For Obese Teens, A Radical Solution: Stomach Surgery
Heather Grill was four years old when she was first teased about her weight. Other kids told her fat people can't go to heaven because they are too heavy to fly with angel wings. In middle school, she remembers being pushed down a flight of stairs by "guys who thought it was fun to watch me roll."
Now 16, and after countless diets, Ms. Grill weighs 472 pounds. She has high blood pressure and an enlarged heart, and is borderline diabetic. She fears going to sleep because her body fat can crush her airways. She has chronic joint pain and takes an antidepressant. "Every day you're in front of the mirror looking for someone else because you don't want to believe it's you standing there," she says.
So Ms. Grill is ready for an extreme measure. She is talking to doctors at Cincinnati Children's Hospital about having a procedure called bariatric surgery that would permanently shrink her stomach by more than 90%.
In the past two years, as many as 150 teenagers around the U.S. have had the surgery, by some estimates, and the numbers are likely to grow. A dozen children's hospitals either offer the procedure or plan programs to meet surging demand. One pediatric surgeon estimates that 250,000 adolescents in the U.S. could be candidates.
The emerging teen-age market for this drastic operation illustrates how serious America's obesity epidemic has become. The National Center for Health Statistics says 15% of children between ages 6 and 18 were obese in 2000, compared with 6% in 1980, and experts believe the numbers are still increasing. The reasons aren't fully understood, though the likely causes include high-calorie diets and insufficient exercise.
Although surgery candidates constitute a tiny percentage of overweight adolescents, health-care experts believe they represent the leading edge of a troubling phenomenon: a generation of children poised to enter adulthood already burdened with maladies such as diabetes and heart disease that will shorten their lives and result in huge medical bills for society. Some worry that obese children pose such a severe problem that their generation could be the first in American history with a shorter life expectancy than their parents'.
Such concerns are helping to erode professional resistance to the procedure, which is not reversible. Two years ago, colleagues urged Mary L. Brandt, a professor of surgery and pediatrics at Baylor College of Medicine in Houston, to begin a program in bariatric, or obesity, surgery. "Absolutely not," she replied. Now, she has changed her mind because "it has become clear that there are children who need this operation," she says.
Skeptics remain. David Ludwig, a pediatrician who runs an obesity-prevention program for children at Children's Hospital Boston, advocates other remedies, including better insurance coverage for rigorous obesity prevention programs and new regulations, similar to antitobacco laws, on how fast-food and soft-drink companies market their products to children. Bariatric surgery for teens may be appropriate in "extreme cases," he says. "It is a sad comment on our society if we have to resort to this procedure frequently" for adolescents, he adds.
Most insurers are refusing to cover the surgery, which can cost as much as $40,000. They say there aren't any conclusive data demonstrating that it works for adolescents and health-care costs are already soaring. Some insurers privately voice concerns that hospitals and surgeons are pushing weight-loss surgery to replace lucrative but waning procedures, including heart surgery.
Bariatric surgery is already big business with adults -- more than 100,000 patients will have it done this year. Results are generally good and insurance coverage varies.
In performing the procedure, doctors use a surgical stapler to seal off a tiny pouch that reduces the stomach from "the size of a bucket to the size of an egg," says Victor Garcia, a pediatric surgeon and head of the bariatric program at Cincinnati Children's Hospital. They also shorten a patient's small intestine by up to four feet, or 20%, and reroute the rest to shunt food quickly from the pouch to the bottom of the digestive tract. This sharply cuts the amount of food a person can eat and absorb.
The Cincinnati hospital, which has done 23 of the procedures on teenagers in the past two years, has seen some complications. One patient had a potentially life-threatening blood clot in her leg and spent a month in the hospital. Another had a leak in the portion of the stomach cut off from the digestive tract, a potentially serious problem that in this case quickly healed on its own. One patient failed to comply with a post-surgery diet and developed a serious vitamin deficiency and months later is still affected by leg weakness.
