Option Play Sleeve-Gastrectomy Is Now an Alternative for Obese Children

By the end of September, Baystate surgeons will have completed their first sleeve gastrectomy on an obese adolescent patient from Baystate Children’s Hospital.

Still a relatively new procedure offered to adolescents, the introduction of the pediatric bariatric-surgery track at Baystate Children’s Hospital — staffed by a highly qualified, interdisciplinary team of pediatricians, surgeons, behavioral-health experts, dietitians, and others — now provides hope for those adolescents whose health is at risk because of their many failed efforts at losing weight.

Despite the fact that the incidence of obesity has declined somewhat in the country, there are still many, many children whose weight remains dangerously high. While we work hard in our weight-loss program focusing on lifestyle modifications such as diet and exercise, not everyone is successful. Also, for some of these adolescents whose weight exceeds 200 to 300 pounds, many are at risk for or already suffering from serious health problems, such as diabetes, hypertension, heart disease, depression, sleep apnea, and liver disease, which can make it harder for them to lose weight. Weight loss from lifestyle modification generally results in a loss of about 10{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of total weight in a year. Only 20{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of those who lose weight successfully are found to keep it off over a five-year period. Therefore, these young adults are not reaching a healthier weight fast enough to address the serious medical conditions accompanying their obesity. While there is a medication to help adolescents with their weight loss, its side effects are a deterrent to their taking the prescription.

That’s where bariatric surgery comes in as an option.

While few studies have been undertaken looking at the sleeve gastrectomy for adolescents, studies in adults show up to 70{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} excess weight loss over 18 to 24 months after surgery. For example, if you are a 5-foot, 4-inch female weighing 250 pounds, you could expect to lose about 90 pounds within two years. Studies on adolescents who have had this surgery suggest that these operations are at least as safe for adolescents as they are for adults, but not enough teenagers have been followed after the sleeve gastrectomy to know if there are any long-term effects on their future growth or development.

Whether you are a child or an adult, in order to lose weight, you need to reduce your caloric intake so that you burn off more than you take in. By reducing the size of your stomach with a sleeve gastrectomy, the amount of food you can eat is decreased, and, as a result, your caloric intake goes down. The surgery also changes the levels of the hormones that control your appetite, so you feel less hungry and fuller for longer periods of time.

During a sleeve gastrectomy, part of the stomach is permanently removed, leaving a smaller-sized stomach in its place. The new stomach resembles a banana and can hold about 1Ž2 cup of food (equal to four spoons of rice, one scoop of ice cream, or a container of applesauce) at a time. The surgery is done laparoscopically with tiny incisions through which cameras and surgical instruments are passed. After the surgery, patients are on a liquid diet, after which soft foods such as applesauce or oatmeal are introduced into the diet before they can begin to eat solid foods about four weeks later.

After surgery, patients will have follow-up visits on a regular basis with their surgeon, weight-management doctor, dietitian, and psychologist. They will have testing done regularly to see if they are progressing with their weight loss and to assess the status of any conditions they developed as a result of their obesity.

To be eligible for the surgery, patients must be 18 to 22 years of age and meet the requirements for having bariatric surgery — that means having a body-mass index (BMI) over 40 kg/m2 or over 30 kg/m2 with at least one obesity related comorbidity, such as sleep apnea, hypertension, diabetes, or liver disease. Testing, including blood work and various radiologic exams, will be done prior to surgery to assess for other existing conditions resulting from their obesity, and to make sure they are healthy enough for surgery.

Patients will also undergo six months of pre-surgery requirements involving visits with a weight-management doctor, surgeon, dietitian, and psychologist. All candidates for surgery are discussed at length by a team of caregivers to determine when and if they are mentally and physically ready to proceed. Because of the length of time involved in pre-op before the surgery, we are offering the program to obese patients as young as 17 years old, who could potentially be ready to undergo their surgery as early as their 18th birthday.

The sleeve gastrectomy is not a magical answer to weight loss. There are many dietary modifications that a patient must make in tandem with the surgery. As a result, we begin to help our patients change their dietary habits from the minute they enter the bariatric-surgery track of our Pediatric Weight Management Program, through surgery and, importantly, after surgery as well. Patients must understand that the sleeve gastrectomy is non-reversible, and will forever change how they eat.

That means munching on a double cheeseburger and gulping down a 12-ounce bottle of soda will be things of the past, and eating small meals that equal about the size of a snack cup of applesauce become the norm. Binge eating can stretch the small stomach, which can cause ulcerations or tears in the wall of the stomach. As a result of their limited eating capability, it is important for the dietitian to make sure patients are eating the right amounts of the correct foods in order to get sufficient vitamins and minerals to maintain their health.

Before being accepted to undertake the surgery, we want to know if a young patient has any mental-health issues such as depression, bipolar disease, or even anxiety, so that these can be treated and managed appropriately. Psychologists will also assess the patient’s family and social dynamics at home in order to ascertain if they have a good support system to help them succeed at their weight loss. Support is crucial. These younger patients will be making a huge change in their life, and if they do not have someone at home to support and encourage them in their efforts and to help purchase the right foods, it will be a much more difficult process for them to undertake on their own. That does not mean that, if a patient doesn’t have a lot of people in their life, he or she will be excluded from surgery. We just need to be sure there is someone there for them who understands the process and who can provide emotional support.

We currently have six adolescents going through their pre-op visits with us, and one whose surgery will be taking place soon. Most of these patients have come from our Pediatric Weight Management Program and Pediatric Type 2 Diabetes Clinic. Our plan is to meet with more pediatricians at their offices in the coming months to make them aware of the new surgical option for their obese adolescent and young-adult patients, many of whom may have tried for years to lose weight unsuccessfully, and who are now sadly ready to give up their attempts at losing weight.

Potential patients who want to make an appointment with our weight-management physicians for their first pre-surgery appointment, or pediatricians who are interested in learning more about the program, can call (413) 794-0813.

Dr. Rushika Conroy is a pediatric endocrinologist at Baystate Children’s Hospital; www.baystatehealth.org/bch