Abstract
I started doing obesity surgery via the minimally invasive approach in the early 2000s. At that time Dr. Tom Inge (Cincinnati Children's Hospital Medical Center) was really the biggest player, and I think still is, in the field. There were a couple of others that had gotten on the bandwagon at that time. Along with myself, there were Dr. Allen Browne (University of Illinois at Chicago) and Dr. Mary Brandt (Texas Children's Hospital). There were a handful of adult surgeons who were interested in kids and working with kids. But nobody had taken a real focused look at it.
Living in Atlanta, I am fortunate that I am close to the Centers for Disease Control and Prevention (CDC). Dr. Bill Deitz was the head of the Childhood Obesity Section at the CDC, and he was also on the faculty here at Emory. And Bill is one of the world's experts on prevention in obesity.
One day in about 1999 or 2000 I ran into him, and he told me a story about Dr. Neil Feins (South Shore Hospital, MA) performing bypasses on adolescents. It had been being done sporadically in adolescents over the years, almost since the inception of this type of surgery, but it did not take a real foothold or become as relevant until the obesity epidemic hit, which probably began in the '80s, and through the '90s and 2000s, when it exploded. It was at this time that my interest was piqued.
First of all, you have to remember that doing a bypass laparoscopically was a difficult procedure. The first laparoscopic gastric bypass was performed in 1993, and laparoscopy really changed obesity surgery. But, there were actually two things that happened simultaneously that changed the face of obesity surgery in adolescents in the United States. One was that we were in the midst of an obesity epidemic, and the other is that the technology advanced to the point that these procedures could be done minimally invasively. For the most part, people were doing gastric bypasses from the very beginning. Then along came the band, which, as you know, is not approved for children under 18 years, so it was slow to be considered in our population. Since that time it has been studied by several centers under an Investigational Device Exemption (IDE). Then, more recently, there is the availability of the sleeve. There is a handful of other procedures, like biliopancreatic diversion, that are not done nearly as often.
The introduction of laparoscopy took these operations from a big, open operation with significant morbidity and dramatically decreased the morbidity and improved the recovery from the procedure.
Then, in 1991, the National Institutes of Health came out with a consensus statement on criteria for when it is appropriate to perform obesity surgery. 1 What this statement said, in a nutshell, is—and this is for adults—if you have a body mass index (BMI) of more than 35 [kg/m2] with a major comorbidity or a BMI of more than 40 [kg/m2] and you have been at least 6 months in a weight management program, and you have no other major contraindications, then the risk of not having the surgery is basically greater than the risk of having it.
Dan, the interesting thing to me is that this consensus statement came at a time when there were significant morbidity and mortality to the procedures, and they were done open. Then along came MIS, which tipped the balance in favor of surgery even further. In the adult world, it just took off.
I think we were a little more hesitant to go forward in kids. I remember sitting in on bariatric surgical meetings in the very early stages, around 2002, and people were beginning to think about how we could translate the practice to pediatric surgery.
At that time, it was very controversial because it was felt to be high risk, and that it should wait until the kids were 18 years old and to let them get true informed consent before they make these decisions.
So that is when we started to look at it and study it and try to answer those questions: Should we be doing it earlier? Is there a benefit to performing it earlier? Is there a benefit to performing it in kids?
Yes. So, the sleeve was not really an option in the early days. It was really between a bypass or a band. There were a few of us that went down the band route because it really looked like it was less invasive, and it looked like it was relatively reversible. And, while it may not have worked quite as well, we thought it was something that was a little less invasive for kids.
Then, Dr. Inge and the Teen-LABS group came along and made the argument that the gastric bypass is the gold standard, so that is what we ought to do. They said, “It has been proven. It has been around for a long time. We have a decent idea of what the complications are and what to look out for.” So, at that point there were two camps in this.
Then the Teen-LABS group came out with the consensus statement on kids, 2 where it pushed the National Institutes of Health criteria a little bit further and said, “Because it is new, because we are still studying it, we really only should be doing it in kids with BMIs of more than 40 [kg/m2] with a comorbidity.” That stance has since been softened, and the subsequent consensus article goes back more toward the adult criteria for kids.
If you looked at what was happening in the adult side, the band data were acceptable, and there were certainly some patients who had great success, including pediatric patients done with IDEs.
What actually happened is that we started to see more of what I call nuisance complications with the band, such as migration. However, with the bypass, there were and still are some long-term morbidities, including nutritional deficiencies. Remember, you are asking teenagers to take vitamins for the rest of their lives, and as you know, teenagers are certainly not any more compliant than we adults are. Subsequently, some of them were getting into trouble with that. Although less common than the nuisance complications related to the band, when you look at major morbidity and mortality from the operations, those from the bypass were higher than those from the band. Then along came the sleeve gastrectomy, which hits a spot between the two, where there might be a little more morbidity than with a band, but not as high as with the gastric bypass—although now, in some studies, 30% or more of patients are having their bands removed, so you can argue that the band actually has more morbidity long term as far as subsequent procedures and such.
