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Bariatric Surgery
Childhood Obesity continues to be on the rise and causes serious health consequences. In this podcast, Dr. Jason Fraser discusses the Bariatric Surgery program at Children's Mercy. We learn who is a candidate for bariatric surgery, the requirements for surgery, why Children's Mercy decided to offer bariatric surgery, the type of bariatric surgery offered at Children's Mercy and results.
Featured Speaker:
Learn more about Jason Fraser, MD
Jason Fraser, MD
Jason D. Fraser, MD serves as a Director, General Surgery Residency Program; Assistant Professor of Pediatrics, University of Missouri Kansas City School of Medicine.Learn more about Jason Fraser, MD
Transcription:
Bariatric Surgery
Dr. Michael Smith (Host): Bariatric surgery is becoming more widely available for kids and Children’s Mercy is leading the way. This is Transformational Pediatrics, the podcast from Children’s Mercy. I'm Dr. Mike. Let’s talk with Dr. Jason Fraser. He’s a pediatric surgeon and director of bariatric surgery at Children’s Mercy. Dr. Fraser, tell us a little bit about the obesity epidemic that we are experiencing right now.
Jason Fraser, MD (Guest): Yeah. So obesity, unfortunately, is becoming much more common in the children/adolescent age group. Even a couple of years ago, the CDC used publish that the obesity epidemic is about one in six children. Now it’s up to one in five. So it’s about 20% of children across the United States are now considered obese. Unfortunately, the fear is that that’s going to continue to rise as we grow as a society. They also have the secondary health effects that come along with it too that you see in adults.
Host: Right. So what is the official definition of obesity in an adolescent? Do we go by the BMI like we do with adults?
Dr. Fraser: Yes. So we do look at the BMI like we do in adults. We also look at the percentile weight because the BMI in adolescents and children isn’t always perfect. So we look at the percentage of the 95th percentile. So a BMI of 40 in an adult correlates to about 140% of the 95th percentile. A BMI of 35 in an adult correlates to about 120% of the 95th percentile in adolescent. So we look at both those, both the BMI and the percentile range in adolescents and children.
Host: Tell us a little bit about how Children’s Mercy decided to offer bariatric surgery.
Dr. Fraser: So the process that went into this is we noticed that there was a very large unmet need in the community and in the region. Obviously, like we had talked about, the obesity epidemic is running rampant, unfortunately, among the children in America. We saw that there were children that were getting larger and having medical issues that were not being met with just medical weight loss therapy alone. We saw that a good percent of our patients at our hospital had obesity and obesity related complications. Therefore we started to look for different treatments that could help them. At that point, we started to explore bariatric surgery as one of those treatments.
Host: So what is the goal then of the program?
Dr. Fraser: The goal of the program is to treat patients and parents in a holistic way to help them live their healthiest life possible. That includes diet and exercise, but also includes medical weight loss therapy, social work, nutrition, exercise physiology, and then ultimately surgery. The goal of surgery is to equip them with an opportunity to transform their life and to develop eating healthy, exercise, but also to develop a healthier life overall spearheaded by weight loss surgery.
Host: What types of bariatric surgery are you performing at Children’s Mercy?
Dr. Fraser: So we do exclusively the laparoscopic sleeve gastrectomy. It’s an operation that’s done through five small incisions. About two-thirds to three-quarters of the stomach is removed laparoscopically. There are other options out there, but the most common operation that’s done across the nation for adults and for adolescents at this point is the laparoscopic sleeve gastrectomy and that’s the one we do here.
Host: Now I know a lot goes into the workup for the surgery itself. There are things that the patient and their family have to accomplish before actually moving on to the surgery. So tell us a little bit about the requirements for surgery and what it is like for the patient leading up to surgery.
