Brittany Caesar is half the girl she used to be. Two years ago, the 16-year-old from Houston tipped the scales at 404 pounds. Today, she weighs 175 thanks to a radical weight-loss procedure that is usually performed only on adults: gastric bypass surgery, in which the stomach is stapled off, leaving a tiny pouch directly connected to the small intestine.
"Before the surgery, I was very depressed. I had no self-esteem. I couldn't walk up a flight of stairs without stopping to catch my breath," says Brittany, a high school junior who, thanks to the operation, is now active in her school's marching band.
Bariatric surgery changes the anatomy of the stomach by causing ingested food to bypass a large portion of the stomach and intestines. This limits the amount of food a person can consume and digest, and results in lower calorie intake and fat absorption. The number of bariatric surgeries has risen steadily, from 20,000 surgeries performed in 1992 to more than 140,000 in 2004.
No one is sure how many of those operations are performed on adolescents -- the first occurred in the mid-1980s -- but doctors estimate that there have been between 300 and 1,000 since 2000 in the United States.
Citing painful side effects and a one in 200 risk of death from bariatric surgery, some doctors worry that the procedure's growing popularity among teens is exposing them to risks they are physically and emotionally unprepared to handle.
At the same time, the growing number of adolescent bariatric surgery centers -- eight across the United States, including St. Christopher's Hospital for Children in Philadelphia, whose gastric bypasses are done by Christine Finck, M.D.; Marshall Z. Schwartz, M.D., is chief of surgery -- is evidence of the high demand for teenage weight-loss measures.
The trend has caught the attention of practitioners who specialize in treating adolescents. In an article published in the journal Adolescent Medicine Clinics, a group of physicians argued that adolescent bariatric surgery should only be used as a last resort, when conventional methods of weight loss such as diet and exercise have failed.
"Until we can get a handle on the problem, [surgery] is the most viable option," says Dr. Thomas Inge, surgical director at Cincinnati Children's Comprehensive Weight Management Center and a co-author of the journal article.
"Sometimes, preventative options are not successful, and sometimes, nonsurgical methods are not successful," he says. "This leaves us with a large number of teens suffering from obesity with medical and mental-health problems."
For some of those adolescents, he says, bariatric surgery may be the right choice.
Nationwide, nearly 16 percent of adolescents aged 12 to 18 are overweight, and 5 percent are considered morbidly obese, meaning they are more than 100 pounds overweight. The added weight makes it much more likely that they will develop depression and other conditions once thought to affect only adults, such as hypertension, Type 2 diabetes and sleep apnea.
"These are the same type of problems you see in older patients in their 60s," says Trish Walters-Salas, the nurse care manager of the adolescent bariatric-surgery program at Texas Children's Hospital. "Using bariatric surgery, we can stop the progression of these horrible health issues."
Many doctors agree that bariatric surgery is not a one-size-fits-all operation. "For some teens, it's not the correct procedure," acknowledges Inge. "The real art of this is selecting the right applicants."
Getting to the operating room depends on a patient's body mass index, or BMI -- the measure of body fat in relation to height and weight. For an adult, a body mass index in the range of 18.5 to 24 is considered normal, with 25 to 29 being overweight, and 30 or greater deemed obese.
For a teenager to be considered for surgery, he or she must have an index of 40 or higher, as well as severe obesity-related illnesses. The American Society for Bariatric Surgery also requires that candidates pass a rigorous screening by a team of nutritionists, pediatricians and psychologists before the decision to operate is made.
The two most common bariatric surgeries are Roux-en-Y gastric bypass, the procedure that Brittany Caesar had, and the laparoscopic band.
Also known as the Lap-Band, it is a reversible procedure in which doctors place an adjustable band around the upper part of the stomach, creating a much smaller stomach cavity.
There are both positives and negatives to each surgery, according to Dr. John Morton, director of the adult bariatric-surgery program at Stanford University, adding that since both procedures are relatively new in adolescents, there is no good data as to which is better for teens.
Stop and Think
The lack of solid information about how well most adolescents tolerate the surgery adds to the uncertainty, and means that both teenagers and doctors alike must stop and think carefully about the possible consequences.
Both procedures drastically restrict food consumption and effectively reduce weight, but there can be serious post-surgical complications. Blood clots, gallstones and gastrointestinal leaks are all potential threats. So are vitamin and mineral deficiencies, as well as susceptibility to early osteoporosis.
And another complication is especially relevant to teenagers, notes Inge, and that's the social changes that come with a new body.
"They are catapulted into a whole different social network, and putting themselves at health risks and risk-taking behaviors -- from STDs to substance abuse -- that they wouldn't have done otherwise," he says.