Dr. Shikora has Left the Building… The Exit Interview of 2009 ASMBS President Scott Shikora, MD, FACS

Bariatric Times. 2009;6(11):14–15.

The staff and Editorial Advisory Board of Bariatric Times interviewed Dr. Scott Shikora, exiting president of the American Society for Metabolic and Bariatric Surgery (ASMBS). Here’s what he has to say on his experiences and challenges as the ASMBS 2009 president and his thoughts on the future of bariatric surgery.

Now that the National Institutes of Health (NIH) and the Agency for Healthcare Research and Quality (AHRQ) are receiving additional funding from the stimulus package, what areas of research and care deserve special emphasis?
Dr. Shikora: Traditionally, medical treatment of obesity gets more funding than surgical treatment of obesity. We need to focus our research on excellent, long-term, comprehensive trials that study all aspects of weight loss surgery—not just on the different procedures, but also on the long-term effects of surgery on weight loss, nutrition, safety, metabolic issues, and comorbidities. With good data, we can expect to increase our funding and also, hopefully, patient access.

What should we be doing with the recently published Betsy Lehman report?
Dr. Shikora: The first step is for the Commonwealth of Massachusetts to endorse the Betsy Lehman report. Once Massachusetts endorses it, then we can push to get other states to consider endorsing it. People are losing jobs, and with it their health insurance. Do you foresee fewer bariatric surgeries in the coming years because of the economy?

Dr. Shikora: Possibly yes, though in my area of the country I have not seen a drop in procedures, at least not yet. This may be because many of my patients are able to maintain their insurance coverage through the Consolidated Omnibus Budget Reconciliation Act (COBRA) or find alternative ways of maintaining their insurance. My biggest concern is how healthcare reform is going to affect bariatric surgery.

You have been an outspoken advocate for access to care for the bariatric patient. How do you see healthcare reform changing the current situation in the United States for this group of patients?
Dr. Shikora: No one knows yet how the healthcare reform act will affect our field of medicine. Hopefully, it will increase access for patients. It may be used against patients, however, and prevent access. Only time will tell.

Do you think in the next five years we will get approval for metabolic surgery in patients whose BMIs are under 35 in the United States?
Dr. Shikora: I am hopeful we will. Data are increasingly supportive of the health and cost benefits of weight loss surgery to treat a large number of metabolic conditions—from diabetes to pseudotumor cerebri.  If the observed benefits of these procedures prove to be durable, it is inconceivable that patients suffering from these otherwise “incurable” diseases will be denied proven treatment.

What is your opinion on the “medical tourism” trend of people traveling out of the United States to have bariatric surgery? It appears to be a financial decision for most people. How can we assist these patients to stay in the United States for surgery?
Dr. Shikora: While I can understand why some patients might travel to another country to get a bariatric procedure, I am completely against it. There are many facilities outside of the United States that provide good service, but unfortunately many do not, and certainly there is no follow-up care with the surgeon for the patient. Good follow-up care is essential to a patient’s success. Also, if a patient suffers a severe complication from the procedure, there may be no recourse for that patient because that procedure was performed outside of the United States and many American programs will not take care of the patient. We need to continue to fight for better patient access to bariatric surgery here in the United States. We need to continue to fight to get insurance companies to pay for these procedures.

What is the role of American Society for Metabolic and Bariatric Surgery (ASMBS) in getting body contouring covered by insurance companies?
Dr. Shikora: Plastic surgical societies should take the lead on getting insurance companies to pay for body contouring in bariatric patients because plastic surgeons are the primary surgeons performing these types of procedures. I think the ASMBS should assume a supportive role in this and should endorse the idea that insurance coverage for body contouring be made available to patients with unsightly and/or unhealthy excess skin.

Do you see any possibility for a reconciliation of the two designations of Center of Excellence (ASMBS and American College of Surgeons [ACS]) going forward?
Dr. Shikora: Yes. Within the next few years, I anticipate cooperation at the very least and complete integration at the most between the ASMBS and ACS for bariatric Center of Excellence certification. I am completely in favor of this, and I am looking forward to the day when these two groups integrate their processes.

When will foreign-trained bariatric surgeons be allowed full membership in the ASMBS?
Dr. Shikora: The criteria of membership for American and Canadian bariatric surgeons does not always translate into criteria that can be applied to foreign-trained surgeons, and therefore the designation for membership to the ASMBS is somewhat different. However, foreign-trained bariatric surgeons are warmly accepted into the ASMBS with an international designation, which is essentially the same as the full membership for United States- and Canada-based surgeons. Those with international designation can serve on committees and have voting rights, just like the full members.

What do you think expanding the society’s realm to metabolic surgery has accomplished?
Dr. Shikora: It is an acknowledgment of where the field of bariatric surgery is heading. We have always been metabolic surgeons, but we just didn’t recognize it. We are not just treating obesity; we are treating many other conditions, such as diabetes, infertility, sleep apnea, hypercholesterolemia. This acknowledgment is long overdue.

What are your thoughts on the change from “allied health” to “integrated health” within ASMBS?
Dr. Shikora: This was a decision that was made by the integrated health members of the ASMBS who believe this terminology change is in their best interests. I completely support this decision.

Do you think there should be specialty certifications for psychologists and dietitians similar to the Certified Bariatric Nurse certification?
Dr. Shikora: I think this is a wonderful idea and I completely support it. Bariatric psychologists and dietitians should follow the bariatric nurses’ lead and form committees to establish examinations for bariatric certification.

