Transforming Lives Through Pediatric Bariatric Surgery with Thomas Inge, MD, PhD

In this episode, Dr. Thomas Inge discusses his journey as a pioneer of pediatric bariatric surgery, which includes a more than 20-year commitment to providing surgical care for severely obese teenagers. He explains his long-term research project that has shown how bariatric surgery can improve the quality of life for young patients. He also details his vision of the department of surgery which is aligned with the hospital’s commitment to CARE: Clinical Excellence, Advocacy, Research and Education. 

“Part of this (surgery) that is really impactful is how these teenagers begin to feel in their own skin and how they navigate life after surgery. And what I mean by that is they really adopt a new lease on life and feel like a hundred-pound weight has been lifted and they feel like they can achieve anything.” 

Thomas Inge, MD, PhD
Surgeon-in-Chief; Chair, Department of Surgery
Director, Adolescent Bariatric Surgery Program
Lydia J. Fredrickson Board Designated Professorship in Pediatric Surgery
Professor of Surgery in the Division of Pediatric Surgery, Northwestern University Feinberg School of Medicine

Show notes

• Dr. Inge comes to the role of Surgeon-in-Chief of Lurie Children's Department of Surgery with decades of experience dedicated to improving adolescent bariatric surgery and advancing knowledge in the field of pediatric medicine.
• His path to pediatric surgery began during his general surgery residency at Stanford University where he saw first-hand that the people there that were taking care of kids and their surgical problems had a real passion for what they did, and enjoyed every day that they came into the hospital.
• As his career in pediatric surgery progressed, Dr. Inge focused on minimally invasive surgery and became acquainted with severely obese teenagers who at the time had very little access to bariatric surgical care. Dr. Inge joined a group of other surgeons who he says set out to right that wrong.
• Now, in his role at Lurie Children’s, Dr. Inge is bringing his knowledge and expertise to a place that he feels has a forward-thinking approach, dedication to research, and exceptional team. Dr. Inge also sees Lure Children's as an ideal place to provide cutting-edge care and training for future leaders in pediatric surgery.
• His vision for the department aligns with Lurie Children's overall commitment to "CARE," which stands for Clinical Excellence, Advocacy, Research and Education.
• As a pioneer of pediatric bariatric surgery, Inge has not only operated on this specific group of patients for more than 20 years, he has also studied them through the Teen Longitudinal Assessment of Bariatric Surgery (Teen Labs) Study. This study is a long-term research effort led by Dr. Inge, assessing the outcomes of bariatric surgery on teenagers. It has provided vital data that has changed perceptions about pediatric bariatric surgery, making it more commonplace. He says the number of freestanding children's hospitals performing adolescent bariatric surgery has doubled over the last decade.
• Unfortunately, pediatric obesity has been on the rise and seems to have been worsened by the COVID-19 pandemic. Dr. Inge applauded the advocacy efforts of the American Academy of Pediatrics, which recently released new guidelines on the treatment of pediatric obesity that support both pharmacotherapy and bariatric surgery as viable treatment options.
• Dr. Inge emphasized that lifestyle changes and healthy habits are essential to the long term success of his patients. He says pharmacotherapy and bariatric surgery should be thought of as tools, but powerful tools that can lead to improved quality of life for patients. 

Transcript 

[00:00:00] Erin Spain, MS: This is Precision, Perspectives on Children's Surgery, from Ann and Robert H. Lurie Children's Hospital of Chicago. I'm your host, Erin Spain. On this podcast, we introduce you to surgeons at one of the country's most renowned children's hospitals to find out how they're transforming pediatric medicine. Today's guest has spent his career improving the art of adolescent bariatric surgery and pushing the boundaries of knowledge in the field. Dr. Thomas Inge is leading the Lurie Children's Department of Surgery as Surgeon in Chief. He joins me today to talk about his vision for the future of the department and his subspecialty, pediatric bariatric surgery. Welcome to the show. 

[00:00:51] Thomas Inge, MD, PhD: Oh, thanks, Erin, for having me.

[00:00:52] Erin Spain, MS: Share with me your path to pediatric surgery and to Lurie Children's. 

