Worlds Apart: the United States Military Bariatric Surgeons Excel in Vastly Different Arenas

by LTC (p) Robert B. Lim, MD, FACS, and MAJ (p) William V. Rice, MD, FACS

Dr. Robert Lim is Assistant Professor, Uniformed Services University of Health Sciences, Bethesda, Maryland. Dr. William V. Rice is Director, Bariatric Surgery at William Beaumont Army Medical Center in El Paso, Texas.

FUNDING: No funding was provided.

DISCLOSURES: The views expressed in this article are those of the authors and do not reflect the official policy of the Department of the Army, Department of Defense, or the United States Government.

ABSTRACT
The United States military bariatric surgeons face unique challenges in providing quality bariatric care. Long-term follow up is very difficult due to frequent patient relocation, and military bariatric surgeons often have to care for patients who have surgery elsewhere. In additon, military bariatric surgeons must anticipate frequent deployments and be well trained in performing trauma surgery. Recently, the United States military bariatric surgeons formed a working group that includes bariatric surgeons from the major military medical centers in the Army, Air Force, and Navy, and established committees in the American Society for Metabolic and Bariatric Surgery and the Society of American Gastrointestinal and Endoscopic Surgeons to help deal with these unique challanges. In this article, the authors discuss how military bariatric surgeons overcome obstacles to provide high-quality bariatric care.

Introduction

The obesity epidemic presents a challenge to the United States’ medical system. That challenge is unique and somewhat more difficult when considered within the United States military healthcare system because there are many differences between the Department of Defense (DOD) medical system and the typical civilian medical center. Despite the differences, the DOD healthcare systems aim to provide high-quality care with emphasis on quality outcomes and patient safety.

The military has a long history in the field of bariatric and metabolic surgery. Dr. Walter Pories, one of the fathers of bariatric surgery, retired from the United States Army as a Colonel, Dr. Alan Whitgrove performed the first laparoscopic Roux-en-Y gastric bypass (RYGB) as a Navy surgeon, and Dr. Robin Blackstone, immediate past-president of the American Society for Metabolic and Baritric Surfgery (ASMBS), achieved the rank of Major in the United States Army.

“I’m always pleasantly surprised to learn how many of today’s leaders in surgery have military backgrounds. We need to seek out and recognize these surgeons. We, in the military, should maintain these relationships and use them along with our connections made during fellowship to help advance medical care in the military and in civilian practice.” said CDR Henry Lin, MD, from the United States Navy.

Upholding Bariatric and Metabolic Surgery Standards
The surgeons of the United States military are operating and performing at high standards in the specialty of bariatrics. Per the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) data, surgeons of the United States military perform 600 to 1,000 bariatric procedures per year among more than 14 medical centers and community hospitals in the United States Army, Air Force, and Navy (Table 1). The sleeve gastrectomy is the most frequently performed operation and comprises 49.2 percent of all surgeries performed. The RYGB comes in as the second most performed operation and comprises 42.4 percent. The average patient is female, Caucasian, is 40 years of age, presents with a body mass index (BMI) of 42.2kg/m2, and has an American Society of Anesthesiologists (ASA) classification of II or III (Table 2). Many of the surgeons in the military are fellowship trained in advanced laparoscopy from distinguished fellowship programs, such as Harvard Medical School, Emory University, Duke University and University of Texas-Southwestern. Many have started the bariatric programs at their assigned Medical Treatment Facility (MTF) and have helped them to flourish despite often being deployed to combat zones in Iraq and Afghanistan. Furthermore, they have done so while maintaining the morbidity and mortality rates of accredited hospitals and centers (Table 2).

There is no DOD-wide standardization of their bariatric programs so the military’s bariatric surgeons emulate quality standards set forth by the the ASBMS and ACS. Most MTFs will utilize a formal multidisciplinary program, and the members of that group will decide proper candidates for surgery. A typical MTF does not have a dedicated mental health provider, dietitian, or bariatrician to help run a bariatric program, rather these disciplines are offered part-time to the bariatric program. Thus, the preoperative assessment and subsequent referrals for preoperative assessment to these disciplines and to the subspecialties, such as cardiology and pulmonology, are usually dependent upon the surgeon. The surgeons also monitor preoperative weight loss and adherence to the lifestyle changes recommended by the dietitians and mental healthcare providers. MTFs do not have specific requirements prior to a patient’s surgery, such as a documented diet or a behavior modification program. Military surgeons can offer whatever bariatric procedure they are most comfortable performing, including the sleeve gastrectomy and the biliopancreatic diversion with and without the duodenal switch. They may also offer a robotic or single-incision laparoscopic procedure without requiring insurance coverage authorization.

