Pros and cons weighed for fat-fighting surgery on minors

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It has been 10 years since Dr. Thomas Inge performed a drastic intervention on a 16-year-old girl weighing more than 350 pounds. The Cincinnati surgeon, seen in this handout photo, was apprehensive about it, "but we knew we were doing the right thing," says Inge, who is leading a multimillion-dollar long-term study assessing the benefits and risks of bariatric surgery in 250 teenagers.

Photograph by: Tine Hofmann, Postmedia News

It has been 10 years since Dr. Thomas Inge performed a drastic intervention on a 16-year-old girl weighing more than 350 pounds.

It was his team's first patient. The Cincinnati surgeon and his colleagues were apprehensive about it, "but we knew we were doing the right thing," says Inge, who is leading a multimillion-dollar long-term study assessing the benefits and risks of bariatric surgery in 250 teenagers.

Since that first case 10 years ago, Inge has performed gastric bypass, or weight-loss surgery on 163 teens. It's a major operation that Dr. Atul Gawande — the prominent U.S. writer and surgeon — has called the strangest he has ever assisted in, one that doesn't repair any injury or defect but rather is done simply to control the compulsion to eat, "to manipulate a person's innards so they will not overeat again."

And such extreme procedures for "morbidly" overweight young people could soon be on the rise in Canada.

Several centres, including Vancouver, Edmonton, Hamilton and Montreal, are exploring creating weight-loss surgery programs for extremely obese adolescents.

Preliminary results from ongoing studies suggest teens can lose, on average, one-third of their weight one year after surgery. And it's been found that the procedure can push diabetes into remission before children even leave hospital.

In one small study involving 11 adolescents with Type 2 diabetes who underwent gastric bypass, "all but one really reversed their diabetes to where you wouldn't even consider them a diabetic," says Inge, surgical director of the Surgical Weight Loss Program for Teens at Cincinnati Children's Hospital Medical Center.

And the psychosocial benefits of surgery can be life altering for teens whose stomachs have defined, and sometimes tortured them, since kindergarten.

But how safe is a procedure in children that essentially leads to a surgically enforced diet?

When should it be done?

How can doctors ensure kids are ready — physically and mentally — for such an extreme approach?

Would private clinics start advertising weight-loss surgery for children, with no wait times?

Although bariatric surgery can lead to significant and rapid weight loss, the long-term metabolic, nutritional and psychological effects among adolescents are unknown, Inge and his co-authors wrote in a special article on bariatric surgery for seriously overweight adolescents published in the journal Pediatrics.

"It's fast, its effective. But the question is: How long does it last," adds Dr. Stan Lipnowski, a Winnipeg pediatrician and member of the Canadian Paediatric Society's Healthy Active Living Committee. "And it doesn't get to the heart of the underlying problem, in many cases."

"I think if you've exhausted all other measures, you may be left with nothing but bariatric surgery," Lipnowski says. But, "We don't know if we can extrapolate the results from adults to kids. What's the success rate going to be like two, three years from now, or five or 10? We don't have that type of followup in adolescents, it hasn't been around that long."

What is clear, Lipnowski says, is the rise in obesity-related Type 2 diabetes in children. "It's staggering."

"We used to think this was an old person's disease. It's not anymore," Lipnowski says. "We see these kids, and we're doing blood tests on them regularly and we're coming up with liver abnormalities, sugar abnormalities, cholesterol abnormalities. We're seeing this not only in teenagers, but in pre-teens. They already have fatty livers."

Obesity rates in children have almost tripled in the last 25 years. About 26 per cent of Canadian children ages two to 17 are currently overweight or obese. Doctors are seeing more children with "morbid" obesity — where a child's weight is two- to three times where it should be. "Some of these kids get short of breath just walking across the street, they're so heavy," Lipnowski says.

They're chronically exhausted and often depressed. Their joints ache. Some have Blount's disease — severe bowing of one or both legs — or non-alcoholic fatty liver disease, or high blood pressure. Many have been tormented about their weight for so long, by the time they seek surgery, they're almost numb to it, Inge says.

"Many of our kids are actually not even in school," adds Dr. Jill Hamilton, an endocrinologist and director of the first program in Canada to offer weight-loss surgery to pediatric patients at Toronto's Hospital for Sick Children.

"These kids aren't looking to be skinny, skinny," Hamilton says.

They want to be able to tie their shoes by themselves, she says, or take the subway without worrying about finding a seat that fits.

"We're following them very intensely,"she says. "We do a whole pre-op work-up and psychological assessment to make sure they know exactly what they're doing. We want to make sure that we do things as safely and as carefully as we can."

Many of her patients have struggled with mental health issues such as anxiety or depression — their own, or their parents — and problems within the family.

"It's a real struggle to work on some of the lifestyle stuff when there are bigger pressing issues around just security at home and security in life," Hamilton says.

Sick Kids has operated on five adolescents so far, the most recent in April. All had a body mass index of between 40 and 60; they've lost between 11 and 41 kilograms. None had surgery before at least six months of intensive involvement in the program, whi*****ludes group sessions and cognitive behavioural therapy and learning a whole new way of eating — rules around chewing slowly to avoid regurgitating, or pain, not drinking and eating at the same time so food isn't flushed through, because there are ways to cheat the surgery's restrictive intentions.

Hamilton isn't trying to push surgery on kids. For many, she says, surgery isn't even on their radar. "We're just trying to find the right solutions for them."

"There are many adults who have been interviewed post-surgery who said, 'Oh my God, if I could have only had this when I was 16 or 17, my life would be very different right now.'"

For massively overweight kids, surgery has the potential to change the whole trajectory of a child's life, she says.

Studies in adults have shown weight-loss surgery can cure morbid obesity in adults. McGill University researchers have reported that permanent weight loss via bariatric surgery reduces the risk of death by 89 per cent compared to no surgery in only five years of follow-up. Another study by the same McGill University Health Centre and McGill University teams shows surgery can lower the risk of developing cancer by up to 80 per cent.

But the surgery carry risks — including the risk of death.

The two most common surgeries are adjustable gastric banding and Roux-en Y gastric bypass.

With banding, a saline-filled band is looped around the top portion of the stomach, creating a small pouch that limits how much people can eat in one sitting. Allergan Canada is seeking Health Canada approval to market it's Lap-Band system for use in adolescents ages 14 to 17 with a body mass index of 35 or more.

Roux-en Y is major abdominal surgery that involves stapling or stitching the stomach to create a small pouch for food that bypasses a large portion of the stomach. Not only do people get fuller faster, but because part of the small bowel is bypassed, fats and sugars aren't absorbed as well as before surgery.

Immediate risks include post-op bleeding, blood clots, wound infections and intestinal leaks. Long-term risks include malnutrition, vitamin deficiencies, anemia and prematurely brittle bones. What's more, pouches can stretch or staples pull loose. A teen can eat 10 small meals a day and easily accumulate more calories than a super-sized meal.

Not all obese teens are destined to become obese adults. And many doctors are wary of altering a child's digestive tract in such a drastic way. But sometimes surgery is not only the best option, it's the only option, experts say.

"It's not that everybody feels bariatric surgery is the way to go, and the only way to go," says Dr. Jean Pierre Chanoine, a childhood obesity expert in the endocrinology and diabetes unit at B.C. Children's Hospital.

"But for now, for serious cases where we know complications are looming and we don't have a magic solution, bariatric surgery is the one that works."

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