12th Annual Minimally Invasive Surgery Symposium

Salt Lake City, Utah, February 20–25, 2012

by Richard M. Kirkner

AUTHOR AFFILIATION: Richard M. Kirkner is Editor, MISS eNews.

FUNDING: No funding was provided.

DISCLOSURES: The author reports no conflicts of interest relevant to the content of this article.

Bariatric Times. 2012;9(8):20–21

This year’s annual Minimally Invasive Surgery Symposium (MISS) featured a full-fledged discussion of evolving quality measures in bariatric surgery, just weeks the before the American College of Surgeons (ACS) and American Society for Metabolic and Bariatric Surgery (ASMBS) announced the merger of their national bariatric surgery accreditation programs. The bariatric/morbid obesity program, led by MISS Founder and Executive Director Dr. Philip R. Schauer and Co-Directors Drs. John Dixon and Bruce Wolfe, featured two and a half days of discussion on the latest discoveries and findings in the field. More than 30 thought leaders presented sessions that provided up to 13.75 hours of continuing medical education (CME) credits, and more than 20 posters were presented during the conference.

Then ASMBS President Dr. Robin Blackstone reported on the evolving quality measures in bariatric surgery.
“It’s a whole new paradigm in how we measure medicine and surgery,” Dr. Blackstone told attendees. “Our goal is to reduce the complication rate by half in next five years.”

The opening session focused on recent findings on the efficacy of gastric bypass surgery for diabetes. Dr. David Cummings provided an update on the latest research on the pathophysiology of diabetes, while Dr. Walter Pories reported on the emerging evidence of surgery for diabetes. Dr. Ted Adams presented six-year follow-up data from the Utah Obesity Study. In this study, 418 of 1,156 patients underwent gastric bypass surgery. Surgery subjects on average maintained significantly lower glucose, low-density lipoprotein (LDL), and triglyceride levels as well as improved high-density lipoprotein (HDL) readings, Dr. Adams said.
Dr. Dixon also presented an update on his research on how gastric bypass may impact sleep apnea in certain patients. He cited a 2004 study that showed obstructive sleep apnea (OSA) was resolved in 87.5 percent of patients who had bariatric surgery. However, the data suggest that patients undergoing bariatric surgery should not expect a cure of OSA after surgical weight loss, Dr. Dixon said, as these patients will likely need continued treatment for OSA.

The first day’s sessions also focused on clinical neuroscience (CNS) manifestations of obesity, including headache, cognition, depression and suicide, and substance abuse and addiction. Dr. Harvey Sugerman explored causes of headache in individuals with obesity, including pseudotumor cerebri, migraine, and eclampsia/preeclampsia. Dr. John Morton explored findings that showed patients with obesity have worse cognition and that gastric bypass had led to cognitive gain. “Gastric bypass provides a biological model for resolution of obesity-related cognitive deficits,” Dr. Morton concluded.

Dr. Leslie J. Heinberg, PhD, reported that clinicians must appreciate the threats depression and suicide pose in the population with obesity because, even after improvement or resolution of the obesity, the underlying psychopathology related to suicide likely remains. Dr. David Sarwer, explored the issues of substance abuse and addiction in the population with obesity, noting that surgeons should place greater emphasis on substance abuse in the perioperative screening.

Sessions on Day 1 of the symposium concluded with a Journal Club review of the emerging literature on gastric bypass, bileopancreatic diversion and duodenal switch, laparoscopic adjustable gastric banding (LAGB), and sleeve gastrectomy, followed by an overview of emerging technologies for metabolic surgery by Dr. Bruce Schirmer. Dr. Dixon reviewed the International Diabetes Federation (IDF) Position Statement on bariatric surgery for patients with obesity with type 2 diabetes mellitus (T2DM). Dr. Dixon noted there is a need to establish better criteria than body mass index (BMI) for predicting benefit from surgery and to define which patients benefit most from which procedures, and for studies to establish the benefit of surgery. Dr. Francesco Rubino followed with a talk that explored the implications of the IDF position statement for surgeons.