Although a few bariatric surgeons did the procedure on adolescents over the past two decades, until recently it was rare and essentially taboo. William J. Klish, a professor of pediatrics at Baylor, for years lectured medical students against the surgery for children. He opposed it after a 400-pound boy he had recommended for the operation more than a decade ago died from a post-surgical infection.
Today, though, he regularly sees obese children who have diabetes, high blood pressure and chronic joint problems. He's had patients who died of suffocation in their sleep. Now he has changed his mind and physicians at Texas Children's Hospital, affiliated with Baylor, are evaluating surgery candidates and expect to perform their first operation early next year.
Some doctors at children's hospitals figure that if they don't perform the procedure, surgeons already doing a brisk bariatric business on adults will add adolescents to their caseload. Pediatricians argue that if bariatric surgery is to be performed on children, it should be done within a comprehensive program involving specially trained doctors, psychologists and counselors in nutrition and exercise.
Alan Wittgrove, a bariatric surgeon in San Diego, says he and colleagues who have done the surgery on adolescents have been criticized by pediatricians for "mutilating our youth." He thinks new programs such as the one at Cincinnati Children's Hospital will help quiet critics by validating the procedure with clinical research. To speed that, some bariatric surgeons who specialize in adults are instructing pediatric surgeons on the procedure. That cooperation could eventually turn into a turf battle, though, as more children seek the operation -- especially if insurers start to pay for it.
The procedure comes with serious risks, including subsequent weight gain, poor nutrition and even death. It triggers biochemical responses in the body that aren't well understood. It requires strict compliance with a harsh diet that is crucial to the procedure's success. Without proper nutrition, the patients may lose desirable lean body mass, suffer serious vitamin deficiency and not get enough minerals to ensure healthy bones.
But the consequences of untreated obesity are also severe. In addition to high blood pressure, diabetes and depression, super-obese children are likely to have abnormally large hearts, which risk failing later in life. They are prone to kidney problems and have a high incidence of liver disease, a precursor to hepatitis and, eventually, a liver transplant. Some girls don't menstruate or ovulate so they get hair growth on their faces. They also risk failed pregnancies and infertility.
The emotional toll includes taunting, the struggle to get a date or a job, the inability to fit in a seat at the movies.
Healthy diets and regular exercise, the recommended strategies for preventing obesity, typically don't do enough once children become very overweight, doctors say. For a child weighing 300 pounds or more, even a brisk walk around the block isn't possible because of serious joint pain and other problems. Once a person reaches a certain weight, their metabolism changes and the body fights aggressively to preserve its level of body fat. Many candidates for surgery report having lost 40 or 50 pounds at summer obesity camps, only to regain the weight -- and more -- once they get home.
Anecdotal reports from kids who have had the surgery are encouraging. Within the first six months, patients can lose more than 100 pounds. In some cases, diabetes goes away before patients leave the hospital. Sleep patterns return to normal. Doctors believe that abnormally large hearts gradually return to a healthier size.
While bariatric surgery is increasingly attractive to some teens, a big question is who pays. Ms. Grill has been cleared for the procedure by doctors at Cincinnati Children's Hospital but her family can't cover the bill. The hospital charges around $40,000, which includes two years of follow-up treatments such as psychological and nutrition counseling.
The family's insurance company, Anthem Blue Cross & Blue Shield, has refused to pay, despite a letter from Dr. Garcia saying the procedure is a "medical necessity." The family has hired an attorney to appeal Anthem's denial.
Since Ms. Grill and other dangerously obese young people will probably run up big medical bills as they get older, doctors at Cincinnati Children's Hospital criticize the no-coverage policy. "We think this is a pay-me-now or pay-me-much-more-later scenario," says Stephen R. Daniels, a pediatrician and director of the hospital's lipid, hypertension and weight-management clinics.
