Abstract
Introduction
Those who read U.S. News & World Report's list of “America's Best Children's Hospitals” will consistently see Texas Children's Hospital ranking high in all of the 10 specialties the news magazine analyzes. It has also earned a top spot in Parents magazine's “10 Best Children's Hospitals.” Part of the reason for making the grade year after year is the hospital's expertise and breakthroughs in such areas as cancer, neonatal care, cardiovascular surgery, and pediatric HIV infection.
Another area where the hospital continues its mission of patient care excellence is bariatric surgery for adolescents. Its Center for Comprehensive Surgical Management of Adolescent Obesity has been performing these surgeries since 2004. The multidisciplinary program draws upon the tremendous expertise found in the hospital's 1,580 board-certified physicians and a nursing and support staff of more than 6,000 employees. Heading up the program is Mary L. Brandt, MD, professor and vice chair of the Michael E. DeBakey Department of Surgery at Baylor College of Medicine. She is a well-known expert in the field of adolescent bariatric surgery and was one of the surgeons who were instrumental in formulating the guidelines and recommendations supported by the American Pediatric Surgical Association (www.eapsa.org). Dr. Brandt works closely with Vadim Sherman, MD, a bariatric surgeon in the BCM adult obesity program. As a team, they primarily perform laparoscopic Roux-en-Y gastric bypasses with excellent results and outcomes.
A Small Program by Adult Standards
Adult bariatric surgery programs often see several hundred patients a year, but the number of adolescents who would benefit from surgical treatment for their obesity is much more limited. Texas Children's Hospital is very selective about who proceeds to surgery. According to Jennifer McAlmond, RD, LD, clinical program coordinator, the program has performed 56 surgeries since its inception in May 2004. The program fields 6 to 10 new inquiries each month. In what is perhaps a sad commentary on the times, the program receives a lot of calls from patients who are too young for surgery. “Our patient age range is 13 to 18 years old,” explains Trish Walters-Salas, BSN, RN-BC, CCM, CBN, who serves as the nurse case manager. “Our youngest inquiry was from an 8-year-old patient. Of course, we had to refer him to another weight management program.”
Although most patients come from Texas, others reside in surrounding states and elsewhere in the country. Since Texas is a big state, some patients live as far away as an 8-hour drive. The program sees its highest activity in the months leading up to summer break. “A lot of them want their surgeries scheduled in the summer,” says McAlmond.
Since adjustable gastric banding is currently not approved by the U.S. Food and Drug Administration (FDA) for patients under age 18, almost every case is a Roux-en-Y gastric bypass. However, two of the 56 patients have received the sleeve gastrectomy procedure. “I don't think many parents of our adolescents know a lot about this option,” McAlmond believes. According to Walters-Salas, doing more of them would probably be a good idea. “With teenagers, it may be a better choice because there will be no malabsorption and vitamin compliance is less of an issue,” she says. So far, none of their cases have required any surgical revisions.
The Program Is Very Intensive
Although patients can self-refer to the program, the team encourages their primary care physician to be actively involved in the pre-operative process. “It makes things so much easier,” says Walters-Salas. Everyone who makes an inquiry is scheduled for a patient orientation session held once a month. This is where team members explain the program and its procedures, often using PowerPoint presentations and talks. Soon after this introduction, an appointment is then scheduled with the entire bariatric team, including Dr. Brandt. “We try not to schedule them to see a surgeon right away,” explains Walters-Salas about this interesting philosophy. “Once they see the surgeon, then they start thinking right away about when the surgery is going to take place. We do it this way to let them know that there is work to be done up front before a surgery date is set.” Adds McAlmond, “We want to see some motivation. We want to see that they are truly committed.” In addition, different patients require different lengths of time to be completely prepared for the surgery and the changes they will experience. Walters-Salas points to the example of one patient, a teenage girl, who was with the program for two years before finally getting her surgery. The vast majority of patients don't have to wait that long; the average length of time to surgery is seven months. During this time, patients receive intense counseling about behavior changes, nutrition information, and what to expect after the surgery.
