A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional
Issue link: https://bariatrictimes.epubxp.com/i/651228
4 Bariatric Times • March 2016 experience weight regain after undergoing IGB therapy. If this o ccurs, the patient may elect to have the balloon implanted again or undergo surgery. I think that if a patient tries IGB and fails at a chieving desired weight loss, he or she may be more comfortable not only discussing, but also seriously considering surgery as a next s tep. This would be a positive change in our field because it would allow us to incorporate in our practice those patients who aren't c andidates for or aren't willing to consider surgery. Although bariatric surgical procedures have steadily increased over the last five years, we are still only treating less than one percent of patients eligible for a weight loss intervention in the United States. One big reason patients aren't presenting for bariatric surgery is fear. Nonsurgical therapies like IGB may help open the door to some of the other 99 plus percent of individuals t hat could benefit from an intervention. IGB could help us capture and engage patients, encouraging them to treat obesity at a less s evere stage, while also providing an opportunity for us to discuss surgery if they are ready. T here are patients that are undergoing diet and exercise programs around the country that we, as bariatric surgeons, may never have an opportunity to engage. Right now, IGB is still new and we are still creating awareness about it as a therapy to treat obesity. In the future, I think we would like for any physician— primary care physician, orthopedist, pulmonologist, and anyone seeing a patient with obesity—to refer that patient to consider a weight loss therapy according to the severity of the disease. For example, patients with BMIs between 27kg/m 2 and 30kg/m 2 should be referred to undergo a medically supervised diet/exercise/lifestyle modification program. If the patient is unsuccessful with such a program, then he or she should then be engaged in discussions about adding pharmacotherapy. After this, the patient might then be offered IGB as an option to treat obesity in conjunction with diet/lifestyle modification. In addition to the patient's stage of obesity determined by BMI, comorbidities should also be considered when determining timing and method of intervention. We need to be aware of the cases in which surgery becomes necessary. For example, in a patient with obesity and type 2 diabetes mellitus (T2DM), we want to intervene sooner for the best possible outcomes. IGB may help us treat these patient populations, whether they undergo IGB and/or surgery. Our field is becoming more recognized by mainstream surgical societies and the public. We have good data on the safety and efficacy of bariatric surgery, and good quality of care through The American College of Surgeons (ACS) and American Society for Metabolic and Bariatric Surgery (ASMBS) Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). Bariatric surgery is viewed as an important field with its own techniques, curriculum, fellowships, journals, textbooks, and training. Eventually, the American Board of Surgery may also consider adding a separate certification for Bariatric Surgery. The bottom line is that we have made tremendous progress as a field and we need to continue to make sure further advancements are done well, with careful attention being paid to quality. Part of maintaining good quality in the field is ensuring quality in training the future generation of bariatric surgeons. This month, Bariatric Times features an update from the Foundation for Surgical Fellowships (FSF), which funds high-quality fellowships in various areas of surgery, including but minimally invasive and bariatric surgery. During its five years in existence, the FSF awarded over $36 million to fund nearly 670 fellowship positions. Fellowships in our field continue to be important. I believe that we need to train not only the right fellows for the job, but also the right amount of fellows necessary given the landscape of our field. We need to evaluate the number of jobs available for new fellows looking to work and care for patients with obesity. The ASMBS is planning to analyze this through a new task force created by ASMBS President Dr. Raul Rosenthal and led by Dr. Eric DeMaria. We will start by looking at the number of cases compared to the number of fellows completing training. From there, we will attempt to figure out the optimal number of bariatric surgeons needed in the US based on our current number of cases and projected growth. We'll also need to analyze the number of surgeons retiring each year, those who may be abandoning practicing bariatric surgery, a nd those who are considered high volume versus low volume. I currently serve as Chair for the ASMBS Numbers Taskforce that i s in charge of estimating the number of cases done in the US. We have reported our estimation of procedures from 2011 and 2014 in S urgery for Obesity and Related Diseases. 1 A s stated in the article, we estimated that 158,000, 173,000, 179,000, and 193,000 p rocedures were performed in 2011, 2012, 2013, and 2014, respectively. Given these numbers and the estimation for 2015, which is being processed, we will be able to make a realistic prediction of how many fellows are necessary per year. We will also be surveying individuals who completed fellowships in bariatric surgery to find out whether they ended up working in the field. While we want to train and plan for the next generation, we want t o avoid overcrowding the field, which we've seen happen in other disciplines such as cardiac surgery. I think we will continue to see a s low but steady growth in the number of bariatric surgeries performed in the US, and the IGB and other endoscopic therapies m ay play a role in getting more patients to surgery. Patients move slowly through the weight loss and weight loss surgery process, and surgeons also slowly adapt to new technologies. I'm encouraged to predict slow, steady growth in our field, as it's better than no growth or overgrowth that we may not be equipped to manage. Sincerely, Jaime Ponce, MD, FACS, FASMBS REFERENCES 1. Ponce J, Nguyen NT, Hutter M, Sudan R, Morton JM. American Society for Metabolic and Bariatric Surgery estimation of bariatric surgery procedures in the United States, 2011-2014. Surg Obes Relat Dis. 2015;11(6):1199–200. A Message from Dr. Jaime Ponce continued... A Message from Dr. Christopher Still continued... replacement. Obesity medicine specialists consider IGB to be another tool in the toolbox manage patients with obesity. Just like patients on pharmacotherapy or after bariatric surgery, the more accountable the patient is gives him or her the best chance for sustained success. The IGB, along with other devices, fits into the treatment paradigm of a comprehensive approach. Sincerely, Christopher Still, DO, FACN, FACP REFERENCES 1. Magkos F, Fraterrigo G, Yoshino J, et al. Effects of moderate and subsequent progressive weight loss on metabolic function and adipose tissue biology in humans with obesity. Cell Metab. 2016 Feb 22. pii: S1550-4131(16)30053-5. [Epub ahead of print] 2. Zezos P, Renner EL. Liver transplantation and non-alcoholic fatty liver disease. World J Gastroenterol. 2014 Nov 14;20(42):15532-8.