Dr. Brian Carmine - Weight Loss Surgery: Should we be Operating Younger?

A Yeah. Now it's a laugh. qué bolé pequeño le Right. Okay. That is just fine. Exactly. In RTX 2032, in fact, the Good morning. It's our good fortune to have Dr. Carmine here today by way of BMC and a joint appointment here. Dr. Carmine did his surgical training at BMC as well as his minimally invasive surgery training and has really been the leader of our bariatric program under whose leadership it's really flourished. Today we'll be hearing a little bit about the current status of the program as well as some of its future directions. So please welcome Dr. Carmine. All right. Thank you. It's good to see everybody. So give you a quick history and status updates in future directions and we'll touch upon some areas of controversy as well. Some changes to current guidelines and I'll give you some closing thoughts. So this should hopefully be a review for everybody so we'll go through this pretty quickly. But as we know our best tool to measure obesity are quickest and easiest is the BMI. It's a bit of an imperfect tool. We know that it doesn't work as well for males because they tend to have increasing muscle mass. But it's good enough for government work. And let's just quantify people's degree of weight. So obviously I'm from 19 to 25 is a normal BMI. 35 to 30 is considered overweight. 30 to 35 is obese. 35 to 40 and this is about where one may consider weight loss surgery is considered severely obese. And anything greater than 40 has this term morbidly obese. I'm not a big fan of the term morbid obesity. In fact a lot of weight loss surgeons will say this because really morbidity starts when your BMI is greater than 25. So we tend to just go by the raw BMI's or class one, two or three obesity. But these are the terms that you'll often see in the medical literature. I used to be unusual to see somebody with a BMI greater than 40 even as recently as 20 or 30 years ago. It's now quite common as our BMI's greater than 50 which is the term is super morbidly obese. BMI is greater than 60 which is super, super morbidly obese and these are the real medical terms. So for every 10 points you would add another super. So a BMI of 70 would be super, super, super morbidly obese. Now you hear me mentioned as a relatively recent problem. These are the CDC heat maps that are so terrifying to look at in 1985 the Centers for Disease Control Lest all the states to report in their obesity rates. And when they did initially most of the states ignored them, those the states and the white. But the ones that did less than 14% certainly in the entire nation. Some states even better than that with less than 10% obesity rates. That kind of holds true until the 90s and more and more states reported in. And certainly we've got a country that appears relatively thin less than 14% obesity rates for the majority of the country. Then in the 90s we start to see this big shift in the composition of our country. We see this 14 to 18% obesity rates. The CDC starts to notice that rates of diabetes are going up. So they start tracking this as well. And really in a very short period of time the entire composition our nation changes. So by 2014 we've got the majority of the South has greater than 30% obesity rates. There's a number of states here that have greater than 40% obesity rates. And really this all happened in a matter of 20 years. And again just as obesity went up, diabetes went up because we know that obesity and diabetes go hand in hand. Obviously it's not just diabetes. Any organ system you have is negatively affected by weight. Increasing rates of stroke, depression, heart disease, fatty liver is becoming one of the leading reasons for considering the liver transplantation. Cancer rates are nine times higher and people who are overweight versus people who are not. So again really any organ system one has is negatively affected by weight. Because of this would be a minus greater than 30. We see a 55% increase rate in all cause mortality, 70% increase in the rate of coronary artery disease, 75% increase in stroke rates and a 400% increase in diabetes. Obviously this translates into increasing risk. This was a very interesting graph that showed how BMI is causally related to all cause mortality. That as your BMI approaches 40, you're four times more likely to die than you give a disease process than you were if you read a normal weight. One of the interesting things that the same studies showed is that actually if you lose this weight you can actually ride the curve back down and your all cause mortality approaches that as if you were never overweight. Which is a little bit encouraging. One would imagine certainly somebody with a long history of obesity might have long history of heart disease, high cholesterol, diabetes, but this study in particular showed that if you can get your weight back down you can ride the curve back down. And it's obviously not just the body. There's a big stigma associated with increasing weight, certainly with young people. 30% of all girls and 24% of all boys report weight-based teasing on that number doubles. If your BMI is greater than the 95th percentile, which is really about a BMI of 30 to 35. So this is a stigma that unfortunately persists into adulthood. It just becomes a little less overt. There's a number of studies that show for instance for job applications. If someone is to apply for a job, a thin candidate is more likely to get a job than an overweight candidate, even if the overweight candidate is more qualified. So obviously, like I like to say, if there was one thing that caused obesity, Pfizer would make a pill for it, we know that there's a number of complex interrelated factors. Genetics, cultural, environmental, and the ideal approach to obesity addresses all of these factors. Thankfully, I think we can all agree that there's a genetic predisposition to obesity. There was, tend to be a lot of accusations, lobby that families back in the day that while you guys are all eating out of McDonald's, you guys are eating in front of the television set. Obviously not good things, but the way you can prove that there's a genetic predisposition is to look at adopted children. They did just that in Denmark. They noted that if two obese parents had a child and put that child up for adoption, no matter where that child was raised, that child still had an 80% chance of growing up to be obese, regardless of the lifestyle of the household. Similarly, if two thin parents had a child, that child had a less than 14% chance of growing up to be obese. The same study, part of the same group looked at identical twins and found that whether identical twins were raised separately or together, they always grew up to be about the same weight, which again suggests this genetic predisposition to be a certain weight. It's all our genes, right? No, because our genes did not change suddenly in 1990. There wasn't this sudden mutation. Really our culture changed. We live in a very different world now. We're all staring at screens ranging from this size to that size. All of our jobs do much more sedentary. Just think about mostly the view in this room, I'm looking at two young to remember this, but when you wrote your notes and saw your patients, you walked around from room to room and wrote your notes and saw your patients. Now we're all staring at a screen, typing it down. Portion sizes, automation, escalators, elevators, all of this has really changed the environment. And this has led those people with this genetic predisposition to become obese, to become obese. Think of it almost like an oncogene. This is the genetics is loading the gun, but the environment is pulling the trigger. So the treatment obviously died exercise behavioral change or always the first step. We do know that they tend to, on average, generate at best 10% weight loss. They