Vol. 2 Issue 1
Pioneering Healthier Lifestyles
Bariatric surgery at Lucile Packard Children's Hospital helps adolescents overcome obesity
On Nov. 9, 2004, surgeons at Lucile Packard Children's Hospital in Palo Alto performed the first bariatric surgery at a California children's hospital, opening the door for obese adolescents to receive perioperative care tailored to meet their special needs. Craig T. Albanese, MD, chief of pediatric surgery and surgical director for the facility's Center for Healthy Weight, emphasized, "It's paramount that adolescent specialists care for these children in kid-centric facilities. This is not a quick-fix operation. This is a tool that helps people achieve a healthier lifestyle and it requires an appropriate support system for the patient and the family." Dr. Albanese and John Morton, MD, director of the adult bariatric surgery program, performed the Roux-en-Y gastric bypass procedure (see sidebar) on an 18-year-old girl.
Why Teens Want Bariatric Surgery
Susan Farreles, MSN, FNP, pediatric weight clinic and adolescent bariatric nurse practitioner, told ADVANCE, "I'm pretty straightforward with these teens right up front, asking, 'Why do you want this surgery?' Invariably, they'll tell me that obesity, diabetes, heart conditions and other weight-related problems run in their families. One girl who I saw recently has a mother with serious weight and heart problems, and she's scared. She knows she'll be in trouble later in life if she doesn't do something about her weight right now."
Farrales emphasized that bariatric surgery isn't just a whim to these adolescents. "Teenagers who are mature and serious about bariatric surgery are very focused they're the ones who know what they want and we can see that they're ready to follow through."
The teen who underwent the bariatric procedure on Nov. 9 weighed 270 pounds and had a body mass index (BMI) of 44, compared to a healthy range of 20-24 for this age group. Struggling with her weight since kindergarten, the teen said, "I've been through every weight-loss program you can think of." Still, she was experiencing worsening headaches, blurred vision, back and knee problems, and breathing difficulties secondary to her obesity.
Criteria for Bariatric Surgery
Adolescents being considered for bariatric surgery at Lucile Packard Children's Hospital must have participated in at least 6 months of a medically supervised attempt at weight management, and have attained physical maturity. Adolescents who have a BMI of 40 or above with a serious obesity-related co-morbidity (type 2 diabetes mellitus, obstructive sleep apnea or pseudotumor cerebri), or a BMI of 50 or above with less serious co-morbidities, may be considered for surgery. The adolescents also must demonstrate a commitment to comprehensive medical and psychological evaluation before and after the surgery and be capable of providing informed consent to surgery.
Selecting Candidates for Surgery
Teens who meet the initial criteria for bariatric surgery are evaluated at the Pediatric Weight Clinic at Lucile Packard Children's Hospital. Staff at the clinic help obese adolescents explore non-operative weight-loss strategies. If none of these strategies are effective, the teen's case will be reviewed by the Bariatric Treatment Board, an interdisciplinary group that includes Dr. Albanese, Farrales, specialists in pediatric and adolescent medicine, psychiatrists, psychologists, dietitians/nutritionists and a physical therapist.
The board reviews the patient's nutritional, medical and psychological status, and also discusses the patient's expected benefits along with risks of the surgery. Board members look for evidence of a supportive family environment, for parents or guardians who will help the teen make the all-important lifestyle changes after surgery.
Dr. Albanese and Farrales discuss the expected benefits and long-term consequences of the surgery with the patient and family. Preoperatively, Farrales works with a nutritionist and physical therapist to provide the patient and family with an overview of treatments, medications and dietary and activity changes that will take place after surgery.
The patient will have an extensive battery of laboratory tests, clinical consultations and diagnostic tests that include a sleep apnea study, pulmonary function test, ECG, echocardiogram and chest X-ray. The patient and family are encouraged to attend monthly support groups both before and after surgery.
Peri/Postoperative Nursing Issues, Care
Rosette Reyes, BSN, RN, a general pediatric resource nurse who works closely with Dr. Albanese in surgery at Lucile Packard Children's Hospital, explained that the major nursing implications for adolescent bariatric patients in the OR are equipment-related. "We have to develop a plan to get the patient in and out of the operating suite safely. We generally walk the patients into the OR and have them climb onto the table with assistance. However, we're a pediatric facility, so we need to take special care that the OR table can accommodate the patient's size and weight."
