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Is weight-loss surgery appropriate for teens?

For Brittany Klein, trying on trendy clothes was "just heartbreaking." Jeans usually wouldn't stretch past her thighs and shirts didn't cover her stomach. Instead of the latest styles, her closet was full of oversized sweatpants and hoodies.

The teenager tried dieting, but always regained lost pounds. Unwilling to face a future of being overweight, she turned to surgery.

"I didn't want to have to struggle with weight for the rest of my life. I was going through my teens being heavy and I was just tired of going through the ups and downs," said the Alberta resident, whose 5-foot-9 frame used to weigh 208 pounds (94 kilograms) - obese, but far from morbidly so.

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When she was 17, Ms. Klein had adjustable gastric band surgery.

A $16,000 procedure, it reduces stomach capacity with a silicone ring. Since her operation at a Toronto private clinic in April, she has lost 26 pounds and has "never been happier."

Teenagers and young adults - including those who are not extremely obese - are increasingly seeking surgery to lose weight, a trend some see as evidence that people believe surgery is a quick and easy solution in an image-obsessed society, instead of a last resort.

"The magic bullet [perception]is definitely an issue. There is no magic bullet to a problem that has not arisen overnight," said Glenn Berall, who runs a childhood obesity clinic at North York General Hospital in Toronto.

Indeed, the facility where Ms. Klein had her operation - which is one of a growing number of weight-loss clinics - says gastric banding can be done on people who are just 20 or more pounds overweight. However, the American Society for Bariatric Surgery and other organizations say weight-loss surgery should be considered only by the morbidly obese or those who are very obese and have serious health complications.

"If somebody is just a little overweight, they wouldn't fall into those criteria, so most surgeons would not agree to do the surgery," said Jack Langer, chief of general surgery at the Hospital for Sick Children.

The use of gastric banding on teenagers is controversial. The U.S. Food and Drug Administration, which approved the procedure for adults in 2001, has not cleared it for Americans under 18. And no long-term studies have been done on adolescent patients, some of whom are still growing, Dr. Langer said.

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"We don't have experience with kids so I don't think we can say whether it's safe for kids," said Dr. Langer, who has performed gastric bypass surgery, an older, more invasive procedure. "We just have to wait for the evidence to come in."

While Canadian statistics are not yet being kept on gastric banding, the number of gastric bypasses - an operation that makes the stomach smaller and allows food to bypass part of the small intestine - has jumped in recent years, according to the Canadian Institute for Health Information. In 2004-05, surgeons in Canadian hospitals performed 1,113 such operations - 196 of them on patients under 30 - up from 819 in 2001-02.

However, advocates of laparoscopic gastric banding promote it as low risk, a minimally invasive and reversible procedure that can help some of the rising ranks of overweight young Canadians take charge of their health. According to Statistics Canada, slightly more than a quarter of Canadians between 2 and 17 were overweight or obese in 2004, a figure that has almost doubled since the late 1970s.

"It's a very good control mechanism that changes the relationship between patient and food - like a barrier, like a policeman inside," said Jacob Joffe, a Toronto surgeon who performs the operation.

Over the past few years, Dr. Joffe has seen an increasing number of teenaged patients, including Ms. Klein, at the private Toronto LaparoscopicBAND Centre, located in a Georgian mansion on a leafy street in the Yorkville neighbourhood. Dr. Joffe, who notes that surgeons in other countries also operate on adolescents, estimates he has performed the procedure on more than 20 teens as young as 16, including an American.

"They're really having a lot of problems coping with their obesity and they can't do anything about it," he said. "They're faced with a tremendous social stigma, so the question is do you wait until they're major adults to do something for them, or do you operate on them now?"

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During the 35-minute procedure, surgeons make four small abdominal incisions and use a long narrow camera and instruments to attach an inflatable silicone band near the top of the stomach. The band creates a small upper pouch the size of an egg, which restricts the amount of food patients eat before they feel full. To further limit food intake, saline is injected in the port to tighten the band's grip on the stomach. The band can be loosened by removing saline.

Complications of the surgery can include infection, band slippage, leakage, erosion, acid reflux and vomiting. Many people with gastric bands also have trouble tolerating red meat, pasta, rice and bread and must chew food carefully so it can pass through their constricted stomach opening.

Despite the risks and restrictions, a young woman from Oakville, Ont., underwent gastric banding in May because she seemed to get heavier and heavier every year despite trying "every diet under the sun" - along with pills, hormonal testing and food diaries.

The 20-year-old, who is 5 foot 1, now weighs about 200 pounds, down from her pre-surgery weight of 229 pounds. Her target weight is 115 pounds, which she hopes to reach in 18 months.

"It does come off slowly, but it's coming off and staying off, so that's, I guess, the most important part," said the McMaster University science student, who did not want to be identified because she hasn't told her friends she has had the procedure. The clinic's American patient was a Washington state high-school football player who, at 6 foot 2, weighed 375 pounds despite dieting. His weight was affecting his game and made him so exhausted he needed to nap after school.

"He was feeling hopeless, that there was nothing he was going to be able to do," said his mother, who asked to be identified by her maiden name, Cindy Malaspina, because her son has not told his friends about his surgery.

Although the U.S. Food and Drug Administration has not approved use of adjustable gastric bands in Americans under 18, doctors can make exceptions. In the 17-year-old's case, the process was stalled by U.S. hospital lawyers who had concerns about malpractice issues. The teenager offered to wait until his 18th birthday, at the end of last month, which would have limited his ability to play football this season. Instead, Ms. Malaspina, 44, decided to take him to Toronto, where he had the procedure in May.

Ms. Malaspina, who herself has had gastric bypass surgery, was not worried about her son having his procedure at 17. Today, he weighs 308 pounds. "You have to weigh what was coming for him . . . His future was sleep apnea, diabetes, joint issues, circulation problems with his legs, possible early death from heart attack," she said.

Four months after her surgery, Brittany Klein sits in a meeting room on the second floor of the clinic, where she has come to have her gastric band tightened. Now 18 herself, she is bubbly and laughing, wearing a sleeveless black top.

She started beauty school in Edmonton earlier this fall and says her self-confidence has climbed. She wears form-fitting clothing and even walks taller.

Her mother, Tamara Klein, sits beside her beaming. "She's more fun now. She's lighter, not only in weight, but in personality."

Although she was reluctant to acknowledge it, Tamara, a former plus-size model, has also had gastric band surgery. Before her operation in February, the 5 foot 8 woman weighed 210 pounds. She now weighs about 185 pounds and plans to lose at least another 20.



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