Centers for Medicare and Medicaid Services’ Decision to Nix Accreditation Requirement a Major Setback to Our Patients, Specialty, and Society

| October 21, 2013

Dear Readers:
Welcome to another great edition of Bariatric Times. In this month’s “Checklists in Bariatric Surgery,” I decided to include the Cleveland Clinic Florida classification of what we call “reoperative surgery.” Most people still call those “revisions,” but as you read the column you will see what we mean as we have grouped them under the name of “reoperations.” We have to differentiate the revisions from conversions and reversals because their indications and outcomes are different. While reversals are always due to complications, revisions and conversions can be related to both complications and failures.

Two years ago, I urged our leadership to develop some guidelines so that medical directors can better understand this conundrum and stop denying a revision, which they considered a second bariatric procedure, for a bleeding marginal ulceration and gastrogastric fistula. In addition, if we divide them as we suggest in these guidelines, we will be able to better collect and interpret the data. I am glad to report that our voices have been heard. Dr. John Morton, American Society for Metabolic and Bariatric Surgery (ASMBS) President-Elect, is chairing a “revisions” committee (wrong term) that will hopefully help us streamline this growing aspect of our practice. I take this opportunity to congratulate Dr. Morton and wish him best of luck in his year as President-Elect.

Dr. Warren Huberman reviews the definition and patients’ perception of “success after bariatric surgery.” Personally, this has been a hot topic of discussion since it will also provide us with guidance on when to reoperate in order to revise or convert a bariatric procedure. Lately, there has been a trend to refer to a patient as a “nonresponder” when expectations of weight loss or remission of comorbidities are not achieved. I believe this is done to remove the word “failure” from patients’ and caregivers’ vocabulary. Both failure and success need to be clearly defined. In addition to Dr. Huberman’s definition of success, I would like to add, as a surgeon, that at least 50-percent “sustained” excess weight loss (EWL) at two years, with remission or improvement of comorbidities as well as improved quality of life, can be seen as a good definition of success.

We also congratulate the team at the Center for Surgical Weight Management at Gwinnett Medical Center Duluth on their excellent bariatric center in Duluth, Georgia. If you haven’t done so, please contact us to see how your center can be featured in an upcoming installment of “Bariatric Center Spotlight.” We want to know who you are and what are you focusing on in your bariatric practice.

By now, the Centers for Medicare and Medicaid Services (CMS) decision to drop Centers of Excellence (COE) and/or accreditation in bariatric surgery is no longer news to you. In my opinion, this is a major set back for our patients, our specialty, and our society. It hurts to see that after so many years of hard work in making bariatric surgery one of the safest specialties in surgery, CMS would drop our accreditation so easily. I disagree with the decision and believe it will damage not only bariatric centers but ultimately our bariatric patients. Time will tell how many patients will get hurt, how many will need reoperations, and when our specialty and society will regain the well-deserved respect. We move on!

In this month’s “Let’s Get Real,” Dr. Walter Pories shares an interesting perspective on current treatment modalities of diabetes. He wonders whether we should still be giving insulin to individuals with type 2 diabetes who are figuratively “swimming” in insulin and asks, “Why not surgery?” Sometimes in medicine, we stick to treatment modalities for decades until we find that we were doing the opposite of what we should have been doing. A clear example of this is the use of steroids in head trauma patients. In the past, it was a must and today it is a must not. I was privileged to participate in a study recently published in Surgery of Obesity and Related Diseases (SOARD) by Park et al that looked at the resolution of diabetes mellitus (DM) in lean patients undergoing Billroth I (BI) or Bilroth II (BII) resections. While both had a considerable improvement, the BII population had a higher remission rate and a significantly longer lasting period. This supports Rubino’s foregut theory.

Also in this issue, Drs. Park and Kim share the case of a patient with advanced stage renal failure. After undergoing Roux-en-Y gastric bypass and rapid weight loss, the patient improved and was able to go off dialysis. Our theory why this happens is similar to the one observed in acute abdominal compartment syndrome—increased intraabdominal pressure resulting in increased intracranial pressure that will result in increased release of vasopressin and decreased urine output. Vassopressin is known as a major vasoconstrictor observed in patients with abdominal compartment syndrome and pseudotumor cerebri patients and is most likely the reason for oliganuria.

I just returned from the 99th Annual Clinical Congress of the American College of Surgeons (ACS) in Washington, DC. The meeting was, as always, an outstanding one. Unfortunately, the city was paralyzed due to the current government shutdown and there was not much to do for those who planned a long family weekend visiting museums and monuments.

While the ACS celebrates its 100-year anniversary, we at ASMBS will celebrate our 30th birthday pretty soon. Make your travel plans and join us at Obesity Week in Atlanta, Georgia, to learn and to have some fun. And don’t forget to get your tickets to the L.E.A.D. (Leadership, Education, Advancement, and Dedication to the Field of Bariatric Surgery) luncheon and awards ceremony Tuesday, November 12, 2013.

Sincerely,

Raul J. Rosenthal, MD, FACS
Editor, Bariatric Times

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