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This document summarizes a study that examined the weight loss outcomes of youth with neurodevelopmental differences who underwent bariatric surgery. The study found that these youth had comparable weight loss outcomes to their peers without neurodevelopmental differences when the surgery was conducted at a specialized center. However, there were some differences in weight loss between youth with autism spectrum disorder and those with intellectual developmental disability. The study suggests that youth with neurodevelopmental differences may require more specialized support during the surgery process and recommends evaluation and support in specialized centers. The study acknowledges limitations such as a small sample size and the need for further research. [Extracted from the article]

Background: Adolescent obesity is multifactorial, but parental history is the most significant risk factor. Laparoscopic sleeve gastrectomy (LSG) is part of the multidisciplinary approach to adolescent weight loss. Objective: We aimed to evaluate the effects of parental history of bariatric surgery, as well as age at time of operation, on adolescents who underwent LSG at our institution. Methods: We performed a retrospective review of patients, aged 10 to 19 years, who underwent LSG from January 2010 to December 2019. The adolescent bariatric surgical dataset maintained by our group was used to obtain patient demographics, weight, body mass index (BMI), and parental history of bariatric surgery. Results: Among 328 patients, 76 (23.2%) had parents who had previously undergone bariatric surgery. These patients were significantly heavier by weight (p = 0.012) at the time of operation but had no difference in postoperative weight loss. When all patients were compared by age at operation (< 16 years, n = 102, ≥ 16 years, n = 226), there were few differences in outcomes. Conclusions: LSG is an effective approach to surgical weight loss in adolescents. Patient age should not be a barrier to weight loss surgery, especially among patients with a parental history of obesity. By intervening at a younger age, the metabolic sequelae of obesity may be reduced. [ABSTRACT FROM AUTHOR]

Adolescents seeking bariatric surgery may present with pre-existing psychiatric diagnoses for which they use chronic medications. To heighten awareness concerning perioperative polypharmacy in adolescents with extreme obesity, we conducted a retrospective review of patients undergoing laparoscopic sleeve gastrectomy between February 2010 and May 2017 at Children's National Health System (CNHS). A total of 167 adolescent patients had pre-existing psychiatric diagnoses which included depression (50%), anxiety (23%), ADHD (23%), and binge eating disorder (11%). Medications prescribed to treat these diagnoses included selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). Additionally, all patients were given fentanyl, ondansetron, morphine, and acetaminophen perioperatively. Although no life threatening symptoms of drug-drug interactions (DDIs) were appreciated, the combined use of many different potent drugs in these patients warrants attention. [ABSTRACT FROM AUTHOR]

Introduction: Severe obesity predisposes youth to a higher risk of venous thromboembolism (VTE). This study evaluates a BMI-stratified prophylactic dosing regimen of enoxaparin in adolescents with severe obesity undergoing surgery. Methods: Adolescents aged 12–20 years received prophylactic enoxaparin at 40 mg SC (for a BMI < 50 kg/m2) and 60 mg SC (for a BMI ≥ 50 kg/m2) every 12 h until discharge. Blood samples were drawn at pre-dose, 1, 2, 4, 6, and 12 h. Plasma Anti-Factor Xa (Anti-FXa) activity was used as a surrogate marker for enoxaparin pharmacokinetics. Results: Ten female and two male obese adolescents (age range 14–19 years) had a mean BMI of 49.9 kg/m2 (38.4–58 kg/m2). Four patients had a BMI of less than 50 kg/m2 and received 40 mg enoxaparin, resulting in a mean dosage of 0.352 ± 0.070 mg/kg body weight. Eight patients were dosed with 60 mg enoxaparin every 12 h, resulting in a mean dosage of 0.395 ± 0.028 mg/kg. Peak plasma anti-FXa activity (Cmax) ranged from 0.14 to 0.30 IU/mL, median Cmax was 0.205 IU/mL. Median Tmax was 5.67 h (range 3.78–7.52 h). Median AUCi was 1.00 h IU/mL (range 0.42–1.67 h IU/mL). Ten out of 12 patients (83%) reached the primary endpoint with anti-FXa activity in the range for VTE prevention (0.1–0.3 IU/mL). Conclusions: Our dosing scheme of 40 mg vs. 60 mg enoxaparin stratified according to BMI proved to be effective in reaching prophylactic anti-FXa activity in 83% of adolescent patients. [ABSTRACT FROM AUTHOR]

