So we've got, um, this has been great in terms of the research and we can continue to discuss it, but we can actually feed in some of the questions from the chat as well, um, and, uh, and kind of just, this will be kind of a round-robin smorgasbord people can, you know, chime in. Um, but, uh, I think that, that the one question from, uh, uh, pretty long ago in the, in the session was, um, you know, uh, how how pediatric surgeons at Freestanding Children's Hospitals completed case volume requirements for accreditation. Um, and this, uh, this, uh, writer was questioning 150 cases with 50 anastomotic, um, you know, uh, cases, uh, partnering with adult credit centers. Uh, Evan, you had some thoughts on that? Accreditation criteria. Yeah, yeah. So, you know, and I've actually, like when I was at NYU I was part of a, an adult center and then start my own free-standing children's hospital center, and I think both pathways are great and I think both pathways can work. Um, for the freestanding centers, the criteria are actually fairly minimal, which I think I mentioned in my talk, which are 100 lifetime cases, 75 of which can be during a, um, During, uh, your fellowship training and then 20 a year, um, if you're gonna be, uh, partnered with an adult program, the adult, and that's to be the MBS director or to be the, um, a verified MBS surgeon, if you're gonna partner with an adult program, you don't have to worry about it because your, your adult guys are gonna be the verified guys and you can just, you know, you can just do and be, and I think that actually in some ways has a lot of advantages in terms of. Uh, a transition of care and revisional surgery, etc. Um, so those are some of the limitations of the free-standing places, but, um, Yeah, I think that the criteria are not as bad as they seem. And if you have questions about that, you can just go to the ASM, the NBSA Quip website where all they're all listed. I think they were dropped to 15 a year for Pete Cents. Yeah, I also think if, if you, if you partner with an adult surgeon until you're, you're at your 100 cases, then you can just, you know, and you're up to 15 in your program, then you're all set. So, um, it's really, it should be 1 or 2 years or, or even 3 with an adult surgeon, and then, um, and then you can get, you know, go on your own. Can I ask a oops, no. Can I ask a business question? So like free-standing children's hospitals, reimbursement for procedures, you know, everything in pediatrics is reimbursed generally. I'm, I'm generalizing about 3 compared to what the adults get. And so how do, how do we How do we address that so that like we can't, there is better access and the freestanding centers can survive. So this is part of why I've gotten out of medi out of clinical medicine and trying to help others. So that, that what you just said actually isn't true. It's not OK. It's true that your hospital leadership negotiates. Payment with insurance companies and often sacrifices, if you're, especially if you're at a combined adult and pediatric place, they sacrifice the pediatric reimbursement. Or if you're in a freestanding children's hospital. You know, I learned in my particular case, they sac with Cigna, they sacrificed my services for the cardiac surgery procedures. However, on the flip side, my Medicaid's all reimbursed about 50% of facility fees. My average was 40%. across all patients and my professional fees were something like 20 to 30% but the, the key is, is making that those of like Tom and Mark who are actually high up in Dave who are high up in their institutions can speak about this maybe as well. The key is, is getting the people at the who are counting the beans to understand that 50% reimbursement for facility fees is great, um, actually, far better than a lot of the private payers in the DC area. And it goes back to what Kenneka was saying to Kenneka before. You have to go talk to these people and advocate and tell them why they should pay you more, um, and then, you know. Every sleep study gets a facility fee. Every radiology test gets a facility fee. Every lab test gets a facility fee. And when you can finally get the bean counters to understand that the overall payment for these patients is huge, and that's why there are a bunch of adult hospitals that live on their bariatric programs. They just have to get out of their pediatric mindset. Evan, while, while, while this is fascinating and, and businesses, we could talk for hours, uh, the program is more clinical and the, the business stuff is so regional and, and site-specific that it's not gonna be a generalizable, you know, help to people looking at this. So I think we should just take it back to clinical questions that are, um, you know, that bands, for instance. People are still asking about bands. We published 5 year data. We're about to publish 10 year data. Bands do seem to have some modest weight loss early on, and then at 5 and 10 years, regain and replacement explantation is the rule for teenagers. It never was FDA approved for teenagers either. Other questions that have come up about simulation training, um, is there simulation training so that people that are getting on their learning curve, want to contribute in this area, are able to do so, um, and, uh, and, and do so safely. Certainly, the simulation with an, you know, an experienced surgeon uh by your side is a time-honored answer to that question, but just throwing it out there. The robot has an excellent simulator that you can spend hours on, and in fact, when I learned robotic surgery at, uh, you know, over 50, I, I spent 20 hours on the simulator before I got on a patient. So, um, and really it was a matter of learning the skills and, and it was very good. There's also FLS, um, you know, but if you're already a pediatric surgeon already doing bariatric surgery, I agree totally with Tom. The key is, uh, is someone in the OR with you or shadowing someone in their OR, um, and I think that's, that's the key. Anybody know anything about the microbiota influencing outcomes, uh, any good data? So, we, I have a study going on at the NIH in our patients, uh, looking at that, uh, actually, the study is probably complete, you know, and they're cranking through the data. You know, it's always, it's so hard to, um, So hard to separate cause and effect when you're talking about the microbiome, um, and it certainly does change after we in adolescence, um, and