Dear readers of Metabolic & Bariatric Care Times,
I cannot believe that it is already November and the holiday season is upon us.
This month, I urge you to read the American Society for Metabolic and Bariatric Surgery (ASMBS) News and Update by Dr. Robin Blackstone. This installment contains information with which readers should become familiar, such as news of improved access to care due to ASMBS efforts working with Health Care Services Corporation (HCSC), a summary of the Device Development in Obesity and Metabolic Disease (DDOMD) meeting, October 16 to 18, 2011, Washington, DC, and the ASMBS’ updated position statement on laparoscopic sleeve gastrectomy (SG).
Recently, the Medicare National Determination Coverage Manual was opened to re-evaluate SG as a valid surgical treatment option for morbid obesity. The ASMBS has made a tremendous effort to provide the Centers for Medicare and Medicaid Services (CMS) with the most recent literature and facts to help them understand how important it is to give our senior citizens access to SG. As a physician, it is frustrating when, due to lack of insurance coverage, you are not able to perform a procedure that you believe is indicated and the best treatment option for your patient. I keep my fingers crossed that CMS will include SG in their revised coverage plan.
On another note, I am still wondering why are we neglecting our Medicaid patients. I have spoken with Medicaid representatives on multiple occasions and have explained that the rates paid to providers are unacceptable. At least at my institution I feel it is impossible to justify an elective procedure in bariatrics with Medicaid rates since the rate paid does not even cover the expenses of our disposables in the operating room.
At the 97th annual meeting of the American College of Surgerons (ACS), October 23 to 27, 2011, in San Francisco, California, I had the privilege to participate in a session chaired by Drs. Dan Jones and Giselle Hamad that featured Dr. Edward Mason as a speaker. Dr. Mason gave, as usual, a master presentation on hormonal changes related to gastric bypass. I am thrilled to announce a new column featuring Ms. Martinez and Dr. Mason that will appear in an upcoming issue of Metabolic & Bariatric Care Times. I am sure that you will cherish Dr. Mason’s stories and thoughts related to his life as a scientist.
Also in this issue of Metabolic & Bariatric Care Times, Dr. Edward Lin touches upon a very important topic in bariatric surgery: the management of hiatal hernias in patients with morbid obesity. I would like to add and emphasize to this excellent contribution the importance of the preoperative evaluation of our patients by means of esophagogastroduodenoscopy (EGD) or upper gastrointestinal (UGI) series. It is well documented in the literature that the incidence of gastroesophageal reflux disease (GERD) and hiatal hernias is higher in the population with morbid obesity. In addition, the preoperative diagnosis of a large hiatal may change the surgeon’s strategy. If an adjustable gastric band (AGB) is the procedure of choice, most surgeons would agree that it should not be performed in a patient with large hiatal hernia. If the procedure planned is SG or bypass and mesh is required to close the hiatal defect, then a two-step approach might be indicated. I would first repair the hernia and defer the stapling procedure as a second step. Finally, it is imperative that hiatal hernias be fixed at the time of the bariatric procedure since they will result in miscalculation of pouch size, GERD, and pain in the long-term follow up.
This month, Dr. Christopher Still gives a wonderful perspective in “Creating Bariatric Surgery Advocates: Why it is Critical to Educate Primary Care Physicians.” One would think that lack of insurance coverage or physician referral is the main reason why patients with morbid obesity do not undergo bariatric surgery. At my facility, we asked 100 patients with morbid obesity that walked into our internal medicine clinic why they were not considering bariatric surgery. We found the number one reason was denial; people do not perceive themselves as having morbid obesity.
Finally, Joe Nadglowski, the Executive Director of the ASMBS Foundation and the President and CEO of the Obesity Action Coalition (OAC), gives us an update on the efforts of the OAC to educate congress, regulatory agencies, and the medical community in order increase access to bariatric surgery.
On behalf of all of us at Metabolic & Bariatric Care Times, we wish you, our readers and industry supporters, a happy holiday season.
Sincerely,
Raul J. Rosenthal, MD, FACS
Editor, Metabolic & Bariatric Care Times