Anthem says it doesn't cover obesity surgery in adolescents. The insurer reviewed its bariatric-surgery policy this spring "with the help of outside medical experts" and determined that there wasn't enough "conclusive medical and scientific evidence" to support coverage for members under age 18, says Deborah New, a spokesperson for the Indianapolis-based insurer.
Advocates of the procedure point to patients such as Natalie Moore. About three years ago, shortly before her 16th birthday, she weighed 325 pounds. Doctors said she'd be dead within a year. Searching the Internet, she entered her obesity-linked medical problems. Gastric bypass was listed as a remedy for nearly all of them. But every hospital she found that performed the operation said she had to be at least 18 years old.
Finally she found a doctor in Spain who agreed to do it. After she and a friend bought plane tickets, Ms. Moore went back to her own physician. "I told her to get me help or get out of my way," she says. The doctor got her an appointment with Dr. Garcia.
As chief of surgery at Walter Reed Army Medical Center in the 1980s, Dr. Garcia had performed gastric bypasses on adults. A few years ago, he did the procedure on a 19-year-old patient at Cincinnati Children's who was so obese she needed a tube to breathe. Her success helped convince Dr. Garcia the procedure could benefit teens. He and his colleagues spent two years developing a program to offer it.
Before Ms. Moore was cleared for surgery, a team including a colleague of Dr. Garcia's, a pediatric psychologist and expert in nutrition and exercise, interviewed her parents and her brother "to see if my family could handle the changes" necessary for success, she says. She watched videos of the surgery and went on a supervised diet for a few months to see if she would lose any weight.
On the morning she went to the operating room, Ms. Moore weighed 298 pounds. She remembers thinking: "This is going to change the rest of my life."
It changed immediately. Before surgery, she was a cupcake junkie and often drank a 12-pack of Mountain Dew a day. Now, protein and vitamins dominate her diet. She concentrates on chewing her food. "The opening to my stomach is the size of a dime," she says. When one patient didn't chew thoroughly, doctors had to thread an instrument down her throat to fish out the food.
Ms. Moore also discovered that her senses of taste and smell had changed. Food such as tuna fish that she liked before the operation now nauseate her. She no longer likes the smell of perfume or food cooking.
Other patients report similar reactions. For reasons that aren't clear, the surgery seems to trigger biochemical changes that suppress appetite, providing an unexpected ally. The long term consequences, though, aren't known.
Maintaining nutrition is a huge challenge, doctors say. Getting sufficient calories and protein is difficult on a small stomach, says Dr. Garcia, as is drinking the recommended two quarts of water a day. If the teenagers drink any liquid within an hour of a meal, they'll be too full to eat and risk not getting needed vitamins.
During a recent "support group" meeting, attended by both young people who had had the surgery and ones who were considering it, Ms. Moore reported that almost two years after her operation she weighs 150 pounds -- half her size when she had the surgery. She raised her blouse to show a large zig-zag scar circling her body like a belt, from a second operation to remove excess layers of skin. "You're losing so much weight you don't have time to put the skin anywhere," she explained later. The scar, she added, is "something I earned."
