November Marks Awareness of Diabetes and Gastroesophageal Reflux Disease: Two Well-known Comorbidties in the Bariatric Patient Population

Dear Friends and Colleagues,

Let me start this editorial message by congratulating Georgeann Mallory and The American Society for Metabolic and Bariatric Surgery (ASMBS) on another outstanding Fall Educational Event in Las Vegas, Nevada. This year, attendance to the event was the highest it has ever been in its three-year run. Attendees enjoyed excellent, state-of-the-art lectures, fun debates, and exciting video presentations. The breaks allowed faculty to interact with attendees and, of course, enjoy lots of gambling. What is interesting to me (although I have feel personal disenchantment for a place like Vegas) is that when meetings are held in there, they always seem to have a great turn out.

In this month’s issue of Bariatric Times, we present our readers with the third installment of our column “Checklists in Bariatric Surgery.” The topic, staple line disruption after sleeve gastrectomy, is a feared but rare occurrence. I am still a strong proponent of proximal gastrectomy and RY reconstruction for those patients who continue to leak after 12 weeks, but we are far from making this personal practice a recommendation or a guideline.

In this month’s “Surgical Pearls: Techniques in Bariatric Surgery,” Drs. Armstrong and Nguyen demonstrate their technique for repairing hiatal hernias. Some highlights of their technique include mandatory posterior dissection of the hiatus and the optional use of mesh reinforcement. Since 2009, at Cleveland Clinic Florida we have been using a running 2-0 prolene suture with barbs (Quill™ Knotless Tissue-Closure Device, Angiotech Pharmaceuticals, Inc., Vancouver, British Columbia, Canada), a product similar to the V-Loc™ (Covidien, North Haven, Connecticut). There is no need for intra- or extracorporeal suturing, the defect seems to close without tension, and, so far, we have dramatically decreased the use of mesh. I strongly recommend you try it.

Also in this issue, we present a review on emesis and other complications after Roux-en-Y gastric bypass. During the 2012 Surgery of the Foregut Symposium, Dr. Patrick O’Leary, Past President of ASMBS, presented on emesis after bariatric operations. His presentation was an outstanding one, and I thank him and his colleagues for putting it into writing for us. I hope you will enjoy this article as well.

In “Anesthetic Aspects of Bariatric Surgery,” Dr. Alvarez reviews the use of ventilators in bariatric patients. As we know, the vital and functional capacity is significantly reduced in patients with super morbid obesity and they retain CO2 that might result in chronic hypercarbia, which makes extubating a problem. This column is a must-read for our fellows.

In another installment of our column “Hot Topics in Integrated Health,” Lisa West-Smith and Pam Davis present more information on the new ASMBS credentialing guidelines for band adjustments performed by physician extenders. I welcome these guidelines and look forward to delegating this task to integrated health professionals. Nevertheless, a band adjustment is to be seen as a delicate procedure. After serving as a co-investigator in both United States Food and Drug Administration (FDA ) trials for the Lapband (Allergan, Irvine, California) and Realize Band (Ethicon Endo-Surgery, Cincinnati, Ohio), my team and I always perform band adjustments under fluoroscopy. We measure an esophageal column of barium not higher than 8cm and the ability of the esophagus to empty in no more than two contractions. Our nutritionists always evaluate these patients first and we tend to not adjust the band unless there is a green light from the nutritionist after the patient changes his or her diet (low fat and low carb) and lifestyle (physical activity).

We conducted a retrospective review in our clinic of over 200 patients who failed with laparoscopic adjustable gastric banding. We found that the most common denominator in failure was having less than four band adjustments at two years postoperative. Most of these failures were related to lack of proper follow up, and we blamed the patients’ ability to access care (e.g., they moved out of state or changed insurance).

We also present a Symposium Synopsis of the Obesity Action Coalition’s Inaugural Your Weight Matters National Convention, which took place October 25 to 28, in Dallas, Texas. The Obesity Action Coalition (OAC), with members from 34 states, put together this very important meeting in aimed at educating on the impact of the obesity disease on our health and the outcomes of bariatric surgery as most efficacious treatment modality. Congratulations to OAC President and CEO Joe Nadglowski and the OAC team.

Lastly, I remind you that November is the American Diabetes Association (ADA) month, and November 18 to 24, 2012 (Thanksgiving week) is gastroesophageal reflux disease (GERD) awareness week. I assume that all readers of BT are well aware of the relationship between obesity and type 2 diabetes and the important role played by the ADA in fighting this deadly disease. However, I am not sure how many of you are aware of a dramatic increase in the number of patients with severe obesity presenting with Barrett’s metaplasia (a condition in which the lining of the lower end of the esophagus changes from one cell type into another) due to GERD. Dr. Jeff Peters presented at Digestive Diseases Week 2011 the topic of the impact of the obesity disease on an increase of esophageal cancer. While the metabolic syndrome is our main focus and concern, we should not pay less attention to the GERD problem in our patient population.

We are now one year away from Obesity Week, scheduled to take place November 11 to 16, 2013, in Atlanta, Georgia. Mark your calendars and do not miss this event that will be the largest scientific obesity gathering ever.
Happy Thanksgiving!

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

Tags: Dr. Raul Rosenthal

Category: Editorial Message, Past Articles