A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional
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22 News and Trends Bariatric Times • October 2016 NEWS FROM THE AMERICAN COLLEGE OFSURGEONS FIRST REPORT FROM NATIONWIDE BARIATRIC REGISTRY EXAMINES THE OUTCOMES OF COMMON SURGICAL TECHNIQUES USED IN POPULAR WEIGHT LOSS PROCEDURES Obesity Rates Remain High: 25 States have Adult Obesity Rates above 30 Percent CHICAGO, Illinois—By analyzing information included in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, the largest bariatric-specific nationwide registry, researchers found that laparoscopic sleeve gastrectomy, a newer type of weight loss surgery that reduces the stomach size by about 75 percent, is a safe procedure with a low morbidity rate. But to achieve even better outcomes, common surgical techniques used in this procedure should be examined more closely. Study results are published in the September issue of the Annals of Surgery. "The MBSAQIP registry is a powerful tool that allows us to look at process measures on a national level so that we can improve the quality of care in bariatric surgery," said first author Elizabeth R. Berger, MD, a general surgery resident at Loyola University Chicago Stritch School of Medicine, Illinois, and an American College of Surgeons Clinical Research Scholar at the time this study was conducted. "This resource allows us to do very highly powered studies that we were not able to do before." Laparoscopic sleeve gastrectomy is a common bariatric procedure, accounting for 42 percent of these weight loss operations. Growing in popularity, the procedure helps obese patients lose up to 70 percent of their excess body weight during the 12 months following surgery. While there are a number of studies showing that sleeve gastrectomy is safe and effective, very few look at specific surgical techniques used in this procedure in relation to complications. During bariatric operations, various surgical techniques —including the use of a staple-line reinforcement, the bougie s ize (a tube used to measure where the stomach is divided), and the distance from the pylorus where stapling is initiated—are used to optimize the procedure and achieve b etter outcomes. But questions remain over the best surgical techniques to use to improve upon the already low complication rates, and to make the procedure even more effective with regard to weight loss. This issue is important because leaks and bleeding are major postoperative complications that remain a constant concern for bariatric surgeons. Although leaks at the staple line used to divide the stomach and bleeding events requiring a transfusion are rare— occurring in less than 1 percent of the operations—these events can require hospital readmission and a reoperation to fix the problem. Using data from the MBSAQIP registry, Dr. Berger and colleagues looked at the largest-ever cohort of patients who had undergone laparoscopic sleeve gastrectomy. They compared different techniques used in the procedure on 189,477 cases performed by 1,634 surgeons at 720 centers between 2012 and 2014. In particular, they evaluated staple- line reinforcement (a layer of material that is sandwiched within the staples), oversewing (meaning the surgeon oversews the staple line to make sure it doesn't bleed or leak) versus stapling alone, as well as bougie size, and stapling distance from the pylorus. The aim of the study was to assess the impact of these techniques on 30-day complication rates, and one-year weight loss. The results showed that 80 percent of surgeons use staple-line reinforcement, however, staple-line reinforcement was associated with higher leak rates (0.96 percent versus 0.65 percent). The use of staple-line reinforcement tended to have lower bleed rates (0.75 percent versus 1 percent), but this effect was not statistically significant after taking into account surgeon and patient factors. Not only is staple-line reinforcement associated with higher leak rates, but it also significantly i ncreases the cost of the operation by over $650 per case. Larger bougie sizes were associated with decreased leak rates, which surgeons would expect, h owever, larger bougie sizes were surprisingly associated with greater weight loss at one year. Increased distance from the pylorus was also associated with increased weight loss—again a finding many find to be surprising. "It is paramount that as professionals, we remain introspective about the work we do and strive to always improve for our patients. While the devil is in the details, this study elucidates some things we can potentially do to get even better results," said senior study author, Matthew M. Hutter, MD, MPH, FACS, from the Massachusetts General Hospital, Boston. "The most important takeaway is the fact that staple-line reinforcement is not necessarily better for bleeding and leaking, and it might not always be necessary. As surgeons, we should examine our individual work flow, looking at bleed and leak rates, and decide whether staple-line reinforcement is being appropriately used, because it's a very costly part of the procedure," Dr. Berger said. "I think this study is important because it gets at the issue of evaluating process measures in surgery and how very important that issue is." The study authors conclude: "Surgeons should consider risks, benefits, and costs of these surgical techniques when performing a laparoscopic sleeve gastrectomy and selectively utilize those that, in their hands, minimize morbidity while maximizing clinical effectiveness." Other study participants include Ronald H. Clements, MD, FACS; John M. Morton, MD, MPH, FACS; Kristopher M. Huffman, MS; Bruce M. Wolfe, MD, FACS; Ninh T. Nguyen, MD, FACS; and Clifford Y. Ko, MD, MS, MSHS, FACS. "FACS" designates that a surgeon is a Fellow of the American College of Surgeons. About the American College of Surgeons. The American College of S urgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for s urgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 80,000 members and is the largest organization of surgeons in the world. For more information, visit www.facs.org. NEWS FROM THE AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS THE AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS APPLAUDS CONGRESSIONAL ACTION ON LEGISLATION TO IMPROVE CARE FOR PATIENTS WITH DIABETES AND OTHER METABOLIC DISEASES Clinicians are missing critical opportunity to prevent diabetes with obesity treatments WASHINGTON, D.C.—A pivotal piece of legislation intended to benefit patients with diabetes and other metabolic, autoimmune and insulin- resistant diseases is headed to the floor of the House of Representatives for a vote after its passage today by the House Energy and Commerce Committee. The National Clinical Care Commission Act, the top legislative priority of the American Association of Clinical Endocrinologists (AACE), calls for the creation of a public/private sector commission that will draw on the expertise of the country's foremost diabetes specialists, physicians, non-physician health care professionals and patient advocates to improve the communication and coordination among federal agencies and help evaluate current federally administered clinical care initiatives News and Trends OCTOBER 2016