手术减肥渐成潮流
希思?格丽尔(Heather Grill)早在四岁大的时候就因为体重而受到嘲弄了。其他孩子告诉她，胖人不能进入天堂，因为胖人太重了，天使的翅膀根本承受不了。格丽尔还记得自己上中学的时候，经常被推下楼梯，因为那些家伙觉得看著她胖乎乎的身体滚下楼梯很好玩。
如今，格丽尔已经16岁了，在经历了无数次的减肥后，她的体重仍然高达472磅，并伴有高血压、心脏扩张和初期糖尿病。她担心入睡，因为在睡梦中体内脂肪可能会压迫她的呼吸道。她还患有慢性关节炎，并需要服用抗抑郁药。格丽尔表示，每天站在镜子前，她都不愿意相信镜子里的人是自己。 所以，格丽尔准备采取一项极端措施。她正在与辛辛那提儿童医院(Cincinnati Children's Hospital)的医生们商谈进行减肥外科手术的事宜，手术将使她的胃永久性地缩小90%以上。
在过去的两年中，美国各地有多达150名青少年进行了减肥手术。根据一些人的估计，该数字还有可能继续上升。数十家儿童医院为了满足这种日益增长的需求开始提供减肥手术，或者推出减肥计划项目。一位儿科医生估计美国大约有25万青少年可能会接受这些治疗项目。
青少年减肥市场的日益兴起表明，肥胖病在美国已经变得多么广泛，多么严重。据美国健康统计中心(National Center for Health Statistics)称，2000年，美国6到18岁的青少年中，肥胖病患者占15%，而1980年的比例是6%。专家认为这一数字仍在不断上升。导致肥胖病泛滥的原因尚未完全查明，但高热量的饮食结构和缺乏运动很可能都在其中。
尽管在肥胖的青少年中需要进行减肥手术的人仅占很小比例，但保健专家们认为，这预示著一种危险的现象：这一代的孩子们有可能刚到成年就背上沉重的疾病负担，比如糖尿病、心脏病等，这将缩短他们的寿命，并给社会带来巨额的医疗支出。肥胖儿童提出了一个严峻的问题，以至于有人担心这代儿童将成为美国历史上第一代平均寿命短于父辈的人。
这种担心有助于削弱减肥手术在医学界面临的阻力，使之成为一种不可逆转的潮流。两年前，曾经有同事劝休斯顿贝勒医学院(Baylor College of Medicine)的外科和儿科教授玛丽?博兰特(Mary L. Brandt)推出减肥手术项目，但被她断然拒绝。如今，博兰特却已回心转意。她表示，显而易见，有些孩子的确需要减肥手术。
但对此持怀疑态度的人仍然存在。在波士顿儿童医院(Children's Hospital Boston)推出肥胖病预防项目的儿科医生大卫?卢威格(David Ludwig)就提倡其他措施，比如为有效的肥胖病预防项目提供更好的保险赔付，以及象限制烟草的法令那样实行新的监管规定，对快餐和软饮料企业销售儿童产品的做法进行监管。卢威格认为，在某些特别的病例中，减肥手术对青少年来说可能是适宜的，但是如果人们不得不频繁地依赖手术解决青少年肥胖问题的话，那么这将是整个社会的悲哀。
大多数保险商拒绝对减肥手术投保，而手术的价格可能高达4万美元。保险商认为，目前还没有任何结论性的数据能证明青少年减肥手术保险是可行的，而且保健成本已经在飙升了。一些保险商私下里表达了对医院和外科医生的担心，怕他们借推行减肥外科手术之机，以此取代那些虽然赚钱但已开始走下坡路的手术项目，比如心脏手术等。
成人的减肥手术已经成为一项重要的业务──今年将有超过10万成年人接受减肥手术。手术效果一般都不错，也有各种保险提供保障。
辛辛那提儿童医院的外科医师、减肥项目主管维克托?加西亚(Victor Garcia)表示，在做减肥手术的时候，医生会用一台外科手术缝合机缩小胃腔，使胃的体积从小桶状减至鸡蛋状大小。医生还会将病人的小肠缩短最多4英尺，即整个小肠的20%，从而改变肠道路径，使食物从胃腔到消化道末端的排空时间缩短。这将大大减少病人摄取和吸收食物的数量。
