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Surgery on Rise for Obese Teens

One of Boston's top teaching hospitals is evaluating dozens of overweight teenagers for stomach-reduction surgery, while a large Massachusetts health insurer has decided to cover a similar operation for adolescents, powerful indications that doctors increasingly see surgery as an option for obese children.

The number of adults undergoing bariatric surgery is growing rapidly. But because 1 in every 100 to 300 patients die from complications and another 10 to 20 percent experience surgery-related medical problems, physicians disagree about whether the operation is appropriate for children.

But given the long-term health risks for obese teens, doctors at Tufts-New England Medical Center decided to open a program for adolescents later this month, joining a small but growing number of US medical centers.

Michael Pina, 15, is scheduled to be one of the first patients. His mother, Sandra Pina, said Michael weighs 320 pounds, suffers from sleep apnea and high cholesterol, and has failed many diets, including Weight Watchers.

At one point, he decided to walk and run in a park near their house. But he felt passersby were staring at him. He has many friends and is a passionate Red Sox fan, Pina said, and he wants to play baseball like other teenagers.

"I'm doing this not because I'm insecure about myself, but because I'm scared of health problems," Michael Pina said. "I don't want that burden on my shoulder, that this is going to lead to bigger problems like diabetes that I could die from."

In establishing the program, Tufts-NEMC doctors were worried about whether teenagers are mature enough to understand and agree to an operation that will affect their lives for years and will require them to strictly limit their eating -- or to say no to the operation if they choose to, even in the face of pressure from their parents to undergo surgery.

Doctors have set up a six-month screening process during which psychologists, nutritionists, and other health professionals will evaluate teenagers who want surgery and make sure they've tried less-drastic measures to lose weight. So far, the hospital has considered 116 teenagers for surgery, enrolled 56 in the six-month program, and approved 11 15- to 19-year-olds for surgery.

Massachusetts General Hospital also is evaluating teenagers for surgery, while Beth Israel Deaconess Medical Center and UMass Memorial Medical Center are considering opening bariatric surgery programs for teenagers, a step at least a dozen hospitals across the United States have taken.

Dr. William Mackey, Tufts-NEMC chairman of surgery, said teenagers don't normally undergo non-emergency operations that carry such a high risk of complications.

"It's one thing to have a 1 percent mortality rate in adults, it's another thing to have a teenager die from an elective surgery," Mackey said. "We eventually decided that there are compelling reasons to intervene in adolescence. Many obese teenagers are already suffering adult problems like arthritis in their knees and hips, diabetes, and high blood pressure."

Dr. Brian Gilchrist, the hospital's chief of pediatric surgery, said their stories are heartbreaking.

"These kids sit in my office, and the tears roll down their cheeks. They suffer. There is tremendous prejudice," he said.

Meanwhile, Tufts Health Plan last fall decided to cover for teenagers a type of obesity surgery known as the Lap-Band, in which a surgeon places a silicone strip around the patient's stomach to shrink it. Weight loss with the Lap-Band is not as dramatic as with traditional stomach bypass surgery, during which a surgeon permanently staples off most of the stomach.

But the mortality and complication rate with the Lap-Band is lower and it's reversible. Both operations severely limit the amount of food patients can eat to about 1,200 calories daily, but the bypass operation also makes it harder for patients' bodies to absorb fat. Tufts is considering covering the traditional bypass operation for teenagers as well.

Tufts-NEMC surgeons will do both types of operations for teenagers, depending on how much weight they need to lose and other factors. Sandra Pina said her son will have the Lap-Band operation. So will Robert, who did not want his last name revealed and who turns 18 today. Doctors told him he can expect to trim down from 380 pounds to 200 pounds.

"I want to play basketball, a little football, and have a little fun," he said. "It's painful to see all my friends doing good things in life and me just sitting there."

Tufts's decision to cover the Lap-Band was unusual, because the US Food and Drug Administration has not approved the device for use in children -- the usual standard that health plans employ in deciding whether to pay for expensive procedures or medicines. But Dr. Robert Nierman, Tufts medical director for clinical coverage, said plan executives "don't know what else to do for these kids."

Plans also are expanding coverage for adults. Blue Cross and Blue Shield of Massachusetts started covering the Lap-Band for adults as of Jan. 1. Harvard Pilgrim Health Care has been doing so for a year. Most plans cover traditional bypass surgery for adults.

The number of gastric bypass operations grew from 23,100 in 1997 to 103,200 last year, according to estimates from the American Society for Bariatric Surgery. No one tracks the number of US children who've had the operation but doctors estimate that it's at least 150.

The surgery is very profitable for high-volume hospitals, as insurers such as Tufts pay $15,000 to $18,000 per case, and some doctors have criticized hospitals and surgeons for rushing into the field for economic reasons.

But most hospitals are proceeding slowly with teenagers, partly because of the difficulty in getting adolescents to follow rules and partly because of the public outcry that could result if an overweight teenager dies from surgical complications.

Extensive school absenteeism probably would disqualify a teenager, because it might mean he or she would not be disciplined enough to follow the restrictive diet required after surgery. Surgeons said they won't operate on teenagers whose families can't care for them after surgery. And teenagers must be at least 100 pounds overweight and have tried and failed less extreme weight-loss measures.

Still, doctors sometimes struggle with the decision about whether to do surgery. Dr. Philip Huber at the University of Texas Southwestern Medical Center in Dallas evaluated a 16-year-old boy who weighed more than 600 pounds. Because the teenager had serious heart problems, cardiologists pleaded with Huber to do surgery immediately. When Huber tried to interview the teenager, he refused to answer questions. The boy also vandalized cars and skipped school. So Huber refused.

The boy developed significant congestive heart failure and died within a couple of months.

"I still think I made the right decision," Huber said. "I was pretty convinced he wouldn't be compliant. He wouldn't even comply with going to school. Besides, there would be exposure for me; it could be a liability issue."

Part of the problem with operating on children is that the field is so new that doctors are unsure of the long-term complications and success rate, or even which type of surgery works best. A half-dozen children's hospitals are coordinating a long-term study.

Meanwhile, physicians must rely on a few published reports involving small groups of teenagers, which may not uncover risks that appear once large numbers of adolescents undergo the operation. But these reports suggest teens experience complications similar to those that adults face.

Dr. Harvey Sugerman, a surgeon at Virginia Commonwealth University's Medical College of Virginia Hospitals, runs one of the largest and oldest bariatric surgery programs for teenagers. A year ago, he published results for 33 teenagers who underwent the operation between 1981 and 2001. Many experienced complications, including four teenagers who had wound infections and six who had hernias. And half the teenagers regained most of their weight after 10 years.

But, Sugerman said, many patients felt much better about themselves, with eight patients marrying and having children and five patients completing college.

Liz Kowalczyk can be reached at kowalczyk@globe.com.


— Liz Kowalczyk
Boston Globe
2004-01-13
http://www.boston.com/news/local/massachusetts/articles/2004/01/13/surgery_on_rise_for_obese_teens/

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