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Doctors Struggle With Surgery Guidelines

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By LAURAN NEERGAARD, AP Medical Writer

WASHINGTON - Amy Topel had tried exercise, weight-loss pills

and every diet, real or fad, around. But at age 15, she'd reached 260 pounds and

a difficult decision: It was time to try surgery.

Operating was scary, but her mother had undergone it and lost

100 pounds _ and Amy was tired of classmates' taunts. So in June, the same

surgeon shrank Amy's stomach. She's dropped 30 pounds and counting.

Gastric bypass surgery has long been a dramatic solution for

obese adults, but more doctors are operating on teenagers, too. Now the first

pediatric guidelines are due out soon, and they'll urge doctors to put more

limits on teens' surgery than on adults' _ because nobody yet knows the

long-term outcomes of such a radical operation on a still-developing body.

The main recommendations:

_To qualify, teens should have obesity-caused problems, either

physical or, like Amy, from the stigma of being fat _ and a starting weight at

least 30 pounds higher than adult candidates.

_Don't operate before teens nearly reach their full height

potential _ usually around age 13 for girls and 15 for boys _ because the

surgery limits nutrient absorption.

_Hospitals should establish a panel of experts in adolescent

obesity, psychology and nutrition to evaluate teens' physical and psychological

well-being and pick the best candidates.

Surgery clearly will help some teens, but " it made sense to

all of us to set the bar a bit higher, " says Dr. Inge of the Cincinnati

Children's Hospital Medical Center, who co-authored the guidelines with fellow

specialists in pediatric surgery and obesity.

The guidelines have been submitted to a medical journal for

publication later this year, and promise to be somewhat controversial. Some

surgeons say there's no reason to be more cautious with teens. After all, heart

disease, diabetes and other obesity-related illnesses can take root in childhood

_ and teens will have longer to reap the benefits of being slimmer.

" There's no doubt surgery is a drastic measure. It is a risk

to life. But at times, living with a condition like this obesity _ it is a risk

to life by itself, " says Dr. Constantine Frantzides of Rush-Presbyterian-St.

Luke's Medical Center in Chicago, who operated on Amy.

There are no statistics on how many teens get gastric bypass;

the number is believed very small but growing.

The operation entails stapling closed part of the stomach,

forming a small pouch that's connected to one end of the small intestine. That

limits how much food it's possible to consume, and how much is absorbed.

Typically, patients lose 70 to 80 percent of their excess body weight in about a

year.

But the surgery itself comes with risks, such as wound

infections, the possibility of stomach leaks, occasionally life-threatening

blood clots.

Once patients recover, they must follow stringent rules: They

eat small servings, carefully counting to get enough protein. They take vitamins

and calcium to counter nutrient deficiencies, including bone loss.

Gorging causes vomiting. The body no longer processes sugar

properly, so too much causes dizziness and diarrhea. Regularly breaking the

rules can bring back the weight.

Such changes are hard enough for adults. So the pending

pediatric guidelines stress having experts evaluate if a teen is mature enough,

and has stable family support, to follow the rules before surgery is offered.

As for size, obesity is measured with a height-to-weight ratio

called the body mass index. A BMI of 30 is obese _ for someone 5-feet-8 like

Amy, 197 pounds. For teen surgery candidates, the new guidelines will recommend

a BMI of 40 _ an additional 60 pounds _ plus serious obesity-caused illnesses;

or a BMI of 50 if they have less serious obesity-related problems, such as being

maliciously teased.

Adults, in contrast, qualify with a BMI of 35 plus

obesity-caused illness.

Amy is the youngest of the 19 teenagers Chicago's Frantzides

has operated on. His top criteria is that the teen's family be overweight, under

the theory that people genetically predisposed to obesity are less likely to

benefit from diet and exercise alone.

" You name it, I tried it, " Amy recalls. " But high school

started and kids became mean and I take all my stress out on eating. "

Life now is about nutritious rationing, she's learning after

half a hamburger one day was enough to make her throw up.

" My brain's telling me to eat, my stomach's telling me no, "

Amy says. But her friends are " amazed. They say, 'You're so skinny!' "

___

EDITOR'S NOTE _ n Neergaard covers health and medical

issues for The Associated Press in Washington.

Copyright 2003 The Associated Press. All rights reserved. This

material may not be published, broadcast, rewritten or redistributed.

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