tend to be ineffective in the long term. Purchasing medications kind of the same story. They're pretty good at kickstarting a weight loss regimen, but they tend to lose their effectiveness over time and the type of results that one sees really aren't to the degree that somebody who might be seeking weight loss surgery is looking for. This comes from the American Medical Association who says that an optimal program can be expected to achieve a weight loss of 20 pounds if continue permanently. Again, two problems with this statement. By the time somebody is looking for weight loss surgery, they tend to be looking to lose more than 20 pounds. And it's very, very difficult to continue a lifestyle change permanently. This is some very discouraging data that shows exactly that. These are the four more popular diets of the time at GenZone, Weight Watchers, and the Orange Diet. We see that the weight loss is modest. You know, in the order of five to ten pounds at best for the average for weight watchers, I completely believe that because I don't consider weight watchers a diet. And I mean that in a complimentary way, Weight Watchers emphasizes portion control. So you eat what you want, but you just eat the right amount of it. You know, I think anything where you're modifying what you want to eat drastically will never work if you're just going to drink kale smoothies or you're not going to eat anything that's white or going to have all your food delivered to your house on a cardboard box. You know, these aren't things that can be sustained for your entire life. So I think those are doomed to fail. But all of these, including Weight Watchers, as we see, the effectiveness drops down over a period of a few months. People just fall off these diet lifestyle changes. This is an experiment done by George Bray in the 1980s. Essentially took a bunch of patients and brought them up into this retreat in upstate in New York. And they had exercise coaching. They had teaching cooking classes, behavioral therapy. It was wonderful. They were, you know, in this bucolic retreat. And they were there for months. And they did great. They lost 30 to 40 pounds with this intervention. But at some point, everybody has to go home. And when they go home, they don't have their personal chefs. They don't have their personal trainers. And really over a period of a few years, almost everybody was back where they started. And some people, in fact, ended up even higher. The NBC network repeated this experiment about 30 years later on the biggest loser. And everybody who did weight loss surgery knew exactly how this was going to end. But it actually wasn't all for not. We got some very interesting science. There was this interesting that he was a physicist who was very, he was trying to find the equation for human metabolism. And he asked to study, his name's Eric King. He asked to study these patients. And so it was really great science, if you think about it, he had this group of patients who he knew was going to lose a tremendous amount of weight. It was guaranteed. And so he collected all this data on them, you know, indirect calorimetry, biometrics, body composition. And then he studied them before the program, during the program, after the program, and many years later. So we did get some fascinating science out of it. And the first chart was what we all knew would happen, which is almost all of them have gained a significant amount of their weight back. Many of them are now higher than they were when they first appeared on the television show. But the fascinating thing that they found is that their basal metabolic rate was much, much slower than it was when they first started the competition, even when they gained their weight back. So not only have they gained their weight back, their metabolism is slower, their metabolism is our remaining slower. It will be difficult for them to ever lose that degree of weight again. There's actually been some follow-up science to this. And some of these patients have gone crash diets again and lost, you know, a fair amount of weight. And he re-measured their metalysis and they're even slower. So really every time you try and lose weight, your metalysis slows and slows and slows and slows. And we see this in our patients, especially in our adult patients, who have tried many diets. Some will come to us and say, yeah, we're not going to die. I lost 80 pounds and I gained it back. And then I tried again and I lost 50 and then I lost 20. And now I can't lose anything. So we sort of see it anecdotally, but this is some of the hard facts that really back that up. So brings us to my area of expertise, which is the surgical options. Two options, predominantly done in the United States of America, as well as here at Children's Hospital, the gastric bypass and the sleep gastrectomy. So who's a candidate for surgery? We'll be harping on this a little bit as we go through the presentation. But really anybody with a BMI of 40, pretty NIH consensus criteria, is a candidate for weight loss surgery, regardless of health issues, or a BMI of 35 to 40 with a weight-related comorbidity. The big ones in adults are diabetes, high blood pressure and sleep apnea. There are some international criteria. For instance, it's known that Southeast Asian men tend to develop the diabetes at a very low BMI. In fact, BMI of 25 to 30. So there are some other countries that are considering this as a metabolic surgery for diabetes and people with lower BMI. That has not yet found favor in the United States, but I suspect it's coming. So let's see if this plays. So this is a gastric bypass. It's kind of the more complicated of the two operations, but I think with my audience, everybody will be able to follow this. So the first step of the operation makes perfect sense. You divide the top part of the stomach from itself and you create this small gastric pouch, totally logical. You've got a small stomach. You're eating less. We then divide the intestine about 40 centimeters, just a little bit of the right. We bring the one distal end up to let the food out of the stomach and we plug the proximal end in about one meter down. So in these videos, blue is food. So we see patients eating. Imagine the green, not only is the digestive enzymes, the bill of pancreatic enzymes, but it's also the hormonal stimulation of eating. So really you get this decreased metabolic response as well as a malabsorbed response by bypassing this first part of the stomach and intestine. So most of this I just mentioned again, small stomach. You physically eat less. We make that connection between the stomach and the intestine, about 11 millimeters, about which is about the size of a dime. The reason for that is we want the food to stay in the stomach so they eat and they feel full. Obviously if you make that connection just a straight shot, there's no feeling of satiety that food just goes right through. Malabsorption historically, this was what a lot of us non-scientists surgeons thought was doing all the work. We thought that really if you're bypassing all the biol, the pancreatic enzymes, you're just not absorbing things as well. Turns out that is a component of it, but probably the most important component of it is bypassing some of the hormones, such as growl in the peptide y-y's. And it really is this metabolic blunting that you get more so than the malabsorption. The dumping syndrome, a number of people will list this as a complication of the gastric bypass. We actually consider it a benefit. What the dumping syndrome is, if you don't know, is if you sometimes very high in sugar, the intestines flood with water. You get this increase in catacolomines, your insulin levels rise, your blood sugar bottoms out, and you feel terrible and you don't eat that ever again. So it's a sort of negative reinforcement. Actually, not everybody who gets a gastric bypass