Purpose of Review: The purpose of this review is to discuss the current state of surgical intervention for obesity in children and adolescents. Specifically, this review will discuss the different types of metabolic and bariatric surgery (MBS) procedures, guidelines for patient selection, and recent findings regarding surgical outcomes and complications. Recent Findings: MBS is safe in adolescents and has also demonstrated sustainable long term weight loss and improvement in obesity-associated comorbidities. A recent prospective multi-institutional trial demonstrated BMI reductions of 3.8 kg/m2 (8%) to 15.1 kg/m2 (28%) after 3 years among adolescents undergoing the three most common MBS procedures. Moreover, MBS is associated with remission of type 2 diabetes, prediabetes, hypertension, dyslipidemia, and abnormal kidney function in 65–95% of patients in the study. Summary: Childhood and adolescent obesity is a continuing problem that has not been adequately addressed by the medical community. MBS is currently the most successful strategy for significant and sustained weight loss and improvement of associated comorbidities. This review focuses on the different types of MBS, the selection and preparation of patients for surgery, and the expected outcomes and common complications. [ABSTRACT FROM AUTHOR]

Aim: To examine the impact of preexisting psychiatric/psychological diagnoses on perioperative analgesic requirements in adolescents with morbid obesity undergoing bariatric surgery. Methods: A retrospective cohort study of adolescents with morbid obesity undergoing bariatric surgery. Primary and secondary outcomes included perioperative analgesic intake and pain scores (Numerical Rating Scale (0–10) NRS) throughout the hospital stay. Results: From our Bariatric Surgery Research Registry, we identified 17 adolescents with psychiatric/psychological diagnoses prior to undergoing bariatric surgery. Fifteen patients from the same registry and without such diagnosis undergoing bariatric surgery during the same time interval served as controls. In both groups, there was a predominance of female patients. During the perioperative period, in both groups, oral morphine equivalent and ketorolac and acetaminophen intake were similar. Notably, the perioperative median pain scores at the times examined were below 5 for all patients. The median pain scores in the PACU, day of surgery, and first postoperative day were similar. Conversely, on postoperative day 2, pain scores were higher in patients with diagnoses of psychiatric/psychological disorders (p = 0.004) compared to those without. Conclusion: In this cohort of morbidly obese adolescents undergoing bariatric surgery, patients with and without preexisting psychiatric/psychological diagnoses had similar analgesic requirements during the perioperative period. This finding appears contrary to those suggesting that preexisting depression and/or anxiety might be associated with increased analgesic requirements during the perioperative period. [ABSTRACT FROM AUTHOR]

