ASMBS News and Update—June 2011

by Robin L. Blackstone, MD, FACS, FASMBS

Dr. Blackstone is President-Elect of the American Society for Metabolic and Bariatric Surgery and Medical Director, Scottsdale Healthcare Bariatric Center, Scottsdale, Arizona.

Electronic voting reached an early quorum with surgeons eager to participate in this year’s election. Dr. Scott Shikora, Senior Past President and Chair of the Nominating Committee, will announce the results of the election for President Elect, Secretary/Treasurer, and the two Member-at-large positions on the Executive Council at the Annual Business Meeting, Wednesday, June 15, from 5:00 to 6:30pm. Other highlights will be a report of our journal, SOARD, by Dr. Harvey Sugerman, as well as reports from selected committees.

Are your nurses certified to care for the bariatric patient? The hallmark of great programs is to have Certified Bariatric Nurses taking care of your patients. In most facilities, this certification may qualify to increase the salary of certified nurses. It also helps programs qualify for Magnet status. On Sunday, June 14, from 8:00am to 5:00pm, the Integrated Health section is sponsoring a CBN preparation course. Make sure your patients get the best care! Make getting CBN a goal for the nursing staff in your program.

The Rural subcommittee is holding a forum for surgeons interested in commenting on the ASMBS BSCOE standards and criteria on Monday, June 15, from 10:00 to 11:45am. ASMBS President, Bruce Wolfe, will introduce the forum followed by discussion of five areas the subcommittee has identified as barriers to rural, low volume, and new programs becoming Centers of Excellence. Roger Kissin, from Communication Partners, will facilitate the meeting.

Ever wondered why the NIH has funded a 40M Longitudinal Assessment of Bariatric Surgery (LABS)? The LABS prospective trial of open and laparoscopic gastric bypass and adjustable gastric band represents one of the strongest levels of evidence in our specialty. The investigators of the multicenter LABS trial, led by President of ASMBS Dr. Bruce Wolfe, will present the evidence from LABS. Both previously published and unpublished results will be reviewed in depth.Don’t miss this critical update on the data!

On Thursday night, within the beautiful setting of the Gaylord hotel, the best party of the year can be found at the Foundation Master Course in Fun from 7:00 to 9:00pm and the ASMBS After Dark party from 9:00pm to midnight. Come and gamble for charity during the foundation event and then rock out with a spin around the dance floor. Bring your friends and partner and seek out the IT party of the week Thursday night, June 16! Proceeds for the Foundation event go to the ASMBS Foundation to fund research, education, and advocacy.

Bariatric Skills Acquisition Center. What surgeon isn’t up for a little competition? The ASMBS Communication Committee, led by Dr. Kevin Reavis, has put together a challenging and competitive opportunity for members to improve their skills. Both integrated health members and surgeons are welcome to compete at the BSAC center located on the floor of the exhibit.

ASMBS TASKFORCE Formed. Dr. Bruce Wolfe has appointed Dr. Anita Courcoulas as the lead surgeon to develop a method to estimate annual bariatric case volume. Recently, disagreement on the annual number of cases from different sources has surfaced. This is a critical question for the Society as a barometer to measure our success in the access-to-care battle. The group has already begun work to establish a methodology by which to make this critical annual estimate.

ASMBS Committee News. This year, the ASMBS Committee chairs/co-chairs and staff have undertaken a process of strategic alignment and implementation of the mission and vision of the ASMBS as it pertains to each committee. The Strategic Plan Implementation (SPI) project, led by President Elect Robin Blackstone and Executive Director Georgeann Mallory, began late last August and has been embraced by both committee leadership and ASMBS staff. The work of the committees is at the heart of a strong society that returns high value to its membership. The process behind this project has created a unique energy within the committee structure that continues to keep the ASMBS in a central role in the care of bariatric patients. This part of the column will begin to highlight the committee work on a monthly basis.

Access to Care Committee. Dr. Wayne English (Michigan, UP) has been tasked by Access to Care Committee Chair, John Morton, MD, to develop an interactive access to care map that would provide information about coverage by state including Medicaid, State Employee, and major insurance companies. Dr. English will be reaching out to the STaRs (State Access to Care Representatives) to help populate the information on major employers on behalf of their State Chapters.

The International Development Committee. Under the leadership of Raul Rosenthal, this committee has organized two key events for the annual meeting: “Bariatric Surgery in Latin America” is scheduled for Monday, June 13, 1:00 to 5:00pm, followed by an international meet-and-greet reception cosponsored by ASMBS and IFSO on Monday, June 13, 5:30 to 7:00pm. The committee obtained funding for three new awards recognizing excellence among paper presentations from the international surgeon community. The first two were funded by the ASMBS Foundation. The third was funded through IFSO by Bariatric Advantage.

