Background
With rising childhood obesity rates, the sleeve gastrectomy (SG) is the most common bariatric surgery procedure. This surgical technique may result in ischemia to the upper pole of the ...spleen. While generally self-limiting, splenic ischemia may have similar postoperative symptoms to more severe complications.
Methods
We retrospectively reviewed 142 surgical videos and medical records from adolescents at our center who underwent SG from 2010 through 2018. The videos were evaluated for splenic ischemia and for the presence of separate segmental polar accessory vessels. The medical records were reviewed for postoperative symptoms of left shoulder pain, fever, leukocytosis, and tachycardia.
Results
We found a 31% incidence of splenic ischemia in the cases reviewed. We identified division of segmental vessels to the upper pole as increasing the relative risk of splenic ischemia by 2.3 (
p
= 0.0055). Immediate ischemic changes noted in the upper pole of the spleen did not correlate with any postoperative symptoms or complications.
Conclusion
The incidence of splenic ischemia during an SG in our adolescent population was higher than in other reports. Division of separate polar vessels increased the incidence of localized splenic ischemia. Our findings suggest that splenic ischemia is incidental during an SG in adolescents and does not manifest any clinical significance.
Graphical abstract
Early presentation and prompt diagnosis of acute appendicitis are necessary to prevent progression of disease leading to complicated appendicitis. We hypothesize that patients had a delayed ...presentation of acute appendicitis during the COVID-19 pandemic, which affected severity of disease on presentation and outcomes.
We conducted a retrospective review of all patients who were treated for acute appendicitis at Morgan Stanley Children's Hospital (MSCH) between March 1, 2020 and May 31, 2020 when the COVID-19 pandemic was at its peak in New York City (NYC). For comparison, we reviewed patients treated from March 1, 2019 to May 31, 2019, prior to the pandemic. Demographics and baseline patient characteristics were analyzed for potential confounding variables. Outcomes were collected and grouped into those quantifying severity of illness on presentation to our ED, type of treatment, and associated post-treatment outcomes. Fisher's Exact Test and Kruskal-Wallis Test were used for univariate analysis while cox regression with calculation of hazard ratios was used for multivariate analysis.
A total of 89 patients were included in this study, 41 patients were treated for appendicitis from March 1 to May 31 of 2019 (non-pandemic) and 48 were treated during the same time period in 2020 (pandemic). Duration of symptoms prior to presentation to the ED was significantly longer in patients treated in 2020, with a median of 2 days compared to 1 day (p = 0.003). Additionally, these patients were more likely to present with reported fever (52.1% vs 24.4%, p = 0.009) and had a higher heart rate on presentation with a median of 101 beats per minute (bpm) compared to 91 bpm (p = 0.040). Findings of complicated appendicitis on radiographic imaging including suspicion of perforation (41.7% vs 9.8%, p < 0.001) and intra-abdominal abscess (27.1% vs 7.3%, p = 0.025) were higher in patients presenting in 2020. Patients treated during the pandemic had higher rates of non-operative treatment (25.0% vs 7.3%, p = 0.044) requiring increased antibiotic use and image-guided percutaneous drain placement. They also had longer hospital length of stay by a median of 1 day (p = 0.001) and longer duration until symptom resolution by a median of 1 day (p = 0.004). Type of treatment was not a predictor of LOS (HR = 0.565, 95% CI = 0.357–0.894, p = 0.015) or duration until symptom resolution (HR = 0.630, 95% CI = 0.405–0.979, p = 0.040).
Patients treated for acute appendicitis at our children's hospital during the peak of the COVID-19 pandemic presented with more severe disease and experienced suboptimal outcomes compared to those who presented during the same time period in 2019.
III
Glucagon-like peptide-1 receptor agonist (GLP-1A) medications are gaining widespread popularity for the treatment of obesity. The optimal use of these drugs in pediatric bariatric populations, and ...especially in those considering metabolic and bariatric surgery (MBS), is yet to be established. We sought to characterize current practice patterns of GLP-1A use at major pediatric bariatric centers across the United States.
We administered an online survey to a purposive sample of 46 surgeons who perform MBS on children and adolescents. Survey questions explored practices prescribing GLP-1As in patients considering MBS, holding them prior to elective operations, and restarting them postoperatively following MBS. Responses were summarized with descriptive statistics and inductive content analysis.
