Study design
Study eligibility
This was retrospective study to evaluate the efficacy of laparoscopic sleeve gastrectomy (LSG) in obese adolescents. The patients’ data was collected from the prospectively maintained database between 2014 to 2019.
Inclusion criteria
All adolescents aged from 12 to 19 years with a body mass index (BMI) of more than 40 kg/m2 or a BMI of greater than 35 kg/m2 associated with obesity-related comorbidities were included in the study. The co-morbidities should be documented by the treating pediatrician or specialized referring physician. All eligible adolescents underwent non-surgical weight loss management such as lifestyle modifications, physical exercise, and dietary control but with unsatisfactory results within a minimum period of 12 months. Adolescent and family education about potential perioperative complications, as well as strict follow-up programs and dietary regimens.
Exclusion criteria
Exclusion criteria included: eating disorders, lack of social family support, developmental immaturity, severe and uncontrolled cardiorespiratory disease, syndromes causing obesity (Prader Willi syndrome), and endocrinal disorders affecting the weight loss such as untreated hypothyroidism and prolactinoma. Patients with history of upper GI surgery were also excluded.
Definitions
The definition of obesity associated comorbidities includes the following: a) type 2 DM (fasting blood glucose of < 110 mg/dl); b) hypertension (systolic blood pressure of < 140 and or diastolic blood pressure of < 90 mmHg); c) obstructive sleep apnea (OSA) (breathing disorder during sleep manifested by snoring, apnea, gasping and chocking sensation); d) Gastroesophageal reflux disease (GERD) (symptoms such as heart burn, regurgitation, and retrosternal chest pain responding to proton pump inhibitor drugs and/or esophageal erosions detected by upper GI endoscopy); e) depression; f) osteo-arthritis [8-13].
Preoperative assessment
All patients underwent comprehensive evaluation by a specialized team consisting of pediatrician, dietitian, bariatric surgeon, and psychologist before operation. Laboratory investigations, including complete blood picture, liver function test, serum creatinine, thyroid function tests, fasting and postprandial blood sugar, lipid profile, coagulation profile, and serum cortisol level, were done. Abdominal ultrasonography was done to detect gall bladder stones and other abdominal pathology. Patients complaining of GERD symptoms were given upper GI endoscopy. An informed written consent was given by parents for all patients preoperatively.
Surgical procedure
Standard 5-port LSG was done using French position with
the surgeon standing between the patient’s legs. Division of the greater omentum from its attachment to the greater curve of the stomach and complete mobilization of the fundus using bipolar sealing device (LigaSure™, Medtronic, USA) was performed. Then, gastrectomy over a 40-Fr calibrating bougie starting 4 cm proximal to pylorus was done using
EndoGIA stapler (Johnson and Johnson or Covidien) resulting in gastric pouch size of 100 ml. Titanium clips were used to control bleeding at the staple line when indicated. A drain was inserted in all cases. Detailed surgical steps and intraoperative complications were recorded.
Postoperative care
All patients underwent oral gastrograffin for early detection of leaks, and then oral intake was started 12 h postoperatively. On the first day after surgery, after tolerance to adequate oral fluids and pain control, the patients were discharged from the hospital. Patients were encouraged to start with clear fluids for 2 weeks, a soft diet for another 2 weeks, and solid food after 4 weeks. Multivitamins, oral calcium, vitamin D, and proton pump inhibitor were prescribed for patient for 1 year after surgery.
Follow up
Follow up visits were scheduled at the outpatient clinic 2 and 4 weeks after surgery then 3, 6, 12, 18, and 24 months and then yearly. All patients were evaluated for excess weight loss, dysphagia, vomiting, eating behavior, comorbidity improvement, and any other complications. A Laboratory investigation was conducted on every visit for detection of any nutritional deficiency, including iron, vitamin D, hemoglobin, albumin, and lipid profile. The patients were advised to do regular daily physical activity. A psychological assessment was done for any psychological problems.
Measurements
Every visit, weight (kg), height (m), and BMI (kg/m2), and waist circumference WC (cm) were measured. Excess weight (EW) = (pre-operative weight−ideal weight) was measured using, and excess weight loss ratio (EWL)% = (preoperative weight−current weight/EW) ×100.
Statistical analysis
Categorical variables are described using absolute numbers with percentages. Continuous variables are expressed as medians and ranges. The Chi-square or Fisher exact test was used to compare categorical variables, with Student’s t test or the Mann-Whitney U test for continuous variables. A P value ≤0.05 was considered to be significant. All statistical analyses were performed using SPSS statistical software, version 23.0 (SPSS, Inc., Chicago, IL).