Overcoming Obstacles
Establishing accredited bariatric centers. There are several obstacles though, that military bariatric surgeons must overcome. For instance, trying to convince their fellow physicians and local commanders that accredited level obesity care is in the best interest of the military has not been easy. It may be difficult for instance to convince an outranking head nurse that he or she needs to spend more money on bariatric or endoscopy equipment to care for patients with obesity. In these instances, military bariatric surgeons can learn from other institutions that have already successfully overcome these obstacles. For example, the bariatric surgeon at Fort Bliss in El Paso, Texas, may be able to help the bariatric surgeon at Fort Gordon, Georgia, with credentialing and establishing a full bariatric program. To that end, in 2009 and under the guidance of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), the United States Army, Air Force, and Navy formed a military working group (MWG) of advanced laparoscopic and bariatric surgeons to help one another implement and maintain sound bariatric and laparoscopic practices. Together they have not only helped each other but have also worked to improve laparoscopic and bariatric care throughout the military.

Establishing appropriate long-term follow up. Establishing good long-term follow up of patients is another obstacle that is challenging for the military bariatric programs. Patients of these programs will likely be reassigned to a new duty station every two to three years making follow up with the operative surgeon highly unlikely. To remedy this problem, the SAGES MWG developed a bariatric network so that their nurses and program coordinators can communicate easily to assist patients with their transfer of care. As such, patients can arrive at their new location with the assurance that they will follow up with a quality bariatric surgeon and program.

Determining insurance coverage. Another obstacle to caring for patients with obesity at MTFs is that not every facility has a surgeon who is trained in caring for bariatric patients. As such, bariatric surgery candidates and patients who have had bariatric surgery in the past are being referred to a civilian provider in his or her network. Tricare is a healthcare program for uniformed service members, retirees, and their families worldwide. Prior to 2012, Tricare did not cover patients for bariatric surgery based on the guidelines of the National Institute of Health (NIH) criteria. Currently, Tricareprovides coverage for patient’s with a BMI over 40kg/m2 and for those with a BMI over 35kg/m2 and an obesity-related comorbidity. The guidelines for those seeking care from civilian providers are somewhat different for those undergoing care at an MTF. For instance, those patients who are referred to the network must have documented proof that they have unsuccessfully tried to lose weight for six months. Additionally, Tricare does not provide coverage for the sleeve gastrectomy or the biliopancreatic diversion when patients are referred to civilian surgeons.[1]

Postoperative patients presenting to MTFs. Another challenge is that patients will arrive in MTFs having had weight loss surgery at a civilian program, often in another state and sometimes several years prior to presenting at the MTF. Their records are often not easily accessible. Furthermore, these patients may not have had adequate follow up due to changes in their location and they may present with nutritional, neurologic, surgical, or even psychiatric complications that have gone unrecognized as being related to a bariatric procedure. This is something that the military bariatric surgeon often handles because it would be impractical and unreasonable to send a patient back to his or her initial program. Further, the patients’ primary care colleagues may not be aware of or recognize the post-bariatric complications. One reason the sleeve gastrectomy is a popular operation in the military is because it is generally more effective than the adjustable gastric band and it does not appear to need as much maintenance as the gastric band and RYGB in follow up.

Maintaining quality care and recording outcomes of miltary procedures. One of the areas in which the MWG would like to improve is building a collaborative bariatric database. The military bariatric programs have not been able to combine their collective experience in a database similar to the Bariatric Outcomes Longitudinal Database (BOLD). The roadblocks have been cost, security of information issues, and propriety of the data since, by definition, patient data are property of the United States government and not the individual provider. It is near impossible then to follow weight loss, comorbidity resolution, and recidivism rates more than two years from the surgery. Without such a database, it is difficult for the military to assure patient safety and ensure quality of care is being given in accordance with the best practices followed by accredited centers. With the combining of the ACS and the ASMBS to form the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBS-AQIP), there may be an opportunity for the MWG to include the military’s bariatric outcomes in this database to help assure that quality care and standards of care are met.

The bariatric surgeons in the MWG have worked hard to ensure that the DOD is continuing to provide high-quality care. Today, they have a surgeon who performs bariatric surgery at almost every MTF. They will soon publish their guidelines for starting and maintaining a bariatric surgery program in the military and for revision surgery. After an invitation from the ASMBS, they now have a military task force that is represented in the ASMBS. The ASMBS has also offered to assist with the military’s incorporation into the MBS-AQIP and the use of their website to publish and maintain the military’s provider network.

The MWG has also included collaborative academic research among their goals. They have submitted two multicenter protocols, each involving at least five MTFs, to study bariatric surgical techniques and outcomes. LTC (ret) Steven Schwaitzberg, MD, the immediate past-President of SAGES, notes, “The military committee has tremendous research potential because the military is not limited by industry contracts and insurance company restrictions as much as we civilians.”

Performing bariatric surgery on active duty soldiers. Currently, it is against the DOD policy to perform bariatric surgery on active duty soldiers. The surgery can only be performed on dependents, retirees from the military, and veteran beneficiaries. With the growth of metabolic surgery, though, and the possible expansion of its use with lower BMIs, perhaps this policy should be re-evaluated. A service member can meet military height and weight standards yet still have a BMI over 30kg/m2. If the service member has diabetes, he or she would likely be better served with a RYGB or possibly a sleeve gastrectomy. It would, however, be important to consider potential problems with performing a RYGB on an active duty soldier, including dehydration and surgical complications, which may prevent him or her from being deployed.