Postoperatively, Reyes and her colleagues use a five- or six-person lifting procedure to transfer the patient off the table. "Preferably, we'll transfer the patient right into the bed that will be used on the medical-surgical floor. The patient goes to PACU for 45 minutes to an hour to recover from anesthesia, then is transported to the floor."
Postoperative nursing interventions are similar to those for abdominal surgery patients in general. "The first patient came back from PACU with a patient-controlled analgesia (PCA) pump, so she was pretty comfortable," explained Pamela Erickson, BSN, RN, staff nurse IV on the med/surg unit that houses adolescent bariatric surgery patients. "She had a number of different incisions and Jackson-Pratt drains, a maintenance IV and an indwelling urinary catheter."
The patient was NPO until a contrast study ruled out any leaks in the operative area, then she carefully advanced her diet under the supervision of the nutritionist. "She was able to pick out the best beverages for healing and nutrition. Then she sipped frequently from her cup, and wrote down the type and amount of her intake," Erickson said.
The understanding that the patient showed on the postoperative unit boded well for her future success. "We emphasize to the teens that bariatric surgery is an irreversible procedure, that it's all about behavioral changes for the rest of their lives," said Farrales. To be a successful candidate for the surgery, teens must make a commitment to lifestyle changes, including at least a 30-minute walk each day.
For the rest of their lives, these patients will be expected to follow dietary guidelines that include three meals a day containing protein and fiber. They'll learn to eat slowly, chew food thoroughly and avoid eating and drinking at the same time. Their total meal size will be limited to less than one cup, and they'll need to drink plenty of water from 90 minutes after one meal until 15 minutes before the next meal. To reinforce these lifestyle alterations and answer specific questions, the bariatric team sees the patients for at least 14 follow-up visits over a 2-year period after surgery.
Longer and Healthier Lives
"There are a lot of people concerned about why we're doing this procedure for this age group," said Reyes. "From the nursing perspective, is this really an ethical procedure? These teens have gone through a prolonged period of physical and psychological testing. Knowing that background history paints the picture for me of what we're doing and why we're doing it. My bottom line is that we're doing this type of surgery to make their lives better and to help them live longer and healthier lives."
Sandy Keefe is a freelance writer and frequent contributor to ADVANCE.
Roux-en-Y Gastric Bypass Procedures
Bariatric surgeons operating on adolescents at Lucile Packard Children's Hospital perform laparoscopic Roux-en-Y gastric bypass procedures, which involve dividing the stomach into two parts. The upper portion forms a small pouch that holds about 1 ounce (30 cc) of food or liquid. The lower part of the stomach, as well as the duodenum and upper portion of the jejunum, are bypassed. The lower portion of the small intestine is attached to the upper pouch of the stomach, leaving a small opening for food to pass from the stomach to the intestine.
The end of the bypassed portion of the small intestine is then connected to the distal portion of the lower intestine, forming a "Y" that allows digestive juices from the bypassed section to empty into the lower intestine to help in breaking down food.
The Roux-en-Y procedure promotes weight loss in two ways:
1. Volume restriction: When food is swallowed and goes into the small stomach pouch, the patient feels full after eating only a modest amount of food.
2. Malabsorption: Because food bypasses part of the small intestine and is then digested in the lower portion of the small intestine, the patient's body absorbs fewer calories.
By using a laparoscopic approach to the Roux-en-Y procedure, surgeons are able to insert special miniaturized instruments through small incisions through the abdominal wall. This method promotes faster healing and recovery, while decreasing postoperative pain, infection rates and herniation risk when compared to open surgery. The procedure takes about 2-4 hours; patients generally stay in the hospital for only 3-5 days and most return to work or school in 2-6 weeks.
An added benefit of the Roux-en-Y procedure is that it helps to modify eating patterns through an unpleasant feedback mechanism. Foods that are high in sugar or fat are not readily tolerated, and often trigger discomfort and flu-like symptoms known as "dumping syndrome." After experiencing these consequences a few times, most patients get the message.