SPRINGFIELD — A weight-loss surgery recently introduced at Baystate Children’s Hospital can mean an end to a lifetime of chronic health problems for teens who have struggled with severe obesity.
Dr. Michael Tirabassi began performing laparoscopic sleeve gastrectomy on patients between the ages of 15 and 20. It can help reverse severe obesity when behavioral and lifestyle modifications have failed to provide needed weight losses of 100 pounds or more.
It involves the permanent removal of a large portion of the stomach and has been done on adolescents in other hospital systems, but only in recent months by Tirabassi as part of the Pediatric Weight Management Program at Baystate Children’s Hospital. It comes at a time when obese teens are being treated in growing numbers for a range of related medical issues from type 2 diabetes to sleep apnea to high blood pressure.
Previously, young patients in the weight management program under the direction of Dr. Rushika Conroy wanting bariatric surgery waited until they turned 18. They could then transition to Baystate Health’s adult bariatric surgery program or elect to be referred elsewhere as there previously been no such option for those under 18 in Western Massachusetts.
Conroy said estimates indicate that about 20% of the pediatric population has obesity and that between 4 and 6% are considered morbidly obesity. It is these adolescents with severe obesity needing to lose 100 pounds or more who are seen as benefiting from bariatric surgery to help with sustained weight loss and reverse the disease’s risks for developing long-term chronic medical conditions, she said.
Tirabassi, a veteran pediatric surgeon, partnered with Baystate adult bariatric surgeon Dr. John Romanelli in preparation for doing pediatric weight-loss surgery.
“The problem with weight loss for adolescents and adults is that people can be successful with short-term weight loss fairly frequently,” Tirabassi said.
He added, “They go on a diet and lose weight. However, the success rate of staying on the diet forever is very low and the weight is gained back. The real role of bariatric surgery for the pediatric and adult population is not to just lose weight but to be successful with long-term weight loss. Keeping the weight off for the rest of their life is what we are looking for. That is the success we are looking for.”
The weight-loss surgery “takes anywhere from 45 minutes to two hours to complete, depending on the patient, and they are usually in the hospital for two nights after surgery,” Tirabassi said.
He stressed that the surgery now offered at Baystate Children’s Hospital is “one little piece of a comprehensive adolescent obesity program” and that “none of the adolescents are going into surgery lightly.”
“The obesity program itself is one we have had for quite a while and the surgery a recent addition to it,” Tirabassi said. “Patients are usually in the program from six months to a couple of years meeting with the pediatric endocrinologist, the nutritionist and the psychotherapist and working on their weight-loss goals before they get to a point where they are ready for surgery.”
The mother of one area patient, who was 16 at the time of the surgery eight months ago, said her daughter has since lost 50 of a needed 80 pounds and that her “blood pressure has gotten a lot better.”
‘We struggled with her weight since the day she was born,” she said. “She tried doing the Mighty program at Baystate Children’s when she was only 8 or 9. She couldn’t lose weight then and we tried other weight-loss approaches. She just didn’t lose weight.”
The woman, who asked for privacy in discussing her daughter’s struggles with obesity, called the surgery a “last resort.”
“This is a last resort for the parent and child going through this struggle,” she said. “No one should jump into it. This should be, ‘We did not get anything accomplished with any other weight loss.’”
She added she was “worried like any mom would be when your child goes under the knife,” but that her daughter “did really well” and continues to adjust day-by-day to the dietary changes that result from the surgery.
“It is not that you have the surgery and all the weight just comes right off,” said the mother who had gastric bypass surgery 10 years ago. “It doesn’t and she is learning that and that it is a lot more work than expected.”
Her daughter, an honor student with a full-time summer job, agreed, saying some days are “hard.” Certain foods she likes upset her stomach now and the emotional transition to a new diet can also cause stomach pain. However, she said she is adjusting slowly and appreciates Tirabassi for his “kindness” as a medical professional understanding and treating her disease.
“Yes, overall it has been worth it,” she said when asked about having the bariatric surgery.
The start of the coronavirus pandemic 19 months ago slowed the introduction of the laparoscopic surgery into the pediatric program, but Tirabassi said he has performed the procedure that is consider low-risk and minimally invasive on about a half-dozen patients to date.
He sees his patients “quite a lot” both before and after the operation.
“Two or three times before surgery and various times in the process of getting cleared for it,” Tirabassi said, “and then two weeks after the surgery for routine wound check and then a month out and then three months and then six and then annually for awhile.”
Tirabassi said that in the decision to offer surgeries “data that supports their use and practice patterns” is reviewed.
“The American Society for Metabolic and Bariatric Surgery has published guidelines on the use of bariatric surgery both in adults and the adolescent population,” Tirabassi said. “They define the eligible adolescent population as being as young as 13 and going up. In our mindset here at Baystate we are not really looking to do the surgery on anyone younger than 15 or 16 unless their surgery was a very special case.”
He said patients “really need to be engaged in the process for success.”
“Every child is different,” Tirabassi said. “But, as I meet with the adolescents, it seems around 16 is when they really start to have that emotional maturity to be engaged in the process and be successful.”
Tirabassi said the surgery, laparoscopic gastric sleeve section or sleeve gastrectomy, “removes about 75 to 80 percent of the stomach and is a permanent, irreversible change to the body.”
The reduction causes an individual to feel full sooner and also results in lower amounts of the hormone ghrelin being secreted when the stomach is empty and that enters the brain to stimulate hunger.
Tirabassi said that “a few weeks before surgery patients have to go on an all-liquid diet and that all-liquid diet continues until they are two weeks out from surgery and then they start on a kind of a baby food diet.”
“This helps them to adapt to the new shape of their stomach,” Tirabassi said. “Usually between one to two months out from surgery is when they finally get back to regular food. But they need to eat smaller meals more frequently and chose their food really well.”
“It does,” he added, “demand a pretty dramatic lifestyle change.”
Tirabassi said that “most patients I have seen in consultation have about 100 extra pounds they do need to lose to get down to ideal body weight” and that in contrast to adults facing such surgery seem “have more complications from the obesity.”
“The adolescents seem to be a little bit sicker and have more complications from the obesity,” Tirabassi said. “They are a little bit more likely to have diabetes, problems with joint pain and walking.”
He attributed this to “the nature of the referral process.”
“There is this mindset of not thinking about adolescents as being eligible for bariatric surgery,” Tirabassi said. “It is only the adolescents who are in really bad trouble that their care providers start to think and reach out about, but there is actually recent data in the literature that not only do the adolescents do really well with bariatric surgery, but respond better metabolically than the adult population does.”
During the first two years after a gastric sleeve resection, Tirabassi said patients are able to lose about half of the extra weight they have.
“This is a real dramatic difference in how they feel about their body,” he said. “It is easier for them to participate in activities and the biggest thing after bariatric surgery is that the success rate for keeping that weight off is high.”
Tirabassi said a number of factors, including a genetic component, can cause childhood obesity and put a young person at risk for a shortened life span without surgical intervention.
“The adolescent who is morbidly obese is on track to become super morbidly obese and disabled in their 20s and 30s,” Tirabassi said. “To break that cycle sometimes requires something dramatic and sometimes bariatric surgery is the right fit to be the dramatic thing to break that cycle.”
He added, “Reversing something like diabetes, which has so many complications in and of itself, is one of the biggest drivers for me in doing the bariatric surgery.”
“These adolescents have potentially a long life ahead of them and their life can be so much different after the surgery,” Tirabassi said. “They lose enough weight to feel healthy and exercise again. There are not that many opportunities to make such a dramatic change in someone’s life, but this is one of them.”