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STAT

An MUSC blog
Keyword: bariatric surgery

Morbid obesity in American adolescents has been steadily rising, mirroring the rise of adult obesity in the United States and other developed countries. According to recent research, bariatric surgery can provide sustainable weight loss and other health benefits to teens with morbid obesity.

“We know that morbidly obese teenagers are at high risk for becoming morbidly obese adults. From recent research available on adolescents who underwent weight-loss surgery, we now know that they can achieve good, long-term weight loss, achieving a 30 percent reduction in BMI,” says Aaron P. Lesher, M.D., an assistant professor of surgery and pediatrics at MUSC Health who specializes in adolescent bariatric surgery.

Pediatric Obesity and Bariatric Surgery

Severe pediatric obesity can affect long-term health and quality of life, and non-operative treatments have shown little effect. It’s an issue with which South Carolina healthcare providers are especially familiar.

“The latest figures are that approximately 6 percent of children under 18 are morbidly obese or have a BMI greater than 35,” says Dr. Lesher. “South Carolina has a higher prevalence of morbid obesity than the national average, and that number is increasing.”

Bariatric surgery has proven benefits for adults with morbid obesity, and healthcare providers have been performing weight-loss surgeries for decades. Still, many providers have been hesitant to perform these procedures on younger patients due to the lack of research on the treatment’s long-term risks and benefits.

“While bariatric surgery has been shown to provide durable weight loss for patients with morbid obesity, there’s been some reticence on the part of surgeons and primary care doctors to do this in adolescents because of the lack of reliable data with long-term follow-up,” explains Dr. Lesher.

That lack of data leads to questions such as:

  • How do adolescents’ long-term weight loss compare to adults’?
  • Will adolescents adhere to the dietary restrictions necessary after surgery?
  • How might adolescents be psychologically affected after surgery?
  • Will adolescents develop the same vitamin and mineral deficiencies that are sometimes seen in adults who undergo bariatric surgery?

New Data Shows Benefits of Adolescent Weight-Loss Surgery

Recently released data, such as that from a study published in The Lancet, shows an eight-year follow-up of adolescents who received bariatric treatment for morbid obesity. The results are promising.

“In comparison to diet and exercise modification, adolescents achieved significant weight loss with bariatric surgery, approximately a 30 percent decrease in BMI,” says Dr. Lesher. “One study showed that bariatric surgery resolved diabetes in 88 percent of adolescents who had the condition prior to bariatric treatment.”

According to Dr. Lesher, this data may make primary care providers more comfortable in recommending adolescents for bariatric treatment. “As surgeons acting in the best interest of our patients, we are willing to offer this service to our morbidly obese adolescent patients because of this long-term data that shows we can provide durable weight loss,” he says.

While most of the longer-term studies for adolescents have looked at gastric bypass surgery, Dr. Lesher says MUSC Health considers sleeve gastrectomy another good option for bariatric surgery in adolescents.

“We don’t have as good long-term data in sleeve gastrectomy as we do with gastric bypass, but we can extrapolate that we will achieve similar weight-loss results. We may even improve the nutritional and vitamin and mineral deficiencies that we occasionally see with gastric bypass,” he says.

According to Dr. Lesher, sleeve gastrectomy offers a slightly lower complication profile, in the immediate postoperative period. It also has a slightly lower long-term vitamin and mineral deficiency profile, because surgeons don’t alter the length of the absorbable bowel during the procedure.

MUSC Offers Expertise in Adolescent Weight-Loss Surgery

MUSC Health’s bariatric program offers extensive expertise in this area, as surgeons have been performing bariatric surgery on adolescents since 1992. The program is accredited by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery’s Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, for both adults and adolescents. It performs the highest volume of adolescent bariatric procedures in the state.

“We were not performing many bariatric treatments on adolescents before 2007,” says Dr. Lesher. “But as we’ve seen better data, we felt that it’s increasingly safe to perform.”

Criteria for surgery mirror those for adult bariatric surgery. Ideal candidates have a BMI greater than 40, or a BMI greater than 35 with major comorbidities such as diabetes. Dr. Lesher says any teen who has a BMI greater than 40, especially those with significant comorbidities such as Type 2 diabetes and who have failed other attempts at weight loss, may benefit from bariatric surgery.

“I think that intervening earlier—before someone reaches a BMI of 50 or 60 or has more comorbidities—may give patients a better chance at long-term health improvement and better outcomes,” says Dr. Lesher.

In adolescent patients, the MUSC Health team prefers to wait until patients are at least 15, though Dr. Lesher says they consider patients as young as 13, in the cases of profound morbid obesity.

“The data suggests that we need to be performing these procedures when patients are skeletally mature,” he says. “We use X-rays to confirm that patients’ bony growth plates have fused.”

As with adults, adolescent patients benefit from MUSC Health’s comprehensive program and experienced team. “We have all of the ancillary and support staff, from pediatric surgeons to adolescent dietitians and psychologists, to achieve optimal long-term goals,” he says.

Dr. Lesher hopes pediatricians and family providers will consider bariatric surgery for young patients who might benefit from this life-changing treatment: “With this recent evidence, we can legitimately say that bariatric surgery is a safe and effective procedure. And it is, by far, the most effective way for these patients to lose weight and to keep it off. This really gives teens a chance to become healthy, productive adults and to modify their behavior and lifestyle sooner rather than later.”