gets the dumping syndrome about half of people do, but the half that does actually loses about 5% more weight than the half that doesn't. Weight loss with the gastric bypass pretty predictable. About a year and a half out, we see about 75% excess weight loss. So if somebody is 350 pounds and they should be 150 pounds, they'll, they're 200 pounds overweight. They'll lose about 150 of those 200 pounds pretty predictable by the first year and a half. Everybody gains a little bit back. The nice thing about the gastric bypass, the first one was done in 1967. We have decades worth of data on it. The long-term weight loss appears to be pretty reliably about 60% at 14 years. So again, you'll, two for 200 pounds overweight, you'll lose 150, you'll keep 120 of that off for the rest of your life. The sleeve is much easier to understand. Let's see if this plays. This will play a little slower. So again, in this model, blue is food. We get a preview of this patient eating here. Just eating, eating, eating, and filling this big, capacious stomach. And then they get their sleeve. No illustration really, I think, does the sleeve justice. It always kind of looks like this, like a banana. Really what we're removing is actually about 90% of the stomach. It always looks like 2-thirds in all the pictures for whatever reason. But 90% of the stomach goes away. One of the things that I think people don't appreciate with the sleeve is that this is permanent. That part of the stomach is gone forever. So really, this is one of these operations that is not reversible. And obviously, you see much less capacity of the stomach. So you get the same restriction from the small gastric reservoir. Some of the hormones that regulate metabolism like the grellen were made in the fundus of the stomach, which is now been removed. Weight loss with the sleeve. Again, the three-year data came out. Everybody got excited. They said, look, this looks like it's just as good as the sleeve. It just goes the bypass. It's much technically easier to do. But then the 10-year data has started creeping out. And what we are seeing is that the sleeves are gaining back, pretty significant amount of weight compared to the gastric bypass. So I do think the sleeve is probably going to start to become less popular as time goes on. It's a bit of a shame. But interestingly, it's been quite popular for about 10 years. We have a number of residents who have gone into bariatric training and a handful of them never did a gastric bypass in their bariatric training. So we have this brief generation of surgeons who doesn't know how to do a gastric bypass now. And I think about another five years they're going to wish they did. So let's come here to what we all wanted to hear about, which is adolescents. So right now the indications are exactly the same as adults, a BMI greater than 40 or a BMI greater than 35 with medical comorbidities. Interesting thing about obese adolescents, there are at least in the referral populations, some maybe some physiologic differences compared to adults. At least in the bariatric surgery population, there's higher rates of dyslipidemia, intracranial hypertension, fatty liver disease, things that we don't really see in the adult population that seems to be more unique to the adolescent population. Now what I'm not certain of is if this is something that is unique to obese adolescents or if it's that obese adolescents with these problems tend to be referred more often. We do know that severely obese adolescents become obese adults. 84% of those with a BMI of the 95th and 99th percentile and that's BMI about in the 30s, mid 30s as children end up becoming obese as adults. However, once your BMI is greater than the 99th percentile which is about a BMI of 40, there's a 100% chance that that child is going to grow up to become an obese adult. It's vanishingly rare for that to not be the case. If your obese as a child, you are more likely to have obesity related health problems as an adult than if you were to become obese as an adult. So an obese child has a much higher chance of becoming diabetic, a much higher chance of having dyslipidemia and atherosclerosis as compared to somebody who became obese as an adult. However, the flip side of that is that if you can get an obese child to become not obese by adulthood, those patients have the same risks of developing those problems as children who were never obese. So what does that mean? So if you have a child who you get thin in their adolescents and say they become obese 30 years later as adults, their odds of developing those medical problems are similar to that as if they were never overweight. However, if they are obese as a child, they stay obese. Their odds of developing these medical issues are much, much higher. So this is the New England Journal article that came out a few months ago, which really had a lot of fascinating data. And this compared, it was the first one to really head-to-head compare the adolescent to adult outcomes that we all sort of anecdotally knew, but this really presented it in a fairly objective way. And they looked at two of our biggest studies, which are the lab studies, which is the longitudinal assessment of bariatric surgery and the teen lab study. Now, what the lab study is, is this was an in-depth prospective assessment of adults, which was 18 or older weight loss surgery outcomes between 2006 and 2009. This would have about 2,500 adults from 10 centers. And they, again, they collected multiple, multiple biochemical laboratory physiologic markers, outcomes on these patients. And they're actually still following up on the data today. On the same time, they did the same thing for adolescents, which was the teen labs. This was for people who were 19 or younger. Obviously, a smaller study, not as many adolescents, getting weight loss surgeries, adults was 240 adolescents from five clinical centers. And so this New England Journal article tried to compare these populations head-to-head. Now, a bit of it was like comparing apples to apples. So the first thing they wanted to do, there was really almost no sleeves. In the study, sleeves weren't being done much in the early to mid-2000s, 2010s. So really what this just consisted mostly of was gastric bypass and lap bands. Nobody's doing lap bands anymore. They fell by the wayside. They've been largest and planted by sleeves. So the first thing that the New England Journal article authors did is they called out all the bands. Let's compare bypasses to bypasses because these are the operations that are being done. So that will list down to 161 teenagers and about 1,700 adults. Now again, still comparing apples to apples. So we've talked about already. Certainly it looks like adolescents have, obese adolescents have different physiology than obese adults. So what they did is they said, let's only look at the adults who were obese as adolescents. So now what we're looking at is people who have been obese their entire life versus getting them early. And let's see if there's a difference between the two of them. So they eliminated all adults from the study who were not obese as adolescents. And that got them down to 396 adults in the 161 in the adolescent cohort. Thankfully their BMI, the gender breakdown was all nearly identical. Their BMI is about 50 on average. But there were some cohort differences. A couple of them make sense. Obviously, the rate of diabetes was higher in the adults than it was in the adolescents as was the rate of high blood pressure. That makes sense. These are problems that tend to become cumulative and reach a certain threshold as we get older. So it makes sense that they might not have it earlier. Interestingly, however, the adolescent population had dyslipidemia rates that were nearly twice as high, which we do see in our practice as well as the adult cohort. So they weren't entirely the same, but