Quota of 50 Anastomotic Procedures in 12 Months May Be Difficult to Achieve for Some Fellows

| July 10, 2014

Dear Readers of Bariatric Times:
For those of you who did not have the opportunity to attend the American Society for Metabolic and Bariatric Surgery (ASMBS) Spring Event in Miami, Florida, the conference was excellent. With an attendance of over 300 physicians and allied healthcare professionals, the success of this event sent our leadership a clear signal that this conference should continue in coming years. I congratulate our program directors, Drs. Dan Herron and Aurora Pryor, for putting together this excellent program. They are already preparing the next ASMBS Spring Event that will take place in Las Vegas, Nevada, in 2015.
In this month’s issue of Bariatric Times, we present our 22nd Checklist in Bariatric Surgery. Checklist #22, which is Part 1 in a two-part installment, discusses vitamin deficiencies in patients with severe obesity. Obesity is a disease process that, in my opinion, belongs to a state of malnutrition. Deficiencies of important minerals and vitamins related to the associated comorbid illnesses and poor dietary habits expose our patients to signs and symptoms that we should recognize in the perioperative period. Remember, some of these patients are coming to see you in consultation before surgery with previously well-established deficiencies. One of the most important deficiencies to keep in mind is the lack of vitamin B1. A significant amount of our patients, approximately 15.5 percent in my experience,1 come for consultation already deficient in thiamine. This will result in Wernicke’s type palsy of the hypoglossal and glossopharyngeal nerves that manifest as dysphagia and present with difficulty swallowing and vomiting. The cardinal symptom is the inability to swallow. In cases of obstructions and/or stenosis, patients complain of heartburn and emesis a short while after they swallow food or liquids; whereas in cases of Wernicke type dysphagia patients cannot even swallow the liquids and emesis occurs instantaneously. Sialorrea without belching can be present.
Another important deficiency to keep in mind is vitamin B12. This deficiency might result in irreversible nerve damage, including peripheral ascending neuropathy (Guillain Barre syndrome), that can result in respiratory failure, mechanical ventilator support, and mortality.
Also in this issue, Dr. Wasef Abu Jaish presents an interesting case series on orthostatic hypotension after bariatric surgery and rapid weight loss. The theories why this rare syndrome occurs are still unclear. Deficiencies of B12 and nerve damage caused by diabetic neuropathy are among some of most accepted theories. It is also subject of debate if these signs and symptoms develop after patients with obesity experience resolution of their obesity-related hypertension. The patients become hypotensive and, due to the neuropathy, they are unable to compensate. This syndrome can be debilitating and should be prevented when possible.2
In a letter to the editor, Dr. Michaels discusses recent research exploring whether body contouring procedures could contribute to the long-term success of bariatric patients in maintaining their weight loss. We thank Dr. Michaels for his letter on this topic.
Dr. Antonio Torres provides a summary of Spain in “Obesity and Bariatric Surgery Trends Around the World.” As we’ve seen in other countries, Dr. Torres states that sleeve gastrectomy is currently the most popular bariatric procedure.
In this month’s Symposium Synopsis, we highlight the 9th International Bariatric Club (IBC) Symposium, which was part of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO)-European Chapter conference, April 30 through May 3, 2014. This month’s Bariatric Center Spotlight focuses on Community Bariatric Center North, an ASMBS Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) accredited center in Indianapolis, Indiana.
We thank Dr. Walter Pories, for his always entertaining and wise cartoons that are presented to you in “Cartoon Corner.”
Lastly, I would like to share with you a concern of mine when it comes to training in bariatric surgery. As you might have seen in your own practices, sleeve gastrectomy has taken over the field and has become the most popular procedure in most practices in the United States and soon worldwide. The Fellowship Council (FC) accredited- training curricula and ASMBS certification are expecting fellows to conduct at least 50 anastomotic procedures in 12 months. For those programs with one fellow, this number can be easily achieved if we count primary gastric bypasses, revisions, and conversions. The quota is more challenging to meet for fellows who are in programs with other fellows. Expecting that a bariatric program perform 150 (that would be the number to certify three fellows) primary gastric bypasses on a yearly basis is becoming unrealistic. How can we fix this problem and what should you do if you are faced with this dilemma? One possible solution might be to count bariatric anastomotic procedures performed as a chief resident and those performed after conclusion of the fellowship training period when in practice. The FC and ASMBS will need to discuss whether those cases performed before and after fellowship training will count only if performed under supervision of a FC-accredited program and by an ASMBS certified surgeon. If your perception is that your numbers will not increase, you should contact the FC and start working on changing the title of your program from bariatric only to advanced GI/Bariatric.

Sincerely,

Raul J. , MD, FACS
Editor, Bariatric Times

References
1.    Carrodeguas L, Kaidar-Person O, Szomstein S, Antozzi P, Rosenthal R. Preoperative thiamine deficiency in obese population undergoing laparoscopic bariatric surgery. Surg Obes Relat Dis. 2005;1(6):517–522; discussion 522.
2.    Lascano CA, Szomstein S, Zundel N, Rosenthal RJ. Diabetes mellitus-associated diffuse autonomic dysfunction causing debilitating hypotension manifested after rapid weight loss in a morbidly obese patient: Case report and review of the literature. Surg Obes Relat Dis. 2005;1(4):443–446.

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