We are Challenged to Make Surgery Affordable While Maintaining Quality and Outcomes

| March 1, 2015

A Message from Dr. Raul J. Rosenthal

Raul J. Rosenthal, MD, FACS, FASMBS, Clinical Editor,
Bariatric Times; Chief of Staff, Professor of Surgery and Chairman, Department of General Surgery; Director of Minimally Invasive Surgery and The Bariatric and Metabolic Institute; General Surgery Residency Program Director; and Director, Fellowship in MIS and Bariatric Surgery, Cleveland Clinic Florida, Weston, Florida


 

Dear Friends and Readers:
Welcome to the March issue of Bariatric Times!
I am writing to you at the conclusion of the 14th Annual Surgery of the Foregut meeting in Coral Gables, Florida. As in previous years, this year’s meeting was well attended with close to 200 registrants and 60 faculty members. The highlight of the meeting was the 2nd Annual International Congress of Fluorescent Guided Imaging Surgery. Fluorescent imaging techniques continue to grow. These techniques are helpful in guide surgeons during all kinds of gastrointestinal, head and neck, and thoracic procedures.

Another highlight of the meeting was the presentation by Walter Pories, MD, titled, “The Impact of Exogenous Insulin on Type 2 Diabetes.” This presentation posed the question, “Why are endocrinologists giving patients with type 2 diabetes insulin if they are hyperinsulinemic to begin with?” Insulin is associated with comorbidities that can become lethal in patients with metabolic syndrome. Dr. Pories called for endocrinologists and medical practitioners to refer these patients to bariatric surgeons instead.

I look forward to welcoming attendees and faculty next year, when we host the 15 Annual Surgery of the Foregut meeting at a new location, the Boca Resort in Boca Raton, Florida, on February 3–8, 2016. We will celebrate our 15th anniversary with lower registration fees, outstanding state-of-the-art presentations, and a phenomenal new venue. Be sure to mark your calendars.

In this month’s issue, I enjoyed reading Spotlight on Surgical Fellowships. In this installmant, two fellows continue to update us on their learning journey, discussing intersting cases they have encountered. Matthew O. Hubbard, MD, MS, describes a case of megaesophagus in a patient with achalasia that was not recognized at the time when a sleeve gastrectomy was performed to treat severe obesity. There are several take-home messages from this case report that I would like to highlight. First, it is important to emphasize that achalasia is present in one percent of patients with morbid obesity and, contrary to what most physicians believe, patients with achalasia can become severely obese instead of being malnourished. Second, at my center we advocate routine pre-operative imaging studies, either a contrast study or an esophagogastroduodenoscopy (EGD), in order to recognize and manage hiatal hernias, gastrointestinal stromal tumor (GISTs), Barrett’s metaplasia, and as in this case, a megaesophagus.

In my opinion, if the diagnosis of achalasia with end-stage megaesophagus would have been made before the LSG was perfomed, I would have favored a Roux-en-Y gastric bypass (RYGB) instead since it would have kept the gastric remnant “in situ” as a potential graft in case of esophageal failure.

Caitlin Halbert, DO, MS, also presents a challenging case—chronic leak after LSG. I hope you are not getting  the wrong impression that sleeves have a lot of leaks. On the contrary, one of the main goals of this procedure is to create a minimal amount of morbidity when compared to any other well-established bariatric procedure. But, because it has become the most popular procedure performed worldwide, it is important to discuss its complications. Dr. Halbert also shares with us an important insight she has had on her journey—a piqued interest in revisional surgery.

I hope we will at some point call these procedures “reoperative” instead of “revisional” surgery. In my opinion, the case described by Dr. Halbert was neither a revision nor a reversal. I believe it would be classified as a conversion. The language is very important in guiding medical directors and allowing them to understand that cases like the two presented in this column are not meant for patients to lose weight, but rather to save their lives. Medical directors still cannot differentiate reoperative surgery for complications versus the ones for non-responders in their policies.

In this month’s Medical Students Notebook, Benjamin Rome discusses the cost-effectiveness of bariatric surgery. He presents an interesting prospective and challenges current studies claiming that bariatric surgery is cost effective. Mr. Rome also raises the questions, “How will long-term results of sleeve gastrectomy compare to those of laparoscopic adjustable gastric banding (LAGB) and RYGB?” and, “Will surgeons’ volume and experience matter?”

We live in an era where medicine is changing from volume based to value based. We have been challenged to make surgery affordable while maintaining quality and outcomes. I do believe that in the long-term sleeve gastrectomy in high-volume centers will result in better outcomes. Thank you to Mr. Rome for this excellent contribution.

This month, we present a “Bariatric Center Spotlight” on the teams of The Bariatric Center of Kansas City & Shawnee Mission Health in Lenexa, Kansas.
We also present another wonderful cartoon corner from Dr. Walter Pories.
I look forward to seeing many of you at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2015 Meeting, April 15–18, 2015, in Nashville, Tennesee.

Sincerely,
Raul J. Rosenthal, MD, FACS, FASMBS

P. S. Don’t listen to my neighbor!

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Category: Editorial Message, Past Articles

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