For years it has been clear that obese children are likely to become obese adults with medical problems; however the crisis occurring today is that increasing numbers of children are becoming ill long before adulthood, and obesity is to blame.

 

The following diseases are caused by obesity and are often cured with weight loss:

  • High blood pressure
  • High cholesterol
  • Fatty liver
  • Type 2 diabetes mellitus
  • Sleep apnea
  • Joint problems with pain
  • Menstrual cycle abnormalities
  • Polycystic ovarian syndrome
  • Anxiety and depression

The American Academy of Pediatrics supports weight loss surgery in select children and adolescents.

"Although behavioral and lifestyle interventions will be successful for certain individuals, youth with severe obesity require effective intervention to prevent a lifetime of illness and poor quality of life."

American Academy of Pediatrics 2019 Policy Paper
Pediatric Metabolic  Bariatric Srugery: Evidence, Barriers & Best Practices
 

Body Comosition Scale

At Children’s Healthy Weigh of Buffalo we use a Body Composition Scale that calculates the body’s percentage of fat and muscle.

Why is this better than a simple weight on a typical scale?

When you are active, you build muscle. Muscle is heavy, so it causes your weight to increase. This kind of weight gain is good! A normal scale cannot determine whether your weight increase is in fat or muscle.  Many people don’t know that they're succeeding until they watch the changes in their body composition over time.  

View a sample body composition report (pdf)

Plot your child’s BMI on the graph below:

BMI chart

How do I know if my child’s weight is in a health risk category?

BMI (Basal Metabolic Index)  is an easy method of screening for weight categories that may lead to health problems. It is calculated using age, gender, height and weight. The following CDC widget will calculate the BMI for children through 19 years of age.  The BMI can be plotted on the appropriate graph with goal of <95%ile.

A vertical sleeve gastrectomy is the most common bariatric operation performed in the U.S. The surgeon creates a small “sleeve” of stomach using staples placed laparoscopically to remove about 80% of the stomach. The smaller stomach holds about three ounces.  Food passes through the gastric sleeve to the intestines where digestion takes place.

Vertical Sleeve Gastrectomy

What is a laparoscopic procedure?

The laparoscope is a slender tool that has a tiny video camera and light on the end. When a surgeon inserts it through a small cut and into your body, they can look at a video monitor and see what’s happening inside you. Other similar instruments will allow surgical cutting and stapling to occur so that the surgery is minimally invasive.  The procedure leaves you with four or  five  small incisions.

In comparison to alternative bariatric surgical procedures, such as gastric bypass or banding, complications following sleeve gastrectomy are much less common.  Micronutrient deficiencies are expected after sleeve gastrectomy, so individuals will take vitamins daily going forward and blood levels of certain vitamins will be monitored alongside routine lab work.   

How long will the surgery take? 
Between 2-3 hours.

How long will I remain in the hospital after surgery? 
Usually two nights.

Will I need to be on a special diet before and after surgery? 
Yes.  A full liquid, low carb diet (such as creamed soups, protein shakes) for two weeks before surgery and two weeks afterward, at which diet will progress.

How long can I expect to be out of school or work? 
Most patients return to their normal routine of school or work 7-10 days after surgery. 

How long will I be off my feet?  
Your surgeon will encourage you to be up and out of bed six  hours after your operation.  Walking is strongly encouraged as soon as possible. 

Will I be left with surgical scars and stretch marks? 
The laparoscopic procedure will leave 4-5 one-inch incisions which heal quickly.  Many patients will be bothered, instead, by the loose skin that occurs with significant weight loss.  Patients are encouraged to wait a minimum of two years before consulting with a plastic surgeon to see if removal of skin folds is an option.  Insurance carriers do not routinely cover this procedure.

What can be expected after Sleeve Gastrectomy?

  • If you have sleep apnea, it is likely to improve or completely resolve.
  • If you have type 2 diabetes, it is likely to resolve so that no further treatment is necessary.
  • If you have high blood pressure, it is likely to improve or normalize.
  • If you have abnormal lipid panels or liver function tests, it is likely that these will normalize.
  • If you are taking medication(s) to treat  polycystic ovarian syndrome (PCOS), you will no longer need these post operatively as hormone levels will normalize.
  • If you have painful, inflamed joints, it is very likely that you will increase activity and decrease discomfort.
  • A portion of the stomach that absorbs vitamins is removed, so you will need to take vitamin supplements 2-3 times per day everyday for life.
  • You will need to strictly follow the pre-op and post-op diet.  Protein shakes will be key.
    • Full liquid diet: two weeks before and two weeks after surgery.
    • Pureed foods: weeks 2-4
    • Soft foods: weeks 4-8 before advancing to normal diet
    • No restrictions, but with attention to eating slowly, chewing food well and not over-eating.
  • You may need to take medication if reflux occurs.  Some people experience discomfort if digestive acids creep up from the smaller stomach to the esophagus.
  • You will need bloodwork drawn every three months up to one year post-op, then every 6-12 months.
  • You will be seen at CHWOB for clinic visits at the following post-op intervals:
    • Every two weeks x 2 then monthly x 4.  Every three months until one year,  then every six months.
  • The loss of significant weight often causes sagging skin over trunk, arms and legs.  Surgical removal of unwanted skin folds is possible, however insurance carriers rarely cover costs. This might need to be paid out of pocket.  

