Preoperative Optimization and Management - Caren Mangarelli, MD - 2024 Pediatric Bariatric Surgery Update Course

So, without further delay, um, again, I'm very honored to introduce, uh, Doctor Karen Mangarelli. Um, she's also been taking care of, uh, kids who struggle with obesity for many years, uh, first at, uh, Duke University and now with us, uh, for a number of years here as well, running our wellness and weight program, uh, but also teamed up with me. Um, she got what she got, um, and, uh, we're trying to, trying to, uh, do the very best we can to, uh, really create options for, uh, the seriously obese kids that want a surgical option. Um, and she's gonna talk to us about the preoperative optimization, uh, in this patient population. So it'll be about, uh, about 10 minutes of presentation and some, uh, some discussion of this because it is a really important topic. So, uh, Karen, take it away. Thank you. Good morning, everybody. Um, So, yeah, we'll see if I can get this done in 10 minutes. Um, so, uh, really, when I think about the pre-surgical optimization time period and what are the goals, um, I would say the first thing is screening for medical and behavioral health issues, um, as well as working those up, doing any sort of referrals as necessary, and providing support to the patient and family as needed. In addition to education regarding the procedures, the risks, benefits, as well as setting expectations for both the pre and post-operative time periods. Um, and then lastly, really lifestyle behavioral change support. Um, and all of these things, we're doing it primarily to improve patient outcomes as well as enhance or improve patient safety. So, the American Academy of Pediatrics in 2019 came out, the section of obesity came out with a technical report and policy statement regarding bariatric surgery, and this is sort of the um inclusion or selection criteria for which patients you should consider. Um, these, uh, were different from previous. Um, they were less conservative and were more in line with adult criteria. Pediatrics obviously is a little bit different because we don't just use, um, the absolute BMI. Uh, we also use percentile of the ninety-fifth percentile. Um, and so, you know, really the criteria is any patient whose BMI is greater than or equal to 40, um, or whose, uh, percentile is at the 140th or more percentile of the 95th percentile for age, um, whichever is lower. And then, um, patients with a BMI of 35 or greater or a P 95, so percentile, the 95th percentile of 120th, um, uh, or greater, and whichever is lower with a comorbid condition. And so, um, again, the same report in terms of exclusion criteria. This is what they listed. I would say, other than the first one listed there, which is a medically correctable cause of obesity, um, Uh, the, there's a little room for discussion and nuance for all the other things listed. Um, and then I would say again, the big difference, um, what, you know, the big changes that were included here was that there was no real lower or minimum age limit, um, identified for, um, bariatric surgery, um, as well as they specifically talked about the Consideration of special populations, um, such as those with developmental disability, cognitive impairment on a case by case basis instead of previously where there was, uh, you know, an automatic exclusion, and I know that other speakers today will be talking about these topics. Um, and, you know, the last thing there was saying that it should ideally be done at or in, in cooperation with the multidisciplinary pediatric center. Um, and I've actually been involved in two different the two main models of care. Um, first is, you know, an adult bariatric program where they add on, um, an adolescent or pediatric component, um, As well as now with a pediatric surgeon who specializes in bariatrics. Um, but, you know, in terms of who these multidisciplinary team members should be, um, I think the first four listed there are critical. So the surgeon, a medical specialist, um, a behavioral mental health specialist, and a registered dietitian. The last three are, I, you know, are sort of, if you have them, that's great, um, but they're, um, sort of what I would say add-on, um, and, um. You know, just a plus if you can additionally uh have those team members available. And in terms of the pre-surgical optimization guidelines, really, it falls into kind of three buckets, medical, nutritional, and psychosocial. Um, so during again, the preoperative time period, There's a lot to get done. Um, there's a lot to sort of think about, but these are sort of, like I said, the main buckets. Um, from the medical standpoint, I think it's really obviously important to review the patient's past medical history, their their previous weight, and History, lifestyle habits, um, are doing a really good review of systems that's specific to the most common, um, uh, comorbidities that you see with obesity, um, especially ones that may impact, um, surgery, so perioperative care as well as, um, Uh, especially considering this is a gastrointestinal surgery. And then medications. Um, so, you know, going through medications that the patient's on, um, thinking about starting new medications and managing those medications preoperatively. Um, and then, as well as some, uh, screening lab work. And then from a nutritional standpoint, the main goals are really going over dietary patterns, um, disordered