Bariatric Times

DEC 2012

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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20 Review Bariatric Times • December 2012 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 FIGURE 1. Military bariatric surgeons William Rice (left) and Robert Lim (right) perform damage contral surgery on a severely injured popliteal artery from an improvised explosive device (IED) for the 274th Forward Surgical Team in Jalalabad, Afghanistan Bariatric Times. 2012;9(12):20–23 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. KEYWORDS military bariatric surgery, trauma surgeon, deployment, unique obstacles in bariatric care, military bariatric task force Continued from page 1 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 longterm 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

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