On Call
Texas Children's Hospital
Center for Comprehensive Surgical Management of Adolescent Obesity
6621 Fannin Street
CC650.00
Houston, Texas 77030
(832) 822-4868
E-Mail:
Website: www.texaschildrens.org
Team Members
Mary L. Brandt, MD
Surgical Director and Bariatric Surgeon
Professor of Surgery
Baylor College of Medicine
Vadim Sherman, MD
Bariatric Surgeon
Assistant Professor of Surgery
Baylor College of Medicine
Jennifer McAlmond, RD, LD
Clinical Program Coordinator
Dietitian
Trish Walters-Salas, BSN, RN-BC, CCM, CBN
Nurse Case Manager
Margaret Lee, MPH
Senior Research Coordinator
David Allen
Research Coordinator
Karin Price, PhD
Psychologist
Gia Washington, PhD
Psychologist
The program at Texas Children's Hospital uses the relatively strict guidelines for patient selection and pre-operative recommendations set forth by the Clinical Task Force on Bariatric Surgery of the American Pediatric Surgical Association, which includes extensive medical and psychological evaluation and treatment. Since teenagers often need more support and counseling than adults, Dr. Gia Washington and Dr. Karin Price, clinical psychologists at Texas Children's Hospital, see patients during every clinic visit prior to surgery and after surgery as well. Most patients are seen in clinic bimonthly before surgery. Every visit is arranged for the convenience of the patient. “We schedule patients who live far away on a day when we have support group,” explains McAlmond. “They will have their nutrition education, go to support group, and then see the surgeon the next day.”
Not the Typical Support Group
Although they are called support groups, don't let the phrase fool you. These are not your average touchy-feely get-togethers often found in adult bariatric programs. Teenagers are a different breed. “We don't sit around and talk about feelings and other issues,” points out Walters-Salas. “We try to focus on making learning fun.”
Texas Children's Hospital in the Texas Medical Center in Houston, Texas.
And fun is exactly what the emphasis is all about. The groups, held on the second and fourth Tuesdays of every month after school (5:30–7:30
According to McAlmond, during the first hour, the teenagers participate in an educational game of some sort. Recently, for example, they dreamed up The Calorie is Right, a take-off of the much-loved television game show The Price Is Right. “We had different food items where they had to guess the calorie count,” she explains. “Whoever was closest won the round.”
After the “game” is over, the teenagers engage in an hour of physical activity such as water aerobics in the facility's indoor heated pool. They also benefit from the skills of an exercise physiologist, Chuck French, who works for the city of Houston. “He is really good at working with the teenagers, getting them to do exercise that is fun,” McAlmond says. Adds Walters-Salas, “If they think it is exercise, they won't do it!” French is available for patients to get in touch with him individually as well. They can also go to the facility every day and participate in a host of activities, including a “boot camp” attended daily by three teenagers in the program.
STATISTICS AT A GLANCE
Surgeons performing bariatric procedures: 2
Number of program inquiries: 6–10 per month
Cases performed: 56 total since May 2004
Types of cases performed:
Laparoscopic Roux-en-Y gastric bypass: 53
Laparoscopic sleeve gastrectomy: 2
Laparoscopic adjustable gastric banding: 1
Average length of stay: 3–4 days
Average overall weight loss at 1 year: 94 lbs (average 43% excess weight loss)
Number of support groups offered: 1 (meets twice a month)
Team composition: 2 surgeons, 1 clinical program coordinator and dietitian (dual role), 1 nurse case manager, 2 research coordinators, and 2 psychologists
The bariatric team at Texas Children's Hospital (back row): David Allen (research coordinator), Dr. Karin Price (Psychologist), Margaret Lee (Senior Research Coordinator), Trish Walters-Salas (Nurse Case Manager), Dr. Gia Washington (Psychologist), and Jennifer McAlmond (Clinical Program Coordinator and Dietitian). (Front row): Dr. Vadim Sherman (Surgeon) and Dr. Mary Brandt (Director and Surgeon).
GUIDELINES FOR PATIENT SELECTION FOR BARIATRIC SURGERY IN ADOLESCENTS
Have failed ≥6 months of organized attempts at weight management, as determined by their primary care provider
Have attained or nearly attained physiologic maturity
Are very severely obese (BMI ≥40) with serious obesity-related comorbidities or have a BMI of ≥50 with less severe comorbidities
Demonstrate commitment to comprehensive medical and psychologic evaluations both before and after surgery
Agree to avoid pregnancy for at least 1 year post-operatively
Be capable of and willing to adhere to nutritional guidelines post-operatively
Provide informed assent to surgical treatment
Demonstrate decisional capacity
Have a supportive family environment
Source: Inge TH, Krebs NF, Garcia VF, et al. Bariatric surgery for severely overweight adolescents: concerns and recommendations. Pediatrics 2004;114:217–222.
