The duPont Hospital is joining three other U.S. hospitals in a Food and Drug Administration study evaluating the safety and effectiveness of gastric banding surgery in teens. The procedure, also known as LAP-BAND, is FDA-approved for adults but only available as an off-label use for teens. In gastric banding, a silicone band is inserted around the top of the stomach, severely reducing the amount of food that can be consumed. The minimally invasive surgery differs from a gastric bypass because the stomach isn't cut to reduce its size. Although the banding is meant to be permanent, it can be removed.
Recruiting is under way for the duPont study, said Datto, who will direct the banding program at the hospital. Eight families attended an information meeting last month to hear about the study and the extensive preparation process before surgery. After hearing the details, Datto said, only two families so far have opted to further pursue the program.
About 50 teens ages 14 to 17 are expected to be enrolled during the five-year study at duPont. Pediatric surgeon Kirk Reichard, who will perform the operations, said the surgery will be appropriate for the small number of teens whose life expectancy might otherwise be threatened because of their weight and complicating health conditions.
"We're viewing this as a disease," Datto said.
For now, patients who will be part of the study will have to pay the cost of the operation out of pocket. The participating hospitals wouldn't reveal the cost, but adult bariatric surgery ranges from $20,000 to $35,000, according to the National Institutes of Health.
Health complications of obesity
Nationwide, more than 1 million teens are considered obese. For most, diet and exercise can rid them of their excess weight.
But once a person is more than 100 pounds overweight -- the range considered to be morbidly obese -- it becomes much harder to lose the weight without medical intervention, said Dr. Evan Nadler, director of minimally invasive pediatric surgery at New York University School of Medicine. With that much extra weight, other health problems are more common, including diabetes, hypertension, sleep apnea and coronary heart disease.
Some pediatric surgeons, including Nadler and Reichard, believe gastric banding is a better choice for teens undergoing bariatric surgery because it doesn't require the stomach to be divided and bypassed. As a result, they said, recovery time is quicker and there are fewer complications.
Still, the undertaking requires a significant investment on the part of the teens and their families. There are monthly progress meetings with doctors, band adjustments and a radical change in the way they eat. If patients aren't motivated to make a change, the procedure isn't going to work.
Patients considering the surgery at A.I. duPont Hospital will spend months preparing for it, learning about better nutrition, exercise and ways to deal with issues such as stress and depression that can trigger overeating. The hospital is hiring a full-time exercise physiologist, a social worker and a nutritionist who will work with all kids in the weight management program, including those undergoing gastric banding.
"This is a major decision. I'm not presenting it as anything less than a major decision," Datto said. "Ultimately, if you are someone who can do what's necessary, then this is going to help."
A difficult choice
During the hourlong gastric banding surgery, small incisions are made in the abdomen. A band about the size of a shower curtain ring is wrapped around the upper part of the stomach. The result is a small pouch -- about the size of an egg -- located below the esophagus. Thanks to the narrowed passageway, food slowly empties from the pouch into the rest of the stomach.
As a result, patients can only eat about 4 ounces of food at a time, Reichard said. They feel full after only a few bites. They must learn to drink after they eat so they don't fill themselves up with liquid and lose valuable nutrients.
Unlike gastric bypass, which involves cutting the stomach, banding can be reversed in the event of pregnancy or another health condition requiring a larger amount of food intake, he said.
Raquel Sabzehroo has lost 60 pounds in the year since she underwent gastric banding surgery at New York University Medical Center, which has been a part of the study for two years. Although no one ever made fun of her because of her weight, she felt pressure to make changes in her life. Just 14, she carried 270 pounds on her 5-foot-7 frame. She was prediabetic. She snored loudly in her sleep.
Though doctors at NYU worked with her to explain the changes awaiting her after surgery, she was surprised how different her life was with the LAP-BAND. A typical meal for her is eight to 10 bites, chewed slowly. If she wants to eat more, she can't -- she's too full.
"Learning how to eat is truthfully the hardest thing for me," said Sabzehroo, 15, of Brooklyn, N.Y. "I loved pizza, bread, sandwiches. I was all about carbs. Now I can't eat bread."
More obese children
There's little doubt: Kids today weigh more than in years past. More than 15 percent of teens are considered overweight, according to statistics from the University of Michigan. About one in six are obese.
There are three likely reasons, Datto said. One is genetics, which may make a teen more likely to be obese than another youth.
Another is the inactive, food-laden environment in which we live, where playing games means sitting in front of a TV or computer and fast-food usurps the family dinner. A study released last week by the Kaiser Family Foundation found more than one-third of all commercials aimed at children and teens were food advertisements, usually featuring high-fat, high-sugar candy and snacks. None of the commercials promoted fruit or vegetables.