There were 22 responses (48% response rate) representing 19 institutions. Most (86%) respondents do sometimes prescribe GLP-1As for patients considering MBS, but the specific indications vary. Practices for holding GLP-1As preoperatively also vary, from not at all to holding for 2 wk. Over half (55%) of respondents sometimes restart GLP-1As after MBS. Free-response themes included still-evolving preoperative utilization patterns, difficulty with access and insurance coverage, and a lack of data informing GLP-1A use in the pre and postoperative periods.
Given the increasing use of these medications for weight loss purposes, this substantial variation in practice highlights a need for further research to examine the safest and most effective use of GLP-1As in the pre and postoperative periods and for practice guidelines to standardize care pathways in pediatric bariatric contexts.
Type 2 diabetes mellitus is a complex and under-treated disorder closely intertwined with obesity. Adolescents with severe obesity and type 2 diabetes have a more aggressive disease compared to ...adults, with a rapid decline in pancreatic β cell function and increased incidence of comorbidities. Given the relative paucity of pharmacotherapies, bariatric surgery has become increasingly used as a therapeutic option. However, subsets of this population have sub-optimal outcomes with either inadequate weight loss or little improvement in disease. Predicting which patients will benefit from surgery is a difficult task and detailed physiological characteristics of patients who do not respond to treatment are generally unknown. Identifying physiological predictors of surgical response therefore has the potential to reveal both novel phenotypes of disease as well as therapeutic targets. We leverage data assimilation paired with mechanistic models of glucose metabolism to estimate pre-operative physiological states of bariatric surgery patients, thereby identifying latent phenotypes of impaired glucose metabolism. Specifically, maximal insulin secretion capacity, σ, and insulin sensitivity, S
, differentiate aberrations in glucose metabolism underlying an individual's disease. Using multivariable logistic regression, we combine clinical data with data assimilation to predict post-operative glycemic outcomes at 12 months. Models using data assimilation sans insulin had comparable performance to models using oral glucose tolerance test glucose and insulin. Our best performing models used data assimilation and had an area under the receiver operating characteristic curve of 0.77 (95% confidence interval 0.7665, 0.7734) and mean average precision of 0.6258 (0.6206, 0.6311). We show that data assimilation extracts knowledge from mechanistic models of glucose metabolism to infer future glycemic states from limited clinical data. This method can provide a pathway to predict long-term, post-surgical glycemic states by estimating the contributions of insulin resistance and limitations of insulin secretion to pre-operative glucose metabolism.
Objective
To understand the regulation of adipocyte size and adipokine expression in relation to gender, anatomic location, adiposity, and metabolic risk factors in adolescents with morbid obesity.
...Methods
Adipocyte size and adipokine expression in paired abdominal subcutaneous (SAT) and omental (VAT) surgical adipose tissues were related to gender, anatomic location, adiposity, and metabolic risk factors in a group of morbidly obese adolescents.
Results
Significant depot‐ and/or gender‐related differences in adipocyte size and adipokine expression were detected. Adjusted for body mass index, adipocyte size in both depots was larger in males than in females and was a major predictor of mRNA levels of leptin, plasminogen activator inhibitor‐1, and adiponectin. Gender, but not adipocyte size, was significantly correlated with proinflammatory cytokine expression. Body mass index and waist circumference were correlated positively with VAT adipocyte size and negatively with SAT adipocyte size. VAT adiponectin and interleukin‐6 expression levels were major predictors of high‐density lipoprotein cholesterol concentrations, independent of gender, adiposity, and insulin sensitivity.
Conclusions
Adipose tissue morphology and function in obese adolescents are influenced by gender and anatomic location; the pattern of gender‐ and depot‐related differences in adipocyte size and adipokine expression suggests that adolescent males, relative to the females, are at increased risk for obesity‐related metabolic comorbidities.
Purpose
For children and adolescents with severe obesity, metabolic and bariatric surgery including laparoscopic sleeve gastrectomy (LSG) is increasingly used to facilitate weight loss and reduce ...associated medical problems. Outcomes of LSG are understudied among patients under age 15 years. We sought to examine surgical complications and weight loss outcomes among children and adolescents who underwent LSG.
Materials and Methods
This is a single-center retrospective cohort analysis at a high-volume metropolitan children’s hospital in the northeast USA between 2011 and 2021. Weight loss was assessed at routine follow-up appointments for up to 36 months postoperatively.
