A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional
Bariatric Times • September 2011
Editorial Message
Raul J. Rosenthal, MD, FACS, Clinical Editor, Bariatric Times, Program Director of
Minimally Invasive Surgery, Director of the Minimally Invasive Fellowship Program, and Director of the Bariatric and Metabolic Institute, Cleveland Clinic Florida—Weston, Fort Lauderdale, Florida.
Dear Bariatric Times readers: I just returned from the XVI World Congress of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), which took place August 31 to September 3, 2011, in Hamburg, Germany. The meeting was a great success. Congratulations to Sylvie Weiner and Dr. Rudolph Weiner on the impeccable organization of IFSO 2011, and to Dr. Karl Miller, President. I also congratulate Dr. Pradeep Chowbey from New Dhelli, India, IFSO President-Elect for 2012. He will host the XVII IFSO World Congress, September 11 to 15, 2012, in New Delhi, India. It seems gastric plication is a hot topic lately, and after attending IFSO, I feel it is necessary to temper some of the buzz we've been hearing lately regarding this new surgical procedure. Bariatric Times readers should keep in mind that this is an investigative procedure, and there are no long-term data available yet regarding its safety and efficacy as a first-line weight loss surgical procedure. I personally have performed one gastric plication procedure (under an Institutional Review Board [IRB] protocol). I found it to be an easy and straightforward surgery, as I only stitched a suture line on the stomach wall. Two weeks later, however, the same patient presented with an abscess in the left upper quadrant, which had to be drained. It reminded me of something Dr. Kelvin Higa's father used to say to him: "If you are trying too hard to get something done, then you are probably doing something wrong." When it comes to gastric plication, I will modify this wise statement by saying, "If you do something that looks too easy and you get a bad outcome, it is probably much more difficult than you think it is." If you are interested in learning more about gastric plication, I recommend that you read the article by Andraos et al in this issue of Bariatric Times. The authors share data, including complications, from 120 gastric plication surgeries they performed in their clinic. I also implore you to refrain from performing or teaching this procedure until IRB-approved, prospective, randomized studies have shown it to be a safe, viable procedure. We surgeons need proper oversight to make sure that we do not innovate without regulation.
Proper Follow Up after Laparoscopic Adjustable Gastric Banding is the
Responsibility of both the Patient and Doctor
I thank Dr. Robert Brolin for sharing with us his "antiobstruction stitch" technique in this month's installment of "Surgical Pearls: Techniques in Bariatric Surgery." Although I do not use the antiobstruction stitch routinely, I do use it when the jejunojejunostomy does not sit straight or looks slightly kinked. In those cases, I have found the antiobstruction stitch to be extremely helpful. Thank you, Bob, for a great contribution to the column. In this month's "Ask the Experts: Dilemmas in Bariatric Surgery," Dr. Alex Gandsas reviews and analyzes a complex case of staple line disruption in a patient with morbid obesity following sleeve gastrectomy— an extremely rare but dreadful complication. Any surgeon performing sleeve gastrectomies should understand why a leak occurs, how to prevent a leak from happening, and what to do when a leak does occur. I recommend mobilizing the gastric fundus completely and the staple laterally to the fat pad; l make sure the bougie I use is not too small and the staple is not too tight at the level of the incisura angularis. I recommend that the surgeon always keeps in mind that the closer the sleeve is to the esophagus and the tighter the sleeve, the greater the incidence of staple line disruption and stricture. The staple line should be reinforced and oversewn. It is also important to remember that in gastrointestinal surgery, no leak will heal if distal obstruction is present, and the sleeve is, by definition, a high- pressure system with distal obstruction (the pylorus). With that distal obstruction in place, there are no glues, stents, or prayers that will get that leak to seal indefinitely. When I practiced surgery in Germany, we used to do anal sphincter dilatation in patients with leaks after low-anterior rectum resections. In fact, Dr. Manuel Galvao just presented on the endoscopic balloon dilatation of the pylorus in patients with leaks after laparoscopic sleeve gastrectomy at IFSO 2011. Also, in this issue of Bariatric Times, we present two separate articles that deal with topics that are inexorably linked— recommended eating and adjustment protocol for the band patient and the protocol for establishing and managing the aftercare program in the bariatric clinic. In Dr. Paul O'Brien's article, he shares his evidence-based
guidelines that all his band patients must agree to adhere to prior to band placement when it comes to eating and band adjustments. And in Dr. Eric DeMaria's column, "Total Bariatric Care," Dr. DeMaria discusses the importance of establishing an effective aftercare program and the urgent need to develop protocol that clinics can follow that will allow them to feasibly provide the level of aftercare all of their weight loss surgery patients will need following their procedures. I believe that Dr. DeMaria's estimate of one million follow-up visits a year in the United States will fall short as we continue to implant more and more bands. In 2010 alone, America implanted close to 80,000 bands. Just think that each of these patients needs four consultations per year plus adjustments. In my opinion, the problem with banding is poor follow up, and proper follow up is the responsibility of both the patient and the doctor. I believe too many bands are placed for the simple reason that band surgery is easier to perform than the other weight loss surgeries. I also believe there is an incorrect perception by patients that if the band does not work, they simply can have it removed and be converted to another weight loss surgery. Converting a band to a bypass is a difficult procedure. Another factor to consider when it comes to bands is that with our economy the way it is currently, some patients simply do not have the money to pay for the band adjustments, and as a result, I believe there may be a large population of what I call "band carriers"— patients who have the band but do to "use" it— and since nonfunctioning bands do not hurt, the band carriers may not feel motivated to have the band removed, even though it isn't working for them.
I hope to see you all at the American Society for Metabolic and Bariatric Surgery (ASMBS) Fall Educational event in Chicago, Illinois, and at the American College of Surgeons Congress in San Francisco, California.
Sincerely,
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Raul J. Rosenthal, MD, FACS Editor, Bariatric Times