Allen Browne

Short-term outcome in the first 10 morbidly obese adolescent patients in the FDA-approved trial for laparoscopic adjustable gastric banding

Background: We received the LAP-BAND Investigational Device Exemption (IDE) from the US Food and Drug Administration in December 2004 to conduct a prospective longitudinal trial examining the safety and efficacy of laparoscopic adjustable gastric banding (LAGB) in morbidly obese adolescents ages 14 to 17 years. Objectives: To report the short-term results of LAGB in the first 10 adolescents with complete 9 months of follow-up. Patients and Methods: Baseline characteristics and outcome data were analyzed in 10 patients enrolled between March 2005 and February 2006. Results: All of the patients were girls. Their mean body mass index (±SD) was 50 ± 13 kg/m2, and excess weight was 171 ± 79 pounds. Comorbidities included depression (3 patients), sleep apnea (3), hypertension (6), dyslipidemia (7), insulin resistance (9), metabolic syndrome (9), and steatohepatitis (in 4 of 5 patients with liver biopsy). Operative time was 45 ± 9 minutes, and discharges were within 23 hours of surgery. Band-related complications were as follows: 2 dehydration, 1 pouch dilation, and 1 port revision. All of the patients lost weight, with a 9-month excess weight loss of 30% ± 16% (range 14%–57%). Hypertension and the metabolic syndrome were resolved in 100% of patients (P = 0.04) and 80% of the patients (P = 0.01), respectively, along with significant improvement in the Pediatric Quality of Life and Beck Depression Inventory scores and a trend toward improvement in high-density lipoprotein cholesterol abnormalities (P = 0.08). Conclusions: At short-term follow-up, weight loss occurred with minimal complications, leading to early resolution of major obesity-related comorbidities. Continued evaluation of the long-term safety and efficacy of LAGB as a surgical adjunct to a comprehensive obesity treatment program is warranted.

Initial experience with the adjustable gastric band in morbidly obese US adolescents and recommendations for further investigation.

Background: The public health crisis of obesity has spread to the pediatric population. In morbidly obese (MO) adolescents, early weight loss intervention can reduce and prevent obesity-related comorbidities and mortality and improve quality of life. The present study was performed to evaluate weight loss efficacy and safety of “off-label” laparoscopic adjustable gastric banding (LAGB) procedures performed in MO adolescents by our adult bariatric program. Patients and Methods: We retrospectively reviewed data from 716 LAGB procedures performed on an off-label basis in adults and 24 adolescent patients ages 14 to 20 years by the adult bariatric program at our institution between 2001 and 2006. Results: There was no mortality. Average operative time was 45 minutes, length of stay for adolescents was 15 hours, and weight loss outcome and overall surgical complication rates are comparable between adolescents and adults. For adolescent subjects, baseline mean preoperative body mass index was 49 kg/m2 and average excess weight loss rates were 22%, 34%, 52%, 42%, and 42% at 3, 6, 12, 24, and 36 months, respectively. The overall complication rate was 29%, with a 25% incidence of pouch enlargement in adolescents (vs 18% in adult patients; P = ns). Two of 24 adolescent patients (8.4%) required laparoscopic band repositioning (vs 1.5% of adult patients; P = 0.06). Conclusions: LAGB is an effective and safe surgical weight loss modality for MO adolescent subjects. Vigilant follow-up for LAGB-related complications and intensive postoperative behavioral management are important for improving long-term success. We recommend continued investigation of long-term efficacy and safety of LAGB in this population.

Blue Rubber Bleb Nevi as a cause of intussusception

The Blue Rubber Bleb Nevus syndrome is a rare disease characterized by a distinctive type of hemangioma which involves the skin and the gastrointestinal tract. In the latter location, these lesions are often responsible for chronic blood loss and secondary anemia, and in rare situations may act as a leading point for an intussusception. The diagnosis of intussusception in children older than 3 or 4 yr is frequently difficult and delayed. In a child with typical skin lesions of the Blue Rubber Bleb Nevus syndrome, an acute illness with manifestations of intestinal obstruction should indicate the possibility of an associated intussusception.

Antibiotic management of complicated appendicitis

A prospective, randomized, double-blind clinical trial was undertaken comparing gentamicin, ampicillin, and clindamycin (GAC) to gentamicin, ampicillin, and placebo (GAP) in children with complicated appendicitis. Of the 64 patients enrolled in this study, 33 were assigned to the GAC group and 31 received GAP. A single GAC patient (3%) was considered a therapeutic failure in comparison to seven children (23%) in the GAP group (P less than 0.05). Duration of fever was significantly prolonged in the GAP patients (4.7 +/- .8 days versus 2.9 +/- .5 days) when compared to the clindamycin treated children (P less than 0.05). Duration of leukocytosis was 3.2 +/- .4 days for GAC patients and 4.9 +/- .9 days for those on the GAP protocol (P = 0.08). On the basis of this experience the routine use of gentamicin, ampicillin, and clindamycin is recommended for all children with complicated appendicitis.

