.4

16.2 ± 8.4

 %EWL

32.4 ± 18

30.9 ± 16.4

 %EBL

36.9 ± 16.4

34.2 ± 18.2

6 months

 N

76

43

 BMI (kg/m2)

35.3 ± 8.9

35.7 ± 10

 Weight loss (kg)

32.3 ± 15.5

38.7 ± 22.4

 % Weight loss

25.9 ± 8.7

28.6 ± 13.4

 %EWL

52.1 ± 23.9

55.2 ± 25.8

 %EBL

58.3 ± 21.7

60.6 ± 27.8

12 months

 N

41

44

 BMI (kg/m2

32.4 ± 8.5

31.8 ± 7

 Weight loss (kg)

42.7 ± 21.9

46.4 ± 16.7

 % Weight loss

32.5 ± 11.3

34.7 ± 9.3

 %EWL

65.8 ± 27

68.5 ± 21.9

 %EBL

71.8 ± 24.7

73 ± 21.2

24 months

 N

8

13

 BMI (kg/m2)

31.8 ± 4.9

31.8 ± 5.6

 Weight loss (kg)

39.5 ± 20.5

53.3 ± 21.7

 % Weight loss

31.2 ± 13.9

37.5 ± 9

 %EWL

64.9 ± 31.5

69.7 ± 16.3

 %EBL

76.7 ± 27.4

76.1 ± 17.2

Data are mean ± standard deviation

P value showed no statistically significant differences between pediatric and adult groups for all variables at all time points

BMI body mass index, %EWL percentage excess weight loss, %EBL percentage excess BMI loss

Postoperative comorbidity resolution was similar in both groups (Table 3). Three major postoperative complications were observed in the adult group (3.5 %). One patient had leakage and one had staple line bleeding, both of which required reoperation. A third patient had pulmonary embolism, which required readmission and medical management. The pediatric group had no major complications. One patient was readmitted for a suspected leak, which was investigated, not confirmed, and symptoms were managed conservatively. Other minor complications are listed in Table 4.
Table 3

Resolution of comorbidities in adult and pediatric patients undergoing laparoscopic sleeve gastrectomy

 

Pediatric

Adult

Diabetes (%)

93.8

87.5

Hypertension (%)

75

77.8

Dyslipidemia (%)

70

78.9

Symptoms of obstructive sleep apnea (%)

90.9

100

P value showed no statistically significant differences between pediatric and adult groups for resolution of all comorbidities

Table 4

Postoperative (<30 days) complications for adult and pediatric patients after laparoscopic sleeve gastrectomy

 

Pediatric

Adult

N

5

8

Rate (%)

5.6

7

Readmission and reoperation

Readmission

1

1

Reoperation

0

2

Major complications

Leak

0

1

Pulmonary embolism

0

1

Bleeding from staple line

0

1

Mortality

0

0

Minor complications

Pneumonia

0

2

Wound infection

2

1

Nausea and vomiting

0

2

Gastroesophageal reflux

3

0

A total of 213 of 297 (71.7 %) qualifying follow-up visits through 24 months were attended by 99 pediatric patients compared with 164 of 268 (61.2 %) visits attended by 85 adult patient (p = 0.01). At least one visit was missed by 40 (40.4 %) pediatric patients compared with 73 (84.7 %) adult group patients.

Discussion

Bariatric surgery in children and adolescents continues to be a controversial topic, with multiple concerns regarding safety and efficacy of bariatric surgery in this age group, the ethical implications of consenting an adolescent for such procedures, potential long-term complications and nutritional deficiencies, and concerns about the compliance of children and adolescents with postoperative follow-up.

Therefore, the safety and effectiveness of pediatric bariatric surgery remains an important unanswered question. LSG is, however, an attractive option for young patients; it has the advantages of not involving a significant malabsorptive component or implantation of a foreign body requiring frequent adjustments.

Weight loss outcomes in our study were similar between pediatric and adult patients at all time points, suggesting that LSG is similarly safe and effective in young and adult patients through at least 1 year of follow-up. Emerging data on patients who are 2 years postoperative suggest that results continue to be similar between the age groups.

Our results are similar to those reported for 24 studies of LSG in adults, where mean %EWL ranged from 36 to 85 % (mean 60.4 %) during a follow-up period ranging from 3 to 36 months [33]. They are similar to results achieved with LAGB and RYGB in adolescents [16, 3437].

