Mid-term Perspective from the Man Wearing the Badge

An interview with Bruce M. Wolfe, MD
2010–2011 President of the American Society of Metabolic and Bariatric Surgery

Bariatric Times. 2011;8(1):18–20

Bruce M. Wolfe, MD, is a graduate of Stanford University and the St. Louis University School of Medicine. His surgical training was completed at St. Louis University. He did additional research training at Harvard Medical School. He recently relocated from the University of California, Davis to Oregon Health and Science University, where he serves at Professor of Surgery. Dr. Wolfe has devoted his surgical career to surgical nutrition, specifically obesity, including the surgical care of patients with obesity and related research. He has made many contributions to the advancement of the surgical treatment of obesity, including a demonstration of the many benefits of laparoscopic surgery. He presently serves as the chair of the National Institutes of Health research consortium on bariatric surgery, known as LABS, and is the current president of the American Society for Bariatric and Metabolic Surgery. He has participated in approximately 1,000 bariatric surgical procedures in his career.

The staff and Editorial Advisory Board of Bariatric Times interviewed Dr. Bruce Wolfe, 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 2010–2011 president and his thoughts on the future of bariatric surgery.

Given the complexity of managing patients with morbid obesity patients, what special (if any) training or qualifications should the bariatric anesthesiologist have? Should the ASMBS be involved in setting those standards?
I do not feel immediately qualified to comment on the training of anesthesiologists, thus I do not believe the ASMBS can or should be involved in the process or setting standards. Anesthesia for patients with severe/morbid obesity is performed on a regular basis for such patients who are undergoing surgical procedures other than bariatric surgery. As a result, expertise and experience among anesthesiologists in dealing with severe obesity is becoming more widespread.

What are next steps for LABS research? What has LABS taught us?
The 30-day safety outcomes study, known as LABS 1, has been completed. The results were published in the New England Journal of Medicine in August 2009.  Further reports analyzing more detailed aspects of that data have been submitted. Basically, we learned that bariatric surgery is very safe. The BOLD data were validated in the process. The next steps for LABS are as follows:
1.    Complete analysis and reporting of the 30-day outcomes data.
2.    Continue the long-term follow-up of the LABS 2 cohort. This cohort consists of 2,450 patients who will be followed as long as the LABS consortium is funded. We are presently collecting 2- to 4-year data. Analysis and reporting of these data will begin in the near future.

Do you think sleeve will replace bypass in the next five years? Where do you think bariatric surgery will be five years from now?
I doubt that sleeve will replace bypass in the next five years because of the neuroendocrine responses related to bypass of the large portion of the foregut and more distal stimulation of gut hormones from the mid and distal gut and the special effects associated. I believe that five years from now, bariatric surgery will be more commonly performed as the implications of severe obesity on general health and survival become more widely known, as do the benefits and safety of bariatric surgery.

Has the accreditation process from Surgical Review Corporation and American College of Surgeons improved patient outcomes? How does the future look for the Center of Excellence program with the Surgical Review Corporation?
I believe establishment of the criteria for accreditation as a designated center or Center of Excellence has improved patient outcomes. The LABS data confirmed the relationship of surgical volume to outcomes. Multiple smaller hospitals doing smaller numbers are no longer performing bariatric surgery, which presumably contributes substantially to the improved outcomes we are seeing at this time.

With two organizations accrediting Centers of Excellence and individual insurers requesting their own information, when do you think the COE concept will become streamlined so we report information to one organization only? Are there any hurdles we need to overcome to make this happen?
It is my opinion that if the ACS and SRC could come together with a common set of parameters of measure, we would then be in a position to inform insurers and others that these are the parameters and the method in which they will be recorded. Then centers would only have to record their data once and could use the data for insurers and others as requested. This “streamlining” will take time but hopefully can ultimately be achieved.

Is there really a role for robotic surgery and single-port surgery?  If so, when and where?
A role for robotic surgery is possible in the future, although in bariatric surgery with the currently used techniques, experienced surgeons have demonstrated a lack of need for robotics. We might see more use of robotics in bariatric surgery at such time as the demand for the procedures outstrips the supply of fully trained bariatric surgeons. Once one is familiar with the robotic techniques, it does make operative procedures, such as gastric bypass, easier to perform with expertise. Other than that situation, I do not see robotic surgery having much of a role.
Single-port surgery already has a role in response to patient demand. I believe it will be very difficult to demonstrate any benefit to single-port surgery other than the cosmetic benefit. The role of single-port surgery remains to be defined as well.