Purpose: Widespread adoption of minimally invasive surgery (MIS) techniques in pediatric surgery has progressed slowly, and the shift in practice patterns has been variable among surgeons. We hypothesized that a pediatric surgeon committed to MIS could effectively change surgical practice by creating an emphasis on MIS.Methods: Annual case volumes from 2000 to 2009 at two tertiary care pediatric hospitals, one with a dedicated minimally invasive pediatric surgeon, were evaluated for trends in MIS for ten different operations. Univariate analyses of the differences between hospitals in the use of the open versus laparoscopic approach were performed. The Breslow-Day test was used to examine differences in use of laparoscopic procedures across hospitals in early versus middle and middle versus late time periods.Results: Between the two hospitals, for 9 of the 10 types of surgery, the number of laparoscopic and open procedures differed significantly (p values ranged from <0.0001 to 0.003). Over the 10-year period, the hospital with a dedicated MIS surgeon had a larger proportion of procedures done laparoscopically for all years. This difference reached statistical significance for appendectomy (p < 0.0001), congenital diaphragmatic hernia (p < 0.0002), chest wall reconstruction (p < 0.0001), cholecystectomy (p = <0.0001), gastrostomy (p < 0.0001), nissen fundoplication (p < 0.0001) oophorectomy (p < 0.0001), pyloromyotomy (p < 0.0001) and splenectomy (p = 0.0006). After grouping the years into early (2000-2003), middle (2004-2006) and late (2007-2009) categories, the hospital with a dedicated MIS surgeon had a significantly higher rate of increase in use of laparoscopic surgery between the early and middle years for four procedures: diaphragmatic hernia repair (p = 0.003), chest wall reconstruction (p = 0.0086), cholecystectomy (0.0083) and endorectal pull-through (p = 0.025).Conclusion: The presence of a dedicated minimally invasive pediatric surgeon led to a significant change in surgical practice with an overall trend of increasing MIS several years in advance of a hospital that did not have a dedicated MIS surgeon. This has implications for resident training in academic medical centers and potential patient care outcomes. [ABSTRACT FROM AUTHOR]

Objectives: Bariatric surgery is an effective treatment for youth with severe obesity. However, outcomes are variable and there remains sparse understanding of predictors of weight loss following surgery. The current study examines the role of adolescent-reported pre-operative social support around exercise, binge eating, and exercise to predict excess body mass index (EBMI) loss from 3 to 12 months post-surgery. Method: Participants were 101 adolescents ages 12-21 ( M age = 16.6, SD = 1.8). Pre-operative body mass index (BMI) ranged from 35 to 87 ( M = 50.3, SD = 8.6). Structural equation modeling (SEM) was used to evaluate a model of the association of adolescent report of perceived social support for exercise with less binge eating (items from the Eating Disorder Diagnostic Scale) and more self-reported exercise (items from the Youth Risk Behavior Surveillance System). The model was used to predict EBMI loss at 3, 6, 9, and 12 months post-surgery. Results: Social support significantly predicted exercise and demonstrated a trend for predicting binge eating, such that more social support was associated with more exercise and a trend for less binge eating. Binge eating was associated with less EBMI loss. However, there was no association of exercise with EBMI loss. Conclusions: Pre-operative binge eating should be a target for identification and treatment prior to sleeve gastrectomy in adolescents. Although not directly or indirectly associated with EBMI loss, perceived social support around exercise was associated with increased exercise, which may make it a consideration for a target for intervention as well. [ABSTRACT FROM AUTHOR]

Children with acquired immunodeficiency syndrome (AIDS) are at an increased risk for lymphoproliferative and neoplastic disorders. Included among these are smooth muscle neoplasms such as leiomyomas and leiomyosarcomas. There have been at least 15 reported cases of smooth muscle tumors in the approximately 8,000 children with AIDS, however the incidence in immunocompetent children is only two per ten million. The lesions in children with human immunodeficiency virus infection are usually found in the lung, liver, and gastrointestinal tract. Here, we present an unusual case of a 12-year-old African American girl with vertically acquired AIDS who presented to the pediatric emergency department with severe diffuse abdominal pain. She was ultimately found to have an appendiceal leiomyoma on abdominal exploration, the first reported case. Our report suggests that smooth muscle tumors of the appendix be included in the differential diagnosis of abdominal masses in children with AIDS. [ABSTRACT FROM AUTHOR]