But the sleeve definitely has less morbidity than a bypass. You still have a potential for leak, but you eliminate the possibility of internal hernias, and the chance of long-term risk of bowel obstruction looks like it is going to be less, with efficacy that is nearly as good. There are several studies that show that it is just as good, and if there is a difference in weight loss, it is not very much. And they all reverse comorbidities.
Yes, pretty much the same time frame. Now, there may be patients who would be better candidates for a bypass, and there may be patients who would be better candidates for a sleeve. There may even be patients where the band would be a good option.
The problem right now is that we do not know how to identify which operation each patient should have. So, for the most part, I think surgical staff are offering various options to patients and choosing with them. I think most surgeons have their biases.
It is very interesting to me that, right now in the pediatric surgery world, the folks who were doing a lot of bypasses are now doing more sleeves. The folks who were doing more bands are now doing more sleeves. So everyone has migrated to the sleeve for different reasons. The folks who were doing bypass are doing the sleeve because it has less morbidity. Folks who were doing the band are now doing the sleeve because it is more efficacious.
I do not think that adolescent bariatric surgery really came about until the advent of laparoscopy. So you can argue that laparoscopy was necessary for us to think about this kind of surgery, but I do not know that that was the tipping point.
When we first started, there was a lot of controversy. You would go to a pediatrics meeting, and people would be throwing tomatoes at you, so to speak. And now, I will argue that not all the pediatricians in the whole pediatric community understand the indications and when it is good to operate and when it is not, but I would argue that it is now much more accepted.
So two things happened. One is that the sleeve came along as a great option, but is still not proven. We do not know the long-term results of sleeve gastrectomy in adolescents. The other thing was, where we hit the tipping point, that enough evidence had been presented that there began to be acceptance in the pediatric community. Not to say everyone is onboard with this, but it is much more accepted than it was previously. And I think society has accepted it.
Yes. However, on a related note, in Georgia, we had the second-highest obesity rate in the country. And we as a system made a commitment to change that. We were going to move that needle. Not necessarily with bariatric surgery, but across the board, we were going to launch a large ad campaign, and we were going to do everything we could to improve the situation in our state. When we went to the Department of Public Health, they understood that obesity, and specifically childhood obesity, would bankrupt the state when you start looking at diabetes, high blood pressure, and other comorbidities in kids. The impacts that that obesity was going to have on healthcare costs and the state's economy were going to be astronomical.
So we did focus groups, and we surveyed the populace, and what we found was very interesting. There was very little recognition that there was an obesity epidemic, and I think it is because 40% of our kids were overweight or obese. So, when an obese kid looked at his classmates, and saw other kids that looked like him, they didn't recognize the obesity, it normalized obesity. Even the parents did not recognize it.
We actually found it necessary to launch an awareness ad—that was somewhat controversial, but was very effective at raising awareness. That led to national media coverage, and I think that we had some play in bringing this to national attention.
And it really was the awareness we needed to address to develop the realization that we have a problem that we need to do something about.
So surgery becomes one of the pieces, one of the tools in your armamentarium. And as more adults get surgery, you see more kids getting surgery. And I can tell you, it is quite dramatic when a pediatrician refers you patients, you perform an obesity procedure, and they have tremendous success in all areas of their life, where they have never had any their whole lives. It is very impactful.
Then Dr. Inge and others were publishing articles on this that showed that it was safe to do, and efficacious, and that was key.
That is a great question. The multidisciplinary team is key. You cannot do this in a vacuum. It is not like a hernia, where you say, “Okay, you meet the criteria. I will schedule you next week,” and see them for a follow-up in a month. It involves focused care for a prolonged period of time to make sure that the kids are ready to accept the change, and that they are able to do what you are going to ask of them.
The key components to the system are the bariatrician—who in our system is a pediatrician—a nutritionist, an exercise physiologist or a physical therapist, a psychologist and access to a social worker, and even specialized nurses. So the system is absolutely key to the program's success. Without those pieces, you could not do it. As a surgeon you could not do it.
Now, as far as support for it, one of the biggest barriers is still how do you pay for it? Many insurance carriers are starting to pay for it, but there are still some that do not. And the reality is that if you look at the healthcare cost of being obese, it is huge compared to the cost of one of these procedures. So it is in their favor to cover it. I think they are just hoping someone else will later on.
The other challenge is that obesity is higher among the impoverished, and a lot of these kids have limited access to care because they are in poverty, or because they do not have resources.
At my institution, our hospital board has given a significant commitment to fighting the obesity epidemic, and that has helped tremendously. But before that, my hospital was anxious about doing this, as were a lot of other places. And when I started, I kind of bootstrapped it, and I did the procedures at the adult hospital where we are affiliated as part of Emory Bariatrics. I had the adult surgeons help me out with these cases. We took care of the kids in our clinic, and it was me, an endocrinologist, and perhaps a diabetes nutritionist, and it worked okay, but it was much less than ideal.
However, the difference compared to when we received institutional support was tremendous. When our board committed to this and we were able to develop a system and set up a clinic, it was like night and day. We now have the whole spectrum, from prevention to medical management to surgery, and it is actually all one program, which is very unique. You cannot do it without institutional support.
Dan, it has been my pleasure. Thank you.