[00:00:57] Thomas Inge, MD, PhD: Yeah, thanks for the question. I first became interested in pediatric surgery when I was a general surgery resident at Stanford University. You know, you have people that influence your decisions in life. I really saw the people there that were taking care of kids and their surgical problems as having a real passion for what they did, and enjoying every day that they came into the hospital. So I said, you know, that's kind of a profession there that I think I could get into and not feel like I had any work at all. The job that's work is not as pleasant as the job that really is just something that you can enjoy every day. So that's how I found my way into pediatric surgery. Once I started my first real job at Cincinnati Children's as a faculty member there, I realized that I enjoyed minimally invasive surgery and I became acquainted with a patient group that really was getting very little of the surgical care they needed and that was a group of severely obese teenagers. So we set out to right that wrong and give them access to surgical care that I think in retrospect we now know they really desperately needed. 

[00:02:02] Erin Spain, MS: Tell me about your path specifically to Lurie Children's. Why did you decide to come here to lead this department? 

[00:02:08] Thomas Inge, MD, PhD: I came to Lurie Children's because I saw an organization that was on a journey that was very aligned with my own. I really do feel like there are very few children's hospitals. that are so forward thinking about so many areas of care and research that are needed today and when I looked at the possibilities here and I looked at the dedicated people in surgery, in and outside of surgery I'd have to say, I was really amazed and I think that when it comes to providing state of the art care, great training programs, and a place that is really leaning into how can we learn more about the diseases that we treat and care about? How can we improve the outcomes better so that the kids of tomorrow will have something better than we were able to offer last year? I felt like there was none better than Lurie Children's as a place to do that. 

[00:03:02] Erin Spain, MS: You mentioned the people at Lurie Children's. We've had several of the leaders from the Department of Surgery on this podcast, and this is really an incredible group. Describe these extraordinary people to me and the team that has been assembled here in the Department of Surgery. 

[00:03:19] Thomas Inge, MD, PhD: So, we have about 85 surgeons on the faculty here in the department, and of course, then there are many times the number of additional people that are dedicated to taking care of the surgical patients in the department, be it nurses, advanced practice providers, and an incredible staff that also is the folks that Make it possible to do what we do on the front lines. We have trainees here who come and bring their own talents. Certainly they come to learn specific things, but bring their own talents and passions for taking care of kids and learning how to carry forward the Lurie way. It's the people, the dedication, far more than the bricks and mortar, the building. Beautiful building, not taking anything away from that. But here, like elsewhere, really, it's the people that matter the most and what they bring to the job every day. They bring that real caring attitude and really a family centered focus. 

[00:04:17] Erin Spain, MS: You mentioned before that there's a lot of opportunity here at Lurie Children's. Tell me about your vision for the department now and in the future. 

[00:04:26] Thomas Inge, MD, PhD: The vision for the department is really to align with the vision for the institution. And I think that that is most succinctly summarized. By the word care, C is the clinical excellence that we bring to our patients. A is the advocacy that we all are responsible for, for the patients that have both common diseases as well as, in particular, the more rare problems. R is for research. I think that the mission of all of the elite children's hospitals in the country that can afford to take the steps necessary to discover cures and, again, make the world better for the kids that we serve have a real responsibility to do so. And then the E part of CARE is really the education that we provide. We want to be the major force in providing really a place where leaders of tomorrow will be educated and trained, and that really is the story of this hospital over the decades. So I'm very proud to be here, I'm very proud to really be able to push for and advocate for and support our ability to perform for surgical diseases and surgical patients along all of those main mission areas of the CARE paradigm. 

[00:05:49] Erin Spain, MS: You really embody that CARE acronym in so many ways. I want to dive into your story and how you've really been an advocate in the area of pediatric bariatric surgery. So when you started, about 20 years ago, surgery and multidisciplinary treatment programs for obesity and pediatrics, that really wasn't something that people thought about. But as you said, you saw a need for this type of care. Tell me about how you embarked on this and really helped to define pediatric obesity care as a subspecialty.

