New Score Adds Important Variables to the BMI in Guiding Procedure Selection for Patients with Obesity and T2DM

A Message from Dr. Raul J. Rosenthal

Raul J. Rosenthal, MD, FACS, FASMBS, Clinical Editor, Bariatric Times; Professor of Surgery and Chairman, Department of General Surgery; Director of Minimally Invasive Surgery and The Bariatric and Metabolic Institute; General Surgery Residency Program Director; and Director, Fellowship in MIS and Bariatric Surgery, Cleveland Clinic Florida, Weston, Florida

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Dear Friends and Readers,

Welcome to another new issue of BT. In “Nutritional Considerations in the Bariatric Patient,” author Laura Andromalos, MS, RD, CD, CDE, presents a review on nutritional complications after bariatric surgery. B12 deficiency continues to be the most feared complication because of the potential irreversible changes of ascending neuropathy or Guillain-Barré syndrome, a disorder in which the body’s immune system attacks part of the peripheral nervous system. However, in my experience, intractable diarrhea and hypoglycemia are the most frequent, unpredictable, and difficult complications to prevent and manage. I have seen diarrhea ensue years after gastric bypass with neither a clear etiology nor a successful treatment modality for it. I also see hypoglycemia become intractable and debilitating, despite medication and lifestyle interventions.

We continue our video case report series with a wonderful contribution from Bryce M. Bludevich, MS-IV; Sean M. Wrenn, MD; and Wasef Abu-Jaish, MD, FACS, FASMBS. The authors present an interesting case of portal vein thrombosis (PVT) in a patient with diverticulitis as a short-term complication after sleeve gastrectomy. I have to acknowledge that I have seen several cases of asymptomatic and also fulminant PVT in patients undergoing all kinds of gastrointestinal surgery. The most recent case I experienced occurred last year when a man who weighed 900 pounds expired after an uneventful sleeve gastrectomy due to PVT. The question we should raise in this case is whether the PVT was related to the diverticulitis or to the initial surgery. In my opinion, the diverticulitis is a coincidence and not the cause of the PVT. Regardless of the answer, the conundrum for clinicians is what to do in these cases. If acute and asymptomatic, most vascular surgeons will recommend anticoagulation. However, if acute and symptomatic or with hemodynamic instability, the most accepted treatment modality is a trans-jugular retrograde thrombolysis.

This month, we also present an interview with Ali Aminian, MD, Associate Professor of Surgery at the Cleveland Clinic, Ohio, who presented the findings of the Individualized Metabolic Surgery (IMS) Score study during the 137th meeting of the American Surgical Association, April 20 to 22, 2017, in Philadelphia, Pennsylvania.[1] Developed from the largest reported cohort (n=900) with long-term postoperative glycemic follow-up, the Individualized Metabolic Surgery (IMS) Score is a new nomogram that classifies patients into three categories of diabetes severity—mild, moderate, and severe—and suggests which surgery type will provide the best balance between diabetes remission and procedure risk. I commend the IMS study authors for developing the IMS score. We need to continue working together with all stakeholders in further development of new types of algorithms. We need to better indicate which procedure fits which patient best. The “Body mass index (BMI) greater than 35kg/m2 with two comorbidities” as the sole indicator for a patient to qualify for a bariatric and metabolic procedure is, in my opinion, completely outdated. We should be able to create scores by adding to the BMI other very important variables, such as age, type, severity of associated comorbidities, and of course the procedure-related morbidity, which are missing in the metabolic score.[2]

In “Ask the Leadership,” I interview American Society for Metabolic and Bariatric Surgery (ASMBS) President-Elect Samer G. Mattar, MD, FACS, FRCS (Edin.), FASMBS, on the ASMBS pathway for approval of new devices and procedures. We need to thank John Morton, MD FASMBS, who started us on this trail while he was the ASMBS President. This pathway was never intended to control or obstruct progress, rather it was born from patients and insurance companies that reached out to us questioning why patients are undergoing new treatment modalities without clear published evidence in the literature.

ASMBS Weekend is taking place June 8 to 10, 2017, in San Diego, California, and I hope to see many of you there. I urge you to not miss this outstanding gathering that was put together by Stacy Brethauer, MD, FASMBS, society president, and Natan Zundel, MD, FACS, FASMBS, program chair. The session topics and faculty were very well thought out and developed with you in mind.

See you in San Diego!

Sincerely,

Raul J. Rosenthal, MD, FACS, FASMBS

References

1. Aminian A, Brethauer S, Andalib A, et al. Individualized Metabolic Surgery Score: Procedure Selection Based on Diabetes Severity. Presented at: 137th Annual Meeting of the American Surgical Association, Philadelphia, PA; April 20-22, 2017.

2. Kalra S, Gupta Y. The metabolic score: A decision making tool in diabetes care. J Pak Med Assoc. 2015;65(11):1237–1241.

Tags: Dr. Raul Rosenthal

Category: Editorial Message, Past Articles