they were close enough. Now this is what the money showed is that the weight loss was about the same. There was, and we'll get a little more granular on this a little bit later, but there was no significant difference in the weight loss between the two. The adolescents and the adults lost between 26% to 29% of their total body weight loss. So and there was no significant difference between the two of those. However, there was a significant decrease in the rate of comorbidities, especially diabetes and high blood pressure. The adolescents did better. They had medical issues related to the weight. Medical issues were much more likely to go away than you were if you were an operate on these people as an adult. So here's the data that showed that 53% of diabetic adults achieved complete remission, but 86% of the diabetics achieved complete remission of their diabetes at five years. And complete remission means completely normal circulating insulin levels and even a little bit A1C less than 5.5. No adolescents were taking diabetic medications after five years. Even those who didn't quite meet the criteria for complete remission still were able to manage their sugars with diet control. One of the fascinating things is one would say well of course some of these adults they've had diabetes for 10 years. They've burned out their pancreas. They're taking tremendous amounts of insulin. Of course their diabetes didn't go away. But the study looked at that. They actually adjusted for the duration of disease and the type of medications and duration of medications. And they found that still the adolescents were much more likely to have their diabetes go away than they were as an adult. High blood pressure the same thing. One percent of adults with high blood pressure achieved complete remission and 68% of adolescents achieved complete remission off of all medications after this operation. So if you look we just look at this no brainer we should be operating earlier. We use diabetes and disease is going to shave decades off of people's lives. If we can prevent it we should get them earlier. Give them the best operation and get them healthier. No question. Maybe. So this data was coming down the pipeline and it led the changes in our current guidelines. One of the indications standards for adolescent weight loss surgery is that you had to complete your axial bone growth. And so what they would do is you take an X-ray of your hand. We would make sure all your growth plates are fused. And if you had achieved skeletal maturity you could have the operation. Well as we started to see this data come down over the last five to ten years we said well listen you know why are we waiting we're denying these patients this operation. Maybe we should be doing this sooner. So in fact the consensus guidelines have now eliminated the skeletal maturity requirement. It was a bit arbitrary for many reasons some are listed here. Obviously we know that you know girls become skeletal mature sooner than boys. So it was a really fair to give these girls operations sooner than the boys. There was some data that shows that if you operate on these patients earlier before they've achieved skeletal maturity they actually end up becoming taller. They have taller stature after you operate on them. If you operate on them before they finish growing they do after. We also know that for a number of reasons probably largely related to what we're eating in our diet we know that currently the skeletal bone age is exceeding the chronologic bone age. People are maturing faster. So again we eliminated this requirement. Should we have? There is some science that's coming out now that shows that there is clearly a bone health impact on these operations in both adults and adolescents. We do see an adult and adolescents a decreased bone density after these operations. This is probably related to decreased vitamin D in calcium and not adequate nutrient supplementation which we'll talk about in a bit. There's been no data really yet that has shown this translates into decreasing bone strength. Even these people who have decreased bone density tend to have increased cortical thickening so the strength tends to be about the same. But this is an area of interest. So it's all great. We should operate on everybody. Everybody with diabetes who's an adolescent should get weight loss surgery, no questions. Well let's talk about some of the ugly things that came out of this article in other areas that bear looking at. So I'll talk about some of the genetic obesity syndromes, the vitamin deficiencies which I alluded to, substance abuse, reoperative rates, weight regained and really how young is too young. So we should be operating on everybody. We should be operating on nine and ten year olds. Anybody who's a bitch who get this, we're giving them these great health benefits. So people got I think a very ambitious and eager to operate on some of these things that we're originally considered no good. So we know Prader-Willey has this component of hypergrelinism and certainly it's operation normalizes or actually makes your growl levels below normal. So should we be operating all kids with Prader-Willey? There are people who are doing this. This is not yet a population that I've been brave enough to operate on yet. We certainly have gotten a couple referrals from this. As I think most of you know, Prader-Willey's patients have this profound hyperphasia and it may be related to the growl and but it may not be. I think in my opinion, one has to seriously examine whether or not you should operate on a patient with Prader-Willey. But there is a cohort of Prader-Willey patients who have now had weight loss surgery and the data looks okay. They don't lose as much as somebody of a similar weight without this syndrome. But some of the data is just if you've got a good support network, if you've got somebody who's supportive and can help the patient at home, that's maybe. I've heard it beetle. So another one of these syndrome that has obesity, a little bit better data for this. So I think this is something that I think adolescent wheelers are a little more comfortable operating on. We've not yet had a bar of beetle patient here, but I think that we would probably entertain this a little more than a Prader-Willey. And then we get a lot of referrals of these patients with pan-hypochaturism. Again, so this is not really, this is more of a metabolic issue, a central metabolic issue than a peripheral metabolic issue. But again, we've had done a number of these patients as they have in literature. Again, the results aren't quite as robust as they are without this syndrome, but they do do better. They do lose weight. So I think for all these patients, again, you need to make sure that they've got an adequate support system, and that this is somebody who you can be assured is going to have lifelong compliance after this operation. This is the key. You're giving them, I often compare this to giving a patient a car. You wouldn't give somebody a car without giving them their license first and making sure they pass a test. And so I think the car analogy works very well for a lot of our patients. I'd be very reluctant to give a ten-year-old a car. I'd be very reluctant to give somebody Prader-Willey a car. But again, if somebody jumps through all the hoops, if you can prove that it's that they are responsible, they know what to use it, they understand, or they've got a support system in place that will help them to understand, I think you can consider it. So some of the ugly stuff that came out of the New England Journal article, vitamin deficiencies, there is more micronutrient deficiencies in adolescents versus adults. Iron deficiency rates were twice as high, and vitamin D rates, deficiencies were much higher in adolescents versus adults. This has been repeated in every single study, in every