Kanika Bowen-Jallow, MD and Faisal Qureshi, MD - 2024 Pediatric Bariatric Surgery Update Course

Don't have to cut us off so we can move on to uh Doctor Kenneka Bowenjalo and Doctor Faisal Qureshi. Uh, Kenneka is at Cook Children's and uh adolescent pediatric bariatric surgeon there doing great work, uh, in the Dallas-Fort Worth area and then actually have, uh, her competition across town here with Doctor Qureshi. I, I don't know which of you is going first, so, uh, are you up first, Kenneka? OK, perfect. Doctor Bones go first. And we're gonna talk about post-operative care. Yes. So, uh, it's a pleasure to be here today with you, Doctor Qureshi and I will be discussing perioperative management of adolescent bariatric patients. Um, so my, my slides will be geared towards the current ERAAS, and that stands for Enhanced recovery after Surgery recommendations for bariatric surgery, which are based on multiple studies. Um, patients should have a carbohydrate drink the night before surgery and clears up to 2 hours prior. Uh, I've listed possible options on this slide, but just be aware that any brand would work. Um, and it's also important to use sugar-free if they are diabetic. Uh, the following medications are given in pre-op 1 to 2 hours prior to surgery. I have included repentant here because I use it and it has become pretty standard in patients that have a high risk for post-op nausea. Um, one of the things that people may wanna discuss, uh, when we get to more of a, a forum is these are a lot of pills that they get at the pre-op area. And so a lot of the questions are, um, is it gonna stay in the stomach? Am I gonna see it? Am I gonna staple through it whenever we do the sleeves? And, um, working with multiple surgeons, um, who have done bariatric adult and adolescent. Um, some scope on every case, some don't scope at all. But I've never seen a pill in the systemic when we scope. So it's not something that I'm really concerned about. Um, intraoperative, uh, DVT prophylaxis is administered at the start of the case. Lovenox or subcu heparin can be used. Um, there is not a standard recommendation and the practices vary greatly. So this is probably something else people are gonna want to talk about. If you pull every adult or pediatric, bariatric surgeon, you will get at least 5 different answers to this question. So we can talk about that a little later. But what the ASMBS does recommend is that you use some DVD prophylaxis um on these patients in the case and postoperatively before they go home. Most of us are not using unless there's an indication to go home on um DVT prophylaxis, if they've got a family history, um, other, um, reasons for that, our patients don't go home on that. Communication with your anesthesiologist is important and it also helps to prevent postoperative nausea. Um, so this means minimizing narcotics. Um, this is done by running any of these meds at a low baseline. Um, we choose to use propofol, um, in the background while they're getting their anesthesia. Um, of course, uh, we Avoid the use of foleys, drains, etc. And although I do a laparoscopic tack block, there is new literature that demonstrates it is not superior to local infiltration of the incisions. Um, so, I don't think that you have to do this anymore. Can you interrupt me with some uh, so there's a question from the audience, I guess, to keep it timely. Uh, why, uh, uh, prepotent instead of, instead of, uh, Zofran? Uh, so we actually use that in the OR prior to extubation, the Zofran. The, um, epiretin is given, um, in preoperative and holding before they go back. And so it's basically, you're trying to get a complete synergistic effect so that, cause the, the number one thing we worry about after the sleeve is nausea. Yeah, wretching, vomiting. So that's why you're kind of see a lot of these things that are basically anti-emetic, so we don't have those issues. So it's not postoperative, they're getting Zofran. The, the dose of Erepent is just in the um pre-op area. So we don't continue that after surgery. All right. So, um, intraoperative, these three meds can be used to prevent nausea prior to extubation. So this is kind of gets into a little bit of what I was saying. Um, we choose not to use Haldol and. Like I said, these are based on, um, ERAS recommendations. We don't use Haldol just cause it's a sedative effects. So when you're trying to wake up a kid and, you know, and they're in the, um, PACCU area, it just doesn't, it's just not helpful for us in our patient population, but