The American Society for Metabolic and Bariatric Surgery Pediatric Committee updated their evidence-based guidelines published in 2012, performing a comprehensive literature search (2009-2017) with ...1387 articles and other supporting evidence through February 2018. The significant increase in data supporting the use of metabolic and bariatric surgery (MBS) in adolescents since 2012 strengthens these guidelines from prior reports. Obesity is recognized as a disease; treatment of severe obesity requires a life-long multidisciplinary approach with combinations of lifestyle changes, nutrition, medications, and MBS. We recommend using modern definitions of severe obesity in children with the Centers for Disease Control and Prevention age- and sex-matched growth charts defining class II obesity as 120% of the 95th percentile and class III obesity as 140% of the 95th percentile. Adolescents with class II obesity and a co-morbidity (listed in the guidelines), or with class III obesity should be considered for MBS. Adolescents with cognitive disabilities, a history of mental illness or eating disorders that are treated, immature bone growth, or low Tanner stage should not be denied treatment. MBS is safe and effective in adolescents; given the higher risk of adult obesity that develops in childhood, MBS should not be withheld from adolescents when severe co-morbidities, such as depressed health-related quality of life score, type 2 diabetes, obstructive sleep apnea, and nonalcoholic steatohepatitis exist. Early intervention can reduce the risk of persistent obesity as well as end organ damage from long standing co-morbidities.
Severe obesity among youth is an "epidemic within an epidemic" and portends a shortened life expectancy for today's children compared with those of their parents' generation. Severe obesity has ...outpaced less severe forms of childhood obesity in prevalence, and it disproportionately affects adolescents. Emerging evidence has linked severe obesity to the development and progression of multiple comorbid states, including increased cardiometabolic risk resulting in end-organ damage in adulthood. Lifestyle modification treatment has achieved moderate short-term success among young children and those with less severe forms of obesity, but no studies to date demonstrate significant and durable weight loss among youth with severe obesity. Metabolic and bariatric surgery has emerged as an important treatment for adults with severe obesity and, more recently, has been shown to be a safe and effective strategy for groups of youth with severe obesity. However, current data suggest that youth with severe obesity may not have adequate access to metabolic and bariatric surgery, especially among underserved populations. This report outlines the current evidence regarding adolescent bariatric surgery, provides recommendations for practitioners and policy makers, and serves as a companion to an accompanying technical report, "Metabolic and Bariatric Surgery for Pediatric Patients With Severe Obesity," which provides details and supporting evidence.
Severe obesity affects the health and well-being of millions of children and adolescents in the United States and is widely considered to be an "epidemic within an epidemic" that poses a major public ...health crisis. Currently, few effective treatments for severe obesity exist. Metabolic and bariatric surgery are existing but underuse treatment options for pediatric patients with severe obesity. Roux-en-Y gastric bypass and vertical sleeve gastrectomy are the most commonly performed metabolic and bariatric procedures in the United States and have been shown to result in sustained short-, mid-, and long-term weight loss, with associated resolution of multiple obesity-related comorbid diseases. Substantial evidence supports the safety and effectiveness of surgical weight loss for children and adolescents, and robust best practice guidelines for these procedures exist.
There is controversy over certain aspects of post-appendectomy care for children with uncomplicated appendicitis. Some institutions have embraced the practice of same-day discharge after ...appendectomy, while others are hesitant due to concerns about increased readmissions or emergency department (ED) visits. Similarly, some surgeons have transitioned to treating gangrenous appendicitis with a single perioperative dose, while others are concerned about increased risk of infection in this population.
We developed a pathway for the management of patients undergoing appendectomy for uncomplicated acute appendicitis which included same-day discharge and elimination of postoperative antibiotics for patients with gangrenous appendicitis. We compared outcomes for children treated at our institution before and after implementation of the protocol.
