Taking the Lead: An Interview with Dr. Jaime Ponce, President of the American Society for Metabolic and Bariatric Surgery

Bariatric Times. 2012;9(8):12–13

Dr. Ponce is the Medical Director for the Bariatric Surgery program at Hamilton Medical Center, Dalton, Georgia and Memorial Hospital, Chattanooga, Tennessee. He is the Vice-President of the ASMBS Tennessee State Chapter and President of the ASMBS.

Questions for this interview were posed by members of the Bariatric Times Editorial Advisory Board.

FUNDING: No funding was provided.

DISCLOSURES: The author reports no conflicts of interest relevant to the content of this article.

Dr. Ponce, do you believe there is still a role for adjustable bands in the United States when data point to the favorable weight loss independent metabolic effects of the stapled procedures, and especially since overseas studies and presentations continue to demonstrate a high rate of band failures and reoperations over time?

-Amir Mehran, MD, FACS, FASMBS

Dr. Ponce: I think there is a role for all procedures, including the gastric band in the United States. The role might be more limited than what some large series have included, as we have learned that the band seems to work better in patients with a lower body mass index (BMI) who have less weight to lose, and who are active, able to have access to intensive follow up, and not experiencing severe diabetes. The band might be the only option acceptable for many patients, and we are still treating only less than one percent of the potential candidates. Many potential patients do not want to even consider any surgical option, so the band could be a better option than medical therapy as shown in the literature. Obesity is a chronic disease that will need continuous care over an individual’s lifetime, and the band will require a revisional procedure in some patients as part of the process of care.
The most important thing that we need to understand is how to address failures with the band and determine in which cases it is appropriate to revise the original banding procedure or convert to other procedures.

Now that the American Society for Metabolic and Bariatric Surgery (ASMBS) is no longer tied to the Surgical Review Corporation (SRC), are you going to amend the bylaws on who can run for council?

-Daniel Jones, MD, MS, FACS

Dr. Ponce: Now that the SRC is not administrating the bariatric surgery accreditation program for the ASMBS, all the committees have been moved to the ASMBS organization. In 2011, the ASMBS Research committee absorbed the Research Advisory Committee, Data Dissemination Committee, and the Data Access Committee for the Bariatric Longitudinal Outcomes Database (BOLD). These committees are still in charge to finalize the analysis of the BOLD data and create some feedback to the centers. Also, the Bariatric Surgical Review Committee was moved to the ASMBS as a stand alone to finalize the accreditation and review process of the programs that were on the review process in 2012. Many members of these committees will be moved to the new structure within the American College of Surgeons (ACS) to oversee the new Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). These new committees, chairs, and co-chairs will be included in the pathway for nomination as candidates for the executive council.

What is your vision for the role of psychologists within ASMBS as well as the evaluation, preparation, and follow up for bariatric surgery patients?

-Karen B. Grothe, PhD, ABPP, LP

Dr. Ponce: Psychology is a fundamental part of the multidisciplinary care for our bariatric surgical patients. All bariatric patients should be evaluated with respect to their ability to incorporate dietary and behavioral changes after bariatric surgery. Any patient with a known or suspected history of psychiatric disease should undergo a formal evaluation performed by a licensed psychologist, psychiatrist, or other mental health professional who ideally has experience in obesity and bariatric surgery. The evaluation should focus on identifying potential contraindications to surgery, such as substance abuse, poorly controlled depression, or other major psychiatric illness. These features are thought to limit capacity for informed consent or increase the likelihood of suboptimal postoperative outcomes. Follow-up counseling should be part of the continuum care.

Can you discuss the ASMBS’s position on medical bariatric surgery tourism?

