We reported a very early amelioration in metabolic and neurohormonal profile, after robotic-assisted gastroplication, in a morbidly obese adolescent. The girl with body mass index (BMI) 38.8 kg/m2
, at the age of 13 years and 6 months, was referred at our Institute by primary pediatric care. Eighteen months of organized and supervised programme of lifestyle modification, including family involvement, didn't show significant results. She was affected by hyperinsulinism, hyperandrogenism, amenorrhea, ultrasound signs of polycystic ovarian syndrome (PCOS), hypertension with left ventricular hypertrophy as co-morbidities. At 15 years of age, deterioration in weight (BMI 42.2 kg/m2
) appeared. Skeletal and developmental maturity was reached. No major controindications for bariatric surgery were found, including eating disorders and psychopathologies. A multidisciplinary intervention with specific nutritional, psychological and training sessions started two months before surgery. Capability to commit to comprehensive medical and psychological evaluation before and after surgery as well as girl and family willingness to participate in a postoperative multidisciplinary treatment were documented; informed consent was obtained. Pre-surgical clinical, metabolic and hormonal parameters are described in . We performed a complete nutritional assessment by anthropometric measures, bioimpedence analysis, indirect calorimetry (IC) and dietary diary. The resting energy expenditure measured by IC (2090 Kilocalories per day) was 99% of the basal metabolism estimated by FAO/WHO formulas.5
Clinical, metabolic and hormonal parameters at the pre and post-surgical time.
The respiratory quotient was 0.79 showing a prevalent use of fat as energetic source, confirmed by dietary diary, outlining a high fat diet (total fat: 45.7% of the energy intake). We instructed the patient and her family with dietary recommendations and guidelines for post-surgical period.The subject performed a modified Bruce test to assess maximum oxygen consumption. The aim of the physical training conditioning was to develop aerobic capacity with adapted exercises: flexibility and resistance exercises were programmed twice a week. Gastroplication was done in Robotic surgery Da Vinci system® (Intuitive Surgical, Inc., Sunnyvale, California, USA) by using 3 trocars instruments (8.5 an 2 trocars 5-mm).
The omentum and the gastrepiploic vessels were dissected away from the greater curvature. The short gastric vessels, the posterior gastric vein, and the posterior gastric attachments were dissected starting from the antrum towards the left crus of the diaphragm and the angle of His. Following the completion of the dissection to the distal antrum (5 cm from pylorus), a 36-Fr bougie was inserted into the stomach. Under its guidance, a row of 10–12 extra-mucosal non absorbable interrupted sutures (2-0 Ethibond™) was placed along the apposed gastric walls of the dissected greater curvature starting 1 cm below the angle of His.
An additional row of non-absorbable interrupted sutures (2-0 Ethibond™) was used as reinforcement, narrowing the stomach permanently (80–100 mL of volume). No intra or postoperative complications occurred. Hospital time stay was 96 hours (48 hours postoperative). Proton pump inhibitors and anticoagulation were prescribed for 14 days. Medical treatment for pain control was required for only 2 days postoperatively and then stopped.
A liquid very low calories diet (VLCD) with high protein content (about 40% of the energy intake) was prescribed 48 hours post-surgery. No vomiting episodes nor dumping symptoms arose. Two weeks post-surgery the patient switched to a soft high protein VLCD supplemented with symbiotic, multivitamin and essential amino acids.
The patient's compliance to the diet and the nutritional status were assessed weekly, providing her and her family psychological support. Three weeks post-surgery the physical training with low intensity aerobic session restarted. As reported in , 4 weeks later the patient showed a significant improvement in clinical, metabolic and hormonal parameters with gut peptides modifications.