Bariatric Surgery

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CHAPTER 28 Bariatric Surgery

As the pediatric obesity epidemic has grown in severity over the past several decades, the use of bariatric surgery in pediatric age groups has also increased by threefold from the late 1990s until 2003. Many bariatric procedures with various modifications have been introduced, including intestinal bypass (jejunocolic or jejunoileal), loop gastric bypass, horizontal and vertical gastroplasty, Roux-en-Y gastric bypass (RYGBP), biliopancreatic diversion (with or without duodenal switch), adjustable gastric banding, and vertical sleeve gastrectomy. Over this spectrum of procedures, one can identify relatively simplistic main goals of each operation: restriction of nutrient intake alone, interference with absorption of nutrients that are ingested, or both. The long-term goal of these procedures is to maintain a degree of weight reduction that improves or eliminates obesity-related co-morbidities or decreases the risk of future obesity-related medical complications and death. Laparoscopic Roux-en-Y gastric bypass, the most common operation in use for adolescents today, will be described in this chapter. Laparoscopic adjustable gastric band and vertical sleeve gastrectomy may also be appropriate alternatives. Each of these operations effectively creates a “tool” that, when used in conjunction with behavioral weight management and close clinical follow-up, will lead to significantly greater weight loss than with any other nonsurgical methods of weight management alone.

Step 1: Surgical Anatomy

♦ The left gastric vessels are the primary blood supply to the proximal lesser curvature of the stomach, from which the gastric pouch is created. Care should be taken to preserve the left gastric vessels during pouch creation.

♦ Several anatomic factors are important to consider during construction of the Roux limb. First, the blood supply of the jejunum is derived from the superior mesenteric artery, and when the mesentery is divided to create the Roux limb, hemostasis is critical. A hematoma in the mesentery can be difficult to manage and can compromise the viability of both the Roux limb and the end of the biliopancreatic limb.

Step 2: Preoperative Assessment and Considerations

♦ A multidisciplinary approach is recommended when offering weight loss surgery to extremely obese adolescents. The team should include an experienced bariatric surgeon, pediatric obesity specialist, nurse, dietitian, and pediatric psychologist or psychiatrist. The program also must have ready access to relevant pediatric subspecialties, including endocrinology, cardiology, gastroenterology, pulmonology, gynecology, and orthopedics for further evaluation or management of specific co-morbidities as needed.

♦ The multidisciplinary team should consider carefully whether the patient and family have the ability and motivation to adhere to recommended treatments preoperatively and postoperatively, including the consistent use of micronutrient supplements.

♦ Adolescents seeking a surgical procedure for obesity should demonstrate a history of sustained efforts to lose weight through changes in diet and physical activity. The most widely accepted body mass index (BMI) criteria for weight loss surgery in adolescents include a BMI of 35 kg/m² or greater and a severe co-morbidity (severe obstructive sleep apnea, diabetes mellitus type 2, pseudotumor cerebri, or severe and progressive steatohepatitis) or a BMI of 40 kg/m² or greater with other less severe co-morbidities.

♦ On the day before surgery, patients are limited to clear liquids. No bowel preparation is required. Preoperative medications include low-molecular-weight heparin (40 mg subcutaneously and continued twice daily during postoperative hospitalization) and a second-generation cephalosporin (2 g intravenously). Sequential compression boots are also used perioperatively and should be applied before the induction of anesthesia.

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