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Janey Pratt, MD and David Lanning, MD - 2024 Pediatric Bariatric Surgery Update Course
With Dr. Janey Pratt & Dr. David Lanning · hosted by Dr. Thomas Inge
Chapter 1 of 4 · Fundamentals
Introduction
Introduction and Session Overview
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
According to 2022 MBSAQIP database, 90% of pediatric bariatric procedures are sleeve gastrectomies, 9% are laparoscopic gastric bypass, and the remainder are biliopancreatic diversions.
The most common revisional procedure is sleeve-to-bypass, performed for inadequate weight loss or bile reflux.
In the US, 90% of pediatric bariatric cases are sleeve gastrectomies, but this is not necessarily true around the world.
For sleeve gastrectomy, the top reason for revision is inadequate weight loss, followed by bile reflux and then stenosis or kinking.
For gastric bypass with inadequate weight loss, revision is ineffective—lengthening limbs or making the pouch smaller does not work.
Gastric bypasses are often revised for ulcer disease, including gastrojejunal ulcers that can develop when patients start smoking as adults.
Re-sleeving is fairly effective in patients with large antrum, inadequate weight loss, or non-bile reflux from retained fundus, though there is no data in children, only in adults.
In one anastomosis gastric bypass (OAGB), the anastomosis is made about 15 centimeters from the GE junction, measuring 150-200 centimeters from the ligament of Treitz, leaving at least 300 centimeters in the common channel.
In single anastomosis duodeno-ileal bypass (SADI), the anastomosis is made 300 centimeters from the ileocecal valve.
Greater curvature plication is purported to be more widely accepted in younger patients because it is not a resection.
Gastric plication is thought to have both restrictive and metabolic components.
Gastric plication is purported to be reversible, particularly early on, though it becomes more difficult further out from surgery.
There is limited data on gastric plication, with most studies in adults and only one other study with a dozen adolescent patients outside of the Richmond pilot study.
The Richmond pilot study enrolled 4 patients aged 16-17 with average weight 139 kg and average BMI 48 (range 41.7-53.7).
Two of the four plication patients withdrew from the study after 90 days; only two completed the full 3-year follow-up.
Average operative time for gastric plication was 202 minutes with minimal blood loss, and patients were kept for 2-3 days.
Weight loss at 90 days averaged 17.7 kg, and at 3 years averaged 45.7 kg for the two patients who completed follow-up.
One plication patient lost 70 kg while another lost some weight but gained a little back, with percent BMI change of 17.5% and 39.7% at 36 months.
Plication patients reported early satiety and good hunger control for the duration of follow-up with limited nausea.
Two long-term plication patients had mild reflux symptoms that resolved without significant intervention, and one had abdominal pain that resolved on its own.
There were no major complications from gastric plication, and only one readmission for nausea requiring a 23-hour stay.
At 9-year follow-up, one plication patient lost 40 kg (BMI 55.8 to 40.4) with resolution of pre-diabetes.
At 9-year follow-up, a second plication patient lost 75 kg (BMI 53.8 to 30.7) with resolution of severe sleep apnea requiring CPAP.
Both 9-year plication patients continue to have good early satiety and hunger control.
When performing revision surgery on 20-year-olds who had sleeves, converting to bypass results in significant weight loss.
In the adult population, if patients have BMI over 50 or childhood-onset obesity, sleeve-to-SADI is typically performed rather than sleeve-to-bypass.
Kids respond differently to revisional surgery than adults, and more research is needed on optimal revision strategies in pediatric patients.
Gastric plication tends to do better in patients with BMI less than 40, according to adult studies.
Limited studies suggest gastric plication causes some metabolic changes in hormone levels, though this has not been completely characterized.