[00:06:21] Thomas Inge, MD, PhD: I finished my fellowship in 2000, and at that time, the obesity epidemic in pediatric age groups was certainly appreciated. At that point, there were, you know, somewhere around 18 to 20 percent of all kids. had a weight that placed them at risk, a weight that put them into the category of obesity. There were a few of them that even had really higher weights, weights that would get them into a category we call severe obesity. And this is really about 15 million individuals when we're talking about nationwide prevalence of obesity. The number of multidisciplinary programs at that time that would treat obesity in Pediatric Hospitals was very few, just a handful maybe of big well developed programs and scarcely even one per state, I would say less than one per state. So when we delve in deeper again and look at the extremes of obesity, there were really no children's hospitals that had a surgical treatment option. And why does that matter? Well, it matters because surgery is the only modality that has a real significant and long term durable solution for kids with severe obesity. When we started to realize that and realized that these kids were suffering, mostly teenagers, were suffering with adult like diseases, for instance type 2 diabetes, and we realized that the adult medical establishment had figured it out and figured out that surgery will reverse. diabetes, we really said, well, enough is enough. We can't have patients that are within our care and our capability that we launch into adulthood with these terrible diseases like sleep apnea and type 2 diabetes, high blood pressure, that are effectively reversible in their teenage years. And so, we're going to get the powers that be together. We'll have a consensus conference and determine what are the necessary steps and processes and prerequisites for children's hospitals that want to offer weight loss surgery for teenagers with severe obesity.

[00:08:33] Erin Spain, MS: And you are an outcomes researcher as well, and you were able to look at this through the lens of research with the Teen Longitudinal Assessment of Bariatric Surgery study that you led, and this really documented and showed key outcomes. Tell me about some of those outcomes over the years and how you were able to really show folks who showed some resistance to doing bariatric surgery in teens, how this study was able to really help validate this surgery as an option.

[00:09:02] Thomas Inge, MD, PhD: Right. So, Erin, just before I do that, I'll tell you though, and brag on the team a little bit. So this study called Teen Longitudinal Assessment of Bariatric Surgery, or Teen Labs as we call it for short, really was a coming together of a number of like minded individuals. at other institutions, so myself, Mary Brandt down in Houston, as well as Mark Michalski in Nationwide, Anita Corcorus in Pittsburgh, as well as Mike Helmrath in Cincinnati, Mac Harmon in Birmingham, all came together as pediatric surgeons and we said, we all have a passion for taking care of kids, we want to take care of this patient population, let's get together and let's put together, the best possible long term outcome study to tell us what happens over a decade. So we want to know not just what happens at one month or six months or one year, we want to know what happens a decade later. We want to tell the good and the bad. If there's bad to be described, what are those risks of surgery that you might not otherwise know about if you don't study? patients long term. So we approached the National Institutes of Health with this idea and after multiple discussions, they too were interested. We submitted a grant to get funding to fund this study. As it turns out, it was not just one grant. But it was three grants and so we were funded in 2006 and continue the study and actually we're wrapping the study up this year after 17 years in 2023. What we've been able to find in the teen lab study are a number of things and you mentioned the idea of using data to change minds and attitudes and convince the non-believers and I think that that is a really important point that we... all focus on in medicine, and particularly in areas that are not as commonly used, like bariatric surgery for teenagers. But the point being that we rigorously collected data at baseline and then annually thereafter to demonstrate the effectiveness of the surgery. I'll also brag a little bit about the study group, the participants in the study, who stuck with us over this decade, really 90 percent of the group. that we originally recruited has maintained contact with us and really the number of visits that they've completed now is really pretty phenomenal, about 85 percent visit completion rate. So with that kind of data, you can actually be pretty confident that you're not missing key components of the study group. and making misinterpretations from the data. What we were able to find is that there is a major weight loss that happens early on and it's by and large durable over the long haul. I'm talking about 25 percent weight loss at one or two years and then about 21 percent at 10 years. And so, excited about the fact that these interventions are not just a short term fix. They do seem to have long term durability. And within that, some of the teenagers who have overperformed, some who are, you know, less than the average in terms of weight loss, but that's the real power then of the analyses we do to try to sort out what are the predictors of those that are going to do very well. What are the predictors of those that are going to average and what are the predictors that are going to be doing below average in terms of their long term weight loss? 

[00:12:26] Erin Spain, MS: Having this data is really important now because the problem of obesity in children and teens has only continued to grow in the recent decades and it even worsened during the COVID- 19 pandemic. Can you just explain what's the state of obesity in American children and teens today? 

