1. RATIONALE FOR BARIATRIC SURGERY IN ADOLESCENTS

2. SCOPE OF THE OBESITY PROBLEM 26% of children and adolescents aged 2 to 17 years were overweight (18%) or obese (8%) - Canadian Community Health Survey 2004 26% of children and adolescents aged 2 to 17 years were overweight (18%) or obese (8%) - Canadian Community Health Survey 2004 For adolescents 12 to 17 yrs - overweight rate more than doubled and obesity rate tripled over past 25 yrs For adolescents 12 to 17 yrs - overweight rate more than doubled and obesity rate tripled over past 25 yrs

3. SCOPE OF THE OBESITY PROBLEM

4. 26% of children and adolescents aged 2 to 17 years were overweight (18%) or obese (8%) - Canadian Community Health Survey 2004 26% of children and adolescents aged 2 to 17 years were overweight (18%) or obese (8%) - Canadian Community Health Survey 2004 For adolescents 12 to 17 yrs - overweight rate more than doubled and obesity rate tripled over past 25 yrs For adolescents 12 to 17 yrs - overweight rate more than doubled and obesity rate tripled over past 25 yrs Obesity during adolescence is the single best predictor for adult obesity Obesity during adolescence is the single best predictor for adult obesity

6. WHY WOULD WE EVEN THINK ABOUT DOING SURGERY FOR OBESITY IN CHILDREN? Because diets, pills, lifestyle changes, and prevention strategies don’t seem to be working…

7. What’s the best kind of bariatric procedure for children?

8. MalabsorptiveRestrictive

9. MalabsorptiveRestrictive –Laparoscopic band –Roux-en-Y gastric bypass –Sleeve gastrectomy

10. OUTCOMES: ADOLESCENTS O’Brien et al. JAMA. 2010; O’Brien et al. JAMA. 2010; 303(6):519-526

11. OUTCOMES: ADOLESCENTS Treadwell et al. Ann Surg. 2008; 248(5)

12. OUTCOMES: ADOLESCENTS

14. CCHMC Bariatric Case Volume (n=144 total over 10 years)

15. ADOLESCENT BARIATRIC SURGERY IN ONTARIO Who should be doing it, and in what kind of environment?

16. ADOLESCENT BARIATRIC SURGERY IN ONTARIO Children are not just small adults…

17. ADOLESCENT BARIATRIC SURGERY IN ONTARIO Integrated multidisciplinary pediatric- oriented medical program –Pediatric medical specialties –Psychosocial support for child and family Surgical expertise Academic environment as part of overall pediatric obesity strategy

18. SICKKIDS TEAM OBESITY MANAGEMENT PROGRAM (STOMP) Multidisciplinary medical/psychosocial program funded through MOHLTC Diabetes Strategy Bariatric surgery funded by MOHLTC through University of Toronto Bariatric Surgery Collaboration High Impact Strategies Toward Obesity Reduction in Youth (HISTORY) multidisciplinary grant funded by CIHR Province-wide initiative for obesity prevention and management

19. Intake/Initial Assessment

20. Parent Group Support Adolescent Group Support Adolescent Individual Appointments Diet/Behaviour/Exercise

21. Intake/Initial Assessment Parent Group Support Adolescent Group Support Adolescent Individual Appointments Diet/Behaviour/Exercise Team Re-Assessment 3-6 Months Ongoing support and treatment Bariatric surgery

22. SICKKIDS EXPERIENCE SO FAR Pre-STOMP Seven cases –4 craniopharyngioma –3 morbid obesity First two: Roux-en-Y bypass –Excellent weight loss Last five: laparoscopic band –All inflated with good initial weight loss –Two required reoperation –One removed at 2.5 years - converted to Roux-en-Y bypass –One removed at 2.0 years - converted to Roux-en-Y bypass –Weight loss results mixed

23. SICKKIDS EXPERIENCE SO FAR Post-STOMP Nine cases –1 craniopharyngioma –8 morbid obesity First three: laparoscopic band –Excellent weight loss in 1, poor weight loss in 2 –One removed after 10 months - converted to sleeve gastrectomy –No complications Last six: –3 Roux-en-Y bypass and 3 sleeve gastrectomy –Excellent early weight loss –No complications

24. SICKKIDS EXPERIENCE SO FAR

25. ONGOING ISSUES What is the best operation for adolescents? Laparoscopic band –Potentially reversible and lower mortality –Higher complication and reoperation rate –Lower efficacy Roux-en-Y bypass –“Gold standard” –Long term issues with vitamin deficiencies and compliance in adolescents Sleeve gastrectomy ?

26. ONGOING ISSUES How many funded pediatric centres should there be in Ontario? –For complex medical care –For bariatric surgery Which model is better? –Pediatric centre with help from adult surgeons –Adult centre with help from pediatric medical specialists Transitioning to adult centres

27. THANKS FOR YOUR ATTENTION!