For more information, contact Dr. Lesher at leshera@musc.edu.
 

Biliopancreatic diversion, more commonly known as the duodenal switch, can offer patients greater weight loss and other health benefits compared with more popular bariatric procedures, such as gastric bypass—if it’s performed by a surgeon experienced in the advanced laparoscopic techniques.

Duodenal Switch Procedure at MUSC Health

MUSC Health is currently the only site in South Carolina offering the duodenal switch procedure, according to Rana C. Pullattrana, M.D., an associate professor of surgery who specializes in general and gastrointestinal surgery at MUSC.

MUSC’s well-respected bariatric surgery program is the oldest in the region and includes bariatric surgeons, advanced practice practitioners, psychologists, dietitians and patient coordinators. Dr. Pullatt has performed more than 700 bariatric surgeries during his career, including nearly 20 duodenal switch procedures. From the success he’s seen thus far, he hopes that number continues to rise.

“It’s a cutting-edge procedure that very few centers in the country offer,” says Dr. Pullattrana. “Less than 1 percent of all bariatric procedures done in the United States right now are duodenal switch. That shows the rarity of the procedure and why it really needs to be performed by someone who specializes in it.”

Bariatric Surgery: Gastric Bypass vs. Duodenal Switch

In a gastric bypass procedure, surgeons create a smaller stomach by dividing it into two sections, one considerably smaller. They then rearrange the intestine to connect to both sections. As a result, patients need to limit the amount of food they eat at any given time.

In the duodenal switch method, surgeons create a smaller stomach but then remove the unused portion. They reroute the digestive tract, bypassing a portion of the intestine entirely. When using this approach:

  • The pylorus remains intact, so patients do not experience dumping syndrome.
  • The volume of the stomach stays a bit larger, so patients may be able to eat more.
  • Patients may experience fat malabsorption.

According to Dr. Pullattrana, the duodenal switch is a technically challenging procedure, which may be why it accounts for such a miniscule percentage of bariatric surgeries to date.

“The first portion of the duodenum [small intestine] is surrounded by a lot of blood vessels as well as very critical structures, including the bile duct,” he explains. “A surgeon needs to be proficient with advanced laparoscopic techniques. Because this is performed on people with very high BMI, it is even more challenging.”

Duodenal switch surgery can take some surgeons 3 to 4 hours. Through their experience and expertise, the MUSC team has shaved an hour off of that, generally finishing a surgery in 2 to 3 hours. “Performing this surgery required some degree of adapting our technique to get especially skilled at it, and now we are,” explains Dr. Pullattrana.

Most patients go home after 2 days in the hospital and follow up with their doctor at regular intervals for the first year (at 1 week, 1 month and then every 3 months). MUSC Health sees patients annually after the first year, to monitor weight loss progress and ensure adequate nutritional intake.

Bariatric Surgery: Duodenal Switch Benefits

So far, results point to very effective weight loss with the duodenal switch. As of March, MUSC patients had an average BMI of 60 kg/m2 with an average weight of 388 lbs at the time of duodenal switch surgery. Average BMI after surgery dropped accordingly:

  • 54 kg/m2 at 1 month
  • 49 kg/m2 at 3 months
  • 47 kg/m2 at 6 months
  • 39 kg/m2 at 12 months

Patients’ overall health also improved. Whereas gastric bypass resolved diabetes in roughly 80 percent of patients, that number is closer to 93 percent after duodenal switch surgery.

“This is the best operation that we have for bariatric surgery,” says Dr. Pullattrana. “Like any bariatric surgery, patients do need to follow lifestyle as well as dietary and exercise guidelines.”

While the duodenal switch has traditionally been reserved for patients considered super obese (characterized as a BMI greater than 50), current opinion amongst bariatric surgeons is that
many who are a fit for other bariatric surgeries would likely benefit from duodenal switch as well.

In general, Dr. Pullattrana says ideal candidates include anyone with a BMI of 35 or greater who has another health condition (such as uncontrolled diabetes) or anyone with a BMI greater than 50 who desires a drastic weight loss.

This surgery is also an option for patients who’ve previously undergone a sleeve gastrectomy without adequate success.

Bariatric Surgery: Managing Expectations and Follow-Up

Dr. Pullattrana says duodenal switch surgery offers similar complication rates to other bariatric procedures. The most common concern is malnutrition.

Because the surgery affects nutrient absorption, patients need to eat a high-protein diet and supplement with vitamins regularly. To best manage this potential complication, Dr. Pullattrana recommends patients keep in regular contact with their bariatric specialty team, especially their registered dietitians. This includes getting nutritional lab panels every 6 months for the first 2 years and annually thereafter.

Emphasizing these post-surgery management details to patients as they’re considering the duodenal switch can help manage expectations and prevent complications in the long term.

Still, he says the potential for health improvement with this surgery is not to be understated. “This is a life-changing, life-altering procedure. Truly, we can make a dramatic difference in an obese person’s general medical condition,” he says.

For more information, contact Dr. Pullattrana at Pullattr@musc.edu.
 

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