Obesity Surgery in Children - Too Much – Too Soon! (page 2)
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.
Problems with Gastric Bypass Surgery for Children
Thanks in part to the popular TV show “The Biggest Loser,” we all now know that weight loss can be achieved without surgery of any kind. It is a tragic indictment of our society that we can spend $10,000 - $40,000 cutting the stomachs and rearranging the intestines of our children, but we cannot spend one-tenth of that amount in diet and exercise programs to prevent and reverse this problem. As such, there are several reasons why I respectfully object to gastric bypass surgery for children:
- While co-morbidities of obesity, such as type 2 diabetes and sleep apnea, are serious, children are not dying before the age of 18 solely from being overweight. Obesity surgery, however, carries a small but finite peri-operative mortality rate. Is it really justifiable for a precious child to lose his or her life undergoing experimental weight loss surgery?
- We do not know the long-term consequences of having one’s stomach cut away from the flow of intestinal contents and then “parked” in the abdomen for potentially 60-80 years with no ability to access it via endoscopy. What are the potential complications of this down the road? Gastric cancers, ulcers, more?
- We do know that the gastric bypass operation comes with several side effects, among them nutrient and calcium malabsorption, iron-deficiency anemia, bone density problems, and folate malabsorption, leading to an increased likelihood of birth defects in subsequent pregnancies. We also know that teens are notoriously non-compliant with parental recommendations to take vitamins (and most other advice from their parents!). Is it realistic to expect adolescents to take responsibility for managing these side effects, and are they prepared for the consequences of not doing so?
- As minors, children and teenagers cannot legally consent to this permanently life-altering operation. Their parents do this for (to) them. Our clinical psychology colleagues inform us that the cognitive ability to understand death does not occur until approximately age 25. If child and adolescent obesity isn’t life threatening, shouldn’t these children have a chance to make the decision to undergo surgery for themselves when they are old enough to understand the risks and consequences of such a decision?
- Lastly, there’s a good chance that obesity surgery may become obsolete in the near future. Given the feverish pace of drug company research into obesity and the rapid advances in understanding the neuro-endocrine-gastrointestinal contributors to appetite control, it is hard not to believe that a medical aid to weight loss will be developed in the next 5-10 years. What will we do with all these re-routed stomachs then?
Obesity surgery for children is a problem of too much, too soon. We must seriously attack childhood obesity in the young (6-7 year olds) when we stand the best chance of changing behavior. We should enroll them in serious diet and exercise programs and, if necessary, take them out of school for 6 months or a year (as with a child with cancer or another serious illness) and spend time and money on treating this problem.
If all fails, gastric bypass surgery can be an option as an adult when the child has grown up, had their children, and most importantly, is more able to understand the life-long risks of mortality, cancer, adhesive bowel obstructions, internal hernias, flatulence, and other health consequences of obesity surgery and can give their own informed consent.
Parents and pediatricians are the gatekeepers and guardians of our youth. We all must think long and hard before recommending a “quick surgical fix” for a chronic behavioral problem. Long-term studies in adults suggest that even with gastric bypass surgery, weight loss may not sustain and weight often returns after 10 years. For a young patient with 50+ years to go, that is truly significant!