Is Surgery the Answer to Fatty Liver Disease in Children?
Is Surgery the Answer to Fatty Liver Disease in Children?
Dr Balistreri: Which procedure do you currently recommend for weight-loss surgery in adolescents?
Dr Xanthakos: We don't know which procedures are likely to be best, or whether they are all equal. Some studies have shown differential effects after restrictive procedures on changes in bile acid levels and bile acid physiology—for example, after Roux-en-Y gastric bypass vs adjustable gastric banding. Other gastrointestinal hormone profiles can be differentially affected by different types of weight-loss surgeries that could, in turn, differentially affect comorbidity resolution and weight-loss maintenance.
In general, with respect to bariatric surgery, we know that weight loss is typically about one third of the patient's starting BMI. Therefore, an adolescent with a BMI of 60 kg/m can be expected to attain a BMI of approximately 40 kg/m postoperatively at 1 year and will remain in the severely obese category. In contrast, an adolescent with a BMI of 40 kg/m is very likely to attain a near-normal BMI status postoperatively, somewhere in the upper 20-kg/m range. We feel that it is important to let severely obese teens with comorbid conditions know about bariatric surgery as an option earlier rather than waiting until they reach very extreme BMIs—in the 50-kg/m to 60-kg/m, or even 70 kg/m, range.
As Valerio notes, in his center sleeve gastrectomy has also become the preferred procedure in North America for both adults and adolescents. Since 2010, most children in our surgical weight-loss program for teens in Cincinnati have had sleeve gastrectomies. In total, we have done 279 cases, of which 125 have been sleeve gastrectomies.
There are fewer data on long-term weight-loss outcomes and comorbid benefits for sleeve gastrectomy compared with gastric bypass, which is the gold standard, but short-term data in adults, going out 5-7 years postoperatively, appear very promising. We are also seeing very good short-term results in adolescents at 1-3 years, with very similar results in percent weight loss and comorbidity resolution.
Gastric banding, in contrast, has fallen out of favor in North America recently. It is not yet approved by the US Food and Drug Administration for adolescents, and we are finding that there is a higher rate of reoperation in adults as well as in adolescents owing to band slippage or band failure, and lower success rates with long-term weight-loss outcomes. This is probably the reason that banding is being eclipsed by sleeve gastrectomy.
To summarize, we are very excited about the ESPGHAN guidelines. We are excited to see a group of pediatric hepatologists specifically take on this issue of pediatric NASH, but I think there is a need for these adolescents to be carefully phenotyped in terms of the severity of their liver disease and followed long-term to determine outcomes after bariatric surgery.
Recommended Surgical Procedures
Dr Balistreri: Which procedure do you currently recommend for weight-loss surgery in adolescents?
Dr Xanthakos: We don't know which procedures are likely to be best, or whether they are all equal. Some studies have shown differential effects after restrictive procedures on changes in bile acid levels and bile acid physiology—for example, after Roux-en-Y gastric bypass vs adjustable gastric banding. Other gastrointestinal hormone profiles can be differentially affected by different types of weight-loss surgeries that could, in turn, differentially affect comorbidity resolution and weight-loss maintenance.
In general, with respect to bariatric surgery, we know that weight loss is typically about one third of the patient's starting BMI. Therefore, an adolescent with a BMI of 60 kg/m can be expected to attain a BMI of approximately 40 kg/m postoperatively at 1 year and will remain in the severely obese category. In contrast, an adolescent with a BMI of 40 kg/m is very likely to attain a near-normal BMI status postoperatively, somewhere in the upper 20-kg/m range. We feel that it is important to let severely obese teens with comorbid conditions know about bariatric surgery as an option earlier rather than waiting until they reach very extreme BMIs—in the 50-kg/m to 60-kg/m, or even 70 kg/m, range.
As Valerio notes, in his center sleeve gastrectomy has also become the preferred procedure in North America for both adults and adolescents. Since 2010, most children in our surgical weight-loss program for teens in Cincinnati have had sleeve gastrectomies. In total, we have done 279 cases, of which 125 have been sleeve gastrectomies.
There are fewer data on long-term weight-loss outcomes and comorbid benefits for sleeve gastrectomy compared with gastric bypass, which is the gold standard, but short-term data in adults, going out 5-7 years postoperatively, appear very promising. We are also seeing very good short-term results in adolescents at 1-3 years, with very similar results in percent weight loss and comorbidity resolution.
Gastric banding, in contrast, has fallen out of favor in North America recently. It is not yet approved by the US Food and Drug Administration for adolescents, and we are finding that there is a higher rate of reoperation in adults as well as in adolescents owing to band slippage or band failure, and lower success rates with long-term weight-loss outcomes. This is probably the reason that banding is being eclipsed by sleeve gastrectomy.
To summarize, we are very excited about the ESPGHAN guidelines. We are excited to see a group of pediatric hepatologists specifically take on this issue of pediatric NASH, but I think there is a need for these adolescents to be carefully phenotyped in terms of the severity of their liver disease and followed long-term to determine outcomes after bariatric surgery.