Dr. Fraser: Yeah. That’s a very good question and a very good because the operation itself is one that we have to do a lot of front work to to be able to get the patients ready for an operation. Usually they’ll come see me or come see our medical weight loss doctors as an initial entrance into the program. But like every other center out there, we need them to go to a significant period of testing, but also through at least six months of medical weight loss therapy in order to figure out if they're ready for an operation but also to make sure that they are emotionally and physically ready for the operation.
So we use the same criteria that pretty much every other program uses across the country, which includes at least six months of medical weight loss therapy. Like I said, that gives us time to figure out if there are other medical comorbidities that we need to address first, but it also allows the patients and the parents time to figure out what their relationship is with each other, their relationship with food. To make sure that they are socially ready, financially ready for an operation. Then we also have patients and parents here, exercise physiologist, our social workers, as well as our psychologists. We want to determine first of all are there any underlying psychological issues that may be there like anxiety or depression because we don’t want those to come to a head after an operation. We want to make sure that patients are well treated before an operation for those kinds of things.
We also want to help people realize their relationship to food because we want to realize what they're taking before an operation so we can help guide that in the right direction and prepare them for an operation, but also help optimize what they're going to be eating after an operation. All those kinds of things take a lot of time because they're big changes that need to happen before an operation so that the even bigger changes and even bigger successes can happen after an operation.
Host: Yeah. In adults, I'm pretty sure leading up maybe a month into the surgery they put the patient on a very low carbohydrate diet. Do you do the same thing with the adolescent patients?
Dr. Fraser: We try to make some similar diet changes as soon as we can with their program. We examine what they're eating right away, and we try to get them to eat a more healthy, almost a bariatric diet before the operation if we can. That’s not always possible or successful. Immediately before an operation, five days before an operation our patients go on a purely liquid diet with the caveat of one, that’s going to be the diet they're going to be on post-operatively for about two weeks. Number two, it also helps make sure that the stomach is empty and makes sure that the stomach is a little bit thinner and more pliable for an operation. It also helps make sure the liver, which sits on top of the stomach during the operation, is a little bit smaller, little bit more tolerable, and better able to tolerate an operation.
Host: In the adolescent population, what’s the recovery like?
Dr. Fraser: So the recovery is usually fairly quick, which is nice because the operation is done through, like I said, the five small laparoscopic incisions. Most people are in the hospital about one to three days. The thing that guides their hospital stay post-operatively is pain and nausea, which is usually fairly minimal on both ends. Then they need to be able to take a certain amount liquid in post-operatively so that they are safe and able to stay hydrated post-op going home. So once they are able to meet those criteria, then they are able to go home.
Activity wise in the hospital, they are up and moving right away because we want to make sure that they are ambulatory and mobile to try to decrease the risk of any blood clots in their lungs or in their legs or pneumonias or any other issues. Ambulating early also helps with nausea a lot. We try to do an enhanced recovery protocols with minimizing narcotics and things like that that really help speed their post-operative recovery. Pain wise is usually fairly minimal. Usually they need very minimal post-operative narcotics and that helps actually with them a lot. They're back to normal activity in one to two weeks barring patient condition and patient tolerance. Most people feel that have had similar operations that have similar recovery to getting their gallbladder out done laparoscopically.
Host: Looking at it from the long term perspective, what kind of results have you experienced with bariatric surgery in specifically the adolescent population?
Dr. Fraser: Sure. So we have seen various results. Most of our results are showing patients lose a significant amount of weight. Globally in the 10/15 year studies, most of those studies are showing, in adolescents, that patients lose about a third of their overall weight or about 60 to 65% of their excess body weight. We are seeing similar results with our patients as well. Some patients lose more, some patients lose less. That’s developed based on patient personality, adherence to the diet, also body type and social issues as well. We see varied outcomes, but most of our outcomes have been very good and most of our patients and parents have been very satisfied with the operation.
Host: So a lot of our listeners, Dr. Fraser, are general pediatricians, general practitioners, nurse practitioners. They are seeing more and more obese patients on a daily basis. Do you have any advice for how they can best manage those patients? And if they are a candidate for bariatric surgery, what’s the process for them to get that patient hooked up with the specialist like yourself?
