Manish Raiji, MD - 2024 Pediatric Bariatric Surgery Update Course

Um, we're at time and, uh, I don't have any producer notes telling me who's the next introducer, so I'll take the liberty since I got the microphone, of introducing, uh, our crosstown colleague, uh, Doctor Manish Raji. Doctor Raji comes from University of Chicago, based at Coer Children's Hospital. Here in Chicago and uh is uh quite interested in not only bariatric surgery, but also pursuing a master's in or maybe pursued it and got it in ethics. So, uh, Manish, interested in hearing your thoughts about some of the controversial areas and then discussing those with you. Certainly, um, let me pull this up. Uh, oh, perfect, we're here. Um, so I'm gonna, I'm gonna switch gears a little bit instead of talking about sort of how we take care of kids. I guess the question is, how do we take care of kids with ethics in mind? Um, there's a lot of controversies that have been brought up already. Um, some of them are ethical, uh, like how, what types of procedures we use for kids, and some of them aren't like whether or not they should use straws, but I think ethics are pretty clearly, um, a, a huge part of taking care of people who may not have the decisional capacity as, um, adult patients. Um, in ethics, in general, we oftentimes will discuss things like the trolley problem where there's, you know, an out of control trolley. In, in our instance, it's obesity, that's running towards, uh, a track, and there are innocent victims on this track. If you switch this, if you pull the switch, you switch the track and 1 person dies in, in exchange for the 5 that were already on there. Um, I think, obviously, we're not talking about random people, we're talking about complications. And when we think about obesity, we think about The complications of obesity, um, as being decreased, uh, life expectancy, increased risk of obesity in adulthood, and all of the risks that are, that are associated with, uh, the comorbidities, um, associated with obesity. By intervening, we are trying to circumvent those particular complications, but obviously introducing other complications of our intervention. And when we think about surgical interventions, we sometimes think of it as a much more active process. We're not just pushing a switch, we're pushing a person over the, uh, an overpass in hopes of derailing the train. The moral outcome is essentially the same, right? There's the, the risk of these, um, uh, complications, but it feels different because we are actively involved in that process. Um, when we think about how children make decisions, um, we think about autonomy. Um, and autonomy generally, Uh, involves intentionality or the ability to select between a menu of different options and select the one intentionally that maximizes your benefit. We think about understanding or the ability to have a grasp of the risks and benefits of any one of those, um, interventions, and then the idea of non-control of being, um, able to make your own decisions free of undue influence of other people. Um, children don't necessarily have autonomy. Um, we have a lot of, uh, there's a lot of literature in pediatric care about how children make decisions, but it's very different than in the adult population. When we think about adult patient, uh, physician relationships, we, there's obviously family, friends, clergy, etc. who influence the patients and can influence the physician, but ultimately, it's the patient and the physician that is at the central portion of this particular relationship. When it comes to children, we have to include the parents and indeed the entire family unit. Um, and so that becomes a huge part of the evaluation of children, uh, when considering them for bariatric surgery. Uh, and we also know that as children age, their relative weight in this particular equation changes. Uh, for example, in neonate. Doesn't have any autonomy or any sway over the decisions that his or her parents are making for him in the NICU. But a 17 year old cancer patient has a lot of influence on the decisions that are being made for her. So, when we think about how parents make decisions for children, there's sort of three basic models um of how we go about looking at this. Constrained parental autonomy places a great deal of weight on the parents because it recognizes the parents as being the arbiter of the entire family unit. The parents are making decisions for a family that's unique, and no physician could ever understand that particular family. This places a lot of Um, emphasis on the parental rights and slightly less influence on child welfare below a threshold of abuse and neglect, of course. The harm principle places a little bit more emphasis on child welfare, but still recognizes the parents as being not only the arbiter of the family, but more importantly, We don't know what that child might want as an adult, but we know that the values, the medical values of children, uh, as they become adults is influenced very heavily by their parents. And so we put a lot of emphasis on what the parents want because we assume that that's what the children will want when they become adults. And there's a best interest standard. The idea that um we should consider the options