The Landscape of Bariatrics: A Discussion on the Role of Intragastric Balloons, Evaluating Case Growth, and Determining Realistic Needs for the Future
A Message from Dr. Jaime Ponce
Jaime Ponce, MD, FACS, FASMBS, is from Chattanooga Bariatrics, Chattanooga, Tennessee. He is a past president of the American Society for Metabolic and Bariatric Surgery.
Welcome to the March 2016 issue of Bariatric Times. It is an honor to provide a summary of the articles being featured this month and also to discuss some important, timely topics in our field.
In “Anesthetic Aspects of Bariatric Surgery,” authors Ingrid Moreno-Duarte, MD, and Roman Schumann, MD, report results of a study aimed to document and quantify the research on anesthesia in patients with obesity. They found that, despite a prevalence of perioperative obesity of approximately 30 percent, an average of just above two percent of scientific abstracts at two leading anesthesiology society meetings were obesity related in the last 14 years. They concluded that future research should focus more on the patient population with obesity.
Authors 2nd LT Solomon Tong, MS; LCDR Jesse Bandle, MD; and CDR Gordon G. Wisbach, MD, MBA, present an interesting case report on late onset abdominal pain after gastric bypass due to a rare diagnosis—jejuno-jejunostomy volvulus. They state that such a complication can be difficult to diagnose nonoperatively and challenging to differentiate from other gastrointestinal disorders since abdominal pain with or without nausea and vomiting, are typically vague symptoms.
This month’s “Emerging Technologies” column features an article titled, “Intragastric Balloons: Closing the Gap on Weight Loss Treatment Options,” which I contributed. In this article, I discuss the clinical trials evaluating the safety and effectiveness of the intragastric balloons (IGB [ReShape® Integrated Dual Balloon System, ReShape Medical, Inc., San Clemente, California, and Orbera™ Intragastric Balloon System, Apollo Endosurgery Inc, Austin, Texas]). I provide an overview of how IGB systems work and discuss their role among current obesity treatments.
When discussing IGB systems and other endoscopic therapies, it is important to emphasize that these therapies are not in competition with bariatric surgery (e.g., Roux-en-Y gastric bypass, sleeve gastrectomy). The balloon isn’t a therapy that offers a long-term, permanent weight loss solution, however, it allows a good, strong diet and weight loss program to work for a patient much better than without the balloon intervention.
Patients who are either not candidates for or do not want to undergo surgery may try multiple diet/lifestyle modification plans, lose some weight, experience regain, and then feel frustrated. The balloon provides an intervention for these patients, allowing them to achieve up to 2 to 3 times the weight loss achieved with just diet/lifestyle modification.
The period of time in which the patient has the balloon (6 months) is a great opportunity for us to teach them how to make dietary and lifestyle changes. So, coupled with a multidisciplinary weight loss program, the balloon has a role in treating obesity at a certain stage—body mass index (BMI) 30–40kg/m2.
As with other weight loss therapies, some patients may experience weight regain after undergoing IGB therapy. If this occurs, the patient may elect to have the balloon implanted again or undergo surgery. I think that if a patient tries IGB and fails at achieving desired weight loss, he or she may be more comfortable not only discussing, but also seriously considering surgery as a next step. This would be a positive change in our field because it would allow us to incorporate in our practice those patients who aren’t candidates for or aren’t willing to consider surgery.
Although bariatric surgical procedures have steadily increased over the last five years, we are still only treating less than one percent of patients eligible for a weight loss intervention in the United States. One big reason patients aren’t presenting for bariatric surgery is fear. Nonsurgical therapies like IGB may help open the door to some of the other 99 plus percent of individuals that could benefit from an intervention. IGB could help us capture and engage patients, encouraging them to treat obesity at a less severe stage, while also providing an opportunity for us to discuss surgery if they are ready.