Dr. Fraser: So I think the second question is a little bit easier one to answer. So I’ll answer that one first. I, myself, I think most bariatric surgeons and most physicians who are involved in weight management will always tell primary practitioners to refer the patients always and refer them often. We are always happy to see them, to get the ball rolling, to have those discussions with the patients and their families about medical weight loss therapies, whether it is surgery or not surgery. So referrals of patients that are starting to be concerning, even if they don’t necessarily meet every criteria for an operation that we've talked about. I think early referrals are very key. The hard thing is, I definitely think from the primary care providers who are seeing a significant increase in obese patients is not only trying to do diet and exercise counselling, but also trying to figure out a way to have those discussions in a very limited amount of visit time.
So I think being able to support patients and being able to have those discussions with parents over and over again and new patients over and over again early on. With planting the seeds of possible need for escalating care to medical weight loss physicians or surgeons is something that’s always possible. Those discussions can be difficult, but they need to be honest. They need to talk about the potential short and long-term implications of severe obesity. Even if they can be difficult, we’re always happy to have those discussions too or in support of our primary physician colleagues.
Host: In summary, what would you like people to know about bariatric surgery?
Dr. Fraser: I think people should know that bariatric surgery is safe. I think they should know that it’s very effective. It has a very low side effect profile. Especially in adolescents where it can be viewed as kind of scary, actually most adolescents do very well with the operation and lose a significant amount of weight. My perspective on this is that patients that are severely obese have a very significant disease. One that we might be able to say okay. If a patient had a cancer, you would do everything you can to try to fix that and prevent their ultimate [inaudible] from cancer. Well, I think we should do the same thing and have the same view of obesity. So if we have treatments out there such as weight loss surgery, we should offer that to patients. Especially if they're safe and they're effective, which medical weight loss surgery is in adolescents and children.
Host: Excellent summary. That’s Dr. Jason Fraser. He’s the director of bariatric surgery at Children's Mercy. That’s for checking out this episode of Transformation Pediatrics. Please visit childrensmercy.org to get connected with Dr. Fraser or another provider. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics or interest to you and be sure to check back soon for the next podcast. I'm Dr. Mike. Thanks for listening.
Bariatric Surgery
Dr. Michael Smith (Host): Bariatric surgery is becoming more widely available for kids and Children’s Mercy is leading the way. This is Transformational Pediatrics, the podcast from Children’s Mercy. I'm Dr. Mike. Let’s talk with Dr. Jason Fraser. He’s a pediatric surgeon and director of bariatric surgery at Children’s Mercy. Dr. Fraser, tell us a little bit about the obesity epidemic that we are experiencing right now.
Jason Fraser, MD (Guest): Yeah. So obesity, unfortunately, is becoming much more common in the children/adolescent age group. Even a couple of years ago, the CDC used publish that the obesity epidemic is about one in six children. Now it’s up to one in five. So it’s about 20% of children across the United States are now considered obese. Unfortunately, the fear is that that’s going to continue to rise as we grow as a society. They also have the secondary health effects that come along with it too that you see in adults.
Host: Right. So what is the official definition of obesity in an adolescent? Do we go by the BMI like we do with adults?
Dr. Fraser: Yes. So we do look at the BMI like we do in adults. We also look at the percentile weight because the BMI in adolescents and children isn’t always perfect. So we look at the percentage of the 95th percentile. So a BMI of 40 in an adult correlates to about 140% of the 95th percentile. A BMI of 35 in an adult correlates to about 120% of the 95th percentile in adolescent. So we look at both those, both the BMI and the percentile range in adolescents and children.
Host: Tell us a little bit about how Children’s Mercy decided to offer bariatric surgery.
