Meeting Highlights: SAGES 2018

| July 1, 2018

by Col. Robert Lim, MD, FACS, FASMBS

Col. Robert Lim, MD, FACS, FASMBS, is Associate Professor of Surgery, Tripler Army Medical Center, Honolulu, Hawaii.

Funding: No funding was provided for this article.

Disclosures: The authors report no conflicts of interest relevant to the content of this manuscript.

Bariatric Times. 2018;15(7):18–19.

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) held its annual meeting April 11 to 14, 2018, in Seattle, Washington. The SAGES 2018 World Congress of Endosurgery offered high-quality bariatric and metabolic surgery education on a variety of topics. Sessions were rated an average rating of 4.6 out of 5, with a 91-percent attendance rate, indicating that the program was of high interest.

Session Highlights

Present and past presidents of the American Society for Metabolic and Bariatric Surgery (ASMBS) chaired many of the nine bariatric sessions, which included two podium abstracts and one video session. Dr. Robin Blackstone chaired a masters course on revisional bariatric surgery, Dr. Ninh Nguyen presided over the topic of managing bariatric mishaps, and Dr. Samer Mattar chaired a session on reflux after sleeve gastrectomy.

What’s next? New Techniques and Technologies in Bariatric Surgery. Dr. Farah Husain, who chaired this session, reported that excellent evidence was presented on single-anastomosis duodeno-Ileostomy, evolving endoscopic techniques for management of leak, and endoluminal procedures.

Dr. Andres Sánchez-Pernaute, who presented on the duodeno-ileostomy technique, reported that this procedure might be the most effective surgery for weight loss, though it continues to be used sparingly, in part due to fear of malnutrition. Trials in Spain show that patients who undergo duodeno-ileostomy have a high percentage of total body weight loss and improvement in Type 2 diabetes mellitus (T2DM).

Dr. John H. Rodriguez, who presented on emerging metabolic endoluminal therapies, commented that endoscopic therapy continues to develop in bariatrics. Many of the new techniques, he reported, such as duodenal mucosal resurfacing, are actually primarioy aimed at T2DM improvement rather than weight loss.

Dr. Dean J. Mikami provided an update on revisional endoluminal procedures for weight regain after bariatric surgery, and Dr. Erik Wilson discussed endoscopic sleeve gastroplasty. They both agreed that endoscopic revisional bariatric surgery and endoscopic sleeve gastroplasty have had some success but need continued studies to assess long-term weight loss and improvement in comorbidities. Both techniques are also technically challenging and require patience and time.   

Dr. Bryan J. Sandler reported that using an endoscopic approach to manage leaks after bariatric surgery has grown and is now considered the first-line method to address leaks. Stents, sutures, clips, internal drainage, and endovac therapy have all had success, but the key is knowing when to deploy each tool for the optimal success (acute vs. chronic leak). In addition, having the ability to work closely with the gastrointestinal team or for the surgeon to perform his or her own endoscopy is helpful because some of these approaches are labor intensive and require multiple interventions. The presenters said the theme of bariatric innovation continues to blossom, and stakeholders need to continue to develop better tools to treat the bariatric patient population, which is increasingly complex.

Evidence-based Pathways in Bariatrics: Are You in Step with the Best? Dr. Racquel S. Bueno chaired this session, and the presenting faculty discussed the evaluation of bariatric surgery outcomes, safety, quality, and cost-efficacy. The final presentation of this session closed with the message that optimization of the bariatric treatment process reduces cost without compromising outcomes.

The Future of Bariatrics, Diabetic Care, and Metabolic Surgery: No Weight Loss Required. This session was chaired bhy Dr. Phil Schauer chaired this session, which included presentations on weight-loss-independent mechanisms of metabolic surgery by David Cummings and the clinical effects of bariatric surgery on T2DM and diabetic cardiac dysfunction by Drs. Ali Aminian and Tammy Lyn Kindel. Additionally, Dr. Ricardo V. Cohen discussed metabolic surgery for Class 1 obesity and T2DM, and Dr. Walter Pories presented on hormones, cytokines, and markers related to inflammation and insulin resistance.

