Although adults have been able to choose laparoscopic adjustable banding surgery for weight loss since 2001, younger patients have had to rely primarily on non-surgical methods or higher risk operative procedures to lose their excess weight. Bariatric surgery has not been performed as commonly in adolescents largely because the long-term consequences have not been fully studied. Now, a FDA-approved study is evaluating the outcomes of one procedure in a strictly controlled study of teens. Beginning in 2006, this trial permits the Center for Adolescent Bariatric Surgery to perform "Lap-Banding," a minimally invasive weight loss procedure, in select patients aged 14–18 years.
Columbia University Medical Center is one of only three U.S. centers presently approved to offer weight loss surgery to adolescents as part of this tightly regulated FDA study. First, patients must first complete a six-month program of rigorous weight loss education and therapy. "The goal of this phase is to determine whether patients can lose 20% of their excess weight," says program director Jeffrey L. Zitsman, MD, FACS, Director, Center for Adolescent Bariatric Surgery at Morgan Stanley Children’s Hospital of NewYork-Presbyterian. "If patients achieve this goal, they can continue with nonsurgical methods and avoid having surgery."
The initial phase includes a comprehensive assessment consisting of a history and physical exam, extensive blood testing, bone age and bone density studies, evaluation by nutritionists and psychiatrists, and stress exercise testing to determine physiologic status. Patients then adhere to a strict program of diet, exercise, and behavior controls, and in rare cases, medical therapy. This multidisciplinary care is provided by an integrated team including pediatricians, pediatric endocrinologists, pediatric gastroenterologists, pulmonologists, exercise physiologists, bariatric surgeons, anesthesiologists, pediatric nurse practitioners, and others. "Our goal is to help patients lose weight without surgery," says Dr. Zitsman. "This requires discipline not only on the part of the patients, but strong support from their families as well."
Only if patients fail to lose 20% of their excess weight after six months are they then considered for surgery. This FDA trial permits just one procedure in adolescents laparoscopic adjustable gastric banding, or Lap-Band® as part of its study of its safety and efficacy in adolescents. During this procedure, several small abdominal incisions are made. Through these incisions, the surgeon places and secures an adjustable silicone band around the upper stomach to create a small pouch. The band can be tightened or loosened by adjusting a saline-filled balloon which lines the inside of the band; at the time of surgery, a small access port is implanted deep below the abdominal wall fat for this purpose. In most cases, the port remains unnoticed by the patient. With the upper stomach pouch made smaller by the band, patients feel full sooner, reduce their food intake, and begin losing excess weight gradually. According to Dr. Zitsman, adverse effects have been minimal in adolescent patients to date, and include post-operative discomfort or nausea for several days.
While some U.S. hospitals perform gastric bypass surgery in adolescents, the Center for Adolescent Bariatric Surgery has elected not to do gastric bypass in such young patients. In gastric bypass surgery, a large portion of the stomach is stapled off, creating a smaller stomach pouch that can accommodate significantly less food than before surgery. In addition, some of the small intestine is bypassed, so that nutrients and calories are no longer fully absorbed. "Patients who undergo gastric bypass lose excess weight more quickly after surgery than those who undergo Lap-Banding, but by three years post surgery, weight loss is equal," says Dr. Zitsman. "We consider Lap-Banding to be safer than gastric bypass for most adolescents because there is no risk of gastric or intestinal leak. Furthermore, gastric bypass is virtually irreversible, and chronic problems with nutrient malabsorption can have long-term effects on growth and development."
To learn more about adolescent bariatric surgery, please visit www.childrensnyp.org/bariatric or call 212.305.8862.
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