Dr. Fraser: So the process that went into this is we noticed that there was a very large unmet need in the community and in the region. Obviously, like we had talked about, the obesity epidemic is running rampant, unfortunately, among the children in America. We saw that there were children that were getting larger and having medical issues that were not being met with just medical weight loss therapy alone. We saw that a good percent of our patients at our hospital had obesity and obesity related complications. Therefore we started to look for different treatments that could help them. At that point, we started to explore bariatric surgery as one of those treatments.
Host: So what is the goal then of the program?
Dr. Fraser: The goal of the program is to treat patients and parents in a holistic way to help them live their healthiest life possible. That includes diet and exercise, but also includes medical weight loss therapy, social work, nutrition, exercise physiology, and then ultimately surgery. The goal of surgery is to equip them with an opportunity to transform their life and to develop eating healthy, exercise, but also to develop a healthier life overall spearheaded by weight loss surgery.
Host: What types of bariatric surgery are you performing at Children’s Mercy?
Dr. Fraser: So we do exclusively the laparoscopic sleeve gastrectomy. It’s an operation that’s done through five small incisions. About two-thirds to three-quarters of the stomach is removed laparoscopically. There are other options out there, but the most common operation that’s done across the nation for adults and for adolescents at this point is the laparoscopic sleeve gastrectomy and that’s the one we do here.
Host: Now I know a lot goes into the workup for the surgery itself. There are things that the patient and their family have to accomplish before actually moving on to the surgery. So tell us a little bit about the requirements for surgery and what it is like for the patient leading up to surgery.
Dr. Fraser: Yeah. That’s a very good question and a very good because the operation itself is one that we have to do a lot of front work to to be able to get the patients ready for an operation. Usually they’ll come see me or come see our medical weight loss doctors as an initial entrance into the program. But like every other center out there, we need them to go to a significant period of testing, but also through at least six months of medical weight loss therapy in order to figure out if they're ready for an operation but also to make sure that they are emotionally and physically ready for the operation.
So we use the same criteria that pretty much every other program uses across the country, which includes at least six months of medical weight loss therapy. Like I said, that gives us time to figure out if there are other medical comorbidities that we need to address first, but it also allows the patients and the parents time to figure out what their relationship is with each other, their relationship with food. To make sure that they are socially ready, financially ready for an operation. Then we also have patients and parents here, exercise physiologist, our social workers, as well as our psychologists. We want to determine first of all are there any underlying psychological issues that may be there like anxiety or depression because we don’t want those to come to a head after an operation. We want to make sure that patients are well treated before an operation for those kinds of things.
We also want to help people realize their relationship to food because we want to realize what they're taking before an operation so we can help guide that in the right direction and prepare them for an operation, but also help optimize what they're going to be eating after an operation. All those kinds of things take a lot of time because they're big changes that need to happen before an operation so that the even bigger changes and even bigger successes can happen after an operation.
Host: Yeah. In adults, I'm pretty sure leading up maybe a month into the surgery they put the patient on a very low carbohydrate diet. Do you do the same thing with the adolescent patients?
Dr. Fraser: We try to make some similar diet changes as soon as we can with their program. We examine what they're eating right away, and we try to get them to eat a more healthy, almost a bariatric diet before the operation if we can. That’s not always possible or successful. Immediately before an operation, five days before an operation our patients go on a purely liquid diet with the caveat of one, that’s going to be the diet they're going to be on post-operatively for about two weeks. Number two, it also helps make sure that the stomach is empty and makes sure that the stomach is a little bit thinner and more pliable for an operation. It also helps make sure the liver, which sits on top of the stomach during the operation, is a little bit smaller, little bit more tolerable, and better able to tolerate an operation.
Host: In the adolescent population, what’s the recovery like?
Dr. Fraser: So the recovery is usually fairly quick, which is nice because the operation is done through, like I said, the five small laparoscopic incisions. Most people are in the hospital about one to three days. The thing that guides their hospital stay post-operatively is pain and nausea, which is usually fairly minimal on both ends. Then they need to be able to take a certain amount liquid in post-operatively so that they are safe and able to stay hydrated post-op going home. So once they are able to meet those criteria, then they are able to go home.