Stuctured physical activity (exercise) has been proven to be an essential component to the success of bariatric surgery. There is, however, no specific guidelines for bariatric patients, both nonsurgical and surgical, concerning exercise. Does the ASMBS have any plans to establish guidelines for the bariatric population concerning exercise?
ASMBS has no immediate plan to establish guidelines. The LABS consortium is looking at the specific disabilities and their impact on physical activity. It may be that the musculoskeletal disease associated with obesity creates as so much individual limitation that standard guidelines regarding physical activity may be of limited value.

What is the society’s strategy (if any) to prevent insurances to mandate 24-hour hospital stay after bariatric procedures?
Hospitals are sending LAGB patients home the day of surgery and laparoscopic Roux-en-Y gastric bypass patients home the day after surgery more and more often in appropriately selected cases. The ASMBS will continue to advocate for preservation of surgeon judgment in determining which patients are suitable for early discharge.

Will you encourage the use of self-perceived Quality of Life (QOL) Instrument use in Bariatric Surgery Outcome Studies?
The LABS consortium chose to use standardized QOL instruments so that the results could be compared to norms and so that investigators could take advantage of the standardized reporting. Construct of a new instrument requires validation and would not have a comparator group of the normal population as do commonly used instruments.

Can you comment on Buchwald’s editorial in the December 2010 issue of Obesity Surgery?
Dr. Buchwald’s point regarding the great difficulty we have getting nonsurgical colleagues, particularly in diabetes, to accept the important role of bariatric surgery is a long-standing challenge. We are making progress, as evidenced by the mention of bariatric surgery in the 2009 guideline update of the American Diabetes Association. The International Diabetes Federation is working on a position statement that recommends consideration of bariatric surgery for patients with type 2 diabetes and severe obesity. Thus, we are making progress despite the articles that appeared in the July 26, 2010 issue of The Lancet.
Editor’s Note: Drs. Buchwald and Scopinaro wrote a letter to the editor of The Lancet,[1] stating their concerns that in the June 26, 2010, issue dedicated to diabetes, there was no mention in any of the articles of bariatric/metabolic surgery. After The Lancet rejected their letter for publication, Drs. Buchwald and Scopinaro, Co-Editors-in-Chief of Obesity Surgery, published their editorial on this topic in the December 2010 issue of Obesity Surgery.[2]

What (if any) are the ASMBS’s plans to facilitate insurance approval for bariatrics (i.e., onerous six-month pre-operative wait)
The ASMBS remains engaged and active in the effort to achieve bariatric surgery coverage for all patients. This effort includes lobbying in Congress, a visit to the White House, and an active program of lobbying at the state and local levels. The ASMBS has provided a package of materials that can be sent to any bariatric surgeon who is facing a coverage issue in their own environment.

Is the current credentialing mandate for bariatric surgeons (ASMBS and ACS) fair to surgeons and prospective patients in rural areas? Are rural surgeons at a competitive disadvantage? Is patient access a problem in rural areas?
It is recognized that small and/or rural hospitals will not have access to high volumes of patients in order to qualify for COE designation. Virtually all of the studies reported to date based on administrative databases as well as clinical (e.g., LABS) have demonstrated improved safety in proportion to the number of cases done per year by the surgeon and center. Our members have been invited to become fellows of the ASMBS and submit their data to the BOLD database. In this way, our members with volumes below that necessary for credentialing have an opportunity to demonstrate their adequate outcomes despite their lower numbers. It will not be possible to change the criteria for center designation unless some evidence to support such a change is generated. If only high-volume centers at COEs enter their data, the database will not be able to address the question of the safety of the lower-volume surgeons.

How do you plan to deal with all of the subspecialties surrounding bariatric surgery (e.g., plastic surgery, nutrition, midlevels, psychiatry)? To what degree can these specialists be incorporated into leadership? Do you have a best guess on political policy/healthcare reform impact on bariatric surgery?
It is increasingly apparent that the postoperative care burden for bariatric surgical programs is threatening to overwhelm their capacity to provide service to additional new patients. One solution is the expansion of pre- and postoperative care to include medical and psychiatry specialists. We will see more of this in the future as pressure is brought on bariatric surgeons to accomplish more cases.

Given your knowledge and exposure to the external pressures on patient access to bariatric surgery (i.e. Milliman, NIH, Obamacare), do you predict that patient access to care will improve or decrease over the next 5 to 10 years?
I would certainly hope that access will be improved over time as the educational barriers are overcome. It is unlikely that the obesity epidemic will decrease substantially in the next 10 years.

References
1.    The Lancet. June 26, 2010; 2193–2278.
2.    Buchwald H, Scopinaro N. An invitation to our medical colleagues: work with us. Obes Surg. 2010;20(12):1716–1717.

Category: Interviews, Past Articles