辛辛那提儿童医院在过去的两年中已经给23例青少年进行了减肥手术，也曾经出现一些并发症。一位患者腿部出现了可能危及生命的血液凝块，后来在医院里住院一个月。另一名患者经过消化道切除的胃腔部份出现了泄露情况，这可能造成严重的后果，但在本例中患者很快自我痊愈了。还有一名患者无法配合使用手术后指定的食谱，造成维生素严重匮乏，数月之后腿部仍感到虚弱无力。
虽然在过去的20年中，有些外科医生曾零星地给青少年做过减肥手术，但即使到最近，这类手术也为数不多，基本上属于无法涉足的禁区。贝勒医学院的儿科教授威廉?克里什(William J. Klish)多年来一直教导医学院的学生不要给孩子做减肥手术。他之所以态度如此强硬，是因为十多年前他建议接受减肥手术的一个体重400磅的男孩因术后感染丧生。
但如今，克里什经常看到遭受糖尿病、高血压和慢性关节炎困扰的肥胖儿童。他的病人中还有的在睡觉时窒息而死。所以，克里什改变了看法。现在，附属于贝勒医学院的得克萨斯儿童医院(Texas Children's Hospital)的医生们正在检查等待手术的青少年患者，预计明年初可进行第一例儿童减肥手术。
一些儿童医院的医生认为，即使他们不进行儿童减肥手术，那些已经做过大量成人减肥手术的外科医生也会给青少年进行手术。儿童医院的医生们认为，如果要给孩子们做减肥手术的话，则必须配合以全套项目，让经过专门训练的医生、心理学家和营养及运动方面的顾问都参与其中。
圣地亚哥的减肥外科医师艾伦?威特格罗佛(Alan Wittgrove)表示，他和他的同事曾经给青少年做过减肥手术，但受到儿科医生的批评，称他们"伤害了青年人"。威特格罗佛认为，辛辛那提儿童医院推出的这类新式项目用临床研究证实了手术的有效性，将有助于平息批评者的声音。为了推动减肥手术的研究，有些专门从事成人手术的减肥医师开始给儿科医生进行手术指导。当然，这种合作最终将演变成双方的竞争，尽管在保险商开始接受减肥手术后，选择手术减肥的儿童可能会越来越多。
减肥手术伴随著巨大的风险，包括术后体重增加、营养不良等，甚至是死亡。手术可能会引发体内的生物化学反应，这些反应还没有被彻底弄清楚。减肥手术后要求辅助以严格的食谱，这对手术的成功与否至关重要。如果不能摄取合适的营养，病人不仅有可能失去理想的苗条身材，还有可能出现严重的维生素匮乏，以及缺乏保证骨骼健康的矿物质。
但不治疗肥胖病的后果也同样严重。除了高血压、糖尿病和精神抑郁外，过于肥胖的儿童还有可能出现心脏异常增大，到晚年有心脏功能丧失的危险。肥胖儿童更容易患上肾病，肝病的发病率也非常高。肝病是肝炎的先兆，最终患者将不得不进行肝脏移植。有些过于肥胖的女孩没有月经或排卵，并且脸上会生长毛发。她们还有无法怀孕和生育的危险。
从精神方面来说，他人的嘲笑、求偶和求职的困难，看电影无法做到座椅上等等，这些都会对肥胖者的心理构成打击。
医生们表示，一旦青少年变得过于肥胖，那些诸如健康饮食和经常锻炼等预防肥胖病的建议往往就无法发挥作用了。对一个体重超过300磅的孩子来说，甚至在街区附近快走都是不可能的，因为他们通常患有严重的关节疼痛和其他病症。一旦一个人体重达到了一定标准，他体内的新陈代谢就会发生变化，他的身体会积极地做出反应以维持体内脂肪水平。许多准备手术的肥胖者表示，他们在减肥夏令营里也能减掉40到50磅的体重，但回到家后很快就会体重增加，甚至超过原来的水平。
已经进行过减肥手术的孩子们的报告令人感到振奋。在头6个月里，病人可以减少100磅以上的体重。有些患者在出院前甚至连糖尿病的症状也消失了。他们的睡眠也恢复正常。医生认为，患者异常增大的心脏也会慢慢恢复到比较健康的体积。