[00:12:44] Thomas Inge, MD, PhD: So, the number of freestanding children's hospitals performing adolescent bariatric surgery has really doubled over the last decade. The number of participating hospitals in this group is now 20 out of 46 reporting, so that's almost half. Well, a decade ago, there were only 11 out of the 46. The case volumes currently, this is as of 2022, in these freestanding children's hospitals. are about 500 per year, and that's up from the year 2020, just two years prior, where 300 were done. So I think along with the fact that we know the COVID pandemic led to a lot of people not getting out and being physically active, it also contributed, unfortunately, to the obesity epidemic because we saw the weights, particularly the weights of patients with obesity rise dramatically. And I think that what you're seeing in response here is that children's hospitals stepped up to the plate, the surgeons and the care teams in those hospitals stepped up and really took this on as a real challenge and are offering surgical care to these patients. 

[00:13:52] Erin Spain, MS: Tell me about the Pediatric Bariatric Surgery Program at Lurie Children's.

[00:13:56] Thomas Inge, MD, PhD: The Bariatric Surgery Program at Lurie Children's is a fully mature and multidisciplinary program that has at its core a surgical procedure for severe obesity, but it has, importantly, all of those individuals that form the care team that make a surgical procedure successful. And that includes a dietitian with special expertise in both bariatrics as well as taking care of youth. It also includes an obesity medicine physician who's also a pediatrician and can offer, for instance, the most modern of drug treatments for obesity in addition to being a strong advocate for lifestyle intervention. We have a nurse practitioner 100 percent dedicated to the program. As well as a psychologist who really helps us to understand sometimes the complexities that are not obvious at the surface. What are the kinds of things that may be yet to be discovered that may impact success or coping after surgery. We have an RN dedicated to the program as well as a program coordinator just to round out the multidisciplinary team. I think that this team is important because everyone has their own specific lens and can provide in the team meetings insights to help us take care of the whole patient and the whole family in the process of addressing this very challenging problem of severe obesity.

[00:15:27] Erin Spain, MS: You mentioned before in your study, in the teen lab study, you're able to follow these patients and follow their successes, but what does a patient have to do to be successful after bariatric surgery and maintain a healthy weight? What have you found? 

[00:15:42] Thomas Inge, MD, PhD: Yeah, so when we're talking to families and patients, we really talk about the surgery in terms of a tool. It's not a tool that they'll get in a box with instructions that You might lose over time, but because the surgery actually is almost like an implant, you know, it's a rearrangement of sorts of anatomy, and so the tool is never lost, but what's important that we focus on is the instructions for using that tool are really important. What I mean by that is it requires attention to good nutrition afterwards. It requires attention to good, healthy physical activity afterwards. And that's not just to make sweat or to raise your heart rate. It's because we want healthy muscles. There is a growing body of literature that tells us that healthy muscles produce endocrine signals in and of themselves that help with maintaining weight loss. And so when we look at healthy eating, healthy activity, those are the two main centerpieces for using the tool. What we also realize though is that there's an emerging literature about some of the other things we do within our lifestyles, and that are things like sleep habits and sleep hygiene. And so this concept of the circadian rhythms that are based on our sleep wake cycle and how they can contribute to weight gain or appetite when they're, for instance, having a lot of variability in late up at night and trying to sleep during the day. So sleep hygiene is a really important concept as well and we're beginning to know more and more about it. So it, again, is important to take vitamins and minerals that we are not getting in sufficient quantities in our diet as well after bariatric surgery, and we're not getting them in sufficient quantities because the meal size is really much smaller than usual. So all of these things and more are part of the curriculum, if you will, for what I call surgery school. We put the whole family through surgery school in an effort to really talk to them about how to use this tool called surgery, and how to use it over the long haul, taking advantage of that first year or two when the weight loss actually just happens. Almost irregardless of what the patient does, that weight loss is going to happen, and use that period of time where you really do feel good about yourself, you really do feel good about the weight loss, to begin to practice all of these good habits for long term success. 

[00:18:14] Erin Spain, MS: I'm sure you have seen some pretty amazing success stories from your patients. Do you mind just sharing what it's like to really see lives transform through the surgeries that you're able to provide? 