it is something that can be used. Um, and this slide shows the four meds that are used commonly for postoperative pain control. Um, so the main thing to understand about, um, Tylenol, whether you're giving it IV or oral, is that you don't wanna exceed 4000 mg a day. So you really have to pay attention to what you're giving. If you're giving the Tylenol in pre-op, part of that ERAS protocol, which you're giving post-op. There are different protocols in terms of if you're gonna give it every 6 hours or every 4 hours. So just kind of know what your total end dose is allowed for the patient to have. Also, Toradol, you know what your max dose is on that. That's what we commonly use. And uh gabapentin, we also use that. I put oxycodone IR on here because once again, this is an ERAS, um, Recommendation if you need it. I have not needed it. We do not discharge patients home on it, but it certainly is an option if you need a narcotic, which we typically do not. Um, but because this does not have Tylenol, that's why the current recommendation is pure oxycodone. And so, I am going to turn it over to Doctor Qureshi, who is going to finish up with the post-operative management. Good morning, everybody. Um, and, and Mark, uh, in answer to your question, it's collaboration, not competition with Kenneka. Uh, you cannot compete with Kenneka. Um, so, uh, you know, the, I'm gonna talk about what happens, uh, after you've done your operation, now what's gonna happen to the child. Um, I think setting up expectations and, uh, I'm not able to move my slide. Yeah. So, I, I think it's very important to set expectations. So in the preoperative area, I spend a fair amount of time talking to the, to the patient. Um, no matter how many visits we've had with them, I find it's amazing how, how little they retain or how frequently I need to repeat myself. So I tell them that 80% of my kids spend about one night in the hospital. I tell them to expect a pain out of 3 out of 5. as Kannika alluded to, I use taps. When I, when I did non-experal local anesthetic or experal local anesthetic at the port sites, my pain control was eh. But taps have really changed the way these kids wake up, and pretty much all of them are going home the next day and the nausea is much lower. Uh, Emend works, uh, like a charm. I love chips. Faisal, sorry to interrupt. What do you use for your taps? What's your, what's your drug of choice? I, I, I use pure expil but diluted down with, uh, uh, normal saline. I don't use any other agent. I don't use rope or BP, but I do do it as soon as the camera goes in. And I put my epigastric port. I then do my tap, and it only adds 3 to 5 minutes to the entire case. Um, ice chips within 4 to 6 hours. We check a hematocrit, and we can talk about this, uh, in the discussion, uh, about 6 hours postoperatively. Yeah, yeah, Evan's giving me a thumbs down. Uh, I ambulate my kids immediately as all else do you all. Uh, we use sequential compression devices and Lovenox. Uh, next slide. Um, and then, um, the next day we start clear liquids, uh, and I give them a little this chart that they have to circle 1 ounce of liquids every 15 minutes, usually with clear proteins and water. And then if they take it for 3 to 4 hours and there's no nausea and there's no, uh, significant pain, we send them home without any uh narcotics, and that tap block works for the next 2 or 3 days. Next slide. So at home, I don't generally give them NSAIDs, um, and we tell them no pills for 6 weeks. Uh, obviously, chewables are OK. We start the multivitamins, the vitamin D and the calcium chewables. I ask them to shower the next day and pat themselves dry. Um, and again, a lot of this I'm giving. Pre-operatively before they go to sleep, uh, and then I reiterated with the family postoperatively, walk, walk, walk, um, no swimming, no baths, uh, hot tubs for 4 weeks, and then within 1 week, 5 days, um, uh, they're back in school. Next slide. Now, in terms of diet, uh, again, I'll come to the details in just a second, but things I reiterate over and over again, eat slowly, chew a lot, uh, very small volumes. Don't use straws. Start to recognize fullness, and then when you recognize fullness, stop eating. And generally no that's the question because I never understood this, and I threw, and it's like I found it in our own documentation and I took it away. Why no straws? So why? I don't get it. Primarily because, primarily because they can drink very quickly with a straw as opposed to lifting up and sipping, not the