Managing Long-term Complications of Bariatric Surgery: Weight Regain and Long-term Nutrition. Drs. Richard M. Peterson and Alfons Pomp co-chaired this well-attended session, which had lively discussions. After discussing the implications for nutrition, the panel discussed the role of revision surgery. Drs. Samuel Szomstein and Walter S. Medlin debated whether to do bypass or duodenal switch (DS) after sleeve gastrectomy. And Drs. Eric DeMaria and Stephen Wohlgemuth presented options for post-gastric bypass weight regain with a lively discussion on medical versus surgical management. The session closed on a positive note, highlighting that, while no single modality is superior in managing long-term complications, patients suffering from this chronic disease have many treatment options.

Drs. Husain, Bueno, Kindel, and Peterson displayed great leadership in organizing their separate sessions, ensuring that the future of bariatric education within SAGES will be clinically relevant and based on high-quality research.

SAGES/IPEG Session: Are You Kidding? You Want to be a Pediatric Bariatric Surgeon? Everything You Need to Know but Were Afraid to Ask. SAGES offered this as a combined session with International Pediatric Endosurgery Group (IPEG) led by Dr. Jane Pratt. Esteemed faculty members and experts in the field of pediatric bariatric surgery discussed indications and guidelines for children, outcomes, and complication management in this unique patient population. They also presented interesting cases.

Military Surgical Symposium. The Military Surgical Symposium showcased the best research of military surgical trainees, offering inspirational keynote lectures and providing essential battlefield skills. Three full-day abstract sessions covered basic science, general surgery, and trauma/critical care research. Bariatric surgeons in the United States military were well represented.

The Military Working Group at SAGES recognizes that there is an education gap for surgeons who deploy overseas to Level II Echelon of Care. Since the current military Clinical Practice Guidelines do not cover surgical care in the austere environment, and appropriate training and/or support is limited for small surgical teams, the deployed surgeon might be forced to make surgical decisions based on availability of resources rather than clinical judgment. Both SAGES and the ASMBS support the uniformed services by providing members with a forum to identify and address military specific concerns in surgery.

Abstracts and Electronic Poster Presentations

Drs. John M. Morton, Amin Andalib, Raul J. Rosenthal, and Pablo Esteban Omelanczuk moderated the bariatrics abstract session. Presentations addressed bleeding after sleeve gastrectomy and Roux-en-Y gastric bypass (RYGB), preoperative cardiovascular risk, and patient outcomes. This year marked the first year that all SAGES poster presentations were electronic. Electronic posters enhance the format possibilities for presenters and broaden accessibility beyond the annual meeting. Posters were presented on Thursday and Friday during the meeting.

Other Highlights

ASMBS State Chapter Meeting. Judy Chen, an ASMBS member and the secretary of the ASMBS Washington state chapter, held the chapter’s meeting the night before the start of the SAGES conference. This was intended to allow ASMBS and SAGES national leadership to foster better communication among the local state chapter and the societies. This initial meeting was a great success, and plans are underway to make this an annual part of the program. 

SAGES Climate Survey: Results and Strategic Planning for Our Future. Lead author Dr. Dana Telem presented the results of a validated climate survey administered to 704 SAGES committee members via SurveyMonkey® in September 2017. This survey, which is the first of its kind, was sent to all SAGES committee and leadership members to better understand how the society is performing and where there are opportunities to improve. Climate was assessed on the overall SAGES experience, including mentorship opportunities, memborship resources, and attitudes and experiences of members within the organization. Free text responses were encouraged to generate qualitative themes. The survey showed that, overall, SAGES has a positive climate; however, several key issues were identified. Based on these data, SAGES is developing programming and devoting resources to better meet the needs of members.

SAGES 2019

Planning is underway for SAGES 2019, which will take place April 3 to 6, 2019, in Baltimore, Maryland. The deadline to submit abstracts for the 2019 meeting is Friday, September 21, 2018. Visit www.sages2019.org/ for more information.

SAGES 2018: study Highlights from the Cleveland Clinic

Commentary provided by Ali Aminian, MD

Dr. Aminian is with the Bariatric and Metabolic Institute, Department of General Surgery,
Cleveland Clinic, Cleveland, Ohio.

P581 A NATIONWIDE SAFETY ANALYSIS OF DISCHARGE ON THE FIRST POSTOPERATIVE DAY AFTER BARIATRIC SURGERY IN SELECTED PATIENTS

Authors: Jessica Ardila-Gatas, MD; Gautam Sharma, MD; S. Julie-Ann Lloyd, MD, PhD; Philip R. Schauer, MD; Stacy A Brethauer, MD; and Ali Aminian, MD

Summary: Introduction of enhanced recovery after surgery (ERAS) pathways have led to early recovery and shorter hospital stay after laparoscopic Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG). This study aimed to assess feasibility and outcomes of postoperative day (POD) 1 discharge after RYGB and LSG from a national database. Based on available national data, early discharge on POD1 might be safe in a select group of bariatric patients without significant comorbidities.