Over the course of six months (minimum) in the program, our team will get to know the patient and family.  When a patient expresses interest in bariatric surgery, the team meets with the surgeon to seriously consider whether or not surgical intervention is the best option.  The decision takes into account the following:

  • BMI >35 with obesity related disease  or BMI >40
  • Problem list: existence of disease(s) that will improve as a result of weight loss
  • Motivation: patient shows diligence and makes slow, steady progress as measured by body composition scale and food logs
  • Consistency: patient attends monthly appointments, completes lab work and any studies ordered
  • Maturity & compliance: patient follows through with recommendations discussed at each visit;  maturely designates good health as the long term goal
  • No smoking of any kind due to harmful effects on surgical site (stomach wall)
  • Agrees not to become pregnant for 18 months post surgery due to changes in vitamin absorption

 Research supports bariatric surgery before a teenager with extreme obesity develops serious disease.

“Bariatric surgery performed late in the course of comorbid conditions may not be as effective as surgery performed earlier. Based on these factors, we proposed that surgery for extreme adolescent obesity may be a beneficial option for highly selected teenagers.”

Teen-LABS (Teen-Longitudinal Assessment of Bariatric Surgery)

Prior to scheduling bariatric surgery, the Healthy Weigh team, with your consent,  will provide medical records  to your Health Insurance Carrier. These will  show related medical and psychological evaluations and interventions,  as well as, previous weight loss attempts. Recent growth charts need to demonstrate that a patient is motivated and diligent.  It is expected that a candidate for surgery has consistently attended monthly appointments for a minimum of six months, and has followed through with diagnostic tests, such as sleep studies and lab work. Clinic notes need to attest to changes to lifestyle that have resulted in the individual’s improved labs and body composition measurements. Our psychologist’s documentation must speak to the patient’s ability to follow through with the pre and post surgical treatment plan.

Once authorization for bariatric surgery is received from a payer, we will work with your schedule and our surgeons to set a date for the procedure and the two night hospital stay.

CHarmonCarroll McWilliams (Mac) Harmon, MD, PhD
Chief of  Pediatric Surgery, John R. Oishei Children’s Hospital of Buffalo
Director of  Pediatric Surgery Fellowship, University at Buffalo
Surgical Director, Children’s Healthy Weigh of Buffalo

Dr. Harmon has an international reputation for his groundbreaking work in pediatric minimally invasive surgery and surgical intervention in childhood obesity. As a  principal investigator in the NIH funded  “Teen Longitudinal Assessment of Bariatric Surgery”, he contributed to a greater understanding of  short and longer-term safety and efficacy of bariatric surgery in adolescents.

Dr. Harmon chairs the Childhood Obesity Committee of the American Pediatric Surgical Association and serves on the Humanitarian Task Force of the Society of American Gastrointestinal and Endoscopic Surgeons.

Prior to moving to Buffalo, Harmon was  clinic director at Children’s of Alabama as well as surgical director of the Children's Center for Weight Management and the Georgeson Center for Advanced Intestinal Rehab.

A past president of the International Pediatric Endosurgery Group, Harmon is author of approximately 100 peer-reviewed scientific publications. He also serves on the editorial boards of the Journal of Laparoendoscopic and Advanced Surgical Techniques and Pediatric Surgical International.

Prior to his work in Alabama, Harmon was an instructor of surgery at the University of Pennsylvania and assistant professor of surgery at the University of Michigan Medical School. 

He earned his bachelor’s degree at the University of Alabama at Tuscaloosa, and his MD at the Vanderbilt University School of Medicine. He also earned a PhD in molecular physiology and biophysics at Vanderbilt. Harmon did surgical residencies at the Vanderbilt University Medical Center and a pediatric surgery residency and fellowship at Children’s Hospital of Philadelphia.

AlanPosnerAlan Posner, MD, FACS                            
Surgical Director of Bariatrics, Kaleida Health

Dr. Posner is a general surgery specialist. His areas of expertise include gastric bypass surgery, gastric sleeve bariatric surgery, lap band surgery, laparoscopic surgery and trauma.  He graduated from Albany Medical College of Union University in 1988 then completed his residency in general surgery at the Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo. He has over 32 years of diverse experience, especially in general surgery. Dr. Posner is the surgical director of bariatrics at  Buffalo General Medical Center.  He predominantly treats adults, but will participate in child and adolescent bariatric surgical procedures along side Dr. Harmon. This ensures  a seamless transfer of  younger bariatric patients as they reach adulthood and continue to need post bariatric follow up.

AAP guidance calls for better access to bariatric surgery for teens with severe obesity

Evidence gathered by  Teen-LABS (Teen-Longitudinal Assessment of Bariatric Surgery) suggest that waiting to surgically treat until a BMI > 50 is less beneficial in the long run as  a non-obese state (BMI<30) may not be achievable. 

Prevention CfDCa. Childhood Obesity Facts. Published 2019. Updated June 24, 2019.

Inge TH, King WC, Jenkins TM, et al. The effect of obesity in adolescence on adult health status. Pediatrics. 2013;132(6):1098-1104.

Beamish AJ, Reinehr T. Should bariatric surgery be performed in adolescents? Eur J Endocrinol. 2017;176(4):D1-D15.

Inge TH, Coley RY, Bazzano LA, et al. Comparative effectiveness of bariatric procedures among adolescents: the PCORnet bariatric study. Surg Obes Relat Dis. 2018;14(9):1374-1386.

Inge TH, Laffel LM, Jenkins TM, et al. Comparison of Surgical and Medical Therapy for Type 2 Diabetes in Severely Obese Adolescents. JAMA Pediatr. 2018;172(5):452-460.

 

 

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