There remains a great deal of controversy regarding the use of bariatric surgery in children, largely because of the significant risks involved, the uncertain long-term effects, and the perception that obesity is largely behavioral or psychogenic in origin. However, the risks are currently acceptable, especially when weighed against the risks of ongoing obesity; the long-term effects appear to be largely correctable; and it is increasingly clear that the morbidly obese have a genetically-based metabolic disorder that happens to manifest itself in the form of a specific behavior (excessive oral intake of food) rather than simply a psychological or emotional disorder. It seems reasonable, therefore, to offer these children some relief of their illness and the hope that they can prevent the substantial sequelae that come with morbid obesity. On the other hand, the operation is clearly not an immediate or permanent cure and it also does not address the underlying cause. Success depends on an extraordinary amount of work and commitment on the part of these kids and their families and friends.
Naturally, the most effective operations also carry the highest risk and, as a result, there is still resistance to letting these operations become widely popular. The less invasive laparoscopic gastric banding operation is perhaps less effective in the long term, but it is adequate for most patients and clearly safer. Nevertheless, although it is probably the best choice for the morbidly obese teenager at this time, there is a great deal of difficulty in obtaining FDA approval for the use of the device outside of a few select centers in the US. We await the results of several well-conducted studies before it can become widely available.
Bariatric operations differ from most other surgical procedures in that a surgeon cannot expect to see a patient in the office, make a decision regarding the indications and risk, and schedule the operation if the patient agrees to proceed. The key to the success of a bariatric surgical program is the large number of clinicians that form part of the team including psychologists, nutritionists, gastroenterologists, endocrinologists, and surgeons. Protocols must be clearly designed and continually modified to achieve the best results and the least morbidity.
The operations are technically quite challenging, partly due to the body habitus of the patients. Special operating tables and instruments are needed to support the weight of the patients and allow proper access to the abdominal cavity. Careful dissection and respect of natural tissue planes are difficult to achieve due to the anatomic distortion caused by excessive adipose tissue but are critical to the success of the operation. Staple lines must be secure but visual confirmation can be difficult. Intra-operative endoscopy and testing anastomoses for leaks with air insufflation are critical adjuncts that have been shown to reduce the risk of dehiscence and death. Postoperative vigilance for even the slightest indication of a problem (unexplained tachycardia) and a low threshold for urgent reoperation are also key to mitigating the effects of an anastomotic leak.
Children who undergo bariatric surgery must be considered patients for life, as the morbidity and recurrence rates are high in the absence of an ongoing program to monitor weight loss and overall health status. Eventual transfer to an adult program might be a suitable option, making it important to foster a good relationship between the pediatric and adult programs so that patient care is seamless.