available for treatment of a condition for a child and select the one that maximizes benefit for the child, not necessarily one that maximizes the benefit for the parent or for the family unit. All of these, there's a, there's a huge discussion in uh pediatric care about which of these three models of decision-making we should utilize for children. But they all rest on this idea of proportionality. What are the outcomes that we're looking for and what are the means that we utilize in order to obtain those outcomes? Uh, when we look at outcomes, we can, we can sort of stratify them as being low to high reward. High reward being things like saving of life, ending of chronic pains, cure, curation of cancer, and I would argue that the treatment of, of obesity. Um, these are high reward, uh, uh, outcomes. And then we can look at the risks. Um, what are the potential outcomes and what are the potential risks associated with the, um, with the interventions that we provide. In instances where you have high-risk procedures for a very low reward, we have to take into deep consideration the desire of the children. Um, when we think about things like Oncologic therapy for children with metastatic sarcomas, very high-risk procedures or medications to treat, very low reward. We think about high-risk, high reward, we can think of things like, um, bloodborne dyscas for children. They may involve, um, high-risk therapies, but with a high uh likelihood of success. And in those instances, we place a lot of emphasis on bridge building, on obtaining assent, etc. And we think about low-risk and high reward, um, procedures, that's where I think bariatric surgery kind of fits in. We've There's been a lot of data showing that the bariatric procedures are, are safe in children, and that the outcomes are excellent for them. And so, in those instances, we start thinking about compelling um therapy. And compelling therapy is important when we start thinking about kids who have who lack decisional capacity. It's difficult to compel therapy on people that have decisional capacity. And so, do we think of children as simply incapacitated adults? Um, and they're very, very different. Incapacitated adults often, often tend to have a lifetime of behavior upon which their surrogate decision makers can base the perceived values of that person. They may have communicated their personal beliefs and they may actually have legal documentation of what they would want done. None of that exists for a child. There's no historical record of choices. And more importantly, we have no idea what their, their developing capacity might be. They might have the capacity to select certain parts of their medical care, but certainly not the capacity to, to, to choose all of them. And there's no legally recognized directives. The child can't decide that this is what I would want done in this particular instance. That's not a, that's not a, uh, I think something that we utilize legally, um, to allow, to guide us on how we would treat a child. And so, there's a couple of sort of unanswered questions that we were left with. I think we have this, um, you know, this idea of beneficence and non-malleficence, which is a classic, um, uh, part of medical ethics is do no harm, um, and do what's right for the patient. And I think that there's been a lot of presentations that we've already discussed that, uh, bariatric surgery is safe and effective, um, and that it does not cause undue harm. And we also know how we can sort of Look at the framework of autonomy for a child. So, I think that some of the unanswered questions are left when it comes to, uh, bariatric surgery and children are issues of justice. Um, And one of the things we can look at is who is affected by, uh, by obesity. We know that kids on Medicare and Medicaid are up to 2 times more likely to suffer from obesity, but yet they comprise just over a third of patients who are obtaining that service. Um, we can, there's also been state-level data that looks at the number of bariatric centers, excuse me, um, the number of bariatric centers per state versus the prevalence of obesity in those states, and there's a, there's a large mismatch. Um, we may not be providing bariatric services to children where they need it most. Um, another question, are there age limits to the performance of bariatric surgery? This idea of capacity, um, we know that children up to the, uh, as young as 7 or 8 years of age, um, require a scent, especially for invasive procedures. Um, we can't simply just take them to the OR and do what we would like to do. So, are there age limits for the performance of bariatric surgery? And most of the guidelines suggest no, but that's, this is still an area that a lot of pediatric, uh, caregivers are concerned about. And, and lastly, how do we evaluate and manage patients with intellectually and developmental delays? These are kids who not only lack um uh decisional capacity, but we have no idea what their decisional capacity may be. And these are children who are much more likely, up to 1.5 to 2 times more likely to have obesity, um, because of the medications that they're on, because of behavioral issues, because of dietary issues. Um, how do we manage children who have intellectual