PHOENIX — Pediatric surgeons performing bariatric surgery on adolescents are encountering challenges not faced before in children's centers, according to presentations by leaders in the field at the annual meeting of the American Pediatric Surgical Association.
“A lot of work goes into this, a lot more than I ever, ever thought,” Michael A. Helmrath, M.D., said, showing before-and-after photographs of his first teenaged patient during a symposium on bariatric surgery at the meeting.
A pediatric surgeon at Texas Children's Hospital Clinical Care Center in Houston, Dr. Helmrath warned of “a steep learning curve” and urged his pediatric colleagues to do their first procedures at the side of a surgeon experienced in bariatric surgery for adults. “Mentorship is important,” he advised. “It is not just you that you are training. It is your entire operating team.”
Symposium speaker Thomas H. Inge, M.D., Ph.D., concurred with Dr. Helmrath's advice. For physicians and surgeons, training requirements will far exceed their previous experience in pediatric surgery, said Dr. Inge, director of bariatric research and surgical director of the Comprehensive Weight Management Center at Cincinnati Children's Hospital Medical Center in Ohio.
Taking an annual continuing medical education course is not sufficient, Dr. Inge said, describing bariatric surgery as “one of the most complex abdominal operations done.”
Just how many bariatric operations have been done on adolescents is not known. Walter J. Pories, M.D., estimated the number of Roux-en-Y gastric bypass procedures as 200–300 in an interview with this newspaper. Dr. Pories, a professor at East Carolina University, Greenville, North Carolina, is head of the Surgical Review Corporation, a nonprofit group created to designate centers of excellence in bariatric surgery.
Although patients under age 18 cannot consent legally, Dr. Helmrath said he requires adolescents to write a letter of assent by hand before he will operate. The letter states that they know they are going to have the operation, what the complications are, and what they need to do. The patients and their parents sign the letter, he said. “If I'm not satisfied, they rewrite it.”
Patient education requires a major effort, Dr. Inge said. He advocated group seminars and one-on-one instruction to ensure adolescents “are fully aware of what they are getting themselves into.”
Dr. Inge emphasized that leadership has to be multidisciplinary and that financial buy-in from the hospital administration is vital. Some essential program components will not be covered by insurance, he warned, and investments in equipment and facilities will be necessary.
Dr. Inge gave a list of examples, starting with gurneys and tables that can support a 535-lb patient. He recommended that hospitals buy a HoverMatt Air Transfer mattress or comparable product to allow staff to move obese patients without injury. Oversized 10X gowns should be readily available, he said, and heavy-duty, extrawide chairs and pedestal-mounted commodes are necessary for family members and patients alike.
Other areas of the hospital also have to make adjustments, according to Dr. Inge. The radiology department, for example, needs to be able to accommodate a still-oversized patient who returns to the hospital with acute abdominal pain after bariatric surgery. Radiology and emergency department staff need to become familiar with specific techniques and life-threatening complications not usually seen in a pediatric setting, he said.
“These are things we are not used to thinking about in pediatric hospitals, but we really must think about,” he said.
The bariatric surgery group will also have to put staff in place to monitor patients and to help them with weight loss, weight gain, and other outcomes after surgery. Long-term postsurgical follow-up of the young patients represents a paradigm shift in duration of care, Dr. Inge said. “This is care for the rest of one's life.”
During another discussion at the meeting, Allen F. Browne, M.D., said the Food and Drug Administration has authorized his group at the University of Illinois Medical Center, Chicago, to test the adjustable gastric band in 50 obese adolescents. The FDA approved the band as an alternative bariatric procedure for adults in 2001.