We identified 575 patients undergoing appendectomy for uncomplicated appendicitis (307 pre- and 268 post-protocol). We observed a significant decrease in postoperative length-of stay (10.6 to 2.6 h, p < 0.0001). There were no increases in postoperative complications, such as superficial (2.6% vs 1.1%, p = 0.19) or organ-space surgical-site infection (1.6% vs 0.4%, p = 0.14), percutaneous drain placement (1.3% vs 0%, p = 0.06), postoperative ED visits (5.5% vs 5.2%, p = 0.87) or readmission (3.3% vs 1.5%, p = 0.17).
These findings suggest that incorporating same-day discharge for simple appendicitis and eliminating postoperative antibiotics for children with gangrenous appendicitis does not increase complication rates. Implementation of similar pathways across institutions has the potential to significantly reduce resource utilization for children undergoing appendectomy for uncomplicated appendicitis.
Retrospective comparative study.
Level III.
Children requiring gastrostomy tubes (GT) have high resource utilization. In addition, wide variation exists in the decision to perform concurrent fundoplication, which can increase the morbidity of ...enteral access surgery. We implemented a hospital-wide standardized pathway for GT placement.
The standardized pathway included mandatory preoperative nasogastric feeding tube (FT) trial, identification of FT medical home, and standardized postoperative order set, including feeding regimen and parent education. An algorithm to determine whether concurrent fundoplication was indicated was also created. We identified children referred for GT placement from 2015 to 2018 and compared concurrent fundoplication rates and outcomes pre- and postimplementation.
We identified 332 patients who were referred for GT. Of these, 15 avoided placement. Concurrent fundoplication decreased postpathway (48% vs 22%, p < 0.0001). After adjusting for reflux and cardiac disease, prepathway patients were 3.5 times more likely to undergo concurrent fundoplication. ED visits (46% vs 27%, p = 0.001) and postoperative LOS (median (IQR) 10 days (5–36) to 5.5 days (1–19), p = 0.0002) decreased.
A standardized pathway for GT placement prevented unnecessary GT placement and fundoplication with reduction in postoperative LOS and ED visits. This approach can significantly reduce resource utilization while improving outcomes.
Prognosis study.
Level II.
Bariatric surgery is 1 of the few effective treatments of morbid obesity. However, the weight loss and other health-related outcomes for this procedure in large, diverse adolescent patient ...populations have not been well characterized. Our objective was to analyze the prospective Bariatric Outcomes Longitudinal Database (BOLD) to determine the weight loss and health related outcomes in adolescents. The BOLD data are collected from 423 surgeons at 360 facilities in the United States.
The main outcome measures included the anthropometric and co-morbidity status at baseline (n = 890) and at 3 (n = 786), 6 (n = 541), and 12 (n = 259) months after surgery. Adolescents (75% female; 68% non-Hispanic white, 14% Hispanic, 11% non-Hispanic black, and 6% other) aged 11 to 19 years were included in the present analyses.
The overall 1-year mean weight loss for those who underwent gastric bypass surgery was more than twice that of those who underwent adjustable gastric band surgery (48.6 versus 20 kg, P < .001). Similar results were found for all other anthropometric changes and comparisons within 1 year between surgery types (P < .001). In general, the gastric bypass patients reported more improvement than the adjustable gastric band patients in co-morbidities at 1 year after surgery. A total of 45 readmissions occurred among gastric bypass patients and 10 among adjustable gastric band patients, with 29 and 8 reoperations required, respectively.
The weight loss at 3, 6, and 12 months after surgery is approximately double in adolescent males and females who underwent gastric bypass surgery versus those who underwent adjustable gastric band surgery. Bariatric surgery can safely and substantially reduce weight and related co-morbidities in morbidly obese adolescents for ≥1 year.
The prevalence of morbid obesity in adolescents is rising at an alarming rate. Comorbidities known to predispose to cardiovascular disease are increasingly being diagnosed in these children. ...Bariatric surgery has become an acceptable treatment alternative for morbidly obese adults, and criteria have been developed to establish center-of-excellence designation for adult bariatric surgery programs. Evidence suggests that bariatric surgical procedures are being performed with increasing numbers in adolescents. We have examined and compiled the current expert recommendations for guidelines and criteria that are needed to deliver safe and effective bariatric surgical care to adolescents.
