Raising the Standard: The Finale

| November 1, 2023

by Anthony T. Petrick, MD, FACS, FASMBS; and Dominick Gadaleta, MD, FACS, FASMBS

Dr. Petrick is Chief Quality Officer, Geisinger Clinic; Director of Bariatric and Foregut Surgery, Geisinger Health System in, Danville, Pennsylvania. Dr. Gadaleta is Vice Chair of Surgery, Northwell Health, and Professor of Surgery, Zucker School of Medicine in Hempstead, New York.

Funding: No funding was provided for this article.

Disclosures: The authors report no conflicts of interest relevant to the content of this article.

Bariatric Times. 2023;20(7–12):34–35.

We would like to take this opportunity to thank our readers for allowing us to share the work our bariatric colleagues have done to improve quality in bariatric surgery over the past five years. Hippocrates has been credited with advancing the systematic study of medicine by consolidating both medical knowledge and prescribing practices. In July 2018, we introduced readers to “Raising the Standard” with the following quote from Hippocrates: “There are in fact two things, science and opinion; the former begets knowledge, the latter ignorance.” (The Law and Oath of Hippocrates; Book 1).

Our stated purpose was to follow in the Hippocratic tradition by examining a range of quality issues in bariatric surgery through the lens of science.

We have shared 58 columns over five years, with an average of nearly 800 views per issue. Columns focusing on the Metabolic and Bariatric Surgery Accreditation and Quality Program (MBSAQIP) were among the most popular. These included, “MBSAQIP: The Evolution of 100 Years of Quality Programs,” “Preparing for Your Virtual Site Visit,” and Dr. English’s series of columns reviewing the MBSAQIP Standards. Columns reporting on care pathways in bariatric surgery were also very popular. The digital edition of Bariatric Times was more widely read than the website. The three columns reporting on MBSAQIP national quality improvement projects, Decreasing Readmissions through Opportunities Provided (DROP), Bariatric Surgery Targeting Opiods (BSTOP), and Employing New Enhanced Recovery Goals for Bariatric Surgery (ENERGY), were the exceptions. These columns were more widely viewed on the website. We are also very appreciative of the six guest columnists who wrote 12 columns over the past five years.

We want to remind readers that the history of bariatric surgery has been one of continuous quality improvement since the 1960s, with seminal moments through each of the last six decades. The 21st century brought accreditation and national standards to bariatric surgery reducing mortality on par with the most common elective general surgical procedures done in the United States (US)—cholecystectomy and hernia surgery. With all the successes, challenges remain.

Venous thromboembolism (VTE) remains the most common cause of mortality in bariatric surgery. The optimal strategy for VTE prophylaxis is still unknown. This question has been considered by both MBSAQIP and several American Society for Metabolic and Bariatric Surgery (ASMBS) committees. Collaboratives will be needed to accrue the number of patients needed to provide enough power to detect significant difference between VTE care pathways. 

Important questions remain about the management of gastroesophageal reflux disease (GERD) before and after sleeve gastrectomy. Sleeve gastrectomy is the most common bariatric procedure in the US; however, the incidence and severity of GERD after sleeve gastrectomy is unpredictable. Identifying patient factors prior to surgery that are likely to result in recalcitrant GERD symptoms and conversion to Roux-en-Y gastric bypass (RYGB) or alternative procedures is another important bariatric surgical challenge.

One of the biggest challenges in the treatment of obesity will be defining the role of glucagon-like peptide 1 (GLP-1) agonists in the management of obesity. These drugs are costly, and the options are rapidly changing. We are starting to see the impact on the number of patients seeking bariatric surgery. Whether this decrease will persist or ultimately increase the number of patients opting for surgery is unknown. We have found the GLP-1 agonists useful for preoperative weight loss and in patients with poor weight loss or weight recurrence after bariatric surgery.

In addition to these, there are many other challenges to improving the quality of bariatric surgery that we have yet to understand. Our peer-reviewed literature remains the most important forum to address these questions. However, just as Bariatric Times utilized digital media to reach our readers, the plethora of web-based and social media platforms will be an important tool to disseminate this work moving forward. As information moves ever more quickly into the public domain, we must continue to seek value in our delivery of health care. Quality improvement requires validation through scientific rigor. We must demand transparent disclosure of conflicts of interest and deliver the most cost-effective care possible.

We hope that we have provided our community with both the knowledge and the tools to implement a culture of continuous quality improvement in their bariatric programs and practices. We will always be appreciative of our readers. 


Category: Current Issue, Raising the Standard

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