Obesity Surgery in Children - Too Much – Too Soon!
Surgical treatment for obesity in children is very controversial and should only be considered as a last resort. Obesity surgery in adults has become popular recently – partly because of the global obesity epidemic, and partly because it is a lucrative business for surgeons – but obesity surgery in children comes with an entirely different set of ethical questions and health concerns. This article outlines the two major types of obesity surgery, their associated risks, and the particular problems and challenges of performing these procedures in children.
Surgical Approaches to Obesity
The two most common operations for obesity are gastric bypass and gastric banding. All obesity surgery in children must be considered experimental; we simply do not know what the long-term effects will be 20-40 years later, when the child has become an adult. Because these procedures are experimental and because children are not just smaller adults, any parent considering obesity surgery for their child should ensure that it is only performed in a children’s hospital by a specialist in surgery on children (a board-certified Pediatric Surgeon). Non-pediatric surgeons should only be allowed to operate on children in extraordinary circumstances and only after their training and pediatric experience has been thoroughly substantiated.
Gastric bypass (also known as Laparoscopic Roux-en-Y Gastric Bypass, or LRYGB) involves cutting most of the stomach away and attaching the small remaining gastric “pouch” to a part of the intestine downstream, thus “bypassing” some of the absorbing surface of the intestine (Figure 1). This operation provides two ways to lose weight: 1) a small stomach so that patients eat less because they feel full; and 2) some malabsorption from the bypassed intestine – so the food that is eaten isn’t fully absorbed.
Gastric bypass results in the fastest weight loss (often over one hundred pounds in a year), but comes with the risk of serious complications, including dying from the operation, surgical complications, vitamin deficiencies, bone demineralization, shortness of breath, birth defects in future pregnancies, and long-term risks of intestinal problems, ulcers, and the need for future operations. But for some massively obese children, gastric bypass might be worth the risk; the weight loss that results has been shown to reverse diabetes in some patients. I recommend Cincinnati Children’s Hospital as the center with the most experience with this operation for children.
The second most common operation is laparoscopic gastric banding. Unlike gastric bypass, gastric banding does not permanently alter the digestive system. An adjustable belt, commonly known as the “lap band,” is fitted around the upper part of the stomach, restricting food intake and decreasing the speed at which food empties from the stomach, thus creating a constant “full” feeling. To control the amount of weight loss, physicians can squeeze or deflate the inflatable saline-filled tube inside the belt.
Gastric banding results in slower but steady weight loss and has the additional virtue of being reversible – the belt can be removed later on. It also is a less risky surgery, with a lower risk of death, fewer long-term complications, and no associated malnutrition. Like gastric bypass, it is considered experimental in children, as the lap band device was only tested in adults when approved by the FDA. Clinical studies are being done on both surgical approaches to try to learn what the long-term consequences of these operations are. There are a few other experimental procedures out there including just cutting out half of the stomach, but parents should be very skeptical.