Introducing “Ask the Leadership.” This month ASMBS President-Elect Dr. Ninh Nguyen Discusses the Controversy Surrounding Accredited Bariatric Centers

| March 18, 2013

Dear friends, colleagues, and readers of Bariatric Times:

With the advent of laparoscopic sleeve gastrectomy (LSG) and the previous popularity and, in my opinion, excessive use of laparoscoping adjustable gastric banding (LAGB), we have seen a large number of gastric bands being removed and converted to either a Roux-em-Y gastric bypass (RYGB) or LSG. In this month’s installment of “Surgical Pearls: Techniques in Bariatric Surgery,” Dr. Natan Zundel presents the main steps in performing a conversion of an LAGB to a GBP. In our experience, weight loss is superior when an LAGB is converted to RYGB rather than LSG. Nevertheless, a significant amount of patients are requesting the LSG as an option and we are lacking the scientific evidence to deny or support their choices. The fact is that removing and converting a band to either procedure is a complex operation. In a significant amount of cases a hiatal hernia is present and needs to be repaired. In addition, the plication must be taken down and the capsule formed around the band must (in my opinion) be removed. The latter is a very important step since the capsule will interfere with staple formation and increase the incidence of leaks. Surgeons in Europe take a different approach in dealing with the capsule and they do the operation in two steps instead. First, they remove the band and then they do the bypass or sleeve 3 to 6 months later hoping that by then the capsule will be thinner. In America our healthcare system will not approve a third operation if it can be avoided and it has been our experience that patients do great with a one-step approach, removing the capsule and using green cartridges instead. Another important factor to keep in mind is the preoperative esophagogastroduodenoscopy (EGD) and fluid removal from the band. We must rule out erosion. In those cases, I absolutely favor a two-step approach.

Also in this issue, we present an interview with Executive Director of The Obesity Society (TOS), Francesca Dea. Here, she gives us a preview of Obesity Week 2013 and discusses what it will offer to the bariatric community. Please start marking your calendars for this event, which will take place November 11 to 16, 2013 in Atlanta, Georgia.

Silvia Leite Faria et al presents an interesting article recommending the amount of carbohydrates allowed in the diet of our bariatric patients. Yes, you heard this right—carbohydrates are allowed in the human diet.
In this month’s Anesthetic Aspects of Bariatric Surgery, Drs. Nicholas Wasson and Stephanie Jones review the technical pitfalls of percutaneous tracheostomy in bariatric patients. I am glad we have not needed tracheostomies for the last 3 to 5 years.

Diane Weiman, an exercise specialist in Maryland, gives us a wonderful overview of the value of exercise after bariatric operations. Although the science does not show that exercise alone as an intervention prevents obesity, I am still convinced that our problem is the lack of mobility in conjunction with processed food.

Lastly in this issue, we introduce a new column titled “Ask the Leadership” in which I ask leaders within the American Society for Metabolic and Bariatric Surgery (ASMBS) questions that many of you may want to ask or believe should be asked. For our debut installment, I interview ASMBS President-Elect Dr. Ninh Nguyen. There is a perception amongst some bariatric surgeons that the concept of having an accredited center with team members who specialize in one disease process, such as obesity, is not beneficial to our patients. Their conclusions, recently published in the Journal of the American Medical Association (JAMA)[1] are, in my opinion, incorrect and shortsighted. The outcomes of bariatric surgery are not measured only by complications, but more importantly in how well patients do in the long term. We know from our data that the likelihood of having complications or dying from bariatric procedures is extremely low. Surgeons are just one piece of a multidisciplinary team who deal with a lethal disease process that needs to be followed for life and might recur requiring further interventions.
I hope you enjoy this issue.

Sincerely,

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

References
1.    Dimick JB, Nicholas LH, Ryan AM, Thumma JR, Birkmeyer JD. Bariatric surgery complications before vs after implementation of a national policy restricting coverage to centers of excellence. JAMA. 2013;309(8):792–799.

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