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Sleeve gastrectomy and childhood obesity: The United Arab Emirates Experience

Moustafa Hamchou, Hilal Matta, Bahjat Sahari, Adnan Swid, Ahmed Al-Salem

Department of Pediatric Surgery, Department of Surgery, Tawam Hospital, Al-Ain, AbuDhabi, United Arab Emirates

 

Correspondence:

Ahmed H. Al-Salem

P. O. Box 61015 Qatif 31911, Saudi Arabia

E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

Fax: 966138630009

Phone: 966546102999

 

Abstract

Background: Obesity and overweight in children is increasingly common worldwide and known to be associated with morbidity. Dietary manipulation and changing their life style may prove to be effective in slightly overweight children but are not effective in obese children and those with comorbidities.

Patients and method: This is a retrospective study of all morbidly obese children who had laparoscopic sleeve gastrectomy (LSG).

Results: Over a period of 4 years (June 2012 - June 2015), 26 children (14 female: 12 male) had LSG. Their mean age was 12.6 years (10.5-15 years) and their mean BMI 47.2 (40-65). Twenty-one (80.8%) of our patients had associated comorbidities. These included sleep apnea (7 patients), hypertension (3 patients), type 2 diabetes mellitus (3 patients), bronchial asthma (4 patients), enuresis (2 patients), and foot and joint problems (2 patients). Two of our patients had Prader–Willi syndrome. The mean follow-up was 1.5 years (1 year - 3 years). The mean operative time was 120 minutes (90-150 minutes). The mean hospital stay was 4 days (3-7 days). Only one of our patients was admitted to the intensive care unit for one day observation because of severe sleep apnea. There were no major complications and no leaks. There was an overall 65.2% weight loss and 70% improvement in comorbidities. Their mean postoperative BMI was 30.75 (24-38). There was also marked improvement in quality of life, self-esteem, productivity and social functioning. There was a significant weight loss in the two patients with Prader–Willi syndrome for the first 2 years but one of them restarted to gain weight again.

Conclusions: Obesity and overweight in children is common worldwide and known to be associated with morbidity. LSG is effective in treating obese children and alleviating their comorbidities. LSG should be performed by experienced laparoscopic surgeons and long term follow-up is important as there is still concern regarding its effects on growth and maturity, and the sustainability of the weight loss.

Keywords:bariatric surgery, children, sleeve gastrectomy, weight loss

 

Introduction

Overweight and obesity are known to be associated with serious health problems including hypertension, type 2 diabetes mellitus, sleep apnea and orthopedic complications, hyperlipidemia and cardiovascular diseases [1, 2, 3]. Add to this the psychosocial complications and financial burden from repeated admissions related to obesity morbidities. This is especially so in an era where there is increasing prevalence of overweight and obesity among children worldwide and obesity during childhood is known to lead to obesity in adulthood [4]. In the United Arab Emirates, the frequency of obesity among UAE youth was found to be two to three times greater than the recently published international standard and nearly one-third of all children in the UAE are overweight or obese [5].

To overcome these complications, it is important to treat obese children by dietary manipulation and changing their life style but severely obese children and those who do not respond to conservative treatment or those with comorbidities will benefit from bariatric surgery [6, 7]. Among the different approaches of bariatric surgery, Laparoscopic Sleeve Gastrectomy (LSG) was shown to be beneficial for obese children [8 -13]. This report describes our experience with 21 children with morbid obesity treated by LSG.

Patients and methods

The medical records of all children with morbid obesity who were treated by LSG were retrospectively reviewed for: age at diagnosis, sex, BMI, co-morbidities, postoperative complications, outcome and follow-up. All patients had a complete blood count, liver function tests, electrolytes, blood urea, creatinine, chest X-Ray, ECG and an abdominal ultrasound as part of their workup. The criteria we adopted for sleeve gastrectomy was a body mass index (BMI) > 40 or BMI > 35 with obesity related comorbidities. The patients and their parents were educated about the procedure and the need for regular follow-up. They were instructed about adherence to nutritional guidelines postoperatively, vitamin supplementation and commitment to a program of lifestyle changes.

Pre-operative work-up included dietary, endocrinological, psychological, and pulmonary and anesthesia assessment. The patients are covered with prophylactic antibiotics and clexane for deep vein thrombosis prophylaxis. Postoperatively, the patients are followed-up every week for 4 weeks and then 6 monthly for one year and then annually. In each visit, the weight, height, BMI and blood pressure are recorded. The patient is evaluated for signs of infection, dehydration, malnutrition and reflux or dysphagia. A meeting with the dietitian is organized and the weight loss and accumulative weight loss are calculated and recorded. Every three months, a complete laboratory work is done including complete blood count, liver function tests, blood urea, creatinine, vitamin B12, calcium, phosphorus, magnesium, vitamin D, serum ferritin, folate, lipid profile and HbA1c.