single MBS equipped database, the adolescents, their vitamin rates are much lower than they are in the adults. Does anybody have a guess as to why that is? Yeah, well, I put the answer. They are compliance. Yeah, they just don't take their vitamins. In studies where the vitamin supplementation is enforced, essentially, if some patient is enrolled in the studies, say, looking at their calcium levels and things like that, a lot of these bone studies, these patients, vitamin D and calcium levels are perfect because, as part of being enrolled in the study, the vitamin supplementation is enforced, they're getting paid to take their vitamins. So their numbers are perfect in these studies, but in the big broad long term studies, the numbers are much lower. Substance abuse. This is, again, a bit of the dark side of weight loss surgery. There is a known increased rate of substance abuse in the adult peri-bariatric population. This is addictive behavior as altogether. There's actually higher rates of gambling addiction. There's higher rates of sex addiction in the adult peri-bariatric population as compared to obese patients who don't undergo the surgery. Some of this is probably what's called addiction sublimation. These are patients who, you know, we're getting this. The food was their reward. They got this dopamine release from their brain every time they ate, and then that was one of the things that compelled them to eat. Well, food doesn't do that for them anymore. So they need to find some other way to get this release. And they, while often turn to these compulsive behaviors, alcoholism tends to be the most common one we see. You know, alcohol is a small chain carbon molecule. It has a tendency to be absorbed more directly into the bloodstream versus going through the liver, and you make it much easier for that to happen after a weight loss surgery. So, you know, these patients become a chief date after this operation. A little bit of alcohol goes a very, very long way, and it becomes a very easy tool for them to become addicted to. Now, preliminary, there is no data that shows this similar increase rate in addictive behavior in adolescents. And this is sort of tattered over and over again. You know, look, these kids don't have these addictive behaviors if the adults do. I'm not sure I believe it. I think the sample size is too small. I don't think that we are, again, have enough data to really say that this is the case. One of the scary things from this New England Journal article is that three, so I think the seven of the patients in the adults population have died. Three of the patients in the adolescent population have died. And two of the three who died died of drug overdose. So, you know, again, consider the time of this article was written. We're seeing overdose deaths, overdose deaths and young people at a higher rate now. Anyway, are we seeing that? Maybe, but I wouldn't be so quick to just assume that. So re-operation rates. Again, another interesting thing that came out of this study, there's a higher rate of re-operation in the teen lab's population than there are in the adult population. So 19.5% re-operative rate in kids versus 10% to five years. And nearly twice as many of these kids are having re-operative surgery. Again, I don't know what to make of those numbers. Both of those re-operative rates are much higher than we see in our national databases. So again, some of these studies were done in kind of the earlier era of laparoscopic weight loss surgery. So perhaps we're sort of still seeing some of the learning curve there for re-operative rates. I also think that there's a lot of these adolescent operations were being done at children's hospitals, much like here, and by pediatric surgeons. So these were surgeons who weren't doing 300 gastric bypasses a year. They were maybe doing 10 to 20 gastric bypasses a year. And so again, there maybe was a little less learning curve. Some of the things that suggests that to me is that the internal hernia rate was much higher in the adolescent population versus the adult population. That doesn't make a whole lot of sense. I mean, that's just sewing one thing to another. But all of us who do hundreds of these a year have developed these little tips and tricks to close these internal hernias to lower our rate. Also an adolescent was much more likely to get a feeding tube than an adult patient. And again, I suspect that maybe the pediatric surgeons are much less afraid of putting in feeding tubes than adult practitioners are. So I think one of the objective things that suggests the practice is practice difference rather than patient differences that the rates of getting the valve ladder out is exactly the same between the two populations. It's pretty hard to argue that somebody doesn't need a gallbladder out and rates of removing gallbladder were higher for both. So this statistic, I'm not quite sure I believe. All right, one of my last topics here, how young is too young? So I've harped on this already. Patients require understanding of this lifelong commitment to lifestyle change. So you really need to have somebody who understands what you need to be able to sense to the operation. Look, I understand this is going to be the rest of my life. I'm going to have to make permanent lifestyle modifications and maybe be able to tell you what those are and know about it. So what you're getting is getting these muddy waters is these younger patients with these real medical issues. You've got, you know, the life threatening or permanent disability is looming. You've got patients going blind from pseudotumorsary bribe. You've got, you know, somebody who has had these apneocathensives been intubated for them or has had to have CPR in the middle of the night for a severe sleep apnea. And they're 10 or 11 years old. You know, I have a hard time, you know, conceptually saying, let's wait three, four, five, six years. You know, when you're now completely blind or you've died in your sleep, it's very difficult for me to say that. So I do think that if you have, in those cases, if you have adequate parental support, somebody who can support the child through this and keep them educated, I think on a case by case basis, these are things you can consider perhaps doing it on the younger age or even pre-edal essence. I think we can all agree this is probably too young. This was this sort of famous case that was done in 2010 in Saudi Arabia. This was a two-year-old boy, again, who was BMI of 41, 79 pounds at age two. He was developing Boeing of femurs. He had severe obstructive sleep apnea. You know, he was two years old. They couldn't keep a mask on him at night. One of the fascinating things about this case is he failed dieting twice. I don't understand how a two-year-old diets because he's not going to the kitchen. He's not making his meals. He's not ordering Uber. So I've got some ethical issues with this one. But he got a sleeve. He is, I think, 12 or 13 years old now and his BMI is 24 and he's doing fine. It's hurt that me is me selling this. I'm not. But he did have a good outcome. But this is one I think you all agree it's probably too young. I mentioned this real quick. If you drill down on this New England journal article, it shows that these patients had the same average weight loss of five years. You can pick that apart a little bit. So while there was no overall difference in the average five-year weight loss between adults and adolescents, there were some differences. Adolescents were much more likely to regain weight than the adults. So they actually did by-modal distribution. The way this average is out is the adolescents in general do a little bit better. They lose more weight in the beginning than their adult cohorts. However, they also tend to swing back the other way and a lot of them gain back more weight than the adult cohorts. So 76% of the adults maintain their weight loss, which is considered greater than 20% since the same weight loss. Only about 60% of adolescents maintain that. And 1% of adults actually ended up being heavier than they were when they first had the operation. 