Introduction

Morbid obesity represents a major medical and socio-economical problem in many industrialized countries today, even among children and adolescents [1, 2]. Prevalence as well as severity of adiposity-associated comorbidities like dyslipidemia, glucose intolerance, and arterial hypertension are increasing dramatically. Some children fail to respond to behavioral interventions and pharmacotherapy [2]. Thus, bariatric surgery remains the last choice for morbidly obese children, and specific guidelines have been established [3]. However, the appropriate surgical technique remains a matter of vivid discussions [4]. Laparoscopic adjustable gastric banding (LAGB) or Roux-en-Y gastric bypass (RYGB) have been adopted from adulthood bariatric surgery [5], although the long-term sequalae of neither technique is clear for children today [6]. Laparoscopic sleeve gastrectomy (LSG) is known as a beneficial weight loss procedure for high-risk patients [7, 8], but has not been advocated for this age group as a stand-alone technique yet. This article presents the rationale for choosing LSG and its efficacy in a small series of children and adolescents.

Material and Methods

Before surgery was considered, all patients (n = 4, female) had been in a multi-modal weight loss program for several years without significant long-term success. At referral, the mean age was 14.5 years (range 8–17), mean body mass index (BMI in kg/m2) was 48.4 (range 40.6–56.3). An extensive preoperative work-up was performed including EKG, Chest X-ray, laboratory parameters (including blood count, electrolytes, metabolic parameters, thyroid function tests, clotting studies, arterial blood gas), lung function tests, sleep study, upper GI contrast study, and abdominal ultrasound. All suffered from comorbidities as features of a developing metabolic-vascular syndrome such as dislipidemia, cholecystolithiasis, and arterial hypertension (Table 1). Moreover, in the 8-year-old girl, Prader–Willi Syndrome had been confirmed genetically at the age of 2. The decision for bariatric surgery was taken unanimously by the patient, parents, and the obesity team.

Table 1 Patient data, follow-up results, and metabolic changes
Full size table

LSG was performed according to Milone [9], but using five-trocars only. With a gastroscope (size 40-F) protecting the lesser curvature, the stomach was resected from the proximal antrum to the angle of His using an ENDO-GIA stapler (Autosuture®, green cartridges). That stapler line was then oversewn with 3–0 vicryl. In three girls with preoperatively diagnosed cholecystolithiasis on ultrasound, simultaneous laparoscopic cholecystectomy was performed.

Results

There were no perioperative complications, and all the patients were extubated immediately. An upper GI contrast study on postoperative day 4 documented a J-like tubular gastric remnant (mean volume 76 ml, range 51–100 ml) and ruled out leaks. Thereafter, patients’ were monitored in our special obesity outpatient clinic. After a mean follow-up time of presently 12 months (range 6–19 months) they had reduced the mean BMI from 48.4 to 37.2. The girl with the longest follow-up had reduced her weight from 121 to 83 kg (BMI from 40.6 to 28.4). LSG failed in no child and laboratory studies ruled out malnutrition or vitamin deficiency. Moreover most comorbidities had improved significantly (Table 1).

Discussion

LSG is basically unknown as a stand-alone technique for bariatric surgery in children and adolescents. In adults, however, it is advocated for the treatment of superobese patients to achieve an initial short-term weight loss and improve the perioperative morbidity, before a malabsorptive situation like the RYGB is performed [7, 10]. However, recent data from adult studies [11, 12] suggest that LSG may also be a safe, beneficial, and effective stand-alone approach. Safe because LSG showed minor complications in less than 5% and major complications requiring reoperation in less than 2% of adult patients [13]. Beneficial because Moon [12] reported that LSG led to a resolution of all comorbidities in over 90% of subjects over 12 months except for dislipidemia, which resolved in 65%. Effective because in the same study of 130 relatively young patients (average age 30 years, youngest patient included at 16 years), the mean BMI decreased by 9.2 ± 3.7 kg/m2 after LSG alone. Moreover, there was a striking loss of appetite in more than half of the patients postoperatively [12].

These findings are supported by Himpens, who compared LSG with LAGB in a randomized controlled study [11]. His patients lost significantly more weight 1 and 3 years after LSG and felt much less hungry as well. Loss of appetite may be explained by the fact that ghrelin levels have been shown to decrease significantly after LSG, but not after LAGB as shown by Langer et al. [14]. Ghreline is an acylated gastrointestinal peptide secreted by P/D1 cells predominantly in the fundus of the stomach when fasting. It acts as a potent stimulus for hunger in the arcuate nucleus and is supposed to drive many superobese patients to eat uncontrollably. Since major parts of the stomach are resected during LSG, this approach may actually turn out to be more of an endocrine antiobesity procedure rather than a pure mechanically restrictive operation. Further studies are needed to investigate this aspect prospectively.

The obvious advantages of LSG are effective weight loss without a foreign body and without a life-long dissociation of the gastro-intestinal tract. Critics have contended that LSG may result in long-term dilatation of the remaining stomach sleeve. However, a follow-up study on 23 such patients has refuted this concern, at least over a mean follow-up time of 20 months [15]. Nevertheless, Weiner [16] and other experts agree that the gastric sleeve should not have a volume much larger than 50 ml because weight loss could be insufficient and pouch dilatation may occur. Since our patients showed only a moderate weight loss after 1 year (minus 11 BMI), the mean volume of their sleeves (76 ml) must be observed critically. However, a re-do sleeve is technically feasible and indicated in case of insufficient weight loss [17].

In summary, LSG is a safe and effective alternative for the surgical treatment of morbidly obese adolescents. It may be used as a stand-alone operation. However, longer postoperative follow-up is required before universally recommending this procedure in children and adolescents.