eating, screenings, um, educating patient and family regarding peri and postoperative diet stages and supplement requirements, as well as screening for and correcting any vitamin or mineral deficiencies. And then this from a psychosocial standpoint, really, it's talking about family functioning. You know, this is one of the things that's unique to pediatrics is, you know, it's not just the patient, um, but you're educating also the family or the support system. Um, going through the patient's mental health history, um, thinking about the patient's cognitive functioning, um, screening for substance use and abuse, as well as screening for social influencers of health or adverse childhood experiences, trauma, um, that may have occurred in the patient. Um, And so this is a lot, but this is, this is sort of what we're trying to get done and screen for during the, the preoperative time period. And so I'm gonna go, you know, I, in the previous slide, I have 33 different things in red here and I'm just gonna touch really uh quickly on these 3 specific topics. So, you know, medications. So, you know, one of the things that's definitely changed, um, recently is that since December 2020, we now have, the FDA has approved 3 new medications for use in patients 12 years and older. Um, you know, previously, almost everything we, um, we did was actually, or all the medications we use, we were primarily using them, um, off-label, and we still do use lots of medications off-label, but we actually now have a few medications that have been FDA approved. You know, two of these three are GLP-1s, and I think that, um, You know, one. I think my points with this are we really do need to think about using medications um preoperatively, um, and postoperatively, but preoperatively, since this is my talk, preoperatively to sort of help with, um, patient, um, uh, patient goals, um, before they actually go to the operating room. Um, but with the use of GLP-1s or, um, I think it's also really important to, uh, to think about perioperatively what you need to do with these medications. And so the American Society, um, Uh, of anesthesiologists just recently came out with a consensus-based guidance on their use, um, and, you know, The GLP ones, one of the ways that they work for obesity is that they slow gastric emptying. And so, um, there has been a concern both, you know, practically and theoretically about, um, Regurgitation and therefore pulmonary aspiration of gastric contents, um, uh, you know, uh, perioperatively and so really they came out with this consensus-based guidelines that for the daily GLP ones, you should think about stopping them or not using them on the day of the procedure as well as the weekly GLP ones a week prior. Um, And again, these guidelines don't matter if the patient's using these medications for diabetes or for um obesity. And then the second topic I wanted to just touch on was, it was micronutrient deficiency. So, you know, Team Labs article that came out, um, like the, the 5-year, um, Basically showed that, uh, that micronutrient deficiencies are not, they do happen, um, that iron is, uh, definitely the most common. Um, vitamin D is both pre and postoperatively, um, but that the, that with time, there were increasing percentage of patients that had micronutrient deficiencies. Um, you know, When it comes to um. When it comes to what to screen preoperatively for, there are There are different guidelines, uh, in terms of what's listed, um, and I will say that practically in our program, we've been, uh, screening for specifically iron and vitamin D preoperatively. Um, we, in the last year though, um, we're at a point where we're thinking about potentially changing those, uh, guidelines or changing the way we do things, mostly because we've had several patients, uh, postoperatively who presented two with B1 or thiamine deficiency, one with folate deficiency, and so, um, again, um, You know, we, it's just important to know that you need to look for these things, um. Ahead of time and correct them if necessary, as well as um think about, um, you know, optimizing or possibly even starting patients on uh vitamins and supplements before they go to the operating room. And then the last topic I really wanted to talk about was substance use, um, and abuse. So, you know, the two big things, uh, especially in the pediatric population, is that, um, At least in our population has been, uh, marijuana use and alcohol use. Um, you know, again, marijuana, obviously both of these substances are illegal for patients under 21, but, uh, we know in real life that there are many patients who are using these substances, uh, before they Turned 21 years old, and I will say in our inner-city patient population, um, as well as the fact that we work and live in a state where marijuana is legal, both, uh, recreationally and medicinally, um, and again, with more and more states, um, passing laws, um, uh, making marijuana use legal, um, My sense is that there will be more and more patients that come in to see us who will be using um marijuana. Now, um, you know, if you think back to what were the exclusion criteria, it did mention um substance use or abuse within the previous year. I, um, you know, As a group, our multidisciplinary team has talked a lot about this topic, and um there are some programs that require complete abstinence before they'll move forward with surgery. I, um, I'm not sure