4% of the adolescents that happened to. Again, I think this is just like with our vitamins, I harp on this over and over and over again. I think this is an issue of compliance. It's very difficult to get an operative 2016. They go off to college. They do all these crazy things. And they lose compliance with their diets. And I think that that is one of the biggest issues with the adolescent populations. So I'll give you some closing thoughts here. Optimizing long-term adolescent outcomes. Increasing referral patterns, eliminating stigma. Can't say enough lifelong compliance. We are what called an imbis-equip center. This is the old American College of Surgeon Center of Excellence. We actually are the oldest certified standalone adolescent weight loss surgery center in the nation. One of the tenants of this program, which again, I cannot stress enough, is that these patients are your patients for the rest of their lives or yours. You have to see these patients once a year, every year, at a minimum for the rest of their lives. And that includes seeing both you, a dietician, and a medical advisor regarding their weight. And this has to be enforced. You have to document that if they don't come to their appointments, you send them letters, you call them. All this has to be documented that you're really following up with these patients. Because this can happen. A patient goes away to you. I see it in the adults all the time. One or two years out. They've done great. Everybody does great at one or two years. And then in the third year, they gain five pounds back. And so, Dr. Carmine said, I gained back a little bit of weight. That's fine. But they gain five pounds every year for 10 years. They gain 50 pounds back. And really, if you're seeing them annually, you can say, well, if you know what I'm known, it's your weight's kind of creeping up. Let's consider maybe some medical adjunct. Let's get you back into dieticians. Let's do some diet education. It's a cool lifestyle. It is no different than weight watchers. It just makes things much easier. But it doesn't work if you don't use it and if you don't maintain it. Referral patterns. Who should be a patient? And I'm going to harp on this a little bit. Again, anybody could be a migratory than 40. Anybody could be a my 35 to 40 with comorbidities. Just like people do better if you get them younger. People do better if you get them thinner. We have one of my big pet peeves in society. This is the idea of fat blindness and these alterations and perception. You know, the average BMI in America now is in the 30s. It's, it's, we're bigger. So people, one of the things that drives me bananas is when somebody ate with a, you know, who's 220 pounds with diabetes has this operation. And so you don't, I think you don't look big enough to have a gastric bypass. It's 25 years ago. They would have been the biggest person in the room. And now they're not. And this is what most people think of when they think of weight loss surgery. They think of my 600 pound life. And these are the kind of people who, this is who has a gastric bypass. It's not me. I'm just a little heavy. And the really the way that we've perceived things has completely completely changed. So really changes perceptions that have lasted decades or centuries have gone away just in the past 25 years. And the prevalence of these these actually shifted our standards. This is an infographic that I love where Kim Kardashian once said that she wore the same dress sizes in Maryland. Well, no, she didn't. The stores have changed their dress sizes and their clothes sizes. So and the way to do that is to get people into the stores. You much rather shopped the store where you're a size eight in the store where you're a size 14. You know, that store has my right clothes. You see these clothes sizes like zeros and double zeros. Those didn't exist in Maryland Rose time. Those would be old size two and size four. So Kim Kardashian would be probably a size 18 if she bought a dress from the 70s. Maryland, a Ruby probably a size eight if she bought a dress. Now men, you guys aren't exempt. Bring a tape measure to the gap and measure a size 34 inch waist and you'll probably get 36 to 37 inches. So they're doing it to all of us. So you guys have probably noticed that your your gene sizes seem much better than your soup pant sizes. And that's one of the reasons because it's your suits being fitted. I thought I didn't realize my waist was that big. I'm going to worry the size gene. It's because the retail stores are trying to get you in there. Sorry. But this is obviously where we're out of control, which is portion sizes. I love this ad from McDonald's from 1967, which is the All American Free Course meal. For 52 cents. This is the cheeseburger. That's the ones about that. It comes in pairs now. I don't know if you can even buy a standalone one. It's a little white paper sleeper fries. It has about 12 to 15 french fries in it. And a seven ounce milk, a seven ounce party milkshake or soda. And seven ounces is less than two thirds of a can of soda. In 1967, this was a large, hearty adult meal. This was a meal that would satisfy a grown man. It was the All American Free Course meal. It's it's now smaller than what we give our children in the happy meal. It really is. A typical meal from McDonald's is more than triple the calories as what was a large hearty adult meal in 1967. I tell my patients to look at plates. So this is a plate from 1950, which the plates are the exact same size. But the big difference is notice the reservoir for food in this plate. If you look at your grandmother's china cabinet, you'll see this. You've got this beautiful three inch design around the room with the plate. You've got this little well in the middle. The food was only supposed to go in the well. Your grandmother wanted to show off her china to her guests. So if they wanted to see the pattern, the food only went in the middle. You can't buy plates like this anymore. Plates look like this. They've got maybe a line around the edge. They've got no well. And think about it. If somebody brought you this, this food and they only put food right there. I just like anybody would say, you know, where's the rest of my food? We've we've lost the sense of the portions that we should be eating. And the last thing I want to talk about is eliminating stigma. So, you know, obesity as you know is a chronic disabling disease. Surgery is the most effective treatment. There's a number of things or a number of things I could say where instead of just. Saying the word obesity say the word cancer. And and people have a completely different reaction to it. So, you know, just say like, look, I've got. I have cancer and I need the most effective treatment for it. People would say, of course you do. And obesity does not have that same reaction. Thankfully, you know, I've been doing this for 10 to 15 years now. And wait, you know, the stigma around weight loss surgery and adults I've seen has almost gone away. Even in the lay person population. It's still there a little bit, but they say, look, you know, I've tried everything. I've done it. I've got diabetes. This is what's going to help me. You know, I need weight loss surgery. And they get it and everybody says great. And you know, in half their friends, oh, you did who's your surgeon? Can I get their card? You don't see, we're not really seeing that yet in the adolescence. There's a lot of blame on the parents. You know, how did you let your kid get like this? There's a lot of embarrassment among the patients. You know, the adult, the adult patients are very happy to, you know, see somebody