Guide for Referring Physicians
With the prevalence of adolescent obesity having tripled over the last three decades, more and more teens are seeking new, alternative weight loss options. If you're thinking about referring a patient for bariatric surgery at the Surgical Weight Loss Program for Teens at Cincinnati Children's Hospital Medical Center, here are some guidelines:
Considerations | BMI | Referral Form | Condition Alerts l Preoperative Care l Psychosocial Fitness l Operations We Perform l About the Center
Considering a teen for weight loss surgery
Though there is currently little scientific evidence on which to base decision-making about obesity surgery in adolescence, we are seeing increasing numbers of teens with intractable obesity and life-threatening or life-altering health problems related to obesity. This is why we consider surgery a last resort for treating severely obese teens (BMI greater than or equal to 40).
Severe Health Problems
Other Health Problems
- Venous stasis disease
- Panniculitis
- Stress urinary incontinence
- Significant impairment in activities of daily living
- Non-alcoholic fatty liver disease (includes steatohepatitis)
- Arthropathies in weight-bearing joints
- Gastroesophageal reflux disease
- Hypertension
- Dyslipidemia
- Hyperinsulinemia
- Significant psychosocial distress
The age criteria reflect our desire to avoid any adverse effect of surgery on adolescent growth and development.
Surgery and obesity article
As the epidemic of pediatric obesity has been increasingly documented, and the efficacy and safety of bariatric surgery has also become evident, more attention has been given to consideration of bariatric surgical interventions for clinically severely obese adolescents. Principles of adolescent medicine and evidence from adult bariatric surgical experience can be used to rationally guide the application of bariatric procedures to a group of young patients who have serious medical and psychological comorbidities of severe obesity.
This review focuses primarily on a discussion of:
- The indications for bariatric surgical intervention in adolescence
- The team approach to delivery of bariatric services in this age group
- Principles of perioperative and postoperative patient management
- The surgical procedures available for weight loss
- The results of bariatric surgical intervention in adolescence
You can download a copy of the article written by Thomas H. Inge, MD, PhD, Meg Zeller, PhD, Victor F. Garcia, MD, and Stephen R. Daniels, MD, PhD, Surgical Approach to Adolescent Obesity (813k) in portable document format (.pdf), which is being published in Adolescent Medicine State of the Art Reviews.
You must have Adobe Acrobat" Reader installed on your computer to read this file. You can download Adobe Acrobat" Reader at Adobe's Web site by selecting the version appropriate for your type of computer.
Back to Top
Body Mass Index (BMI)
BMI is weight in kilograms divided by height in meters, squared. For reference, a BMI calculator can be found on the American Society for Bariatric Surgery web site.
Back to Top
Bariatric Fast Track Referral Form
Before we send a questionnaire packet to your patient, the Surgical Weight Loss Program for Teens staff would like you to complete and fax the Bariatric Fast Track Referral Form below. This form includes information about:
You can download a copy of the Bariatric Fast Track Referral Form (106k) in portable document format (.pdf).
Back to Top
Medical condition alerts
The presence of certain circumstances or medical conditions alert the Surgical Weight Loss Program for Teens medical team to the fact that bariatric surgery is not a good idea. These conditions include:
- A medically correctable cause of obesity
- A substance abuse problem within the preceding year
- A medical, psychiatric or cognitive condition that would significantly impair the patient's ability to adhere to postoperative dietary or medication regimens
- Current breast-feeding, current pregnancy or planned pregnancy within two years of surgery
- Inability or unwillingness of either patient or parent to fully comprehend the surgical procedure and its medical consequences, and the need for lifelong medical surveillance.
Back to Top
Preoperative care
Patients and parents are counseled by bariatric surgeons, a bariatric physician, nurse and dietician in multiple settings to ensure that truly informed permission is obtained from the parents and informed assent is obtained from the patient.
Preoperative laboratory screening includes:
- Lipid profile
- Urinalysis
- Oral glucose tolerance test
- Hemoglobin A1C
- Fasting blood glucose
- Thyroid function tests
- Pregnancy test for females
The preliminary evaluation may suggest the need for consultation by a cardiologist, pulmonologist or endocrinologist.
Back to Top
Psychosocial fitness for an operation
A successful outcome from bariatric surgery requires an informed, highly motivated patient with considerable emotional resources. Our interactions with these patients are focused and intense; nonetheless we rely heavily on the judgment of referring physicians to assess psychological fitness for an operation.
We also require that all prospective surgery patients undergo psychological screening by our psychologists. Patients must demonstrate commitment to behavior modification and comprehensive medical and psychological evaluation both before and after surgery.
The dietary diary that we ask all patients to complete may suggest which patients are at risk for poor weight loss. Specifically, those who eat frequently throughout the day (we refer to this as "grazing") do less well than patients who tend simply to eat large, infrequent meals. In general, we are cautious about patients with serious eating disorders, especially active bulimia or binge-eating, although these do not constitute absolute contraindications.
Expectations about the operation must be realistic. These operations are successful only by making it more difficult or uncomfortable for patients to eat at much at one time. Gastric bypass surgery does not:
- Change metabolism
- Reliably eliminate hunger
- Produce durable weight loss without considerable effort
Patients must be deeply committed to weight loss for these operations to be successful.
We are happy to see patients that you think are candidates for bariatric surgery, but if you have reservations about a patients' fitness for surgery it is important that you share those reservations with us beforehand. A call or note would be greatly appreciated.
Back to Top
Operations we perform
A number of bariatric operations are performed at various centers, but by far the most commonly performed bariatric procedure today, and the procedure recommended in the 1991 National Institutes of Health (NIH) consensus panel report, is the Roux Y Gastric Bypass. During this procedure, a 20cc gastric pouch is created, and a roux limb of jejunum is surgically connected to the pouch. The procedure restricts food intake and produces an element of malabsorption. It is very likely that gastric bypass also alters the physiology of digestion to reduce the hunger drive in these patients.
Back to Top
Cincinnati Children's was the first pediatric medical center in the country to offer a Comprehensive Weight Management Center incorporating weight loss surgery. Currently we perform almost all bariatric surgery by laparoscopy.
The guiding principle in forming the Surgical Weight Loss Program for Teens team is that weight loss surgery for teens should not occur in isolation, but in an environment that meets the unique physical, medical, behavioral, psychosocial and emotional needs of adolescents and their families.
Back to Top
