First, my congratulations to Dr. Inge and his colleagues for
continuing to bring responsibility and rationality to this charged area of
surgery in children. While I am pleased that he has shown that Gastric
Bypass Surgery can reduce the severity of type 2 diabetes, I suggest that
it is the weight loss that reverses diabetes and not the surgery.
Unfortunately, this is not a randomized trial nor does it compare results
to a cohort of obese patients with similar non-surgical weight loss. One
has to ask the question – success at what price?
We all now know that weight loss can be achieved without surgery just
from watching “The Biggest Loser” on TV. It is a tragic indictment of our
society that we can spend $10-40K cutting the stomachs and rearranging the
intestines of our children, but we cannot spend 1/10 of that amount in
diet and exercise programs to prevent and reverse this problem. Dr. Inge
knows that I respectfully object to Gastric Bypass Surgery in children for
many reasons:
1. While co-morbidities are serious, children are not dying from
obesity before the age of 18, and the surgery still carries a finite peri-
operative mortality rate. How many dead children are justified?
2. We do not know the long-term implications of having one’s stomach
cut away from the flow of intestinal contents yet “parked” in the abdomen
for potentially 60-80 years with no ability to access via endoscopy. Will
there be an increase in gastric cancers, ulcers, etc.?
3. We do know that the bypass operation involves some degree of
nutrient malabsorption, risking pernicious anernia, calcium malabsorption
and bone density problems, as well as folate malabsorption with a
potential increase in birth defects in subsequent pregnancy. We also do
know that teens are notoriously non-compliant with parental
recommendations to take vitamins (and most other friendly parental advice
to teenagers).
4. Children and teenagers cannot consent to this permanently GI- and
life-altering operation. Their parents do this for (to) them. In fact, our
clinical psychology colleagues inform us that the cognitive ability to
understand mortality does not occur until approximately age 25. (Hence,
the enthusiasm of our young soldiers and the ease of abuse of childhood
combatant recruits in some countries.)
Further, it is hard not to believe that given feverish pace of drug
company research into obesity, and the rapid advances in understanding the
neuro-endocrine-GI contributors to appetite control coupled with known
drugs and conditions with serious appetite suppression, that a medical aid
to weight loss will be developed in the next 5-10 years. Then what do we
do with all these re-routed stomachs? (Not to mention the children’s
stomachs that went into the pathology bucket! Hey Mom, I want my stomach
back!)
Obesity surgery is a problem of too much, too late. We must seriously
attack childhood obesity in the young (6-7 year olds) when we stand the
best chance to change behavior. We should enroll them in serious diet and
exercise programs and, if necessary, take them out of school for 6 months
or a year (as a child with cancer or other serious illnesses) and spend
time and money to treat this problem.
Indeed if all fails, they can have bypass surgery as an adult when
they have achieved growth, had their children, and most importantly, can
understand the life-long risks of mortality, cancer, adhesive bowel
obstructions, internal hernias, flatulence, and give their own informed
consent.
While I applaud the Cincinnati Children’s Group and colleagues for
venturing into this difficult area in the most responsible way possible, I
chastise those that do this as a part-time effort without rigorous life-
long follow-up and study and my adult obesity colleagues who treat
children as adults without regard to their unique cognitive status and
those who pursue this highly remunerative surgery for monetary gain.
I have had several pediatricians call me saying they have a patient
who just had surgery for obesity – they have no idea what kind of surgery
(except perhaps a path report “normal stomach”), and they have no idea how
to manage their eating, what to do when the patient gets gastroenteritis
or abdominal pain and are looking for guidance.
Finally, pediatricians are the gatekeepers and guardians of our
youth. You should not allow non-pediatric surgeons to operate on children
except in extraordinary circumstances and then only after you have
interrogated their training and experience with children. You must think
long and hard before you recommend a “quick surgical fix” for a chronic
behavioral problem.
Sadly, long-term studies in adults suggest that even with gastric
bypass surgery, weight loss may not be durable and weight often returns
after 10 years. For a patient with 50+ years to go, that is significant!
Conflict of Interest:
None declared
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