and developmental delays? Um, and I think that answering these kinds of questions ultimately, um, relies on data because when we think about, um, all of the, um, earlier ethical concerns that existed in bariatric surgery, most of them were around efficacy and safety. Um, and we've, I think we have answered a lot of those questions. Um, and so now the next sort of steps that we have to start thinking about, um, as a community of bariatric surgeons is How do we answer the questions of how we utilize this service, um, and this therapy for, for patients in a way that's equitable. So that's, that's a great, great way to end that, uh, um, Manish. I, I, you know, I'll take the liberty of asking the first ethical question again that I, I raised before, which is, is it ethical to withhold defective treatment, um, based on an arbitrary BMI threshold when we know we can make them healthier, we can save their kidneys, we can save their diabetic foot ulcers and amputations, we can save their retinas. I, you know, I struggle. No, I, I agree. I think that, I think that, um, it's difficult to, to, uh, people have thought of bariatric surgery as some sort of endpoint to a spectrum of failed other options. Um, and I don't think that's a good way of looking at bariatric surgery. I think of it as a very effective strategy that ought to be thought of more, more as a primary. Uh, especially when we and isn't that what the, the clinical practice guidelines are intending to do, to say to offer therapy when it's available, not, you know, not when you've tried everything else. I mean, this is really, uh, you know, I, I think you did a great job framing this or framing it, uh, I use the word frame shift. I mean to use the word frame twice, uh. But it's, it's a frame shift in how you think about it and I think certainly maybe not how we think about it, but how a lot of the referring pediatricians and families think about this because You know, they still think about, they still think that this is some risky thing that has, uh, you know, it's very dangerous that they're subjecting their child to and there's a lot of pediatricians that still think that. And how do we, how do we communicate this friendship because it is, it's like we've shown, Tom's shown and many of you have published plenty of papers that show that this is a safe procedure in children. And it's certainly safer than not operating on them. And then oops, I was gonna say, and, and the other piece is just the, the disparities with the kids that have access to this because it's, you know, this is a disease of, uh, of, you know, across the board, but disproportionately affects the vulnerable populations that don't have the same kind of insurance access, yeah, and I think that involves state and federal level advocacy, um, I think that that's a huge ethical issue. Yeah, I was gonna also say, you know, before we can even sort of tackle the, the perceived risk of operation or it being a last, you know, resort procedure. We have to first tackle the whole, um, sort of societal bias that, that, you know, obesity is a personal choice, like that that actually has to come first because I think that's what is the first barrier that leads people not to seek. Any kind of care or treatment in the first place is that it's still widely believed that, that, you know, people struggle because it was their own personal failure, and if they just try harder, that they can be successful. So, you know, I, I think that that's the first barrier that we have, the hurdle we have to overcome. Karen, I agree with you, and I, it's, you actually use the word. It's when everybody, when kids or parents say to me, they just need to. Anytime they're saying just, like, immediately my antenna go up cause I'm like, OK, we need to go back to the disease process, right? And kind of re-explain some of that too. I also think it's something that we do in medicine on other levels, though, right? I mean, like kids who can get heart transplants, what kind of family support do they have, all those other pieces. There's a lot of this goes back to some of those pieces too, like, what if they don't have a family to support them? Well, we don't let some kids have stuff cause organs are so scarce. Should we let these kids? It, it just gets very complicated, which is why this, the whole program and that family piece is so important to ensure success. I, I like to challenge pediatricians with the question of you would send a child who's 2 years old to have their tonsils and adenoids removed permanently from their body without their assent, um, in order to treat, uh, sleep apnea. And by the way, that is only 35% effective in kids with obesity. Yeah, and our ENT surgeons are recognizing that as well now. Yeah. And it makes me crazy that I'll get these kids after they've seen ENT because they have sleep apnea, and I'm like, and I always stop like, stop those surgeries. You need to have this other one first. And then, then if you still need your tonsils out, great, we'll get there. But like, come on, let's, let's focus. But it, it, it is just that mindset. I think you hit it on the, you know, on the head, Karen. It's like still weight bias and weight stigma that's out there. We need more pediatricians like you. Mhm