Inpatient Stay and Follow-Up
At Texas Children's Hospital, two rooms on a general pediatric surgical floor have been designed and equipped especially for teenagers who undergo bariatric surgery. All of the nurses have been trained to care for these patients. The average length of stay is three to four days, which is a little longer than for most adults. The few extra days to be able to take in enough fluid and move around easily are appreciated by the patients and their families, particularly those who live far away. These patients often go home to remote areas of Texas where finding appropriate help would be difficult if they ran into a problem. This way, both patients and the team can be confident that the teenagers can handle their recovery at home.
Patients engaging in water aerobics in the indoor heated pool at the Metropolitan Multi-Service Center in Houston, Texas.
Once released from the hospital, patents return after one week to see the entire team, including Dr. Brandt, either Dr. Washington or Dr. Price for psychological support, McAlmond for nutrition counseling, and Walters-Salas for nursing care. They are on a monthly schedule thereafter for the first six months. This is then followed by bimonthly visits until patients reach the first anniversary of their surgery. “At 12 months, we assess their adherence to the nutritional and activity guidelines,” says McAlmond. “If they are doing well, we will start seeing them every four months.” Those who aren't meeting their goals return on a monthly or bimonthly basis to get them back on track.
The complication rate after surgery is the same in teenagers and adults. Most complications are easily treated and resolve quickly. Some teenagers develop marginal ulcers. “They want to try smoking, which can get them into trouble,” Walters-Salas says. “All of our patients with ulcers admitted to smoking.” Three patients developed thiamin deficiency from inconsistent multivitamin intake. “We have some patients who struggle with remembering to take their vitamins,” admits McAlmond. “It can be very difficult sometimes with this population.”
So far, the average one-year weight loss has been 43% of excess weight, which averages 94 pounds. The average BMI for the teenagers accepted into the Texas Children's Hospital program is 61 (with a range of 41–95), which is much higher than that found in the average adult bariatric program. “Our kids are pretty big, weighing in the 300- to 400-pound range,” points out Walters-Salas.
An Important Research Site
As an academic medical center, Texas Children's Hospital is involved in numerous research studies. The adolescent bariatric program is no exception in this regard. In fact, the hospital is one of five institutions participating in the Teen Longitudinal Assessment of Bariatric Surgery study (Teen-LABS). Funded in June 2006 by the National Institute of Diabetes, Digestive, and Kidney Disorders (NIDDK), the goal of Teen-LABS is to facilitate coordinated clinical, epidemiological, and behavioral research in the field of adolescent bariatric surgery. This is accomplished by the cooperative development of common clinical protocols and a bariatric surgery database. The database collects information from participating clinical centers performing bariatric surgery on teenagers. In addition to Texas Children's Hospital, the other Teen-LABS consortium members are Cincinnati Children's Hospital and Medical Center (data-coordinating and clinical center), Children's Hospital of Alabama in Birmingham, the University of Pittsburgh, and Nationwide Children's Hospital in Columbus, Ohio.
Patients may also participate in two related studies. The first is called “Teen View.” This focuses on the patient's perceptions and emotions prior to weight loss surgery and then again after surgery. A second study, “Teen Intake,” is analyzing the dietary intake of teenagers before and after undergoing a bariatric procedure.
Future Challenges
Both McAlmond and Walters-Salas agree that the program at Texas Children's Hospital will face several challenges that lie ahead. One of these is the fact that the program continues to grow. Dr. Brandt likes to dream about seeing the program go out of business if children would start at an early age with good eating and physical activity habits. Alas, neither Brandt nor the other team members anticipate this happening anytime soon. “Our program will continue to grow until changes are made to the American culture,” bemoans McAlmond.
Walters-Salas sees the challenge as making sure parents are on board and are willing to make the necessary lifestyle changes in the household. “They are the ones who go to the grocery store, shop, and cook,” she says. “We can't ask the teens to do this by themselves.” McAlmond has seen what happens when parents are unwilling to make these necessary changes. “The teenager will struggle and be unsuccessful,” she says. “This is why we require that parents attend all clinic visits, support groups, and nutrition counseling sessions with their teen.”
Unfortunately, the current economic climate has forced a change in the way insurance companies reimburse bariatric surgery for adolescents. Walters-Salas points to the fact that a lot of employer groups have decided to save money by excluding these procedures from their company agreements. She spends a lot more time these days putting together comprehensive letters of medical necessity and supportive materials. “I have had to do more talking with medical directors at insurance companies to outline the seriousness of the teens' comorbidities,” says Walters-Salas. As a result, she is constantly explaining the cost–benefit ratio of bariatric surgery for adolescents. “They may be spending money, but in the long run, they will save money.”