it certainly does change for the better in terms of fermiculates and the other, um. Uh, species you want in your microbiome, uh, to be healthier, but no one, I mean, it's gonna be like nearly impossible unless we start doing fecal transplants, uh, to figure out whether that's because of the surgery and the weight loss, or that's the way the weight loss is working. I mean, the weight loss surgery is working. Um, the, the, uh, it's, it's, and even the adult data, they can't, you know, separate those two things out. So, I think. You know, that's another one of Justin's hot topics that can, uh, can go in the research world, but uh it's a really difficult study to do. Um, I, I think it's showing things though in weight gain, the initial sort of weight gain, right? As we're seeing that, particularly something just came out about the non-nutritive sweeteners and how they're actually, those people, that doesn't decrease your weight. Like it actually. Increases weight gain as well. So sugar drinks and the non-nutritious sweetener. So, and they're thinking that that's a piece of that. So I think that's all coming, but that goes back to sort of the obesogenic environment and all the changes we made along the way that are making the problem worse. So, we're 4 minutes to time. Um, you know, I think we've covered a great deal of material here, um, really some great discussion too. Um, just real quick, anybody wanna make any predictions for 2024, 2025? What's gonna be the next, next big thing? What do we need to be keeping our eyes on? Let's start with Mark. I, I'm gonna try a robotic sleeve gastrectomy. Love it. Taika. I'm actually, so Jamie, I am going to Mark Mowski's, uh, I'm gonna go watch Mark do one down at Nationwide. I'm gonna take a road trip and go watch him do one. Mika, what's, what's happening new? What's, what's gonna be the next latest and greatest? I was just so excited to hear everybody talking about equity and diversity because 20 years ago, uh, you guys probably don't remember some of you, we, there were talks that were given. And the, one of the reasons I think I got into this field was because of my research in, um, pediatric um disparities. And it was such a huge disparity between the kids. That were getting bariatric surgery and the kids that needed bariatric surgery and I was so upset about it and I'm just so happy that we're all tuning into that and cluing into that and, and making a difference in that stage so I, I couldn't be happier right now. Perfect, David De Manish. Yes, go ahead. Uh, 2 things. I, I honestly, um, one of my takeaway home, take home points from this is that You know, 500 cases, it's, it's not even moving the needle, right? I, I hope that in the years to come, we'll be thinking about how we can intervene sooner with maybe uh different alternative types of surgery as well as medications in combination. Uh, and as far as the robot, I've been fortunate to, to be using the robot for, for 20 years. Um, I, it has kind of, uh, fallen away because, uh, I was initially turned off by the 8 millimeter instruments for the XI, but the quality of the, the AMR and the instruments and the staplers are so much better. I did go see someone do 4 cases, 4 bariatric cases, an adult surgeon, by 11 o'clock with 2 rooms flipping. So that's where the puck is going to go. We need to skate to it. Denise, what are you thinking? I, I think, I think the, the influence of pharmacologics is gonna be the big story of the next couple of years because I think that the pharmaceutical industry has a lot of interest in proving that this is the best possible method of, of, of treating this particular disease, uh, and I, I also think it's a partnership, isn't it? Yeah. And I, but I also think that a lot of the endoscopic procedures are interesting. Um, and I think that there's obviously a thirst for figuring out ways of treating obesity that don't necessarily involve surgery per se, even though an endoscopic procedure is You know, technically, it's a it's a surgical procedure, but an endoscopic one. And I think that those competing interests might be interesting for those of us who, you know, who, who practice bariatric surgery, and I think we're gonna have to be adaptable. And I just want to point out again that uh we, we thank our sponsors. We got sponsors that are innovating and engineering things to make our work better and to make our patients, uh, our, our work product better. So, uh, visit sponsors and um if you, if you like what you see, give it a try. Um, any other thoughts? You didn't give me, you didn't ask me my, my, well, you've been talking so much. I was, I was, I was, no, but I'm gonna make the most controversial. I was gonna make the most controversial comment, so maybe I don't have to make the most controversial prediction. No, I just, I, I think that, um. Really, we all need to uh use our influence to really push, um, Just medical schools and teaching about the disease of obesity, um, you know, again, if we're ever gonna make a dent in weight bias and stigma, we, we need, we need it to be in our own profession, like recognized as something to study in pathophys and, you know, again, and some med schools are doing a great job, but the vast majority are not, and Um, so we're never gonna make any movement on a societal level if we don't at least start trying to push and use our influence to start within our own profession. All right, Mark, I just wanna give the most common, the most controversial comment. It's gonna stir up the most conversation. Trick Mahomes is gonna supplant Tom Brady as the GOAT in the next few years. That is the biggest prediction that I have here. Mahomes is gonna win it in 2 weeks, and he's gonna pass Brady and be the GOAT. Yeah, there you go. Do you have anything, Steph? No, I'm, yeah, thank you everybody so much. This has been so great. Yeah, every faculty, thank you so much. Thank you to the audience for tuning in. Thank you to Laurie Children's, uh, Procare Consultants, and Akron Children's, and Uh, and certainly you have to call out, uh, Isla and Carolyn for, uh, all the great work they did behind the scenes to make this happen. Yeah, and nobody even knew Isla like lost power at our house, and yet the show went on. It was all great. But uh thank you, everybody, and thank you to Medtronic and uh Teleflex. All right. Have a good day. Thank you.
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