A full exploration of gastric plication, including a discussion of gastric plication for LAGB, kicked off the second day of sessions. Drs. Schauer and Ninh Nguyen debated the merits of gastric placation. Dr. Nguyen argued that gastric plication presently lacks scientific rationale and data, and that there is no evidence of its metabolic effect. Dr. Schauer countered that the procedure is ready for prime time. A videofest of surgical technique involved a discussion of banded and non-banded gastric bypass with Dr. Schauer, who noted that banded Roux-en-Y gastric bypass (RYGB) may achieve greater percentage of weight loss than non-banded RYGB in patients with morbid obesity and super-obesity.

The Friday morning videofest continued with Dr. Nguyen’s review of the technique for single-incision bariatric surgery. Dr. Alfons Pomp later explained duodenal switch. After the review of techniques in bariatric surgery,  attention turned to complications as Dr. Jeffrey Allen discussed unusual band complications and Dr. Paul Cirangle explored how to avoid complications in sleeve gastrectomy. Dr. Chris Cobourn, shared new insights into slip-pouch dilation in LAGB.

Controversies in bariatric surgery were the focus of the afternoon session, which started with Dr. Morton urging colleagues to impart caution to patients about the use of alcohol post-surgery because surgery can change an individual’s alcohol metabolism.
The controversies kept coming as Dr. Ponce discussed LAGB for BMI below 35kg/m2 and Dr. Tomasz Rogula explored the benefits and drawbacks of bariatric single-incision surgery. Dr. Titus Duncan made the argument that bariatric surgeons should also add plastic surgery to their skill set for post-RYGB patients, provided they are trained by an expert in the field.

The sessions on day two concluded with a focus on malpractice. Dr. Ramsay Dallal noted that malpractice suits are common, and in fact, the probability of being sued approaches certainty overtime. James Saxton, Esq., explored how new patient safety requirements will impact surgical practice.

Access to care was the focus of day three’s morning sessions. After Dr. Blackstone reported on the work of the joint task force, course co-director Dr. Bruce Wolfe updated participants on Medicare coverage for bariatric surgery, including sleeve gastrectomy for which at the time MISS took place, the Centers for Medicare and Medicaid Services (CMS) were requesting more data before making a determination. He also noted the federal government has assigned decision-making for benchmark plans under the Affordable Care Act to the individual states, a move that could result in disparate coverage of bariatric procedures across the country. Dr. Mitchell Roslin concluded the session on access with a discussion on insurance coverage.

The bariatric/metabolic segment of MISS 2012 concluded with the popular “New Frontiers” presentations. Dr. Dixon explored the emergence of diabetes surgery for those with BMI lower than 30kg/m2; however, he noted that the evidence for such surgery is limited, and that randomized clinical trials are needed to document benefits that are less substantial in individuals without obesity.
Dr. Stacy Brethauer explored how medical tourism may impact bariatric surgery, noting that, according to the Center for Medical Tourism Research at the University of the Incarnate Word, San Antonio, Texas, 1.1 million Americans traveled abroad for medical care in 2009. The appeal of medical tourism is primarily cost (procedures can cost up to 80 percent less than in the United States) and avoiding long wait times, Dr. Brethauer explained. He also reviewed the ASMBS recommendations on medical travel for bariatric surgery.

The program wrapped up with four sessions on emerging techniques and technologies including, robotics for bariatric surgery, endoscopic stent management for leaks and strictures, and an update on endoluminal sleeve techniques. Dr. Schauer finished the sessions with an overview of novel bariatric devices, including drugs, nonsurgical endoluminal devices, implants, space-filling stomach balloons, and altering electrophysiology. These devices represent a “major paradigm shift” in managing obesity, Dr. Schauer said.

Program development for the next MISS, to be held March 2013 in Las Vegas, Nevada, is underway. For information, visit www.MISS-cme.org.

Category: Past Articles, Symposium Synopsis