Results
There were 12 patients under 13 years of age (< 13), 45 from 13 up to 15 years of age (13–14), and 57 patients aged 15 years or over (≥ 15). Among all patients, 70% were female, 41% were Hispanic, and 18% were non-Hispanic Black. There were no operative mortalities. Two patients had surgical complications requiring reoperation. Follow-up beyond 6 months occurred for 62% of patients. Weight loss was evident for each group at all time points, and there was no statistically significant difference among groups at any time point. BMI
Z
-score reduction at 6 months was 1.53 for the < 13 group, 0.89 for the 13–14 group, and 0.86 for the ≥ 15 group and at 36 months was 1.79, 1.50, and 1.16, respectively.
Conclusion
These results support that LSG is a safe and effective method of achieving weight loss for young adolescents with severe obesity. Strategies to promote postoperative follow-up are needed.
Graphical Abstract
Severe obesity is often associated with co-morbid conditions such as diabetes mellitus, hypertension, and obstructive sleep apnea. Successful weight loss can result in remission of these conditions. ...The authors retrospectively examined the co-morbidity profiles of pre-operative gastric sleeve adult patients from the MBSAQIP database with subjects from our adolescent bariatric program. Five conditions were compared: hypertension (HTN), type 2 diabetes mellitus (T2DM), dyslipidemia (DL), obstructive sleep apnea (OSA), and gastroesophageal reflux disease (GERD). Patients were matched by gender and body mass index (BMI). The prevalence of each condition was statistically more significant in the adult cohort. Successful weight loss at an earlier age may reduce the prevalence of these co-morbid conditions.
Background
Laparoscopic adjustable gastric banding (LAGB) is used to treat obesity in adults. Less is known about long-term results of the procedure in adolescents.
Objectives
To evaluate LAGB 5-year ...outcomes in teenagers with severe obesity.
Setting
Children’s hospital, USA.
Methods
Adolescents (14–18 years) underwent LAGB in an FDA-approved observational clinical trial. Outcomes including anthropometric measurements, comorbid conditions, complications, and band retention were collected through 60 months.
Results
One hundred thirty-seven subjects underwent LAGB (94 female, 43 male; 43% white, 37% Hispanic, 17% black; 4% other). Mean age and body mass index (BMI) pre-operatively were 17.0
+
1.2 years and 48.3
+
8.2 kg/m
2
, respectively. Comorbidities were present in 71%. Maximum weight loss occurred by 36 months (mean % excess weight loss (EWL) 40.6
+
35.2, mean % excess BMI loss (EBMIL) 41.6
+
34.9) and was maintained through 5 years for most subjects. There were no significant differences in weight loss by gender. Twenty-three (18%) of 127 adolescents reporting at 60 months achieved 50% excess weight loss. Postoperative heartburn and emesis occurred in 70% and 32%, respectively. Complications requiring additional surgery occurred 80 times in 63 patients. Thirty-three (26%) of 127 subjects contacted at 5 years had undergone band removal.
Conclusion
In this study, fewer than 20% of adolescents with severe obesity lost > 50% of their excess weight following LAGB. Nearly 50% of patients required additional surgery. With reports of success following sleeve gastrectomy and gastric bypass, we believe that LAGB is not a preferred choice to treat adolescents with obesity.
Abstract Background Bariatric surgery has shown to be an effective weight loss treatment in morbidly obese adolescents. We compared outcomes of laparoscopic adjustable gastric band (LAGB) to ...laparoscopic vertical sleeve gastrectomy (VSG). Methods A single institution, retrospective evaluation of a prospectively collected database of LAGB and VSG patients. Results 174 morbidly obese patients underwent bariatric surgery at our institution between 2006 and 2013. 137 patients underwent LAGB and 37 underwent VSG. There were no significant differences between LAGB vs. VSG groups on day of surgery for age, gender, ethnicity, weight, and BMI. At 24-month follow up, patients who underwent VSG vs. LAGB displayed significantly greater percent excess weight loss (70.9 ± 20.7 vs. 35.5 ± 28.6, P = 0.004) and percent preoperative BMI loss (32.3 ± 11.0 vs. 16.4 ± 12.7, P = 0.004). Both VSG and LAGB significantly improved levels of HDL, HgA1c, and fasting glucose. LAGB patients had more complications than VSG patients. Conclusion Bariatric surgery is an effective treatment strategy in morbidly obese adolescents who have failed medical management. VSG results in greater short term weight and BMI loss when compared to LAGB. Longer follow up with more patients will be required to confirm the long term safety and efficacy of VSG in adolescent patients.
PDF
