According to the CDC, obesity affects nearly 14 million children and adolescents in the United States. With the number of cases growing, Duke pediatricians saw a need to develop a bariatric surgery program for adolescents in 2009.
Today, Duke is the only center in North Carolina to be accredited as a comprehensive center for adolescents by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, and is one of the largest programs in the country, says Dana Portenier, MD, a Duke weight loss surgeon.
“We are seeing more adolescents and children struggling with obesity and are performing more surgeries,” says Portenier. He notes that more adolescents are having surgery because dieting is often ineffective and losing weight is important because patients can develop complications from obesity comorbidities. “Surgery is the best tool we have in our armamentarium.”
Portenier attributes the increase in obesity to a variety of factors such as genetics, poor dietary habits, and a sedentary lifestyle. “It’s a combination of environmental factors,” he says.
Multi-modal approach for treating obesity
The American Medical Association classifies obesity as a chronic disease which requires a multi-modal approach. Duke offers such an approach through its healthy lifestyles program, which includes behavioral and medical therapies. Patients work with a dietitian, a medical weight loss team psychologist, and an exercise specialist. “We also do a basic medical workup to see if any medical causes are associated with a patient’s obesity, and work with the family to ensure that the social context in which they live is optimized,” Portenier says.
Before becoming a surgical candidate at Duke, an adolescent must first successfully complete the healthy lifestyles program for six months to one year. “They will need to be adherent and also have sufficient resources and support in order for surgery to be effective for the long term,” Portenier says.
Surgical candidates must have a body mass index (BMI) greater than 40, which means they’re 100 pounds over their ideal body weight, or have a BMI between 35 and 40 but also have an obesity-related co-morbidity such as hypertension, high cholesterol, sleep apnea, or diabetes.
“After surgery, patients continue in the healthy lifestyles program,” Portenier says. “If they aren’t compliant, they could develop new problems such as malnutrition or vitamin deficiencies. Ideally, patients will partner with us for life by staying in the program.”
Duke is also at the forefront of treating bariatric patients by employing a shared medical appointment model. “When patients come for a doctor’s appointment, they also attend educational classes, receive an individual assessment, and can attend group sessions for motivation and bonding with other patients,” Portenier says. “Our goal is to provide value in every visit.”
Innovative surgical technique
Furthermore, Duke surgeons consider the adolescent patient specifically when choosing and performing surgery. They use an innovative single-incision approach using laparoscopy and magnetic retractors. “Surgeons often make only one tiny incision in the navel so no scar is visible,” Portenier says.
When considering which of the three major bariatric surgeries to perform— sleeve gastrectomy, gastric banding, or duodenal switch—surgeons tend to use the sleeve gastrectomy more often for adolescents because if they struggle with obesity later in life it could allow them to have either of the latter two options in a fairly simple manner.