New Study Shows Lower Incidences of Cardiovascular Events and Related Fatalities in Patients with Morbid Obesity Who Underwent Bariatric Surgery Compared to Patients Treated with Medical Therapy Alone

| February 17, 2012

Dear Readers of Bariatric Times:

In this issue of Bariatric Times, we deliver to you more outstanding articles and columns. If you have a smart phone or tablet and have not done so already, please make sure you visit the Android Marketplace or Apple App store and download the BT App for your mobile device.

I would like to start my editorial by highlighting our column “Ed Mason at Large” a forum where Dr. Mason provides us with amazing and  insightful answers to questions from the BT editorial advisory board and readership. If you have any questions for Dr. Mason, please send them to Angela Hayes at ahayes@matrixmedcom.com as soon as possible so that we can include it in our next issue.

In this month’s installment of the American Society for Metabolic and Bariatric Surgery (ASMBS) Foundation News and Update, Dr. David Provost gives us an update on the Foundation’s events and announces the Walk from Obesity that will take place throughout the country during 2012.

You will enjoy Dr. Marina Kurian’s excellent case report on endoscopic management of leaks after laparoscopic sleeve gastrectomy (LSG). LSG continues to establish itself as the most popular bariatric procedure worldwide, and we are obliged to develop algorithms on how to deal with its rare,  but difficult to manage, complications. The incidence of leaks is extremely low, but the concept of high pressure with distal obstruction makes them challenging. While scopes, glue, and stents are an option in the acute setting, it is imperative that we rule out a stenosis of the distal portion of the sleeve. Distal obstruction and back pressure have always been the reason for perpetuating fistulas. In addition, once a tract is being formed, after 30 days there is a low probability that a stent that will help a proximal leak to close.

Also in this issue we introduce a new column, “Hot Topics in Integrated Health,” edited by Laura Boyer. In the first installment, author Karen Schulz discusses relocation and follow up for the postoperative bariatric surgery patient. The numbers presented are stunning and shed light on the poor long-term follow up reported in the literature. With 37 million Americans relocating on an annual basis, it will always remain a challenge to see our patients return to our offices. ASMBS Clinical Issues committee has done a titanic job in 2011 under Stacy Brethauer’s leadership. The committee published an excellent white paper on global healthcare that complements Schulz’s column. With all bariatric centers enrolled in the new ASMBS/American College of Surgeons (ACS) database, bariatric practices should be able to track and follow bariatric patients regardless of where the primary procedure was performed. In fact, I believe we should make patients responsible for not following with their doctors.

In this month’s “Anesthetic Aspects of Bariatric Surgery,” the authors provide a clear review of what we should be looking for when our patients undergo general anesthesia in order to have a safe and smooth endotracheal intubation and extubation. Mallaputi’s score, neck circumference, and extensive pre-oxygenation seem to be the key aspects to stay out of trouble on induction. Fully awake and sitting position are key when extubating our patients.

During the 28th Annual Meeting of the ASMBS in Orlando, Florida, June 12 to 17, 2011, Dr. Phil Schauer moderated a panel debate entitled, “Metabolic Surgery for Diabetes: Which Operation is Most Suitable for Diabetic Patients?” In this Group Symposium, the four panel members, Drs. Jaime Ponce, Ricardo Cohen, Michel Gagner, and Vivek Prachand, presented their procedures of choice in operating on patients with diabetes and defended their positions through research and personal case examples. In this issue, we present a summary of this excellent session.

I would like to close by calling your attention to the The Swedish Obese Subjects (SOS) study published in the January 2012 issue of The Journal of the American Medical Association (JAMA).[1] This article, authored by Lars Sjorgstrom et al, examines the incidence and mortality of cardiovascular events (strokes and myocardial infarction) in bariatric patients compared to a matched group of patients with morbid obesity that were treated with medical therapy for their obesity. The authors compare over 2,000 patients in each arm and present a 14-year follow-up analysis. Not surprising was the significant lower incidence of cardiovascular events and related fatalities in the bariatric surgery group when compared to the medical treatment group. Nevertheless, what I thought was the most enlightening from this study was the significance of high insulin levels as a predictor of success. Those patients that had morbid obesity and high insulin levels were the ones that benefited the most from bariatric surgery when it came to prevention of cardiovascular events. The authors comment that insulin levels rather than body mass index (BMI) might be a better marker to indicate surgery.
I hope you enjoy this month’s issue of BT.

Sincerely,
Raul J. Rosenthal, MD, FACS
Editor, Bariatric Times

References
1.    Sjöström L, Peltonen M, Jacobson P, et al. Bariatric surgery and long-term cardiovascular events. JAMA. 2012;307(1):56–65.

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