Results

During a 4-year period (June 2012 - June 2015), twenty-six children (14 females and 12 males) had LSG at our hospital. Their mean age was 12.6 years (10.5-15 years). Their mean BMI was 47.2 (40-65). All patients had an abdominal ultrasound which showed fatty liver but none of them had cholelithiasis. Twenty-one (80.8%) of our patients had associated comorbidities. These included sleep apnea (7 patients, 3 of them were severe and required C-pap), hypertension (3 patients), type 2 diabetes mellitus (3 patients), bronchial asthma (4 patients), enuresis (2 patients), and foot and joint problems (2 patients). Two of our patients had Prader–Willi syndrome. One of our patients had an associated hiatal hernia. This was repaired laparoscopically during sleeve gastrectomy. The mean operative time was 120 minutes (90-150 minutes). The mean hospital stay was 4 days (3-7 days). Only one of our patients was admitted to the intensive care unit for one day observation because of severe sleep apnea. There were no major complications and no leaks. Three patients developed mild port site infection. The mean follow-up was 1.5 years (1 year - 3 years). There was an overall 65.2% weight loss and 70% improvement in comorbidities (Fig. 1). There was also marked improvement in quality of life, self-esteem, productivity and social functioning. There was a significant weight loss in the two patients with Prader–Willi syndrome for the first 2 years but one of them restarted to gain weight again (Fig. 2 and 3).

Figure 1: Diagrammatic representation of the preoperative and postoperative BMI.

10.4 2 1

Figure 2: Diagrammatic representation of the weight loss in one of the patients with Prader-Willi syndrome. Note the sustained weight loss postoperatively.

10.4 2 2

Figures 3: Diagrammatic representation of the weight loss in the second patient with Prader-Willi syndrome. Note the initial weight loss which was followed by regaining of the lost weight.

10.4 2 3

Discussion

Obesity among adults and children is an increasing worldwide health hazard. There are not enough local or regional studies determining the frequency of obesity and overweight in children. In one study, more than 30% of children and adolescents in the United States are currently overweight or obese, whereas the prevalence of obesity is as high as 21.4% in young children [14]. In a national study in the UAE, they found that UAE children are at increased risk for overweight and obesity and 10-year-old children had 1.7 times the rate of overweight compared to the international standard and 1.9 times at 18 years old [5]. It is also important to note that adult obesity can be predicted from childhood overweight and obesity, providing further emphasis on the scientific importance of childhood overweight and obesity [15].

In the pediatric age group, obesity is known to be associated with serious long term complications. These include obstructive sleep apnea, type 2 diabetes mellitus, hyperlipidemia, and orthopedic complications [1, 2, 3]. Add to this, the serious psychosocial complications which manifest early and more seriously in children than adults. In adults, bariatric surgery has a long-standing record of success, inducing significant and sustained weight loss, relieving comorbidities, and prolonging survival [16, 17, 18]. Unfortunately, there is no effective solution for treating obesity and its associated comorbidities in children. Nonsurgical weight management (NSWM) programs achieve modest weight loss results at best. The results of weight loss surgery in children and adolescents are still scarce, despite recent studies suggesting favorable short and intermediate-term outcomes that are comparable to those in adults [8-11, 19, 20]. There are however, still concerns regarding the effects of bariatric surgery on growth and maturity, and the sustainability of the weight loss.

Recently and as a result of development of minimal invasive surgery, there is more interest in LSG to treat obese and overweight children. This was also influenced by the success of laparoscopic sleeve gastrectomy in adults. Laparoscopic Sleeve Gastrectomy (LSG) is gaining acceptance for the treatment of morbidly obese children. Recent reports show that morbid obesity and the associated co morbidities were successfully managed by LSG for children even as young as 5 years of age [8]. The youngest patient who had LSG for morbid obesity was 2.5 years old but most reported children were above 10 years of age [8, 11, 21, 22]. In our series, the mean age of the patients was 12.6 years (10.5-15 years). There are few publications addressing the long term results of LSG in children and most published result show significant reduction in body weight and significant improvement in the associated comorbidities such as sleep apnea, type 2 diabetes, and hypertension [8, 13, 21-23]. In one detailed study with a follow-up up to 24 months, patients attending follow-up visits at 3 (n = 88), 6 (n = 76), 12 (n = 41), and 24 (n = 8) months postoperatively experienced median excess weight loss (EWL) of 28.9%, 48.1%, 61.3%, and 62.3%, respectively [8]. At 6 and 12 months follow-up, 42.1% (n = 32) and 73.2% (n = 30) of patients achieved at least 50% EWL, whereas 7.9% (n = 6) and 4.9% (n = 2) had 25% or less EWL, respectively [8].

Our study is the first from the UAE and our results are similar to those published from around the world. Our follow-up is relatively short but there was a 65.2% weight loss and 70% improvement in co-morbidities. This improvement in co morbidities was combined with marked improvement in quality of life, social functioning, self-esteem and productivities. There were no major complications or leaks and only one of our patients required admission to ICU because of sleep apnea. Our results are encouraging and long-term follow-up is important in this regard. It must be emphasized that LSG is not without complications and should be performed by experienced laparoscopic surgeons. Only two of our patients had Prader–Willi syndrome which is a small number to draw conclusions from but in contrast to others, both of our patients lost a significant weight loss during the first two years postoperatively but after that one of them restarted gaining weight. The reason for this is not known. Alqahtani et al reported a sustained and significant weight loss in 24 children and adolescents with Prader–Willi syndrome [24].

In conclusion, obesity and overweight in children is common worldwide and known to be associated with morbidity. LSG is effective in treating obese children and alleviating their co morbidities. LSG should be performed by experienced laparoscopic surgeons and long term follow-up is important as there is still concern regarding its effects on growth and maturity, and the sustainability of the weight loss.

 

 

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