that that is the right way to go. Um, one, because, um, you know, ideally, we wanna be helping these patients before, um, surgery as well as through surgery and after surgery. And if we, um, have a hard stance that against, you know, any use whatsoever, um, I'm afraid that we'll be, you know, uh, Restricting surgery to patients who may need, really, really need it for medical reasons. Um, and so, I really like to look at it more as, um, sort of harm reduction or harm mitigation during that preoperative period. So again, there's been, you know, when it comes to marijuana, there's not a ton. That we know most of the studies that have been done recently have all been done uh in adult populations. Um, you know, there's concern about, um, Both, uh, pain, um, and, you know, cabin, I can't say the word, but cabininoid receptors and they're, um, for patients who are regularly using marijuana that, that may influence perioperatively and postoperatively their pain. Um, you know, uh, with smoke, just like with nicotine, I think there's some concern about, um, wound healing, as well as concern about vomiting, um, and, uh, of course, you know, the munchies if you're using marijuana. Um, but at least the studies, the short term, so up to 2 years, studies looking at adults have not shown that outcomes are any different in patients who, um, Admitted the use of mari or who disclosed the use of marijuana. Um, and so, again, I think that we will be seeing more and more of these patients, um, especially also, you know, the two pats, we have two patients who are actively seeing right now who've disclosed regular use, um, both of them, it has been, they're self-medicating their mental health, specifically anxiety. Anxiety disorders. We know that anxiety disorders have increased like 4 times, um, you know, pre versus post-COVID, um, and so, again, I think that we as a group have decided that um our biggest goal is to reduce use, um, to one of them, we've helped set up for them to get into a substance use program. Um, As opposed to just out and out denying them surgery. And then alcohol use, we, you know, this, the teen labs again, there, there's a paper that came out that I listed here, which just shows that alcohol use disorder um is not uncommon and um that we have to be aware of it and we need to be screening. We need to be educating our patients and families about their risk, and we need to continue to screen postoperatively in these patients. And then my last slide, just a few other points, um. You know, I do think it's important with pediatric patients that um you get them in the room alone, um, at some point just to make sure that this is what they want for themselves. Um, it's obviously in our, in the patients that are cognitively um normal. Um, and then I do think that, um, That it's also, um, you know, thinking about, um, ongoing insurance coverage for the patients postoperatively and doing your best to sort of, um, preemptively discuss that as well as their transition of care. Um, And I think that that's all I have for you guys this morning. Thank you, Karen. That was awesome. And I think you brought up some really important points. In particular, talking about sort of this, what is realistic, right? Abstinence or actually stopping things. I, I put there in the chat that one of the things that we run into is the insurance companies requiring the drug screens, and then if anything is positive, denying. Have you run into that or anybody else run into stuff like that? Not drug screens, like, so we, at least so far we haven't had any of the insurers require us to do drugs, drug screens, um, you know, again, I think. You have to be a little bit careful about your notes and how you discuss things, um, um, but yeah, that has not been a problem, um. Our biggest thing is that they think of it, or at least one of the insurers has thought of it similarly to them smoking nicotine and wanting us to do um uh an ABG um and pulmonary function tests on the patient, but, um, but yeah, um, not ask. I have, we haven't had anybody who's asked for drug screens, so yeah, we have the um. A couple of the insurance, the CMS are, are requiring it, and that's something also in the adult world for Georgia too, and they just took it all abroad. So we're just sort of trying to Deal with some of that. So I always let the kids know very early on, you're gonna have a drug screen. Let me know when we can do it too. So we can sort of have because then you can have those conversations about what's realistic and not with some of this stuff. And then the, the alcohol thing has been a huge piece. Um, my favorite was my patient who came in and she goes, so I understand that I'm not gonna be able to drink as much. And I said, no. She goes, cause currently my tolerance is at about 10 shots. Yeah, yeah, you're probably able to do 10. I don't know what the so we sort of have those things, but there was, um, another question. I was gonna, it seems like it's, it's mostly doctor-imposed these, uh, the testing that I've, uh, heard about kind of in, in our own, you know, midst, uh, and I've always wondered, you know, uh, where's the, the data and evidence supported? I think the adult establishment in bariatrics and Jamie's here and can comment, um, is much more concerned about wound healing and, and, and such than, um, than typically we are in the pediatric world, um, so I haven't certainly mandated in my practice. Right. So