Weight-Loss Surgery for Children: Expert Q&A
Childhood obesity is an epidemic in the United States. More than 3-million children are overweight for their age and height. Obesity can lead to diabetes, high blood pressure and high cholesterol. If not addressed, children can have significant health issues throughout their childhood and adulthood.
Dr. Jason Fraser is a pediatric surgeon and performs bariatric surgery at Children’s Mercy. He also serves on the American Pediatric Surgical Association Pediatric Obesity Committee.
Recently, we spoke with Dr. Fraser about the type of surgery he performs, misconceptions about obesity and his advice to parents before considering surgery for their children.
What type of procedures are available for children, and what are the benefits and drawbacks of each?
Dr. Fraser: There are a couple different options: the most common are the laparoscopic sleeve gastrectomy and the laparoscopic gastric bypass. In the sleeve gastrectomy, a good portion of the stomach is removed and this limits the amount of food that can be taken in. In the gastric bypass, a small pouch of stomach is made which is then re-routed to a section of small intestine. This procedure limits the amount of food able to be taken in and also limits the absorption of the food.
We perform the laparoscopic sleeve gastrectomy at Children’s Mercy. The advantage of the surgery is that it’s minimally-invasive (laparoscopic) and only a few small incisions are made. We use a small camera and special tools to remove a large portion of the stomach, including the part that produces the hunger-inducing hormone ghrelin. That way, when the child eats, they feel full sooner.
The biggest drawback to the sleeve is that most of the stomach is gone, but this procedure doesn’t require the anatomy to be rerouted like it does in gastric bypass.
In a gastric bypass procedure, the surgeon will leave a small pouch of stomach and reroute the lower part of the intestine to the stomach. This procedure limits the amount a food a person can take in and decreases the amount the body can absorb. The biggest long-term risk with bypass is nutrition deficiencies. Because the intestine is rerouted, the patient will need lifelong replacement of vitamins and nutrients.
While both surgeries are very safe, it is felt the laparoscopic sleeve gastrectomy is easier on the developing adolescent body and you do not see the nutritional deficiencies seen in the bypass.
What is the minimum age for surgery and are there other requirements?
Dr. Fraser: We do have a certain criteria to determine if surgery is the best option for a child. Our target demographic is adolescents, ages 10 or older. However, we would consider younger children if there were specific circumstances.
Bariatric surgery patients need to have a body mass index of at least 40 (or above 35 if other medical conditions like type 2 diabetes, sleep apnea, fatty liver disease or others are present). They also need to have a stable and supportive home situation because they will need help after the operation.
When a patient meets those criteria they have to participate in six months of supervised medical weight loss. We want to make sure they’re committed to the program and doing what they need to do, because it’s a significant undertaking before and after the operation. Making a change to living a healthy lifestyle before surgery and continuing it after surgery is a big part of being successful. We also want to make sure there are no other medical issues that need to be addressed before an operation and to give them a chance to lose weight without an operation.
The child will meet with a dietician to identify what they’re eating and how they’re eating. They’ll keep a journal of their food and start to transition to how they’ll be eating after the surgery, since the diet will significantly change.
Each child will receive a psychological evaluation to better understand his or her specific needs in the lifestyle change process. The child and family will also regularly meet with a psychologist and/or social worker and exercise physiologist as part of their medical appointments to help implement change.
Everything we do pre-op is getting the patient ready for post-op and the life they’re going to have after surgery.
Why is this multidisciplinary approach important?
Dr. Fraser: The biggest benefit to having our medical and surgical weight loss teams work together in one location is that it provides patients with comprehensive care. Having open communication improves patient access and facilitates patient care. We talk on an almost daily basis about our patients and we’re all working toward the same patient-centered goal.
Some critics say that obesity is a lifestyle issue, and adolescents should lose weight by exercising and changing their diet vs. having the surgery. What do you tell those critics?
Dr. Fraser: Obesity is much more than just a lifestyle issue and to try to distill it down to this is unfair. I tell the critics, yes, you can try and change the lifestyle of these children, and even with this operation they’ll still have to change their lifestyle. This is why prior to an operation there is the required supervised medical weight loss period. But things can gets to a point when lifestyle changes alone are not enough.
Sometimes even when the child eats healthy and loses weight it’s not significant enough to impact the child’s overall health. Then the safest and best thing for them is an operation.
When you have a patient who has severe obesity they’re at risk for having the secondary effects like high blood pressure, diabetes, sleep apnea, fatty liver disease and an increased risk of heart disease.
Obesity is disease, like cancer. Sometimes you treat cancer with only chemotherapy and that works, but a lot of people will also need surgery. Left untreated, the cancer will shorten their lives. To deny a proven operation or proven treatment will actually cause them more harm. The same is for obesity, why would we deny these children potentially a life-saving procedure?
What do you tell people who think having surgery is “the easy way” out?
Dr. Fraser: It’s not an easy way out. You have to have tremendous commitment before and after the operation. It’s a complete lifestyle change in what you’re eating, how you’re drinking and how you’re exercising.
There’s a lot of bias out there and misconception that children with obesity are not trying hard enough. However, for many patients they’re eating the right things and exercising, but they just can’t get to the point where they need to be.
As a health care industry, we need to help shift this way of thinking and bias, and give people the education to really understand this epidemic. This is not just a social problem that will take care of itself. To think that way is short-sighted. The more we talk about obesity and how it’s a medical issue, the more people will begin to understand it.
The bottom line is that if you have a patient with significant overweight at 12, then there is a good chance you are going to have a patient with significant overweight well into adulthood and have complications related to their weight.
What advice do you have for parents considering surgery for their child?
Dr. Fraser: The biggest thing I’d say is do your research, talk to your pediatrician and talk to your child. Be open and honest with them and find out what they want. Also, consider talking to a surgeon. Find one that will support your child and your family throughout the entire process.
Bariatric surgery is a safe and successful operation. It doesn’t mean that the patient has failed. It doesn’t mean the parents have failed. It doesn’t mean the provider has failed. It is an established treatment options for patients who need it and can really be a big benefit for them.
Surgery helps decrease complications that come with having obesity, and improves the quality and length of life.
Learn more about Surgical Weight Loss at Children’s Mercy or call 816-234-3199 to schedule a consultation.