Activity wise in the hospital, they are up and moving right away because we want to make sure that they are ambulatory and mobile to try to decrease the risk of any blood clots in their lungs or in their legs or pneumonias or any other issues. Ambulating early also helps with nausea a lot. We try to do an enhanced recovery protocols with minimizing narcotics and things like that that really help speed their post-operative recovery. Pain wise is usually fairly minimal. Usually they need very minimal post-operative narcotics and that helps actually with them a lot. They're back to normal activity in one to two weeks barring patient condition and patient tolerance. Most people feel that have had similar operations that have similar recovery to getting their gallbladder out done laparoscopically.
Host: Looking at it from the long term perspective, what kind of results have you experienced with bariatric surgery in specifically the adolescent population?
Dr. Fraser: Sure. So we have seen various results. Most of our results are showing patients lose a significant amount of weight. Globally in the 10/15 year studies, most of those studies are showing, in adolescents, that patients lose about a third of their overall weight or about 60 to 65% of their excess body weight. We are seeing similar results with our patients as well. Some patients lose more, some patients lose less. That’s developed based on patient personality, adherence to the diet, also body type and social issues as well. We see varied outcomes, but most of our outcomes have been very good and most of our patients and parents have been very satisfied with the operation.
Host: So a lot of our listeners, Dr. Fraser, are general pediatricians, general practitioners, nurse practitioners. They are seeing more and more obese patients on a daily basis. Do you have any advice for how they can best manage those patients? And if they are a candidate for bariatric surgery, what’s the process for them to get that patient hooked up with the specialist like yourself?
Dr. Fraser: So I think the second question is a little bit easier one to answer. So I’ll answer that one first. I, myself, I think most bariatric surgeons and most physicians who are involved in weight management will always tell primary practitioners to refer the patients always and refer them often. We are always happy to see them, to get the ball rolling, to have those discussions with the patients and their families about medical weight loss therapies, whether it is surgery or not surgery. So referrals of patients that are starting to be concerning, even if they don’t necessarily meet every criteria for an operation that we've talked about. I think early referrals are very key. The hard thing is, I definitely think from the primary care providers who are seeing a significant increase in obese patients is not only trying to do diet and exercise counselling, but also trying to figure out a way to have those discussions in a very limited amount of visit time.
So I think being able to support patients and being able to have those discussions with parents over and over again and new patients over and over again early on. With planting the seeds of possible need for escalating care to medical weight loss physicians or surgeons is something that’s always possible. Those discussions can be difficult, but they need to be honest. They need to talk about the potential short and long-term implications of severe obesity. Even if they can be difficult, we’re always happy to have those discussions too or in support of our primary physician colleagues.
Host: In summary, what would you like people to know about bariatric surgery?
Dr. Fraser: I think people should know that bariatric surgery is safe. I think they should know that it’s very effective. It has a very low side effect profile. Especially in adolescents where it can be viewed as kind of scary, actually most adolescents do very well with the operation and lose a significant amount of weight. My perspective on this is that patients that are severely obese have a very significant disease. One that we might be able to say okay. If a patient had a cancer, you would do everything you can to try to fix that and prevent their ultimate [inaudible] from cancer. Well, I think we should do the same thing and have the same view of obesity. So if we have treatments out there such as weight loss surgery, we should offer that to patients. Especially if they're safe and they're effective, which medical weight loss surgery is in adolescents and children.
Host: Excellent summary. That’s Dr. Jason Fraser. He’s the director of bariatric surgery at Children's Mercy. That’s for checking out this episode of Transformation Pediatrics. Please visit childrensmercy.org to get connected with Dr. Fraser or another provider. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics or interest to you and be sure to check back soon for the next podcast. I'm Dr. Mike. Thanks for listening.