who's overweight and say, oh, have you ever considered weight loss surgery? I know somebody who does it. The patients will never admit it. We recently sort of experienced this. We were trying to hold this seminar and we were looking for a patient who would be willing to speak at the seminar. And none of our patients isn't, no, I don't want anybody to know. I did this. They were very embarrassed about it. None of them would be embarrassed to say, you know, I had, you know, like a Wilm cell tumor removed. Or, you know, I had my leukemia treated. Nobody would be embarrassed to talk about that. They're embarrassed to talk about their obesity treatment. And again, some way parents are reluctant to ask for referral. They think that this is radical. They think that this is something that shouldn't be done on young people. The one exception we've noticed, and we see this fairly universally, I would say, probably 80 to 90% of our patients have one parent who had weight loss surgery. And that tends to be, you know, some of that obviously because of, you know, we mentioned obesity is genetic. But also, you know, they said, listen, we've had it done. We know that it works. I see my child heading down the same pathway. I don't want them to end the way as long as I did. And they refer to them. So obviously, you know, I'm up here talking, but there is a huge team that makes this work. Every member of the team is as important as every other member of the team. I compare this to sort of the Toyota assembly line. And the premise of that is that if you're on the Toyota assembly line, any person on the team, there's no hierarchy. Any person on the team has the ability to raise concerns. Stop the line, say, listen, I don't think this, you know, something's wrong with the brakes. You know, this is the same thing here. You know, only once everybody on this team agrees that somebody is a good candidate for surgery, do we perceive a surgery? So there's me. I've got my three surgical partners who help cover here, Dr. Richman, who's our medical director. And we've got dietitians. We've got our social workers. We've got our nurse practitioner Anne Marie, who's sitting there in the audience. Psychologists, really, this whole team is needed against educate these patients to follow them in the long term, ensure compliance and make sure that we are adequately selecting these patients who will do well in the long term. Well, that was terrific. And I can now explain the Saturday night phenomenon I had this week. I have a home expanse of my wife. We had our exciting set of an update at REI because we're going on a trip and it has some clothing and went to get help about buying pants. And I didn't know what size of my waist was. I looked at my blue jeans, which I've had for a long time. And there was size 32. And it was stunning how those 32 pants at REI did not come close to fittings. I understand why. Yes. Nope. I'm not sure I need to be your patient yet, but I know. I understand what Levi's has done. So, it's really frightening when you show these, every time I look at those maps that you show at the beginning of your talks, how clearly it's not all genetic. These genes didn't change that quickly. Our society has changed meals, screens, habits, whatever. Why don't we see the number of cases that you do per month here in the children's hospital increase? We are seeing it increase, but not at the same rate as those maps. We are complete believers that although we used to think that operating on big people wasn't what we do at a children's hospital, we got a little people. We are complete believers in Dr. Shammer who drove this to build the program to have adult surgeons who are trained in doing things on big people to take care of children in the right environment. Is it all the stigma? Is it the insurance? Is it a combination of things? It's not the insurance. Massachusetts has one of the best rates of weight loss surgery coverage. I can go on and on about the insurance companies, but the coverage of weight loss surgery tends to be one can imagine why this is inversely proportional to obesity rates. Massachusetts is actually the second thinnest state in the nation. Therefore, we have one of the best rates of obesity surgery coverage. It's not that. They are fairly good at covering it. I think there are two things, a couple of which I touched upon already. 300,000 weight loss surgeries are done a year in the United States of America. Those 300,000 weight loss surgeries represent 1% of the eligible population. 99% of people who are eligible for weight loss surgery don't get an operation. All in all, we're not hitting the people who even come close to hitting the people who might do well from this surgery. The adolescent stuff I think is, and this has been a learning curve for me, has been a bit of a different way to sort of get people in rooms. With the adults, they, as I mentioned, they love talking about it. You're never going to see me on a billboard on a mass spike saying come get weight loss surgery. The patients are the billboards. You look great. What did you do? They tell them and they refer them. As I mentioned, the adolescents are different. Even a bit of embarrassment on the parents part of them. My kid has to get gastric bypass. There's this stigma. You don't get the same, you don't tend to this critical mass of patient referrals that you do for adults. I think for the adolescent population, really the people who we need to be educating and talking to are the pediatricians, the family, medicine doctors, who historically have been pretty reluctant to consider weight loss surgery. They've been waiting for these New England Journal studies to come out. We are seeing an increased referral. The other thing is that they see the patients. One patient tends to do it. You operate on one patient for one referral source. They do well. Let me start bringing this up with my other patients. Again, like anything, you need to achieve this critical mass before it really takes off. The education needs to be focused more on referring providers than relying on. If you build it, they will come theory of setting up a practice which works for adults. We should have you going to visit more of our pediatrician practices like some of us do. I think that's probably right. They see one patient have a time that is going to be filling your... If only 99% of eligible patients are not coming to you, we are going to have a shortage of obesity surgeons when this gets us out. Other questions, comments? I had a elective that was all about obesity. It was something that you could take. That completely opened my eyes to this problem and the stigma is in the actual science behind it. Is there any effort to put that into medical school curriculums to change practitioners even before their pediatricians, before their family medicine that you are your team have made? Yeah, I'm not aware of anything specific. I think that, again, as obesity has now impacted, it's really the number one health problem in America. It's a preventable health problem. Cancer rates are high because someone is obese, heart disease, stroke. These are all things that are on the rise again because of the prevalence of obesity. I think that the medical schools are getting... I never heard of Grell and Orleptin when I was in medical school. They knew they existed but nobody ever really talked about them. But now everybody who gets out of medical school knows what those two hormones are. So I do think there is a little bit more obesity education. I think we've done a pretty good job in the adult population. I think most adult providers are aware that once somebody reaches this weight, we should be sending them. We should be bringing up the idea of weight loss surgery. We're not there in the pediatric population yet, as I mentioned. So Brian, outstanding talk. What I found was pretty striking is not