Nonalcoholic fatty liver disease in severely obese adolescent and adult patients

Nonalcoholic fatty liver disease (NAFLD) is increasingly an indication for liver transplantation in adults. While severe obesity (SO, BMI ≥40 kg m−2) in adults is long standing, it is recent in duration in adolescents. With adolescent obesity on the rise, NAFLD is becoming the most frequent liver disease in adolescents. The hypothesis that SO adolescents and adults have different severity of NAFLD because of longer duration of obesity in SO adults was tested.

Pancreatic pseudocyst complicating treatment of acute lymphoblastic leukemia

In the management of children with acute lymphoblastic leukemia, L-asparaginase has become established as an effective drug in the usual multi-agent therapy; and the significance of pancreatitis as a complication of this drug is well recognized. Less well appreciated, however, is the progression of such pancreatitis in some patients to pseudocyst formation and the possible necessity for surgical management. Two adolescent girls who developed pancreatic pseudocysts while being treated with L-asparaginase are described in this report. Both were being treated for acute lymphoblastic leukemia for periods of 18 and 4 months, respectively, prior to the onset of pancreatitis. Both were in remission of their leukemic disease when typical clinical and laboratory manifestations of acute pancreatitis developed. In one girl, a pancreatic pseudocyst became apparent 2 weeks following the diagnosis of acute pancreatitis and in the other girl, this complication developed over a period of 8 weeks. The usual nonsurgical management of pancreatitis over protracted periods of time was ineffective in the treatment of the pseudocysts. Surgical drainage (internal in one and external in the other) was successful in both in eradicating the pseudocyst, and in neither did further evidence of pancreatic disease subsequently occur. In both resumption of chemotherapy, omitting L-asparaginase, was well tolerated. One has been in remission of leukemia and in good health for a 3-year period of follow-up observation, while the other subsequently had a relapse of leukemia and died 18 months following the onset of pancreatitis.

Patterns of surgical weight loss and resolution of metabolic abnormalities in superobese bariatric adolescents.

PURPOSE The aim of the study was to compare the baseline and the 18-month follow-up for weight and metabolic characteristics of superobese (SO) (body mass index [BMI] ≥50 kg/m(2)) and morbidly obese (MO) (BMI <50 kg/m(2)) adolescents who participated in a prospective longitudinal study of gastric banding delivered in an adolescent multidisciplinary treatment program. METHODS Clinical information was extracted from an institutional review board-approved database of bariatric adolescents. Fasting cytokine and acute phase protein serum levels were analyzed by enzyme-linked immunosorbent assay. Liver histopathologies were assessed using the Kleiners classification score. RESULTS Other than BMI, MO (n = 11) and SO (n = 7) patients have similar degree of insulin resistance, dyslipidemia, and nonalcoholic fatty liver disease. Serum C-reactive protein (10.2 ± 5.6 SO vs 4 ± 3.9 μg/mL MO [P < .02]) and leptin (71 ± 31 SO vs 45 ± 28 MO ng/mL [P = .04]) were more elevated in SO patients. Although weight loss is similar (30 ± 19 kg MO vs 28 ± 12 kg SO, P = .8 at 18 months; mean percent change in BMI, 22.8% ± 11.6% vs 20.5% ± 10.3% SO, P = .2), SO patients has less resolution of insulin resistance and dyslipidemia but experienced significantly improved health-related quality of life. CONCLUSIONS The SO adolescents demonstrate equivalent short-term weight loss and improved quality of life but delayed metabolic response to a gastric banding-based weight loss treatment program compared with MO patients, illustrating the importance of early referral for timely intervention of MO patients.

ASMBS pediatric metabolic and bariatric surgery guidelines, 2018

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.

Extra-anatomical vascular bypass and external skeletal fixation in limb replantation

The scientific background for limb replantation began 75 yr ago with the work of Hopfner and of Carrel and Guthrie. Thirty-five years ago, Hall indicated that the techniques were available, but it was not until 17 yr ago that Malt and McKhann performed the first successful replantation of a limb in man. Since then, the techniques have become more sophisticated and guidelines have been formulated. Many successful replantations have been reported. We present two children with partial amputation of a lower limb. Both had severe soft tissue and bone damage sufficient to contraindicate replantation by conventional criteria. Wound sepsis resulted in failure of replantation of the first childs limb replanted by conventional methods. The second childs limb was salvaged. Extra-anatomical vascular bypass graft separated the critical vascular anastomoses from the open contaminated wound. External skeletal fixation allowed aggressive open wound treatment. In selected cases, these two techniques would appear to increase the chances for successful limb replantation.

Paired Editorial to SOARD-10-151

Q3 Q1 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 This is a very important and unique paper. The length and the completeness of the follow-up give us a better understanding of the natural history of patients that use an adjustable gastric band to control their disease of obesity. Not all patients succeed and manage to reach a healthy body composition. Many attain partial success. Many attain partial success and then they lose their partial control of the disease. Some become dissatisfied with this form of treatment and seek other forms. Unfortunately, we do not have similar reports on other weight management techniques. Currently, obesity is a chronic incurable disease. It is important for the patient and their healthcare providers to understand this fact. Then results such as those that are in this report can be put in a better perspective. Results such as these and expected outcomes should be discussed with patients with obesity before they make decisions on weight management techniques. Similar reports on other weight management techniques would empower both the patients and the healthcare providers as they make decisions about weight management techniques and as they experience the results. This report sets a mark that reports about other weight management techniques should strive to match or surpass.