Metabolic and Bariatric Surgery in the Present and Future: The ASMBS Presidency Entrance Interview of Dr. Ninh T. Nguyen

This column is dedicated to sharing the vast knowledge and opinions of the American Society for Metabolic and Bariatric Surgery leadership on relevant topics in the field of bariatric surgery.

This Month’s Interview With:

Ninh T. Nguyen, MD, FACS
Department of Surgery, University of California Irvine Medical Center, Orange, California; President-Elect, The American Society for Metabolic and Bariatric

This Month’s Topic: Metabolic and Bariatric Surgery in the Present and Future: The ASMBS Presidency Entrance

Funding: No funding was provided in the preparation of this manuscript.

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

Bariatric Times. 2013;10(11):10–11.

Dr. Rosenthal: Do you anticipate that the recent decision by the Centers for Medicare and Medicaid Services to not require Medicare patients to go to accredited centers and/or surgeons will impact the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program?

Dr. Nguyen: I do not think that the recent Centers for Medicare and Medicaid Services (CMS) decision will have a significant impact on the development of the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP). It is important to note that a number of third-party payers were the first to initiate bariatric surgery accreditation programs in 2002. Subsequently, the American Society for Metabolic and Bariatric Surgery (ASMBS) and American College of Surgeons (ACS) developed their centers of excellence programs in 2004 and 2005, respectively. The CMS did not adopt their facility certification requirement until the 2006 Medicare National Coverage Determination (NCD) for bariatric surgery. In April 2012, the MBSAQIP was established with unification of the ACS and ASMBS programs and the standards will likely be released in the early part of 2014. At the current time, the majority of, if not all, third-party payers continue to support facility accreditation in bariatric surgery. Even the Michigan Bariatric Surgery Collaborative support programs that perform an annual volume of cases (minimum of 25 bariatric cases per year) with an infrastructure for data collection and quality improvement process. Currently the ACS and ASMBS have more than 700 accredited centers. I anticipate that this number will dramatically increase with the roll out of the new MBSAQIP standards. The unfortunate consequence of the CMS decision to omit the requirement for facility certification is that it will allow higher risk Medicare patients to potentially have their bariatric surgery performed at centers that are ill-equipped to care for the obese, that lack essential multidisciplinary support and follow-up, and potentially at centers with little or no experience in bariatric surgery. The combination of the above factors may compromise patient safety and lead to more adverse outcomes and even higher risk of death for Medicare patients.

Dr. Rosenthal: How might this affect the ASMBS and the field of bariatric surgery as a whole?

Dr. Nguyen: The field of bariatric surgery has changed substantially over the past decade. Mortality associated with bariatric surgery has decreased dramatically from as high as 1% in the late 1990s to as low as 0.1% in the late 2000s. This improvement is attributed to the increase in utilization of the laparoscopic approach to bariatric surgery, increase in utilization of the laparoscopic adjustable gastric banding, and most importantly, embracing the concept of facility accreditation in bariatric surgery. Several studies have reported improvement in outcome for Medicare beneficiaries since the initiation of the CMS bariatric surgery national coverage decision (NCD) and others have shown that after 2006, accredited centers have significantly lower in-hospital mortality compared to nonaccredited centers. In a study from our group published in the Journal of the American College of Surgeons in 2012, we found that accredited centers have more than a three-fold lower rate of in-hospital mortality compared to nonaccredited centers (0.06% vs. 0.21%).[1] As a field, we have come a long way since the late 1990s and I am afraid that the recent CMS decision may compromise much of our effort in patient safety, and their decision may lead to adverse heath outcomes for their Medicare beneficiaries.

Dr. Rosenthal: How about new surgeons? Might this entice more surgeons to get into performing bariatric surgery?

Dr. Nguyen: I think there will be more surgeons getting into bariatric surgery, but not enticed by the recent CMS decision. Bariatric surgery is a wonderful and professionally rewarding subspecialty of general surgery. I was first attracted to the field of bariatric surgery because of the technical challenge of the laparoscopic Roux-en-Y gastric bypass operation. I was still in my minimally invasive surgery fellowship in 1996 when I saw my first laparoscopic gastric bypass. After fellowship, I went to UC Davis to initiate the laparoscopic bariatric surgery program there and slowly accumulate experience with this complex operation. Besides the technical challenge of the laparoscopic procedure, I started to see the beneficial effects of bariatric surgery on health outcomes and quality of life of my patients. It is very gratifying to see patients start physical activities that they were not able to do for years. It is also gratifying to see their medical conditions like diabetes, hypertension, and even sleep apnea resolve, and quality of life improved. To witness such a transformation occurring in a relatively short time period at follow up is amazing and it is very satisfying to know that I have contributed to the overall improvement of my patient’s health.

Dr. Rosenthal: In 2011, you published an article in the Journal of the American College of Surgeons discussing trends in use of bariatric surgery, 2003 to 2008. Have there been any updates since then? Are surgeries up? Down? The same? From your own experience, what would say have been the trends in field from 2008 to now?

Dr. Nguyen: We have not updated that paper, but we recently published an article on changes in the makeup of bariatric surgery and found a rapid increase in the utilization of the laparoscopic sleeve gastrectomy. Using the University HealthSystem Consortium database, we analyzed 60,738 bariatric operations performed at academic medical centers between 2008 and 2012. Within that time period, the proportion of laparoscopic gastric banding decreased from 23.8 percent to 4.1 percent, the proportion of laparoscopic gastric bypass decreased from 66.8 percent to 56.4 percent while laparoscopic sleeve gastrectomy increased to 36.3 percent of cases in 2012. I predict that laparoscopic sleeve gastrectomy will be the most commonly performed bariatric operation in the United States by the end of 2014. With regards with the number of surgeries nationwide, I think we are on a rebound with increasing in volume of bariatric surgery which has coincided with the return of the economy. The ASMBS estimated approximately 150,000 to 160,000 bariatric procedures were performed in 2010.

Dr. Rosenthal: What is next for the ASMBS? What is your vision?

Dr. Nguyen: The ASMBS is moving forward with many other important projects and initiatives. Soon we will roll out our new and improved ASMBS website that will have much more information not only for our professional members and medical colleagues, but also for the public. We are in our final phase of completing an important educational initiative to develop a comprehensive two-volume textbook. This book is appropriately named the ASMBS Textbook of Bariatric Surgery with contribution from worldwide experts in bariatric surgery and integrated health members. Within the ASMBS, we now have almost 30 established ASMBS state chapters. The main goal for the state chapters is to identify the needs and opportunities within their state to ensure their patients have access to high-quality prevention and treatments of obesity. At the time of this writing, we are about to embark on the first Obesity Week educational event, which has been in the planning phase since 2007. Obesity Week 2013 is designed to be the preeminent scientific and educational conference worldwide by co-locating the ASMBS and The Obesity Society (TOS) annual meetings. We are expecting more than 4,500 attendees at this inaugural event, so I hope to see everyone there. Lastly, my vision for the ASMBS is to support the advancement of the art and science of metabolic and bariatric surgery by continually improving quality and safety of care, continually fostering collaboration with our medical colleagues, and improving the education and access to bariatric surgery for our patients.

References
1.    Nguyen NT, Nguyen B, Nguyen VQ, Ziogas A, Hohmann S, Stamos MJ. Outcomes of bariatric surgery performed at accredited vs nonaccredited centers. J Am Coll Surg. 2012;215(4):467–474.
2.    Nguyen NT, Masoomi H, Magno CP, et al. Trends in use of bariatric surgery, 2003-2008. J Am Coll Surg. 2011;213(2):261–266.

Category: Ask the Leadership, Past Articles