The Risks and Rewards of Bariatric Surgery
Bariatric surgery for obese adolescents can be offered safely with multidisciplinary team management. It can reduce body weight by one-third and resolve comorbidities. But it's an extreme option that must be undertaken with great consideration by the patient, family and medical center alike.
Thomas Inge, MD, PhD, of the Division of Pediatric Surgery, recently outlined the systematic approach to program development taken by him and Victor Garcia, MD, at Cincinnati Children's, the nation's first pediatric medical center to offer bariatric surgery. He was also lead author for a group of national experts in stating concerns and guidelines for use of this surgical option for adolescents.
"Based on the worsening epidemic of pediatric obesity and the health problems that obese adolescents develop, Cincinnati Children's assembled a team that was thoughtful in bringing a drastic option to patients with significant health needs for weight reduction," Dr. Inge says.
He notes that transferring a commonly performed adult procedure to the pediatric setting required learning how to deal with the physical, emotional, social and psychological needs of teens who weigh 250 to 650 pounds. Consequently, the multidisciplinary team includes pediatric experts in bariatric surgery, obesity evaluation and management, psychology, nutrition and exercise physiology. Pediatric subspecialists in anesthesiology, endocrinology, pulmonology, gastroenterology, cardiology and adolescent medicine complement the team as needed.
Team Evaluation for Candidates
When an overweight teen reaches a Body Mass Index (BMI) greater than or equal to the 95th percentile for sex and age, referral to a comprehensive weight management program is recommended. Beyond the 99th percentile, physicians look at the specific BMI number in considering options. If a teenager has a BMI between 40 and 50 with severe health problems and an inability to lose weight using tried and true methods, bariatric surgery should be discussed with the patient and family.
"The referring pediatrician should be confident that all reasonable non-surgical weight loss options have been exhausted," Dr. Inge says."In addition,we have an open dialogue with the family because this procedure requires the commitment and motivation of both the teen and the parents."
If a patient meets preliminary criteria, the next step is evaluation by the entire team. Currently, about two of every three teens who meet with the team are selected for surgery. They must show a willingness and ability to comply with a lifelong regimen of strict dietary guidelines and daily intake of vitamins and minerals.
Two surgeons operate on every patient."Because this is a complex and risky surgery,we believe it is best to leverage the judgment and skill of two surgeons against those risks to make it safer for adolescents," Dr. Inge says.
Lifelong Follow-Up is Key
For teens, lifelong follow-up at Cincinnati Children's is essential. "During the first year,we see patients a lot. Then we move to visits at 18 months and two years post-surgery, then yearly after that. At these visits, they're seen by the whole team. The nurse practitioner, dietitian and psychologist are important in helping these teens to operationalize the dietary requirements," Dr. Inge says.
Bariatric surgical experience at Cincinnati Children's has shown that teens can lose up to one-third of their body weight, with about 90 percent of the loss occurring in the first year. "That's just remarkable, because it would be essentially impossible without the surgery," Dr. Inge says. As a result, the three most common comorbidities almost always resolve: obstructive sleep apnea, diabetes and high cholesterol. In addition, hypertension usually improves or resolves.
One concern of researchers is whether bariatric surgery, when performed during adolescence, can improve the average lifespan for obese people."Adults with extreme obesity have three or more times the risk of death of people with a BMI in the normal range, irrespective of other diseases. Because this surgery reverses obesity-related diseases in teens,we believe that the increasing risk of death due to obesity should decrease," Dr. Inge explains.
Cincinnati Children's has partnered with five other children's hospitals to form the Pediatric Bariatric Study Group.
 |
| Months after surgery, Natalie continues to demonstrate the benefits of bariatric surgery and her own hard work. |
At Cincinnati Children's, Dr. Inge and his collaborators are pursuing National Institutes of Health grants to compare the results of bariatric surgery in morbidly obese adults and teens, as well as to study other aspects of the effects of bariatric surgery on adolescents.
"Safety is our primary concern," Dr. Inge says."We must determine not only the risks and benefits of the surgery, but also the health risks for those teens who suffer from extreme obesity and choose not to undergo weight loss surgery."
Dr. Inge is surgical director of the Comprehensive Weight Management Center at Cincinnati Children's. His article about bariatric surgical experience at Cincinnati Children's was published in the Journal of Pediatric Surgery (39[3]:442-7; discussion 446-7, 2004 March). His article on concerns and recommendations was published in Pediatrics (114[1]: 217-223, 2004 July).