Pediatric Committee. Pediatric Committee leadership has been working hard on the ASMBS Pediatric Best Practice Guidelines. The pediatric guidelines pave the way for the ASMBS to establish ASMBS Pediatric Center of Excellence program. The guideline document has completed the public comment phase and will be presented at the Executive Council for approval of the draft. Once approved the draft will be posted on the ASMBS website and published in SOARD. This has been a tremendous collaborative effort between the Pediatric Surgery Committee and Clinical Issues Committee. If you are currently treating adolescent patients or have an interest in developing an adolescent program, don’t miss the Pediatric/Adolescent Symposium on Thursday at the annual meeting!

Program Committee. Chair Dr. Marc Bessler has prepared a very strong and diverse offering of education for the membership at this year’s annual meeting. We thank him for his leadership as the Program Chair these last two years. At the end of the meeting Marc will pass the responsibility for the Program Committee to Dr. Ninh Nguyen, who will chair the final independent meeting of ASMBS in June of 2012 and the first joint annual meeting with the Obesity Society in November of 2013. Dr. Dan Herron has agreed to accept the position as Co-Chair of the Program Committee and will serve the next two years as Chair of the Professional Education Subcommittee and then follow Dr. Nguyen as Chair.

Research Committee. In May, a grant was submitted on behalf of the ASMBS Research Committee to request support for a risk adjustment analysis using BOLD data. The barrier to providing outcomes-based COE status (vs. volume-based) is that we have not been able to make sure we are comparing programs fairly. With a very low adverse event rate, smaller prospective trials have not allowed for risk adjustment. It is hoped that with a very large cohort of patients an analysis will distinguish groups at higher risk for adverse events. Current risk adjustments available from NSQIP or that include older data includes open and laparoscopic procedures and different types of primary and secondary procedures. The ASMBS is very hopeful of funding which will allow this critical project to go forward. This is part of the overall effort of the society to move toward structure, process and outcomes based COE designation. The integration of the Research Advisory Committee, Data Access Committee and Data Dissemination Committee is going very well and the new committee structure should be in place in June.

State and Local Chapter Committee. Dr. Michael Nusbaum, past president of the ASMBS New Jersey chapter, has agreed to become the co-chair of this important committee. Wisconsin was recognized by the ASMBS Executive Council during their April teleconference. The growth of the ASMBS State Chapter program is essential to promote collegiality, fight for access to care and improve the education of our surgeon members.

Quality/Standards Committee. The ASMBS established a unique quality initiative in patient safety when it established the ASMBS Center of Excellence Program. ASMBS established a paradigm of structure and process that allowed us to influence patient safety in a profound way by contributing to a remarkable decrease in the mortality of bariatric surgery from 0.8 percent in 1998 to 0.9 percent in 2011. We coupled certification with a requirement for reporting outcomes and currently have 438 facilities listed as fully approved ASMBS Centers of Excellence on our website. Meanwhile the quality conversation in the United States has continued and six years after the first centers were designated it is time to review, refresh, and revisit the original assumptions that led to the current standards and level of participation.

In a COE survey conducted with the membership in the spring of 2010, over 80 percent of the membership supported a joint designation between the ACS and ASMBS. To address these issues the Executive Council approved a new committee, the ASMBS Quality/Standards Committee, tasked with the following:

•    Maintain oversight of the ASMBS BSCOE program administered by Surgical Review Corporation with regular reports to the Executive Committee of the ASMBS
•    Examine, update and support the development of new standards to keep pace with change in the quality environment
•    Establish collaboration between the ASMBS Centers of Excellence Program and the ACS Bariatric Network.

Early on, the committee will look at two issues. The first impacts the access of patients to receive care in their local area. The second is that our current program does not have a pathway for surgeons in rural communities, geographically isolated communities, and new programs trying to get started either with an experienced COE surgeon or with a fellow. In order to begin to address this, a rural subcommittee of the Quality and Standards Committee was established to advise the Society of the unique barriers to provide care for these centers and to identify solutions. A forum to discuss these issues will be held at the annual meeting on Monday, June 15, 10:15am to 11:45am.