Comments: The study showed that implementation of enhanced recovery pathway with early discharge from hospital after laparoscopic bariatric surgery seems to be well tolerated and feasible in a considerable fraction of patients. If patients are selected appropriately, the study suggests that early discharge does not lead to increased rates of early complications or readmissions.

We used information from the United States national data. Currently, some centers are involved in the national pilot program called the E.N.E.R.G.Y. (Employing New Enhanced Recovery Goals for Bariatric Surgery) program, which was designed and implemented by the American Society of Metabolic and Bariatric Surgery (ASMBS). Many other bariatric programs use components of ERAS in their practice.

S043 EFFECT OF REVISIONAL BARIATRIC SURGERY ON TYPE 2 DIABETES MELLITUS

Authors: Essa M Aleassa, MD; Monique Hassan, MD; Kellen Hayes, MD; Stacy Brethauer, MD; Philip R. Schauer, MD; and Ali Aminian, MD

Summary: Bariatric surgery significantly improves Type 2 diabetes mellitus (T2DM); however, a small percentage of patients after bariatric surgery either have persistent hyperglycemia or relapse after initial remission of their diabetes. These patients are usually managed with antidiabetic medications. There are limited data on the antidiabetic effects of revisional bariatric surgery. Findings of this study, which is the largest series to date, indicate that revisional surgery in patients with persistent or relapsed diabetes after bariatric surgery can significantly improve the glucose control.

Comments: Diabetes is a chronic, progressive disease. In medical treatment of diabetes, we usually start with prescribing one drug to control blood sugar. If it fails, the next step would be a combination of two or more drugs. If that fails to control T2DM, then injectable medication, including insulin, is added to the drug list. Basically, we escalate the therapy in chronic diseases, including diabetes, to effectively control the disease.

We can follow the same concept with surgery. If one surgery fails to improve diabetes, we can escalate the care and convert to another surgery or do a corrective procedure to improve diabetes. For example, in this study, we showed that conversion from restrictive procedures, such as gastric band or gastroplasty, in patients who had persistent diabetes to diversionary procedures, such as gastric bypass, can significantly improve diabetes. We also showed that corrective surgery after gastric bypass to revise the size of the gastric pouch can significantly improve the excess weight and diabetes status. Furthermore, reoperative surgery in a majority of patients who were on insulin led to the discontinuation of insulin.

It is important to emphasize that obesity and diabetes are chronic diseases that might require additional therapy if initial treatment fails. This paradigm is well accepted for many other chronic medical and surgical conditions, such as cardiac disease or joint problems. The result of this study showed that persistent T2DM with inadequate weight control could be an indication for revisional bariatric surgery. Unfortunately, many patients and physicians do not consider the option of reoperation to improve metabolic outcomes. Furthermore, many insurance providers do not cover reoperative bariatric surgery.

S038 LONG-TERM IMPACT OF BARIATRIC SURGERY IN DIABETIC NEPHROPATHY

Authors: LeAnne Young; Zubaidah Nor Hanipah, MD; Stacy A. Brethauer, MD; Philip R. Schauer, MD; and Ali Aminian, MD

Summary: Bariatric surgery significantly improves glycemic control in patients with T2DM. However, limited literature is available on the impact of bariatric surgery on end-organ complications of diabetes, including diabetic nephropathy. The aim of this study was to assess the long-term renoprotective effects of bariatric surgery in patients with T2DM. Findings of this study, which is the largest series of bariatric surgery in patients with diabetic nephropathy to date, showed a high resolution rate of albuminuria (in almost 50% of patients) in the intermediate to long term postoperative follow up.

Comments: Bariatric surgery significantly improves glycemic control in patients with T2DM. However, limited literature is available on the impact of bariatric surgery on end-organ complications of diabetes, including diabetic nephropathy. The aim of this study was to assess the long-term renoprotective effects of bariatric surgery in patients with T2DM. Findings of this study, which is the largest series of bariatric surgery in patients with diabetic nephropathy to date, showed a high resolution rate of albuminuria (almost 50% of patients) in the intermediate to long-term postoperative follow up.

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