Lap Band Diary

This is a guest post written by Matt Papa, PhD

Scientific evidence points to morbidly obese pediatric patients facing diseases once thought to affect only the adult population. These children are high-risk candidates for serious problems of a physical, psychological and metabolic nature. For the most part, this targeted group does not represent typical children who just happen to be overweight. In his paper [1], recently published in the peer-reviewed journal Seminars in Pediatric Surgery, Dr Caniano points out that morbidly obese children have increased rates of heart disease, sleep disorders, high blood pressure and type 2 diabetes. A significant percentage of these pediatric patients’ serious medical problems will require treatments including prescription medication. Even with treatment, these children will continue to be at risk for premature morbidity as adults, which will contribute to a decline in life expectancy rates linked to obesity.

Some physicians argue that a possible solution in reversing this pattern in morbidly obese children may include bariatric surgery. Bariatric surgery has proven beneficial in morbidly obese adults. Studies show adults lose significant amounts of weight and maintain weight loss following the procedure. However, no long-term studies exist for the pediatric group. The consequences of bariatric surgery for morbidly obese children are unknown. They may or may not be similar to adult studies.

Obligation To Do What’s Best For The Patient

Considering the extreme condition of these morbidly obese children, traditional methods such as a lower calorie diet, regular exercise workouts and behavioral therapy fall short of reversing the consequences of obesity. Studies reveal that substantial weight loss from such typical methods can reduce a patient’s BMI by 3% after a one-year period of medical supervision in an intensive weight loss program. But, for children in this group with a BMI of over 40 kg/m2, it’s not enough [2]. Therefore, patients and families in this particular group should be provided with information on surgical options. This information should be specific in nature including risks and benefits. They should be given resources to counseling and further consultation. In order to serve the best interest of these patients, a doctor would be obligated to present this alternative [3].

On the other hand, for those patients who might lose enough weight to show that a reversal of their continued obesity is possible, a doctor is obligated to continue traditional medical treatment because it would be in the child’s best interest. Surgery would not be warranted.

Continuing the medical responsibility to ensure the best health for morbidly obese pediatric patients, a doctor is obligated to conduct a careful assessment for each patient. In addition, all the traditional methods for weight loss conducted in a hospital setting should fail before surgical intervention is considered, Dr Caniano MD, Professor of Pediatric Surgery, explains. A doctor should also seek the possibility of low-risk clinical trials to address morbid obesity in a pediatric patient.

Obligation To Cause No Harm

Doctors take an oath to treat the sick and to never use their livelihood to cause injury or harm. In that regard, considering the risks of bariatric surgery and the unknown consequences for pediatric patients, there could be a valid argument against surgery.

The two bariatric surgeries performed most often are the Roux-enY gastric bypass (RYGB) and the adjustable gastric band (ABG). Both surgeries come with risks. The RYGB can be done with open surgery or laparoscopically. In those cases where RYGB fails, gastric bypass revision may be considered. Risks include tube leakage, massive bleeding or blocked arteries. Long-term nutritional risks also exist. Patients must take nutrient supplements as directed to reduce risks for calcium, iron, folate, and several vitamin (D, B6, B12, B1) deficiencies.

The AGB procedure presents other risks. Patients may experience complications with infection because the band is a foreign object to the body. There may be mechanical complications as well. It is possible the band may slip out of position or cause erosion of the gastric wall.

To date, an article in Annals of Surgery, presents the most complete review of both procedures based on one-year follow-ups [4]. The report concluded that both procedures led to sustainable and significant weight loss for patients. Both procedures also caused significant complications for patients but there were no deaths related to the gastric band procedure or the bariatric surgery.

The reality of the complications following bariatric surgery may be hard for a young patient to comprehend. A patient and/or the family may think surgery is a quick fix and not think about unanticipated problems. The low rate of serious risks published in the report might cause a patient to underestimate possible consequences. A patient might tend to overlook what it would be like to stay in the hospital for a long time or to undergo a second surgery.

The Question Of Informed Consent

Considering that morbidly obese pediatric patients are under the age of legal consent, parents must sign consent for surgery for minor children. That policy assumes that parents know their children and know what would be in their best interests. It is possible that patients and parents have an optimistic view based on what they see in the public. They are presented with a large amount of information through social media. These venues often highlight success stories and picture former morbidly obese patients in great shape. The media depictions are not always representative of typical cases, but still influence patients and families.

Dr Caniano explains that due to the nature of a surgical intervention, a lengthy process must occur prior to informed consent. The process ensures that traditional methods of weight loss have failed, the patient and family have met with medical professionals and a pediatric surgeon on a regular basis, and they have received in-depth accurate information on risks and benefits of procedures and have taken sufficient time to consider the consequences [5].

Concerning informed consent, the minimum expectations for the amount of information given to patients and families include the following elements:

· Inform responsible parties of the patient’s diagnosis

· Explain details of the proposed surgery

· Discuss risks and benefits

· Determine the patient’s post-operative actions and behaviors needed for success

· Tell about alternatives to surgical intervention

· Reveal financial aspects

The Question Of Justice And Ethics

Obesity rates in the United States are growing at an alarming rate. For children in this country, one in every three in the socially disadvantaged group is obese. African American girls and Hispanic and Native American boys and girls experience particularly high rates of obesity. Due to the fact that children from families who are socially and economically challenged score lower in childhood health indicators than their more affluent Caucasian peers, they may not have access to important information. They may not be aware of resources in medical weight management of bariatric services.

It seems professional advocacy is needed to make sure all morbidly obese children and their families are aware of available services. If obese children require intervention to achieve better health, community efforts should be organized to provide information and resources to these families [6]. Once patients and families are in the hands of pediatric surgeons and other medical professions, all aspects of bariatric surgery and alternatives must be offered in a clear concise manner. All of these steps need to occur to fulfill ethical, medical and societal obligations to the morbidly obese pediatric patient.

References

1. Donna Caniano. Ethical Issues in Pediatric Bariatric Surgery. Seminars In Pediatric Surgery. 2009: 18: 186-192

2. Levine MD. Ringham RM. Kalarchian MA. et. al. “Is family-based behavioral weight control appropriate for severe pediatric obesity?” International Journal of Eating Disorders. 2001:30:318-28.

3. Inge TH. Xanthakos SA. Zeller MH. “Bariatric surgery for pediatric extreme obesity: “Now or later?” International Journal of Obesity. 2007:31:1-14.

4. Treadwell JR, et. al. “Review and meta-analysis of bariatric surgery for pediatric obesity”. Annals of Surgery. 2008:248:763-76.

5. Engelhardt HT. The Foundations of Bioethics. New York, New York. Oxford University Press. 1986.

6. Blacksher E. Ethical and political challenges to seeking justice. Hastings Center Rep. 2008:38:28-35.

Matt Papa, PhD, works as a biochemist at Washington University in St Louis, MO. He has been twice awarded research grants by the American Heart Association to support his research in blood coagulation diseases. In his blog he discusses latest obesity research findings, provides information on popular weight loss programs and gives away a Nutrisystem diet promotional coupon.