only the impact that the surgery made, but also the 20% re-operation rate in the kids. Can you expand a little bit more in where these complications, where these issues with technical problems, where the operation had to be revised, or better effect, and also is there any impact in terms of surgeon and center volume? Because obviously that's pretty important to discuss with parents before they make that decision. Yeah, so I think that's the case. So like I said, if you look at the rate of gallbladder, or colceasectomies, which is one of the, would they consider you consider that a re-operation? And when you lose weight, you are more likely to develop colce tones. If I've taken the gallbladder out, used to be standard practice for when somebody got a gastric bypass, you took the gallbladder out at the same time. That was shown to have a little bit higher rate of complications. So now you only take it out if they develop an issue with it. But the colceasectomy rate was the same for adults versus adolescents. Now they were technical things that were a bit higher. Internal herniary was much higher in the adolescent center versus the adult centers. And I suspect that that is likely related to surgeon volume. So I do think that there's, I think that there's, that number I think is less of a reflection of having the surgery done as an adolescent, and perhaps more of a reflection of center volume. Because four out of the five centers were, were, it was a pediatric surgeon doing the operations. My question now that you have decades worth of data looking at the science of how the operation actually works, you stress compliance as well. We lift the forcing control those different things. So if that BMR goes down or is the body actually processing the 1800 calories a day differently so that it doesn't have the same impact on weight gain? Or are you just tricking the brain into not ingesting those calories? So it's, it's both. I mean, obviously physically you've got the restrictive component to it where you're just, you can't just fit as much food in. But there is, you know, Grellen gets its name. The reason why it's got this funny name, G-H-R, is that it, it triggers the release of growth hormone. It's the purpose of Grellen actually is to get somebody high Grellen levels reduce your ability to reproduce. So when your Grellen levels are high in your bloodstream, it means you're hungry. Evolutionarily that, that, that, you know, slows down your metabolism. It says, you know, hold dormant. Don't, don't have any babies. You know, wait till the long winter passes or the famine passes. And then, and then when the Grellen levels fall low again. Okay. So, so again, so what we see is that when we do these operations, the Grellen levels flatline, not only are they low, are they not high, they're lower than they are in a baseline population. So there is this, this sort of central, you know, revving up of the metabolism. If we go, I can show you the, one of the interesting things about that New York Times article, the New York Times graphics. So this patient, Rudy Paul's, he's the one who, he's the one in the yellow here. You see he gained weight and then he lost and then the metabolism went down. And then it went up. Rudy Paul's is the one person in that cohort who had weight loss surgery. He had a gastric bypass. So you see he gets this metabolic boost from getting, he's not, he's not where he started, but he gets this metabolic boost from having a gastric bypass. You know, he loses the weight. So, so there really is this, again, this, this metabolic component, both, both central and peripheral. The other thing that Grellen trips off is, Grellen is directly, Grellen levels directly tight insulin resistance in the body. So once your Grellen levels go down, your cells become almost instantaneously sensitive to insulin. So these patients who still have, you know, a functioning pancreas, it's not unusual for, for hours after the operation, a diabetic patient should be no longer diabetic, just before they lose a single ounce of weight. Brian, thank you for an excellent talk. I just have a quick fact question. Is it looking at your data? It would seem that with a gastric bypass, 40% of patients fail at 10 years. And with a gastrectomy, in fact, 50% fail. Are those, did that, so that's not a, so that's not the, look at back that table there, there. So this isn't, this is excess weight loss. So basically, again, to make the math easy, so a patient who's 100 pounds overweight at 10 years, the gastric bypass will have 60 pounds off at, this is just percent weight loss. So it's, this isn't failure rate. So I'm sorry, I still don't understand it, percent weight loss or percent. Percent excess weight loss. So how do you calculate excess weight? So again, that, that is why most of the studies now, we found, we have not found a good way or a way that we all agree on on how to chart weight loss. The New England, the New England Journal article uses just raw, pure weight loss, which is 20% weight loss. But think about somebody who's 600 pounds versus somebody who's 250 pounds, you know, the one who's 600 pounds is going to lose a larger portion of their weight than somebody who's 220 pounds. What we at BOSIMENTAL Center and some of the more higher volume places like to use is this idea of excess weight loss, which is, you know, how much you are overweight compared to the graph. Now the graph doesn't work, the graph is imperfect. You've got different body types, you've got different body compositions. But basically, you know, do you start healthy weighted to BMI of 19 or BMI of 25 or BMI of 23? But it gives us our best ballpark. And these are based on BMI of around 23. And just assuming that the body morphic data is the same for all comers, which it's not, you know, but on average with this, if you're, you know, this is excess weight loss. So if you're 250 pounds, you should be 150 pounds for your height, you're 100 pounds overweight. You'll keep 60 of those pounds off of the bypass. You'll keep 50 of those pounds off with a sleeve. So it doesn't answer the question. How many of these people will actually have a normal BMI? Nobody ever gets a normal BMI. I'm not going to say nobody, but it's very, very unusual. And one of the things that you get, you get in some of the physiology of obesity. Again, think of, think of this patient who is 600 pounds overweight. That patient is 600 pounds, the patient's 420 pounds overweight. If I gave you 420 pounds and said, carry this around every minute of the day for the rest of your life, you'd never be able to do it. But these people are doing it every day. They're getting up. They're walking. They're going to work. These people are, you know, for lack of a word, these are professional weightlifter endurance athletes. And so you develop this very heavy musculoskeletal core once you've been obese. So our patients will harp on this. Let's say, well, the chart says, I'm still overweight. You're not. You know, there's, we sort of hear, I'm not heavy. I'm just big bones. These patients are big bones. These patients have a very dense musculoskeletal core. Now, a lot of that goes away when they lose weight, but it doesn't entirely. One of the things that a lot of the medical providers like to do is look at closed sizes. So you may, you may see somebody, you may have a woman who's 170 pounds after this operation. The chart still says she's overweight, but she's wearing a size six. You know, simply because her core is heavier than that, it's never been overweight. Well, this clearly should go on forever, but we're already five minutes past the hour. And I think that's shows how much interest there is and how important it is what you do. So Brian, we thank you for your continued education for us. But more importantly, for leading our program and helping the kids. So thank you. Thank you. Thank you. Thank you.