“Even within our [MWG] group, there is not a consensus about how we should resolve this issue,” says LTC Yong Choi, MD, Chief of Bariatrics at Dwight D. Eisenhower Medical Center in Fort Gordon, Georgia. This may be a more significant problem in the near future as it is estimated that one out of every four recruits is ineligible to enter active duty because they do not meet the weight standards. According to the former Chairman of the Joint Chiefs of Staff, Air Force General (ret) Richard B. Myers, this is likely to also impact national security.[2]

Bariatric surgeons in the combat zones. Perhaps the biggest challenge for military bariatric surgeons, though, is the need to support the military’s mission in combat. The military’s bariatric surgeons thuse also have to excel in trauma care. Military bariatric surgeons are general surgeons by training and, thus, by definition, the trauma surgeons for the military. General surgeons are the most frequently deployed physicians in the military, typically going to the combat zone every 15 to 18 months. Most will be deployed on the battlefield with a Forward Surgical Team (FST) or a Combat Support Hospital (CSH). The FST is a small 20-person team designed to do damage control surgery for patients who will not survive the transport back to the CSH, and therefore they are placed closer to the battlefield. Thus, they will operate in a very austere and often dangerous environment treating the sickest of trauma patients, whose mechanism of injury is predominantly from penetrating wounds or blast injuries. It is not unusual for a military bariatric surgeon to go from performing a single-incision laparoscopic sleeve gastrectomy in a state-of-the-art laparoscopic suite one month to performing a neck exploration for a penetrating zone II gunshot wound in a poorly lit, nonventilated operating room in the mountains of Afghanistan the next month (Figure 1). Successful military bariatric surgeons have to be experts at both. The CSH is also located in the combat zone and is the hub for all military medical evacuations in that area. Several FSTs of a particular region will therefore send their patients to the CSH. CSHs typically have several surgeons with subspecialty training in areas like vascular, neurosurgery, urology, and ophthalmology. The CSH also has a computed tomography scanner, a radiologist, and the ability to hold patients for days. During one deployment, the general surgeon may work at a CSH and in the next tour, work in an FST.

Frequent surgeon deployment. Deployments represent another large hurdle for bariatric surgeons. “Most of the time, we can provide COE level of care, but when one of us is deployed, that leaves only one surgeon behind to run the ship. During those times, we reduce the number of procedures we do in order to take better care of the postop patients,” states Bob Wilcox, a former surgeon in the United States Air Force and currently contracted by the military as a bariatric surgeon at Fort Carson, Colorado.
Most institutions have only two surgeons performing bariatric surgery, which requires coordination at higher levels within the military to make sure both of them are not deployed at the same time. This, however, cannot be guaranteed. Reintegration is another big concern for the bariatric surgeon as they may go six months or more without doing an advance laparoscopic bariatric procedure.

Moving Forward
Despite all of these obstacles, the military, by all metrics, provides safe, quality care in the fields of bariatrics and obesity care. The military bariatric surgeons remain committed to providing the highest quality of bariatric care. The military members are thankful for the support they have received from societies like ASMBS and SAGES, which offer a military discount on dues. These dues are waived completely in a year when the surgeon in deployed. Without such programs it would be extremely difficult for the military surgeon to afford to be active in a society. By staying active in these societies, the military maintains a professional relationship with its civilian counterparts and can stay atop the technological and clinical advancements in bariatric and laparoscopic surgery.

“Because of the potential for research and technical advancement, the relationship between civilian and the military should be fostered and allowed to grow,” states COL (ret). Rick Satava, MD, former president of SAGES and the Senior Science Advisor of the US Army Medical Research and Material Command. Since the group started in 2009, SAGES has provided a platform for the military to describe its technological advancements and combat experience as it relates to surgery. They have held a plenary session at the last three SAGES meetings highlighted by talks from the United States Army’s Medical Command Commander, BG Carla Hawley-Bowland and the most recent Surgeon General of the Navy, Vice Admiral Adam Robinson. They have demonstrated the use of laparoscopy in the combat theatre to allow some soldiers to return to duty faster and the use of laparoscopy in the trauma setting to prevent the need for a large laparotomy incision. They have also shown the capabilities of military surgeons during natural disasters, such as the earthquake in Haiti.

LTC Eric Ritter, MD, USAF from Uniformed Services University of Health Sciences in Bethesda, Maryland, says, “We’ve had some good success with the group, but there is a lot more we need to do and there is always something we can improve upon. Fortunately with this group [of military surgeons], we have very highly motivated and responsible laparoscopic surgeons. All of us would like to do more.”

REFERENCES
1.    TriWest Healthcare Alliance. www.triwest.com. Jan 2012. http://www.triwest.com/en/provider/clinical-information/clinical-guidelines/bariatric-surgery/. Accessed September 29, 2012.
2.    Mission: Readiness Military Leaders for Kids. http://www.missionreadiness.org/2012/junk-food-sold-at-school-called-a-national-security-threat/. Accessed September 23, 2012.

Category: Past Articles, Review