bubbles. That's what people say, but I don't know where the air is coming from if the straw is underwater. You know what, I threw it away. I told the patients to drink from straws, and there's no problems. OK, I think, I think it's, I think it's surgical. I agree with you. I think it's myth. Yeah, it's myth. I, I, I like, I was like, where? I did, I had never like I was like, where did this come from? So I just told him, I took it away from everything. I said straws are fine. Um, the other question I have is the pills that we got a lot of stuff we're gonna discuss here, I know, and I don't wanna interrupt your presentation too much. I don't know how many more slides you have. But the pills, because I started saying small pills are OK and kids did fine with small pills and what and then what's the definition of a small pill and then, and then I said, you know what, does it really matter? and I just, and I don't think I don't think that matters either the esophagus, in the esophagus, the stomach. Be much bigger than the esophagus, yeah, and, and I, and I think you're both right, but I don't know who the audience is, so I had to be careful of what I do. What I do, what I practice is not exactly what this represents. This is our standard, what we do. And then Kenneka, just to, to know how scared people are of you, they didn't interrupt you. They just interrupt me. So the funny thing about the straws, so it is all about the straws. That's where you went wrong, Faisal, because everybody has that same question. Everybody's looked it up. Everybody's tried to find evidence for it, and you can't find anything. Yeah, yeah, no, no, I agree. I agree, but that's the reason I do it is because I don't want them going too fast, and you know, immediate preoperatively, the fear of that is very, very small. Um. And the other thing is, the other question I have is how many of us, because you start your liquids post-op day one, I actually start them as soon as they wake up. So I let them do ice chips, uh, that day. Some of it depends, uh, Marcus, you know, if I'm doing a 7:30 start, then yes, then they get liquids, but if I'm doing a later start, that kind of depends. And then, uh, the, uh, um, in, in my environment, I like to, um, I, I don't want them starting clear liquids at 10 o'clock and me getting a phone call to patients nauseated, if that makes sense. So yeah, so I agree with you. We actually, I, I actually, you know, it's funny is everybody, it's sort of like I, I think of this like we did with Pyloric, right? We used to drag it out for days and days and then we said just make an ad lib and they'll regulate themselves. I actually think the patients regulate themselves. Um, there is a another question here. Um, why no baths for 4 weeks? I didn't catch that because I would have called you out. Yeah, so, so, so I think that, um, um, uh, I let them pretty much at this point in time do whatever they want. I tell them mostly. Hot tubs and um I don't want them soaking for too long and most of my kids actually start taking, if number one, very few of them take any baths, uh, but if they, I tell them at least 1 to 2 weeks, and again, I'm being super conservative in this presentation. Yeah, no, that's fine. I, I, I, I let, I let all my patients bathe immediately. I don't think it's, well, yeah, they can take showers the next day, no problem. Yeah, or, and I don't even think baths make a difference, but, uh, OK. So we'll let you, we got 6, we got 6 minutes for you to finish in discussion. Sorry. No worries, no worries. The discussion started. So week one, an ounce of fluid every 15 minutes, uh, I, I need them to be taking at least 40 ounces of liquids and 40 g of protein. Uh, week two, it's about blended soups consistency, and I say no lumps, bumps, or chunks, um, and we'll talk about that. 60 g of protein, 60 ounces of fluids. Week 3, weeks 3 to 6, it's a soft diet, applesauce, mashed potatoes consistency, and I, you know, I joke with them. I say, it's the mark of the devil, 6 6 6 60 g of protein, 64 ounces of water, and 600 to 800 calories of, of, uh, of calories, right? And start exercising. And then week 4, it's 466, 66. So, you know, 60 g of protein, 64 ounces of water, 600 to 800 calories, and then 60 minutes of exercise. Um, and that, and the week. And onwards, it's pretty much a regular diet, small portions, uh, moist cooking methods, and then 1, 1/4, 1/2 cup portion size. Um, and that's my post-op protocol, and I know that I'm not living with the patients and I'm not living with the