The 13th Annual Minimally Invasive Surgery Symposium

Las Vegas, Nevada March 6 to 9, 2013

by Stuart Michaelson

Stuart Michaelson is a freelance medical writer

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

Funding: No funding was provided

The 2013 Minimally Invasive Surgery Symposium (MISS), which took place March 6–9, 2013 at the Red Rock Hotel in Las Vegas, Nevada, featured more than three dozen speakers and panelists who tackled subjects such as super obesity, obesity-medicine certification, and the epidemiology of type 2 diabetes. The symposium also featured optional workshops offering hands-on training in laparoscopic suturing and practice management information.

The 2013 MISS provided the opportunity for participants to earn up to 25.25 AMA PRA Category 1 credits, as designated by the symposium’s sponsor, the University of Cincinnati.

The Wednesday sessions focused on colon issues, including surgical challenges in patients with obesity, preparation of patients with obesity for surgery, and robotics. On Thursday, following more on colon treatments, hernia discussions included such topics as synthetic and biologic meshes, ventral/incisional hernia, and laparoscopic hernia repair in emergent situations.

Friday’s session kicked off with the metabolic/bariatric surgery program and a look at central obesity and metabolic syndrome. Dr. John B. Dixon, discussing the epidemiology of type 2 diabetes, noted the “actually improved survival of people with type 2 diabetes, particularly in developed countries.” Dr. Ralph DeFronzo followed with a keynote address on diabetes pathophysiology.

After a lighthearted admission that he had “never owned a computer,” Dr. DeFronzo discussed the medical and economic burdens of projected obesity trends in the United States and United Kingdom. He noted that by 2030, there will be 65 million and 11 million more obese adults in the United States and United Kingdom, respectively, and that the obesity epidemic will produce 7.2 million more cases of obesity, 6.5 million more cases of heart disease and stroke, and 580,000 more cases of cancer.

Dr. DeFronzo lamented the hereditary nature of diabetes, stating it “starts when you make a mistake and choose your parents,” while adding that, for the obese battling its ravages, the “outlook for bariatric surgery looks very bright.”

On Friday, a topic much on the minds of bariatric health professionals and patients alike was discussed: the controversial proposal by the Centers for Medicare and Medicaid Services (CMS) to end the certification requirement for centers performing bariatric surgery.

This much-debated topic arose in Dr. Ninh Nguyen’s talk, “Does Bariatric Accreditation Matter?” Since MISS 2013, CMS announced their decision to reverse the CMS requirements determining that Medicare only cover bariatric procedures at accredited facilities.

The debate began when researchers at the University of Michigan requested reversal from CMS based on their study that showed certified hospitals are not any safer than other facilities, and that rates of serious complication and mortality for bariatric surgery have declined across the United States. Those in opposition of the CMS reversal presented statistics at MISS 2013 indicating that mortality rates have improved “tremendously” over the past decade.

Dr. Jaime Ponce, American Society for Metabolic and Bariatric Surgery (ASMBS) President who also spoke Friday on gastric banding and hiatal-hernia management, voiced his opposition to the change in a subsequent interview. Noting the Bariatric Surgery Center of Excellence (BSCOE) role in maintaining acceptable standards as part of a culture for the practice of bariatric surgery, Dr. Ponce stated in a July 2013 interview that this ‘culture’ has been used even by facilities that have not been able to get the accreditation. “We don’t need to lose this kind of quality process in the care of our high-risk patient population. Accreditation has worked to date, and we question why we should gamble with patients’ lives now. Quality improvement and patient safety are enduring efforts, which can best be accomplished by the bariatric surgery facility accreditation,” he said.

Saturday’s final day featured a continuation of the metabolic/bariatric surgery program, with a look at new drugs and devices. Other topics included combining drug therapy with surgery to manage obesity, an update on endoluminal concepts, an update on vagal slim and blocking, controversies, and new frontiers.

In one highlight, Dr. Stacy Brethauer took on the topic, “Super, Super Obesity: Options and Results.” Reviewing technical challenges, Dr. Brethauer discussed airway ventilation, vascular access, positioning, abdominal wall thickness, and thick visceral fat. Dr. Brethauer listed organ injuries (1.6%), anesthesia events (0.9%), equipment failure (0.8%), and anastomosis revisions (0.6%) as common adverse intraoperative events (AIE). He concluded that patients with higher body mass index (BMI) are at higher risk. He also said that an open approach results in a high complication rate and higher mortality, while primary bypass can be performed safely, and that a staged approach may result in better weight loss (though the latter needs further study).

Dr. Robert Kushner presented “The New Obesity Medicine Certification: Time to Step Onboard?” Dr. Kushner explained that determinants of obesity include genetics, biology, environment, personal responsibility, healthcare, economics, ecology, diet, physical activity, and stress/emotions. The multidisciplinary care team, which is critcial in treating patients with obesity, includes a registered dietician, a primary care physician, an obesity medical specialist, and a bariatric surgeon.

Dr. Kushner said reasons supporting a certified obesity medical physician include the fact that there are too few physicians to provide perioperative care for bariatric surgery patients, as well as the need to anticipate future advances in treatment of obesity.

Discussing the American Board of Obesity Medicine (ABOM), formed in 1997, Dr. Kushner expressed the hope that the ABOM will provide a pathway for physicians who want to specialize in caring for patients with obesity and help promote a higher standard of care from bariatric surgery centers.

Attorney James W. Saxton, who has represented physicians in state and federal courts in professional liability cases for nearly three decades, led a discussion titled, “Impact of Healthcare Reform on Bariatric Surgery.” The discussion examined the benefits of re-admission prevention, reduction in surgical site infections, and the advantages of postoperative management, including surgical site follow ups and a focus on lifestyle issues, such as smoking cessation, self-care management, exercise, and behavior modification.

The session also focused on the need for a bariatric surgeon to demonstrate the ability to act as a principal care provider, managing all elements of a patient’s care for an extended period of time, and to coordinating care for certain chronic conditions.

The four-day program concluded with a presentation by ASMBS Executive Director Georgeann N. Mallory titled, “First Quarter 2013 and Beyond.” She discussed significant changes and progress in the bariatric surgery field, and pointed out that ASMBS, which remains the largest society in the world dedicated to metabolic and bariatric surgery, has collaborated with the American College of Surgeons (ACS) to unify bariatric surgery accreditation.

The 14th Annual MISS will take place February 26 to March 1, 2014 in Las Vegas, Nevada. For complete information, please visit the MISS website: MISS-cme.org.

Category: Past Articles, Symposium Synopsis