the, the primary difference I think that, that you run into is if you're doing bypasses, you cannot have them on nicotine. Um, uh, nicotine is leads to ulcers after bypass. So if they're using nicotine, that's gonna be a disaster after a bypass. So if you're doing far more bypasses in the pediatric population, we're doing, you know, sleeves. And so with a sleeve, it really doesn't. Doesn't matter, you know, I have seen no data that that um. Uh, cannabis makes any difference whatsoever. Although there are a couple of cases, and we've had one where excess cannabis can lead to a cannabis intolerance which causes, you know, basically continuous vomiting, and, you know, we spent a long time trying to work up a child who had this and and eventually figured out that that's what was going on and could not convince this kid to stop. Using cannabis and so I think that there, there, there are side effects of that particular drug that can cause problems, so you have to be aware of it and look for it, but I haven't seen I, I don't have the, we don't do the same testing in the kids. We don't test them for nicotine when we're doing sleeves on them. Yeah, I, I've run into the same thing, Janie. I had a patient, same exact thing, came in vomiting, and it was all hyperemesis from the, uh, cannabis. Uh, I wanna make sure we get to a question in the, from the audience, uh, from Etienne Saint Louis. Uh, I realize we may not have data on this yet, but I'll ask your anecdotal experience. Do you think that the neoadjuvant use of GLP1 analogs and perhaps more of their preoperative cessation impacts expected weight loss following bariatric surgery? This is a really interesting question, and I have been worried about this. I still am worried about it. In our program, we, we, we purposefully don't offer GLP-1s pre-op unless they have very high BMIs, so over 50, but I'm concerned that pre-op GLP-1s may affect outcomes of surgery. I don't think we have any data. I haven't seen it in the adult or the pediatric population, but I, I agree with this question. I don't, we don't know. We absolutely don't know. Yeah, that's really interesting. Um, I mean, we can't really get it for most of our patients, so I don't really have a lot of patients on it because, um, it's, you know, it's not covered by our state Medicaid and, um, even if it was, there's currently no supply of it across the country. So, um, so yeah. Um, but that is a really interesting question, and that, that may, you know, definitely need to be looked at and studied in the future. So Janie, uh, Janie, actually, we, we do have, uh, phenter uh phentermine and topiramate before and after sleeve and BMI greater than 50 adults. It was published in Sword in 2019. I had to give a talk to at NIH, um, on drugs and surgery, and, uh, there was no signal there. It actually did look as though, um, there was, uh, far greater weight loss preoperatively as well as, um, a greater weights. Loss postoperatively when they were continued. That was not GLP-1s, that was phentermine and topiramate, right? So I'm, I'm actually not worried about phentermine because it's a totally different mechanism of action, but we believe, and, and you know, this has been shown that the rapid gastric emptying that is induced by the sleeve gastrectomy is part of how the mechanism for the sleeve increasing your GLP-1. So if you're taking a GLP-1 pre-op and it's, it's causing feedback that causes your stomach to slow down because if you, if you have, you know, a hormone that's produced by rapid gastric emptying, it's obviously going to have a feedback mechanism to slow down your gastric emptying. Now you've got maybe some upregulation of the of the receptors or downregulations. of the receptors, you've got something going on in there that could potentially interfere with your outcomes after bariatric surgery, and that's what I'm concerned about. I don't think there's any data on it, but they do work by opposite mechanisms. Yeah, so it might, it might just make us think more about the 2nd generation drugs rather than the 3rd generation if we're thinking about preoperative use. I reject that we don't really, I mean, I would change, I would, I would change the terminology a little bit because do we really care how much of the weight loss at the end of the day is from the medication versus the surgery. So I think when we're all long gone, almost every patient is gonna get some sort of GLP1 bio triagonist or surgery, and they're gonna get surgery, and then they're gonna get a bio-triagonist sometime after surgery. And so I think that like part of this discussion is what is surgical outcomes, right? Like, who really cares? All I care about is that 5 or 10 years down the line for any patient that I treat, that they have as much health benefit from the intervention that I provide and that, and the other interventions that, uh, the team supporting, um, the pediatric weight management provides. So, um, I think it's an important question just from a mechanistic standpoint. At the end of the day, if the GLP1 analogs get 20% pre-op and then surgical outcomes are no longer 60 to 70%, they're now only 30 to 40%, but the sum total is still 60 to 70%, does it really matter? All right Mark, you're gonna I'm gonna have to go. I'm gonna, I'm gonna have to cut off. I know this, this is gonna happen on everyone. We're not gonna get, we're not gonna all be satisfied. Put, put comments in the chat.