The prevalence of morbid obesity has risen sharply in recent years, even among paediatric patients.1 Bariatric surgery is becoming an increasingly common method of weight loss, with resulting improvement in quality of life and increased survival.1
Laparoscopic sleeve gastrectomy is a recognized surgical treatment for morbidly obese adults, and such surgery is also performed in children between 10 and 12 years of age.2 However, this is the first time, to our knowledge, that such surgery has been carried out in a morbidly obese infant.
An 11-month-old girl was referred to the Obesity Surgery Clinic on 19 November 2011 with a history of excessive weight gain due to hyperphagia and a lower respiratory tract infection which had been recurring for over 2 months (Figure 1).
The weight gain pattern, as recorded, is shown in Table 1.
|Date||3 December 2010||8 February 2011||29 March 2011||3 May 2011||8 November 2011||19 November 2011|
The patient's parents were able to provide a history of breastfeeding, the frequency of which had been about 12 or 13 times per day since the child had been 6 weeks old. Family history indicated that there had been an elder child who suffered from morbid obesity and respiratory complications and died at the age of 18 months, weighing 22 kg. There was no history of obesity in either parent nor any history of seizures or hearing or visual imparments. The patient was referred from the Endocrine Department of Topiwala National Medical College and Nair Hospital for surgical management at the Obesity Surgery Clinic. Following investigations, the patient showed normal cognitive milestones and genitals and there was no evidence of hypotonia. At the time of admittance to the Obesity Surgery Clinic, the patient weighed 19 kg and was 81 cm in height (Figure 2).
Haemography of the patient returned normal results, which can be seen in Table 2.
In addition, ultrasonography revealed grade I fatty liver whereas two-dimensional echocardiography was normal.
An overnight dexamethasone suppression test generated a result of 0.71 ng, which is less than the value of 0.8 ng expected in a patient with Cushing's syndrome. A cortisol test conducted at 0800 hours revealed cortisol levels of 22.8 μg/dl, which was within the normal cortisol level range of 3–23 μg/dl.
The coding regions for leptin, leptin receptor, melanocortin receptor 4 and the ShB1 gene were sequenced by Cambridge University, UK (Dr P Pawal, Topiwala National Medical College, 2011, personal communication), and all were found to be normal, with the exception of the gene mutation which results in leptin deficiency, which is to date the only treatable genetic form of obesity.
The parents of the patient were able to give a history which detailed their consanguineous marriage and their elder child, who weighed 2.75 kg at birth and excessesively gained weight from 6 weeks of age until reaching 22 kg in weight at 18 months of age, when he died from a lower respiratory tract infection. As a result, the parents were aware of these issues with their second child and that the patient's only option for survival was to undergo a laparoscopic sleeve gastrectomy.
During the course of the surgery, it was clear that the patient had a large stomach for her age and she displayed retrogastric and splenic adhesions which contributed to the inflammation of fat cells that is normally found in those with morbid obesity. The surgery was uneventful and the patient responded positively to the procedure.
The results of the haematology tests 1 month after the surgery showed that the patient's haemoglobin concentration was 11 g%, total cholesterol was 16 000 cells/mm3, the mean corpuscular volume was 67.93 fl, mean corpuscular haemoglobin level was 20.60 pg, mean corpuscular haemoglobin concentration was 30.32 g/dl and the platelet count was 2.11 × 105/mm3.
The results of the biochemistry tests 1 month after the surgery showed that the patient's blood urea nitrogen level was 10 mg/dl, creatinine 0.4 mg/dl, sodium 138 mEq/l, potassium 5.0 mEq/l, total protein 6.8 g%, albumin 4.0 g%, total bilirubin 0.3 mg/dl, alkaline phosphatase 264 units (U)/l and fasting insulin 18.4 μU/ml. The histopathology report indicated that the laparoscopic sleeve gastrectomy had been successful with no evidence of neoplasia.
The patient's appetite and food intake have reduced substantially since the surgery, and the level of physical activity has improved. At 15 months of age, the patient could not stand on her own but walked with the aid of a walker and crawled on the floor. At 2 years of age, the patient walks independently, weighs 16 kg and is about 88 cm in height. In addition, the developmental milestones of the patient appear normal.
Although bariatric surgery for infants is still a new and developing technique, it may be in the best interests of a patient who has been referred from the endocrine department. One such case is described here, of a child whose elder sibling died from the complications associated with morbid obesity and in whom laparoscopic sleeve gastrectomy was performed with the aim of increasing the patient's survival.
Bariatric surgery has been advocated as an intervention for those with extreme obesity and is most effective for those with early childhood-onset obesity to reduce weight and serious obesity related medical conditions, and also to improve psychosocial status.3
Non-operative approaches to weight loss have shown less than optimal results; therefore, paediatric patients are increasingly seeking bariatric surgical interventions if respiratory complications are involved.4
A genetic syndrome works pathologically on the patient's hormones, specifically ghrelin and leptin. Ghrelin is a circulating hormone that is mainly produced by the body and fundus of the stomach and acts as an appetite stimulant, encouraging food intake, and is responsible for weight gain in children.5,6 Endogenous ghrelin is a potentially important regulator of the complex systems which control food intake and body weight.6 Leptin acts on the receptors in the hypothalamus of the brain to inhibit the activity of peptides, therefore producing a feeling of satiety and signalling that the body has had enough to eat, especially of high-calorie foods.7
Laparoscopic sleeve gastrectomy removes the excess part of the body and fundus of the stomach, along with the ghrelin-secreting portion, thereby reducing appetite and subsequent food intake. Laparoscopic sleeve gastrectomy also enhances formation of peptides such as glucagon-like peptide 1 and peptide YY from the small intestine, both of which play a role in weight loss.5 This surgery reduces the stomach size to a more normal size for the patient's age and weight. The remainder of the stomach continues to grow, but not at the same rate as before the surgery. Laparoscopic gastric band and gastric bypass surgeries play a role in weight loss but demand lifelong tolerance of, respectively, an artificial device or significant malabsorption.2
Although no appropriate weight loss technique for infants has been identified thus far,8,9 judicious use of surgical procedures after the failure of conservative treatments in a life-threatening medical condition can sometimes benefit the patient. Both laparoscopic adjustable gastric band surgery and laparoscopic sleeve gastrectomy reduce excess body weight and fat mass in children. Plasma ghrelin levels are down-regulated by laparoscopic sleeve gastrectomy whereas hypothalamic growth hormone secretagogue receptor type 1a protein expression level is elevated following sleeve gastrectomy. Laparoscopic sleeve gastrectomy results in complicated feedback between the hypothalamus and the digestive tract.10
With the instigation of a well-developed department of bariatric and metabolic surgery hosting trained surgeons, anaesthetists and equipped postoperative intensive care units for children, patients such as those described here could be offered the best chance of survival through surgery. Although this surgery has been a pioneering attempt with mixed reactions from fraternity colleagues, we conducted this procedure in a charitable, sincere and honest manner with the patient's best interests in mind, owing to the family income of Rs.100 per day.