parents, and they probably just listen to about 10% of this, and then they kind of self-regulate themselves and they move on very quickly. Um, the good news is we tell them the information. I've not had kids come back with steak stuck in their esophagus or their, or their stomach, so some of this is getting through, and I think that's my last slide. Hey, Faisal, one from one of, one of my favorite, uh, bariatric nurses, um, in the chat is asking about, uh, what about Levson? So I've been using it for, for a while and kids that are just struggling, you know, a day or two after surgery, uh, because of smooth muscle relaxant. Did anybody else using Levsin? I have not. I haven't used it in this situation, but that might be a good option. Oh, it's, it's, it's actually quite effective whether the effectiveness is pharmacologic or placebo, I don't know because I'm a good salesman, but uh. That's, that's, it's worth a try. It's a good idea. We, we use it in Richmond. It works well. And do you, it's for all comers right away? I know it's for people. Well, it depends if we're having a run of people that are struggling, then yeah, but, uh, no, it's, it's actually, um, it's actually just as needed, uh, for patients that, you know, just are not getting down their fluids initially or they're at home and they're calling and, and, and talking about difficulty with, you know, swallowing, um, so it's, it's helpful. There's another question in the chat about uh data in adults from high volume ambulatory centers about reducing its ablation pressures and ensuring excellent muscle relaxation. Does that factor into your and anesthesia's intraoperative management? I have not done any of that. Yeah, I think it's amazing. So yeah, and me. So if you look at the adult bariatric surgeons out there, they're all using some version of a product called Air Seal. And essentially what it does, because you know it starts when you're doing like the app. And the kid's not relaxed, and then you can't see anything and then, you know, just like any other case. Um, so what this does cause, um, storch is only regulating the pressure like every 20 or 30 seconds. That's why it takes so long to notice a difference once you start to lose your pressure. Um, what Air seal does is it's second to second. And so bariatrics, adult bariatric surgeons are doing, um, bypasses and sleeves at a pressure of 10, where we typically are doing it at 15 and higher because you're trying to get that insufflation pressure. And so I trialed it at our institution and was able to get pressures down for APIs to 10. Um, and so there is a, we've actually had an, a recent APSA question that came out if you guys get the weekly ABSA questions, and it was regarding this. It it was regarding operating at lower pressures, you have less TNF alpha, they have less pain after surgery. And so I think, um, it didn't get into if it's going to show less in, um, clotting of your portal system because, you know, you get more venous returns. So there's a lot of things we haven't been able To prove yet, but I think the things that they have shown is that it does decrease pain, and you can still get great visibility, and it's actually a really good product to work with. So yes, the, the other trick, Kenneka, is if you put sorts or striker on pediatric mode, it actually will check more frequently. It'll check the pressure more frequently. I know the ACL people don't want to tell you that, but, uh, but you can actually put it into pediatric mode and do that. We have 2 minutes left for, or 1 or 2 minutes left for, uh, discussion here. Uh, so I was gonna mention on that same point though, you know, we realized a long time ago when I would walk into an adult colleague's OR and it looks like they have just a magnificent view from a big tent standpoint, uh, because the laparoscopic, uh, pressures are the same boat, but, you know, a lot of times, you know, if there's been a a post post, uh, Uh, partum state, you know, you have a lot, I think, more, uh, a difference than we have in, in our adolescent population. So, I think that we have to use higher pressures in part because we have, uh, abdomens that have different physical properties. I think that's true in women, not necessarily in men. That's right. Unless it's the beer gut. OK. So, uh, there's a question here. What's the most common procedures you are doing? Sleeves. 90% sleeve gastrectomies. I'm gonna show a slide about that. OK, excellent. Me too. All right. All right. Well, we are at time for this one.