Background: Obese patients have a higher risk of venous thromboembolism when immobilized due to surgery. The objective of this study was to assess anti-factor Xa activity in adolescent bariatric surgical patients receiving prophylactic enoxaparin. Methods: Four morbidly obese adolescents undergoing laparoscopic sleeve gastrectomy were enrolled. Enoxaparin was administered (40 mg subcutaneous (SC) if BMI ≤50 kg/m or 60 mg SC if BMI >50 kg/m) for prevention of venous thromboembolism every 12 h starting after induction of anesthesia until discharge. Plasma anti-factor Xa activity was assessed over 12 h after the first dose and used as a surrogate marker for enoxaparin levels. Non-compartmental analysis of anti-factor Xa activity levels was performed and compared with previously published studies. Results: Patients recruited were 16 to 18 years of age with a mean BMI of 52.6 ± 5.8 kg/m (>99th BMI percentile). Peak anti-factor Xa activity ranged from 0.20 to 0.23 IU/mL in our study population, compared to 0.38 to 0.53 IU/mL in the cited lean comparator groups. Conclusions: Our current dosing practice of 40 mg SC for individuals with a BMI ≤50 kg/m and 60 mg for individuals with a BMI ≥50 kg/m resulted in anti-factor Xa activity that was sufficient for adequate thromboprophylaxis in adolescent bariatric surgical patients. Our data also demonstrates lower drug exposures in the obese when compared to lean patients. Therefore, randomized controlled efficacy and safety studies are urgently needed to guide the use of low-molecular-weight heparins in the pediatric and adolescent obese population. [ABSTRACT FROM AUTHOR]

Introduction: In adults, the association between obesity and obstructive sleep apnea (OSA) is established, and many are concerned OSA increases surgical risk. Pre-operative screening for OSA is standard, and this is also the case in adolescent bariatric surgery. We noted many of our patients were without significant OSA, despite being obese. We reviewed our experience with screening polysomnography (PSG) to determine any predictive variables or complications. Methods: All bariatric surgery patients from our hospital who had undergone PSG were included, and were stratified into 'OSA' or 'no OSA' by obstructive apnea-hypopnea index (OAHI), as well as by sex. Results: A total of 49 adolescents enrolled during the study period: 10 males and 39 females. OSA prevalence was 42.9 %; males 80 %, females 33.3 %. Height, weight, body mass index (BMI), and prevalence of hypertension were significantly higher in patients with OSA. By sex, females also had more metabolic syndrome and witnessed apneas, while only weight and BMI remained significant in males. There were no peri-operative complications. Conclusions: Despite uniform obesity, less than half our adolescents had significant OSA on PSG. As no modeling exists to predict OSA in morbidly obese adolescents, we continue to recommend routine PSG, especially in higher weight and BMI patients, and those with hypertension. [ABSTRACT FROM AUTHOR]

Calcified catheter "cast" found on radiologic studies after central venous catheter removal is a rare complication that has been reported twice. Both cases were associated with thrombus. In this case report, we present a 15-year-old boy with acute lymphoblastic leukemia who demonstrated on CT scan a radiopacity in his left brachiocephalic vein after removal of an implanted venous access device. This was initially thought to be a retained catheter fragment. Diagnostic studies, including venogram, excluded the presence of a retained catheter fragment. Additional procedures to retrieve a nonexistent catheter fragment were thus avoided. Therefore, a catheter "cast" should be considered as part of the differential diagnosis when calcification is found on an imaging study after removal of an implantable venous access device to prevent an unwarranted surgical exploration. [ABSTRACT FROM AUTHOR]

Persistent interstitial pulmonary emphysema (PIPE) is a syndrome characterized by air-leakage in the perivascular tissues of the lung, primarily affecting mechanically ventilated neonates. Reports in the literature of infants developing PIPE with no history of respiratory distress syndrome (RDS) or mechanical ventilation are scarce. Here, we present a case of a 3-month-old former full term male infant with no history of RDS or mechanical ventilation who presented with focal cystic lung disease associated with spontaneous tension pneumothorax. He was ultimately found to have PIPE based on pathologic evaluation of the resected cystic region. We believe that focal PIPE should be included in the differential diagnosis of cystic lung disease in a full term, unventilated infant, even when spontaneous pneumothorax is the presenting entity. [ABSTRACT FROM AUTHOR]