ASMBS Clinical Focus. The relationship between obesity and heart disease. One of the hot topics in obesity is the relationship between obesity and heart disease. This may be a good topic for a local CME talk or for some one-on-one discussion with the cardiologists or physicians in your local area. Obese patients are 30 percent more likely to develop heart failure, with each increase in BMI increasing the risk of heart failure by five percent for men and seven percent for women. Eight-seven percent of obese patients have left ventricular hypertrophy.[1] The traditional paradigm of cardiac physiology and obesity-related increasing circulating blood volume and cardiac output to changes in cardiac function. A new study provides the basis to challenge that traditional paradigm. Eight-eight women without identifiable cardiovascular risk factors and BMI from 21 to 45kg/m2 were studied using cardiovascular MRI to determine left ventricular and right ventricular mass and volume. Overweight was associated with a significant LV and RV hypertrophy but no increase in dilatation. There was a 130-percent increase in serum leptin in the BMI 25 to 29 in the subjects with hypertrophy. Leptin receptors are found in the myocardium.[2]

Medical weight loss has some beneficial effect. In a study of 60 subjects with an average BMI of 37 and average age of 46, 47 (78%) completed a comprehensive medical weight loss program with weight loss of 9.2kg at 6 months and 3.8 kg at 24 months. Weight loss was accompanied by an improvement in ventricular function and even though there was weight regain, a beneficial effect persisted.[3] This effect of persistent benefit of medical weight loss, despite weight regain is called a LEGACY effect and it is seen in diabetes as well as patients with cardiovascular disease.

These studies have produced a change from a paradigm of cardiac hypertrophy that is caused by increasing circulating volume as the patient gains weight to a process driven in the main by increasing levels of leptin. Cardiac hypertrophy begins even in the overweight patient.

Bariatric surgery, in particular Roux-en-Y gastric bypass (RYGP), affects both risk of heart failure and atherosclerosis. Bariatric surgery acts to improve cardiac function through the BRAVE effects: Bile flow alteration; Reduction of gastric size; Anatomical gut rearrangement with altered flow of nutrients; vagal manipulation and enteric gut hormone modulation.[1] The current paradigm for the etiology of atherosclerosis includes actions through the adipocyte, hypertension, type 2 diabetes, dyslipidemia, systemic inflammation and oxidative stress and the endothelium. Bariatric surgery addresses many of these issues to stop atherosclerosis.[4]

The American Heart Association issued a new scientific statement on Bariatric Surgery and Cardiovascular Risk Factors on March 14, 2011 where they said “Bariatric surgery can result in long-term weight loss and significant reductions in cardiac and other risk factors for some severely obese adults.”[5]

Personnel note. This year, I have had the privilege to be mentored by one of the truly great research scientist/surgeons in our field, Dr. Bruce Wolfe. While doing an outstanding job leading the ASMBS, Dr. Wolfe has continued to manage the LABS consortium and has worked countless hours on the NIH guidelines. In addition, he has swayed the FDA to approving bariatric surgery in BMI 30 and above and been tireless in his work on advocacy including a pivotal presentation at the Institute of Medicine. His personal work ethic, commitment to making sure that the ASMBS work product is scientifically accurate and presented fairly, superb organizational skills, personal integrity, essential kindness and willingness to mentor others has been critical training for the President Elect. I thank him for his service, his mentorship, and his friendship.

The ASMBS Annual Meeting is a unique educational experience. It takes a village to plan the program, develop the content and facilitate the meeting. Thank you to all the volunteer faculty, members, and staff that make the meeting an amazing success.

I want to thank our friends at the Bariatric Times for allowing us to get the word out about what’s going on in our society to our members through the ASMBS Update. See you in Orlando!

References
1.     Ashrafian H, Athanasiou T, le Roux CW. Heart remodeling and obesity: the complexities and variation of cardiac geometry. Heart. 2011; 97(3):171–172.
2.     Rider OJ et al. Ventricular hypertrophy and cavity dilatation in relation to body mass index in women with uncomplicated obesity. Heart. 2011;97:203–208.
3.     Delas Fuentes L et al. Effect of moderate diet-induced weight loss and weight regain on cardiovascular structure and function. J Am Coll Cardiol. 2009;54(25):2376–2381.
4.     Ashrafian H et al. Effects of bariatric surgery on cardiovascular function. Circulation. 2008;118:2091–2102.
5.     Poirier P et al. American Heart Association scientific statement on bariatric surgery and cardiovascular risk factors. Circulation. 2011;123:1683–1701.

ASMBS Mission Statement
The American Society for Metabolic and Bariatric Surgery was founded in 1983 to establish educational and support programs for surgeons and integrated health professionals. Our mission is to improve the care and treatment of people with obesity and related disease; to advance the science and understanding of metabolic surgery; to advocate for health care policy that ensures patient access to high-quality prevention and treatment of obesity. For more information, visit www. ASMBS.org.

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Category: ASMBS News and Update, Past Articles