Background
One lung ventilation (OLV) results in inflammatory and mechanical injury, leading to intraoperative and postoperative complications in children. No interventions have been studied in ...children to minimize such injury.
Objective
We hypothesized that a single 2‐mg·kg−1 dose of methylprednisolone given 45–60 min prior to lung collapse would minimize injury from OLV and improve physiological stability.
Methods
Twenty‐eight children scheduled to undergo OLV were randomly assigned to receive 2 mg·kg−1 methylprednisolone (MP) or normal saline (placebo group) prior to OLV. Anesthetic management was standardized, and data were collected for physiological stability (bronchospasm, respiratory resistance, and compliance). Plasma was assayed for inflammatory markers related to lung injury at timed intervals related to administration of methylprednisolone.
Results
Three children in the placebo group experienced clinically significant intraoperative and postoperative respiratory complications. Respiratory resistance was lower (P = 0.04) in the methylprednisolone group. Pro‐inflammatory cytokine IL‐6 was lower (P = 0.01), and anti‐inflammatory cytokine IL‐10 was higher (P = 0.001) in the methylprednisolone group. Tryptase, measured before and after OLV, was lower (P = 0.03) in the methylprednisolone group while increased levels of tryptase were seen in placebo group after OLV (did not achieve significance). There were no side effects observed that could be attributed to methylprednisolone in this study.
Conclusions
Methylprednisolone at 2 mg·kg−1 given as a single dose prior to OLV provides physiological stability to children undergoing OLV. In addition, methylprednisolone results in lower pro‐inflammatory markers and higher anti‐inflammatory markers in the children's plasma.
Abstract The past four decades have witnessed a marked rise in the number of children and adolescents with obesity. Severe obesity has also become increasingly prevalent. More young patients who have ...obesity are being referred for weight management and weight loss surgery, thus posing new challenges to both the medical personnel who care for them as well as the institutions in which that care is provided. This manuscript is generated from the material presented at the Education Day symposium entitled “Surgical Care of the Obese Child” held at the 42nd Annual Meeting of the American Pediatric Surgical Association in Palm Desert, CA, on May 22, 2011. Herein the presenters at the symposium update the material addressing evaluation of a young person for weight loss surgery (including the team approach to patient evaluation and institutional infrastructure and responsibilities). The procedures most frequently available to young patients with obesity are identified, and current outcomes, trends, and future direction are also discussed.
Previously we showed that a single local injection of the avian paramyxovirus Newcastle disease virus (NDV) strain 73-T caused long-lasting, complete tumor regression of human neuroblastoma and ...fibrosarcoma xenografts in athymic mice. Here we report the antitumor effects of NDV administered by either the intratumoral (IT) route to treat a variety of human carcinoma xenografts or by the systemic (intraperitoneal, IP) route to treat neuroblastoma xenografts (6.5–12 mm in diameter). For IT treatments, mice were randomized into treatment groups and given a single IT injection of NDV 73-T, vehicle (phosphate buffered saline, PBS), or UV-inactivated NDV. For systemic therapy, mice (
n=18) with subcutaneous IMR-32 human neuroblastoma xenografts received IP injections of NDV (5×10
9 PFU). Significant tumor growth inhibition (77–96%) was seen for epidermoid (KB8–5–11), colon (SW620 and HT29), large cell lung (NCIH460), breast (SKBR3), prostate (PC3), and low passage colon (MM17387) carcinoma xenografts treated IT with NDV. In all cases, tumors treated IT with PBS or replication-incompetent, UV-inactivated NDV displayed rapid tumor growth. After a single IP injection of NDV, complete regression of IMR-32 neuroblastomas was observed in 9 of 12 mice without recurrence for the 3–9 month follow-up period. Six mice with recurrent neuroblastomas after one IP injection received one to three additional IP treatments with NDV. Three of these six mice showed complete regression without recurrence. These data show that: (1) NDV administered either IT or IP is an effective antitumor therapy in this system, (2) replication competency is necessary for maximal effect, and (3) multiple NDV doses can be more effective than a single dose. These studies provide further rationale for the preclinical study of NDV as an oncolytic agent.
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