What is your opinion on the need and/or benefit for anesthesiologists to have special training to manage patients who are morbidly obese. Would competency training or testing of anesthesiologists on the management of the surgery patient who is morbidly obese be helpful?
Dr. Shikora: Yes, it absolutely would be beneficial. Anesthesiological management of a bariatric patient is unique compared to anesthesiological management of a nonbariatric surgery patient. Efforts to establish competency training and certification for anesthesiologists in bariatric surgery should be made by the anesthesiologists. Again, I recommend anesthesiologists follow the lead set by the bariatric nurses and form a committee to develop a mechanism for certifying anesthesiologists in bariatric surgery.

What is the latest stance by the ASMBS on sleeve gastrectomy?
Dr. Shikora: Sleeve gastrectomy was just endorsed by the ASMBS. A position paper has been written and approved and will be available on the ASMBS website as well as published in the journal Surgery for Obesity and Related Diseases very soon.

What is the role of the vagus nerve in weight loss surgery? Do we block, stimulate, cut, or preserve it?
Dr. Shikora: Eighty percent of the vagus nerve is used to send signals from the gastrointestinal tract to the brain. There are limited data available on the effects of cutting the vagus nerve, though many surgeons do it as a routine part of bariatric surgery. There is research available, however, that shows that vagus nerve stimulation and blocking may be beneficial for weight loss and, therefore, may in the future prove to be a legitimate surgical option for the bariatric patient.

Your data suggested we need to reinforce the staple line, but insurance does not pay for it. What is the role for buttress material on staple lines?
Dr. Shikora: There are a number of articles that have been published that show that buttressing of staple lines reduces bleeding and is safe. Data are inconclusive on whether buttressing staple lines reduces leakage. More research is needed. I personally am in favor of buttressing staple lines.

How would you characterize the link between bariatric surgery and type 2 diabetes? Would you opt for prolonged and effective medical treatment in preference to Roux-n-Y gastric bypass surgery for a patient with type 2 diabetes whose BMI was less than 40?
Dr. Shikora: This really is the patient’s choice. If the patient’s BMI is 35 to 40, then surgery should be considered.  However, data are still evolving for the 28 to 34 BMI patients. I would like to wait and see what these data tell us before subjecting a patient with diabetes whose BMI is less than 35 to surgery. Again it will be up to the patients to decide what treatment they desire.

What recent discovery(ies) surrounding obesity do you feel will alter future methods of treatment in patients?
Dr. Shikora: I believe the research regarding the incretins, GLP-1 and PYY, is important. We are learning that bariatric procedures may have more hormonal mechanisms of action than physical mechanisms such as restriction and malabsorption.

What is the role of bariatric surgery in the treatment of children and teenagers who are obese?
Dr. Shikora: Comprehensive medical means for weight loss should be tried before considering surgery in children and adolescents who are obese. Children may be more easily managed than adults on a medical weight loss plan because typically it is the parents who are purchasing and preparing all of their children’s meals. This can help keep the child more adherent to the plan. Bariatric surgery should have a role in children and adolescents who have shown intractability to medical weight loss, and I would not hesitate to offer bariatric surgery to this type of patient.

Why is it taking so long to develop an approach to tackling the increasing national problem of childhood obesity?
Dr. Shikora: Bariatric care for adults who are morbidly obese is currently unable to get the proper support and attention it needs, so of course it is even a greater problem for children and adolescents. Mainly, this is due to the continued discrimination of people, young and old, with severe obesity. Society continues to view obesity as a lifestyle problem and not the diease we know it to be. Other diseases that can be caused by lifestyle choices, such as human immunodeficiency virus and alcoholism, receive research funding and almost unlimited access to care. So why not the disease of obesity?
Societal discrimination against people with obesity negatively affects our ability to develop and implement an active approach to treating the increasing problem of obesity in children and adolescents. In addition to a lack of funding and the negative attention obesity as a disease receives, there are also ethical dilemmas that surgeons face when considering weight loss surgery in children—those being the complications of the procedures and the potential long-term effects of the surgery. Better long-term research and education of the public on obesity should help us overcome these obstacles.

In this age of “transparency,” as we continue to grow exponentially, and profits from bariatric surgical support materials can be very lucrative, many are attracted to our field for other than altruistic reasons. Therefore, rather than ask the generic question about “disclosures,” do we have the right to ask to what degree and how much authors and researchers are actually paid by a commercial entity for their research and opinion about same?
Dr. Shikora: I think that most of the current disclosure forms cover this issue and allow the reader to make his or her own conclusions on the potential for conflict of interest. Many require the clinician to list income above $10,000.00 per year and also to disclose stock ownership. (Editor’s note: for additional discussion on this topic, please see Letters to the Editor in this issue of Bariatric Times.)

What do you see as the biggest challenge to the incoming ASMBS president?
Dr. Shikora: First, healthcare reform: We just do not know how it is going to affect us. The new president of the ASMBS will also need to continue to guide us on access issues, economic issues, and the greater restrictions on teaching courses due to the new AdvaMed guidelines.

What were the most rewarding and the most disappointing aspects of being ASMBS President?
Dr. Shikora: The most rewarding part of my job as president of the ASMBS was the opportunity to work with a very talented executive council and wonderful ASMBS office staff and to have access to the top-notch opinions and advice from the members. Being president was an honor and a job I took very seriously and enjoyed immensely. The most disappointing part of my job was the realization that I just could not fix everything. For example, there are still many hurdles to overcome in regard to improving patient access to bariatric surgery and getting insurance companies to pay for the procedures. Also, I am disappointed that the issues between the ACS, the Surgical Review Committee (SRC), and ASMBS on Center of Excellence designation are still not settled.

Category: Interviews, Past Articles