虽然说减肥手术对某些青少年越来越有吸引力了，但由谁来做手术仍是个大问题。格丽尔已经得到辛辛那提儿童医院的允许进行减肥手术了，但她的家庭却无法交付手术费用。医院的收费是4万美元，其中包括为期两年的术后治疗，诸如心理咨询和营养顾问等。
但格丽尔家投保的保险商Anthem Blue Cross & Blue Shield拒绝支付手术费用，尽管加西亚大夫出具了一封证明手术必要性的信函。格丽尔家已经聘请了律师，就保险商的拒绝提起诉讼。
辛辛那提儿童医院的医生们批评了保险商不予投保的做法，因为格丽尔和其他过度肥胖的青少年在长大以后可能会用掉巨额的医疗账单。脂肪、高血压和体重控制门诊的主管和儿科医师斯蒂芬?丹尼斯(Stephen R. Daniels)表示，在他们看来，保险商面临的是个"现在付款还是将来支付更多费用"的问题。
总部位于印第安纳波利斯的保险公司Anthem表示不会对青少年减肥手术投保。公司发言人德波拉?牛(Deborah New)表示，今年春天公司在外界医学专家的帮助下，对减肥手术保险进行了审议，结论是：没有足够的"无庸置疑的医学和科学数据"支持对18岁以下青少年减肥手术投保。倡导减肥手术的人会举出娜塔丽?摩尔(Natalie Moore)这样的病人作为例证。大约3年前，摩尔在16岁生日前不久体重还是325磅，当时医生说她的生命最多可维持一年。通过在国际互联网上进行搜索，摩尔找到了与她的肥胖病相关的链接。几乎所有的网站都把胃替代管疗法列为治疗手段之一。但摩尔找到的每家进行这种手术的医院都告诉她患者年龄必须要达到18岁以上。
最后，摩尔找到一位西班牙的医生同意为她手术。在和朋友购买了飞机票之后，摩尔又回头找到自己的医生。这次，她的医生帮她预约了加西亚大夫。
加西亚在80年代是Walter Reed Army Medical Center的外科主任医师，曾经给成年人做过胃替代管手术。几年前，加西亚在辛辛那提儿童医院给一位19岁的患者进行了这一手术，这位患者极度肥胖，必须依靠导管呼吸。这个病例的成功使加西亚深信减肥手术可以造福青少年。于是，他和同事们花费了两年的时间开发和推出了青少年减肥手术项目。
摩尔说，在她获准进行手术之前，由加西亚的一位同事、一位儿童心理学家和一位营养及运动专家组成的小组拜访了她的父母和哥哥，察看她的家庭能否为手术的成功提供必要条件。摩尔观看了手术的录像，在手术后的几个月内一直采用医院监督的食谱，等待著观察自己能否减肥。
在进手术室的那天早上，摩尔体重298磅。她回忆说，当时她想手术将改变她以后的生活。
她的生活明显起了变化。在手术前，摩尔嗜食纸托蛋糕，每天能喝12罐Mountain Dew。但手术后，她的食谱主要是蛋白质和维生素。摩尔还发现她的味觉和嗅觉也发生了变化。比如金枪鱼一类的食物是她手术前非常喜欢的，但现在这些食物令她感到恶心。她也不再喜欢香水和煮饭的味道。 其他病人也报告说有类似的反应。原因目前还不清楚，看上去好像是手术引发了体内的生化反应，压制了胃口，导致了出人意料的变化。但长期内会有何后果还不得而知。
医生们说，术后维持营养成份是个巨大的挑战。加西亚认为，通过缩小的胃获取充足的热量和蛋白质是非常困难的。另外，也难以保证每天饮用医生建议的2夸脱水，因为如果青少年在饭前1小时内喝了任何液体，他们都将吃不下任何东西，而无法获取所需的维生素。
最近，支持青少年减肥手术的团体举行了会议，由曾经进行过手术或考虑过动手术的年轻人参加。在会上，摩尔报告称，她在做过手术大约两年后体重仅为150磅──是手术前体重的一半。摩尔撩起上衣，露出象皮带一样环绕身体的"之"字巨型伤疤，这是为了去除减肥后多余皮肤而做二次手术留下的。摩尔说，这个伤疤是她减肥的成果。