A systematic review and meta-analysis of bariatric surgery for pediatric obesity included 8 studies reporting data on 352 LAGB patients and 6 studies on 131 RYGB patients. Both procedures resulted in clinically significant weight loss, in addition to comorbidity improvement and resolution [16].

Multiple methods are used to report weight loss after bariatric surgery, and problems associated with each method include the reference point for the EWL [38]. To allow comparison among studies, we report several weight loss outcome measures, including absolute weight loss, BMI loss, percentage of weight loss, %EWL, and %EBL. However, we believe that %EBL is more suitable for younger patients, because it accounts for differences in height between follow-up visits.

Most studies report improvement and/or resolution of obesity-related comorbid conditions after bariatric surgery in adults and adolescents [16, 39]. In a systematic review of bariatric surgery not including LSG in patients aged 9 through 21 years, resolution of comorbid conditions ranged from 50 to 100 % [16]. This is similar to our results, which ranged from 70 to 94 % in pediatric and 78 to 100 % in adult patients.

Complications after bariatric surgery vary among procedures. Eight LAGB studies that included 352 pediatric and adolescent patients reported reoperation in 28 (8 %), mainly for band slippage (43 %) [17]. Multiple complications included gastric dilation, intragastric band migration, hiatal hernia, cholecystitis, and tubing crack. Six studies of 140 young RYGB patients included one death 9 months after surgery due to severe Clostridiumdifficile colitis, in addition to eight potentially life-threatening events, including shock, pulmonary embolism, severe malnutrition, gastrointestinal obstruction, and postoperative bleeding [16]. In a systematic review comparing LAGB with RYGB in adults, operative mortality was less than 0.5 % for both procedures.

However, postoperative complications were higher after RYGB (9 % RYGB, 5 % LAGB), whereas long-term reoperation rates were lower after RYGB (16 % RYGB, 24 % LAGB) [39].

Reported complications following LSG in adults ranged from 0 to 29 % (mean 11 %) in a review of 15 studies, with 0.3 % mortality [17]. Our pediatric and adult patients had 5.6 and 7 % complication rates, which is in the lower end of this reported range. Our adult patients had more major complications compared with pediatric patients. This was demonstrated in a comparative study of the perioperative outcomes of RYGB, LAGB, and laparoscopic gastroplasty in adolescents compared with adults, which reported a higher 30-day complication rate in adults compared with adolescents (5.5 % adolescents and 9.8 % adults) [40]. One report described LSG as a procedure positioned between LAGB and RYGB, with higher readmission and reoperation rate than LAGB, but lower than RYGB [41]. No mortalities occurred in either group.

Our pediatric patients were significantly more compliant with follow-up visits compared with the adult group. Results similar to those of our adult group were reported from a recent compliance study, where 72 % of 53 adult patients missed at least one follow-up visit between 1 month and 2 years postoperatively [42]. Pediatric patients may have better compliance compared with adults, if parents actively participate in their child’s postoperative program.

A clear strength of our study is that our data represent the largest cohort to date that describes LSG in children and adolescents, which includes the evaluation of safety and efficacy, comorbidity resolution, compliance, and comparative analysis with a similar group of adult patients undergoing the same procedure performed by a single surgeon. However, some limitations exist, namely the retrospective study design, decreasing number of patients at each follow-up point due to being lost to follow-up or not yet achieving different time points of their postoperative care, and relatively short follow-up.

Conclusions

Weight loss was similar in pediatric and adult patients who underwent LSG. Pediatric patients had fewer major complications compared with adults and were more compliant with follow-up visits. Comorbidity resolution was similar in both groups. We believe that LSG in pediatric patients is at least as safe and effective as it is in adults. However, pediatric bariatric surgery should only be performed in specialized centers, with a multidisciplinary team approach. Long-term follow-up will allow a more detailed assessment of the potential of LSG as a safe and effective primary weight management approach for morbidly obese pediatric patients.

Acknowledgments

The authors acknowledge the contribution from Shaikh Ali Alshehri Obesity Chair, and Chair team members Ms. Nesma Mustafa, Ms. Layla Al-Farra, and Mr. Sulthan Najmudeen. They also thank the participants who took part in the study.

Disclosures

Drs. Aayed Alqahtani, Hussam Alamri, Mohamed Elahmedi, and Rafiuddin Mohammed have no conflict of interest or financial ties to disclose.

Copyright information

© Springer Science+Business Media, LLC 2012