-Amir Mehran, MD, FACS, FASMBS

Dr. Ponce: The ASMBS has published a position statement on global bariatric healthcare.[1]The rationale published may answer your questions.
The following is a summary of the position statement and recommendations:
1.    Because of the unique characteristics of the bariatric patient, the potential for major early and late complications after bariatric procedures, the specific follow-up requirements for different bariatric procedures, and the nature of treating the chronic disease of obesity, extensive travel to undergo bariatric surgery should be discouraged unless appropriate follow up and continuity of care have been arranged and transfer of medical information is adequate.
2.    The ASMBS opposes mandatory referral across international borders or long distances by insurance companies for patients requesting bariatric surgery if a high-quality bariatric program is available locally.
3.    The ASMBS opposes the creation of financial incentives or disincentives by insurance companies or employers that limit patients’ choices of bariatric surgery location or surgical options and, in effect, make medical tourism the only financially viable option for patients.
4.    The ASMBS recognizes the right of individuals to pursue medical care at the facility of their choice. Should they choose to undergo bariatric surgery as a part of a medical tourism package or pursue bariatric surgery at a facility a long distance from their home, the following guidelines are recommended:
• Patients should undergo procedures at an accredited Joint Commission International (JCI) institution or, preferably, a bariatric center that is MBSAQIP accredited. Patients should investigate the surgeon’s credentials to ensure that the surgeon is board eligible or board certified by a national board or credentialing body. Individual surgeon outcomes for the desired procedure should be made available as a part of the informed consent process whenever possible.
• Patients and their providers should ensure that follow-up care, including the management of short- and long-term complications, are covered by the insurance payor or purchased as a supplemental program before traveling abroad.
• Surgical providers should ensure that all medical records and documentation are provided and returned with the patient to their local area. This includes the type of band placed and any adjustments performed in the case of laparoscopic adjustable gastric banding, as well as any postoperative imaging studies performed.
• Before undergoing surgery, the patient should establish a plan for postoperative follow up with a qualified local bariatric surgery program to monitor for nutritional deficiencies and long-term complications and to provide ongoing medical, psychological, and dietary supervision.
• Patients should recognize that prolonged traveling after bariatric surgery could increase the risk of deep venous thrombosis, pulmonary embolism, and other perioperative complications.
• Patients should recognize that there are risks of contracting infectious diseases while traveling abroad that are unique to different endemic regions.
• Patients should recognize that travel over long distances within a short period before bariatric surgery could limit appropriate preoperative education and counseling regarding the risks, benefits, and alternatives for bariatric operations. This also significantly limits the bariatric surgery program’s ability to medically optimize the patient before surgery.
• Patients should understand that compensation for complications could be difficult or impossible to obtain.
• Patients should understand that legal redress for medical errors for procedures performed across international boundaries is difficult.

5. When a patient who has undergone a bariatric procedure at a distant facility presents with an emergent life-threatening postoperative complication, the local bariatric surgeon on call should provide appropriate care to the patient consistent with the established standard of care and in keeping with previous published statements by the ASMBS. This care should be provided without risk of litigation for complications or long-term sequelae resulting from the initial procedure performed abroad. Routine or nonemergent care for patients who have undergone bariatric surgery elsewhere should be provided at the discretion of the local bariatric surgeon.

What is next for the ASMBS? What is your vision?

-Raul J. Rosenthal, MD, FACS, FASMBS

Dr. Ponce: The ASMBS will need to fully embrace training in metabolic and bariatric surgery at all levels. Now we have representation in the American Board of Surgery with Dr. Ninh Nguyen, and our training committee will develop curriculum for residents.

We will have the best educational offerings with our meeting during the Obesity Week in November 2013 as well as international symposiums and intermediate events.

Good quality data will be generated in the future MBSAQIP process. It will be essential to use the data to improve quality. Continuous collaboration will be needed to improve and maintain better outcomes. Quality saves money, improves patient care, and will expand access.

The use of technology to the fullest extent will be needed to allow remote and universal collaboration. The world is getting smaller and we must reach every place to export our educational offerings and quality initiatives. Learning from each other will be a global experience.

We will continue to embrace research and science that explain the therapy and help us to understand better treatment plans for individual patients.

Industry will complement our progress and not the other way around. We will be working with the industry for innovation, separated from sales with complete transparency, and developing a research platform for new products.
Lastly, the ASMBS will continue to be the authority on guidelines using quality data in the future.

References
1.    American Society for Metabolic and Bariatric Surgery Clinical Issues Committee. American Society for Metabolic and Bariatric Surgery position statement on global bariatric healthcare. Surg Obes Relat Dis. 2011;7(6): 669–671.

Category: Interviews, Past Articles