There are patients that are undergoing diet and exercise programs around the country that we, as bariatric surgeons, may never have an opportunity to engage. Right now, IGB is still new and we are still creating awareness about it as a therapy to treat obesity. In the future, I think we would like for any physician—primary care physician, orthopedist, pulmonologist, and anyone seeing a patient with obesity—to refer that patient to consider a weight loss therapy according to the severity of the disease. For example, patients with BMIs between 27kg/m2 and 30kg/m2 should be referred to undergo a medically supervised diet/exercise/lifestyle modification program. If the patient is unsuccessful with such a program, then he or she should then be engaged in discussions about adding pharmacotherapy. After this, the patient might then be offered IGB as an option to treat obesity in conjunction with diet/lifestyle modification.
In addition to the patient’s stage of obesity determined by BMI, comorbidities should also be considered when determining timing and method of intervention. We need to be aware of the cases in which surgery becomes necessary. For example, in a patient with obesity and type 2 diabetes mellitus (T2DM), we want to intervene sooner for the best possible outcomes. IGB may help us treat these patient populations, whether they undergo IGB and/or surgery.
Our field is becoming more recognized by mainstream surgical societies and the public. We have good data on the safety and efficacy of bariatric surgery, and good quality of care through The American College of Surgeons (ACS) and American Society for Metabolic and Bariatric Surgery (ASMBS) Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).
Bariatric surgery is viewed as an important field with its own techniques, curriculum, fellowships, journals, textbooks, and training. Eventually, the American Board of Surgery may also consider adding a separate certification for Bariatric Surgery. The bottom line is that we have made tremendous progress as a field and we need to continue to make sure further advancements are done well, with careful attention being paid to quality.
Part of maintaining good quality in the field is ensuring quality in training the future generation of bariatric surgeons. This month, Bariatric Times features an update from the Foundation for Surgical Fellowships (FSF), which funds high-quality fellowships in various areas of surgery, including but minimally invasive and bariatric surgery. During its five years in existence, the FSF awarded over $36 million to fund nearly 670 fellowship positions.
Fellowships in our field continue to be important. I believe that we need to train not only the right fellows for the job, but also the right amount of fellows necessary given the landscape of our field. We need to evaluate the number of jobs available for new fellows looking to work and care for patients with obesity. The ASMBS is planning to analyze this through a new task force created by ASMBS President Dr. Raul Rosenthal and led by Dr. Eric DeMaria.
We will start by looking at the number of cases compared to the number of fellows completing training. From there, we will attempt to figure out the optimal number of bariatric surgeons needed in the US based on our current number of cases and projected growth. We’ll also need to analyze the number of surgeons retiring each year, those who may be abandoning practicing bariatric surgery, and those who are considered high volume versus low volume.
I currently serve as Chair for the ASMBS Numbers Taskforce that is in charge of estimating the number of cases done in the US. We have reported our estimation of procedures from 2011 and 2014 in Surgery for Obesity and Related Diseases.1 As stated in the article, we estimated that 158,000, 173,000, 179,000, and 193,000 procedures were performed in 2011, 2012, 2013, and 2014, respectively. Given these numbers and the estimation for 2015, which is being processed, we will be able to make a realistic prediction of how many fellows are necessary per year. We will also be surveying individuals who completed fellowships in bariatric surgery to find out whether they ended up working in the field.
While we want to train and plan for the next generation, we want to avoid overcrowding the field, which we’ve seen happen in other disciplines such as cardiac surgery. I think we will continue to see a slow but steady growth in the number of bariatric surgeries performed in the US, and the IGB and other endoscopic therapies may play a role in getting more patients to surgery. Patients move slowly through the weight loss and weight loss surgery process, and surgeons also slowly adapt to new technologies. I’m encouraged to predict slow, steady growth in our field, as it’s better than no growth or overgrowth that we may not be equipped to manage.
Jaime Ponce, MD, FACS, FASMBS
1. Ponce J, Nguyen NT, Hutter M, Sudan R, Morton JM. American Society for Metabolic and Bariatric Surgery estimation of bariatric surgery procedures in the United States, 2011-2014. Surg Obes Relat Dis. 2015;11(6):1199–200.