But parenting also plays a role, Datto said. After all, parents are usually the ones who do the shopping. Kids eat the food they bring home. They often mimic the inactivity of their parents.
Whatever the cause, obese teenagers live a life full of daily challenges, said Dr. Allen Browne, a pediatric surgeon at the University of Illinois Medical Center in Chicago. The hospital was the first in the nation to participate in the FDA study of banding in severely obese teens.
Because of their weight, these teens can't participate in society the way most of us do, he said. Moving around often is extremely difficult. They're teased, ridiculed and sometimes even labeled as learning disabled at school because of the difficulties interacting with teachers and other students, Browne said. Depression is common.
Studies have compared the quality of life of obese teens to those battling cancer, Browne said. The findings were startling. When asked about their perception of quality of life, the kids with cancer thought their lives were better than those who were obese.
"These are not fat, lazy, stupid slobs. They are kids trapped in their biology and by some extent our society. These kids don't do it to themselves. Why would anybody do this to themselves?" he said.
Finding success
Earlier this year, Nadler published the first-year results of the gastric banding study at NYU. Fifty-three morbidly obese teens, weighing an average of 297 pounds, underwent the surgery. They lost an average of 50 percent of their excess weight within a year. About 10 percent experienced minor complications -- including a slipped band, a wound infection and a hiatal hernia -- but none required readmission to the hospital.
Now there are 63 patients who have passed the one-year mark with the gastric band, including 16 who have had it for two years. There's a waiting list with more than 100 teens on it, Nadler said. Most are ready for the surgery but are waiting until the hospital secures another grant to cover the cost of the operations. The cost for the first 50 patients at NYU was covered by a philanthropic grant.
Most insurance companies aren't covering the cost of adolescent gastric banding because it's still an experimental surgery, he said.
The gastric banding study at the University of Illinois Medical Center received free LAP-BANDs from the company that manufactures them, but no other financial support, Browne said. Patients who receive Illinois public aid had their surgeries covered, but the rest were left to cover the cost themselves. Because only a few families could afford the cost, Browne said, the hospital worked with the doctors to make the cost more manageable for patients.
Browne hopes that by demonstrating the safety of gastric banding, more insurance companies will cover the cost.
Reichard said duPont Hospital is talking with the state about the possibility of having its young Medicaid patients covered if they undergo gastric banding. But Delaware Insurance Commissioner Matthew Denn said more information is needed and no decision has been made.
Long-term change
For the teenagers, the hard part begins after the surgery, said Sabzehroo, one of Nadler's patients. Even though she had spent months learning about good nutrition and health, it was an adjustment once she realized how she would be eating for the rest of her life.
"It's hard," she said. "I realized I was gaining weight because I was addicted to food."
Reichard said patients are initially put on a strict protein diet, discouraged from drinking caffeinated beverages and encouraged to be active in whatever way they can. But for some of these teens, the most activity they can muster is walking for 30 minutes in the mall, said Browne, who has bought timers for some of his patients so they could make sure they were getting 30 minutes of exercise.
Browne said he discovered one of his patients wasn't losing as much weight as expected because he was consuming about 2,000 calories a day from Gatorade. For the most part, though, he said, cheating is the exception rather than the rule.
Waiting for morbidly obese teenagers to become adults to have gastric banding surgery doesn't make sense because it's not a condition they're going to grow out of, Browne said. If anything, they're going to get worse. Nadler said he's performed surgery on obese 25-year-olds who already had damage to their kidneys and arteries.
"I think it makes sense to get to these kids sooner because you can keep them from having these complications," Nadler said. "There's no other group of people we deny therapy to because of their age."
Reichard, who will serve as clinical director of the division of surgery at duPont Hospital, expects the number of patients undergoing the surgery to be small. Of adolescents with a BMI, or body mass index, of 40 and more, only 10 percent to 20 percent are sick enough to be considered for banding, Datto said. And only a few of those will be emotionally mature enough to go through the surgery.
Dr. Alison Hoppin, associate director for pediatric services at the Massachusetts General Hospital Weight Center, said that while gastric banding is not an option for most obese patients, it may be the right choice for a select few morbidly obese youth. For each prospective patient, doctors must determine whether the benefits of the surgery will outweigh the risks. And it's important to make sure the teen has exhausted every other weight-loss option before trying surgery, she said.
For any gastric banding program to be successful, Browne said, it must teach teens that they will be the ones guiding their success.
"The surgery is the easy part. It gets a lot of press," he said. "But what is important in the success of the kids, in terms of getting control over their lives, is their preparation beforehand and their support afterward."
Contact Kelly Bothum at 324-2962 |