Patients with Crohn’s disease are at risk for developing both internal and external fistulae. These can be asymptomatic incidental radiologic findings or causes of incontinence, chronic pain, abscesses, and sepsis. They can have a devastating impact on quality of life. Careful prospective studies of therapy are few in adult medicine and entirely lacking in the pediatric age group. Assessment and management require a coordinated effort between gastroenterologist, radiologist, and surgeon. Principles of management include surgical drainage of infection combined with medical therapy. Only infliximab has been studied in prospective, double-blinded fashion and clearly shown to be of use in the short term. There is good evidence that metronidazole may be useful acutely and that 6-mercaptopurine azathioprine may help to maintain closure. Diverting ostomies are of very limited value and corticosteroids seem to make matters worse. There are many other therapies that have been reported to be helpful in small, uncontrolled studies. [ABSTRACT FROM AUTHOR]

Nitric oxide (NO) appears to play a paradoxical role in intestinal physiology. Although NO has potent bactericidal effects, a growing body of evidence suggests that it mediates intestinal injury and breakdown of gut barrier function. Data from our lab and others show an increased incidence of bacterial translocation following endotoxin challenge, and upregulation of inducible NO synthase (iNOS) mRNA and protein in the intestine. These phenomena co-localize with enterocyte apoptosis at the tips of the intestinal villi and immunoreactivity to nitrotyrosine. Electron microscopy reveals swollen mitochondria, implicating these organelles as putative targets for NO or its reactive nitrogen intermediates. We review some of the literature and discuss our current work in trying to define this mechanism. [ABSTRACT FROM AUTHOR]

A 3-year-old boy with familial long QT syndrome type 2 presented with recurrent syncope despite adequate beta-blocker therapy. Two family members had experienced sudden cardiac arrest, and one other relative had experienced sudden cardiac death. Given the high risk for ventricular arrhythmia/syncope, the decision was made to perform primary cardiac denervation therapy through a minimally invasive approach without concomitant automatic cardioverter-defibrillator implantation. Using video-assisted thoracoscopic surgery, the left-sided sympathetic ganglia from T2–T5 were identified, and dissection along the sympathetic chain with transection of the corresponding rami along T2–T5 in addition to the lower half of the stellate ganglion was performed. The chest tube was removed on day 1 after surgery, and the patient was discharged on postoperative day 4. During 14 months of follow-up evaluation, no intervening episodes of ventricular arrhythmia or syncope and no symptoms of Horner’s syndrome were noted. [ABSTRACT FROM AUTHOR]

Presented is a case of a 13 year old boy who was seen by his pediatrician with complaints of profuse sweating and intermittent headaches. A routine blood pressure measurement at that time was markedly elevated at 180/110 mmHg. A 24-hour urinary catecholamine evaluation was positive for the presence of metanephrines. Serum samples confirmed the presence of high levels of circulating catecholamines, suggesting the diagnosis of a pheochromocytoma. An MRI of the abdomen was obtained which demonstrated the presence of a 5 cm mass between the iliac arteries behind the rectum. An (123)I-metaiodobenzylguanidine (MIBG) scan revealed an enhancing lesion at the Organ of Zuckerkandl with no other lesions present. The diagnosis of an extra adrenal pheochromocytoma was established. After appropriate pharmacologic adrenergic blockade, the patient was brought to the operating room for a laparoscopic resection. The accompanying video illustrates a laparoscopic resection of a pheochromocytoma at the Organ of Zuckerkandl using a 10-mm port for the umbilicus and 3 5-mm working ports. The working ports were placed in the left upper quadrant, right upper quadrant, and right lower quadrant. The mass was removed using an Endocatch bag through an extension of the umbilical incision. The patient tolerated the procedure quite well, and the patient was started on a clear liquid diet on post-operative day number one. The patient was discharged home on post-operative day number three, tolerating a regular diet, and and oral pain medicine. The patient is currently symptom free with normal catecholamine levels 12 months after surgery. [ABSTRACT FROM AUTHOR]