[00:18:27] Thomas Inge, MD, PhD: Yes, it is amazing to see and part of what has been my joy in practice of surgery for my career. And that is to be able to take a complex problem or set of problems, because many of these patients, you know, when you look at their problem list in their medical records, it's, more than you can count on two hands, problems that are related to obesity. So, surgeons commonly say, you know, it's really nice to work with our anesthesia colleagues and other team members and have an hour in the operating room and be able to remedy a dozen medical problems. While that's a little bit of hyperbole, it's not as well, because what is so rewarding about this for the patients as well as for the team, that you can have an awful problem like type 2 diabetes that is going to lead to blindness, kidney diseases, and even microvascular diseases, cardiovascular diseases. You can take that disease of type 2 diabetes and you can reverse it and you can give patients the hope. of really not having all of those problems that are the consequences, the complications of diabetes happen to them. You can take a patient that has sleep apnea that might not get any good night's rest throughout the week, but broken up sleep because of these crisis episodes that are occurring all night long in sleep apnea, and you can reverse that within a month of surgery. So that they're able to have a fresh night's sleep, they're able to think clearly the next day without having just inordinate sleepiness during the next day. And they're able to learn better. We know that when we effectively treat sleep apnea, patients can attain far better scholarly achievement when it comes to just actual heart outcomes and learning outcomes. So it is pretty fascinating to see, it's pretty fascinating to research in terms of what is the real magic of surgery that allows a patient to have surgery and then maintain that weight loss when virtually no other treatment modality available can result in that long term success. 

[00:20:39] Erin Spain, MS: There's been a lot of media attention on the American Academy of Pediatrics guidelines related to the treatment of obesity that involve when and why interventions such as weight loss medication and bariatric surgery should be offered to patients. What are your thoughts on these most recent recommendations? 

[00:20:56] Thomas Inge, MD, PhD: Yeah, thanks for asking about that, and this is a great example of the A in care, that's advocacy, and the American Academy of Pediatrics is all about advocacy, it's all about creating evidence based guidelines, and we were very pleased to see this year, very early this year, that the American Academy of Pediatrics actually published A new clinical practice guideline that spoke directly to how to treat kids and teenagers with obesity. So inclusive in that very comprehensive guideline, of course, was dedicated sections about the pharmacotherapy of obesity and about surgery for obesity. I'll have to say that pharmacotherapy for obesity is advancing. So, we've seen now over the last 20 years... The transition from what I would say first generation drugs, which were virtually ineffective for obesity and had their own set of adverse effects, to second generation drugs, which we continue to use today. And now, really over the past 18 months or so, we've seen the emergence of a third generation of very effective obesity drug therapy. And so it was really nice to see that the AAP called this out particularly and said, you know what? It's okay to treat with these drugs this condition of pediatric obesity, this not just a condition, but a disease. And from a very conservative organization with a long history, this was really pretty impactful. And so I do believe that the story is yet to be completely told with regard to the drug treatment. And it really has raised in us this need to compare head to head drug therapy to surgery. And so we're in the process now of designing a study with my research partner, Justin Ryder, a study to do just that, look at the most powerful of third generation anti obesity pharmacotherapy and compare it to vertical sleeve gastrectomy. So the AAP also fully endorses surgery for the treatment of severe obesity and made that again re-emphasis the need for surgery. in this latest guideline. 

[00:23:06] Erin Spain, MS: Anything else that you want to add that we didn't mention that you think it's important to mention?

[00:23:11] Thomas Inge, MD, PhD: You know, we've talked a lot in terms of disease outcomes and I think that it's really important to call out the other part of this that is really impactful is how these teenagers begin to feel in their own skin and how they navigate life after surgery. And what I mean by that is they really adopt a new lease on life and feel like a hundred pound weight has been lifted and they feel like they can achieve anything. And that really, I think, speaks to the most powerful reason why patients come to us. They can't tell often that they've got high blood pressure or that their lipids are up. What they can feel, though, is the way they're treated. And they feel marginalized, they feel ridiculed. High school can be a very cruel place. After the surgery, they really take on a new persona sometimes. And really feel like the quality of their life is just enormously better. And that's what our research has shown us as well. And the quality of life can be measured in many different ways, but certainly developing relationships, developing career plans, and having that thought of, you know, one of these days, I'm gonna be able to accomplish whatever I want to accomplish, is the real understanding that they get over time. And it's really nice to see that metamorphosis.

[00:24:30] Erin Spain, MS: Well, thank you so much for coming on the show and talking not only about the department and your vision for the department, but the important work that you're doing. And we look forward to these new studies on the horizon. 

[00:24:41] Thomas Inge, MD, PhD: Okay. Well, thanks, Erin. 

[00:24:45] Erin Spain, MS: For more information, including how to make a referral or an appointment, visit luriechildren's.org.