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FALL 2005
Caring for Adolescents
The pediatric surgery team at UCSF Children's Hospital carefully weighs the risks and benefits of surgical interventions in growing adolescents. For some conditions the team favors a more aggressive approach. In others, more conservative management is preferred.
Pectus repair
Surgeon Michael Harrison, M.D., continues to refine ways to treat pectus excavatum, a disfiguring skeletal deformity in which the sternum is concave and the chest sunken. The condition typically becomes apparent during the adolescent growth spurt.
Standard repair is performed one of two ways. The misshapen sternum can be reconstructed through a chest-wall incision and fixed in place with a short metal strut, or — in a less invasive surgery called the Nuss repair — a stainless steel bar is inserted over the ribs and under the sternum through a small chest incision. Pressure from the bar gradually remodels the chest and then the bar is removed. Both these procedures are quite painful initially, requiring a five-day inpatient stay and epidural anesthesia.
Harrison has developed and will soon test a refinement of the minimally invasive remodeling technique, one that uses magnets to incrementally move the breastbone into proper position. A magnet is implanted behind the breastbone, then a second magnet is placed on the skin above it to exert outward force. The patient can adjust the device, Harrison said, so that skeletal remodeling occurs more slowly and with less pain.
Managing Obesity
Childhood obesity is a worrisome problem in the United States, where 17 percent of adolescents are overweight and 4 percent are obese. Obese children and their families are treated at UCSF Children's Hospital through the Weight Assessment for Teen and Child Health (WATCH) clinic, under the direction of pediatric endocrinologist Robert Lustig, M.D. The WATCH team includes endocrinologists, psychologists, nutritionists, exercise physiologists, adolescent medicine specialists and pediatric surgeons. UCSF takes a conservative approach to obesity surgery, favoring medical and behavioral interventions whenever possible.
"Interventions such as the Roux en Y gastric bypass procedures that permanently alter the anatomy should be used sparingly," said Diana Farmer, M.D. Some mortality is associated with the procedure, a risk that is too high for children under the age of 18, in the opinion of the UCSF team. Instead, said Farmer, UCSF offers reversible laparoscopic adjustable gastric banding as a treatment of last resort. The banding device has been extensively used in adults with good results, and studies of its use in adolescents indicate that it is equally effective in this age group. Banding also avoids the life-long malabsorptive risk that accompanies permanent gastric bypass, a serious concern in young women who may become pregnant. "We see it as a useful adjunct to behavior modification in selected patients," said Farmer."
Bowel Disease and Intestinal Rehabilitation
Pediatric surgeons work in conjunction with pediatric gastroenterologist Melvin Heyman, M.D., who heads a comprehensive program in pediatric intestinal rehabilitation for patients with intestinal failure resulting from a birth anomaly or disease process. Pediatric surgeons offer several bowel lengthening procedures for children and adolescents.
In one approach, the Bianchi procedure, the small bowel is split along the mesentery. Reconstructing the bowel from the split segments adds additional length, with the advantage that the bowel segment tends to widen in diameter as the child grows. Alternatively, a STEP procedure can be used for short bowel syndrome, in which the bowel is lengthened through a series of accordion-like divisions. The team also works closely with transplant surgeons who have developed a small bowel transplant program for adults and children.
In concert with UCSF pediatric gastroenterologists and the inflammatory bowel program, pediatric surgeons offer open or laparoscopic ileoanal pullthrough for familial polyposis and severe cases of ulcerative colitis. A pullthrough procedure is also performed in infants with Hirschsprung's disease. Surgery also can be useful in some adolescent patients with Crohn's disease. The standard treatment in adults, relatively high doses of steroids, is less desirable in adolescents because it can stunt growth. Depending on individual circumstances, surgery to remove the diseased bowel may be a better choice.
Consultations and Referrals
For information about UCSF Pediatric Surgery, call (415) 476-2538 or email pedsurg@surgery.ucsf.edu.
Fall 2005 Table of Contents
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