American Society For Bariatric Surgery Research Articles

21st Annual Meeting American Society for Bariatric Surgery

21st Annual Meeting American Society for Bariatric Surgery

Clinical approach to the critically ill, morbidly obese patient.

In the absence of a national registry, the prevalence of critically ill, morbidly obese patients in the United States is not known. On the basis of a retrospective study spanning 7 years of intensive care unit (ICU) data (1994–2000), it is estimated that the incidence of morbidly obese patients requiring intensive care treatment approaches 14 cases per 1,000 ICU admissions per year (1). However, this figure is likely to underestimate the true incidence because the database was restricted to nonsurgical patients. The growing interest in gastric bypass underlines the increased public awareness of the medical and economic consequences of this epidemic. The latest numbers released by the American Society for Bariatric Surgery indicate that the rate of bariatric surgeries has risen in the United States alone from 37,000 cases in the year 2000 to 62,400 cases in 2001 and it is expected that the total number of cases may exceed 100,000 by the end of 2003 (2). Most of the reviews that have provided data on morbidly obese patients have focused on the impact of obesity on individual organ function. Yet, clinical investigations addressing the care of the critically ill, morbidly obese patient are scarce. A recent review published in the AJRCCM detailed the principles and approach to outpatient treatment of obesity (3). The present commentary is aimed at (1) describing the common challenges of treating morbidly obese patients in critical care settings and (2) reviewing the current concepts and suggestions for therapy.

American Society for Bariatric Surgery -- 21st year.

American Society for Bariatric Surgery -- 21st year.

Surgery for Obesity

AS BARIATRIC SURGERY FOR THE treatment of patients with morbid obesity surges in popularity in the United States, ethical and scientific questions about the approach are mounting. While bariatric surgery has been performed since the 1960s, improvements in laproscopic methods and a 1991 Consensus Statement by the National Institutes of Health (NIH) that established criteria for eligibility for surgical treatment of morbid obesity opened the door for insurance coverage and set the stage for an explosive increase in its use. According to the American Society for Bariatric Surgery (ASBS), about 47000 surgeries for treatment of morbid obesity were performed in 2001. Last year about 63000 bariatric surgeries were performed and this year an estimated 98000 will be done. The majority of procedures are: Roux-en-Y gastric bypass, stapled gastroplasty, and adjustable gastric banding—all of which are designed to reduce stomach size and thus control calorie intake ( JAMA. 2002;288:2793-2796). The NIH criteria for obesity surgery eligibility are a well informed and motivated patient with a body mass index (BMI) of greater than 40, or a patient with less severe obesity (BMI greater than 35) who has high-risk, comorbid conditions such as type 2 diabetes and cardiopulmonary problems.

Anesthetic Considerations for Bariatric Surgery

According to the National Institutes of Health, obesity is a major health problem with clearly established health implications, including an increased risk for coronary artery disease, hypertension, dyslipidemia, diabetes mellitus, gallbladder disease, degenerative joint disease, obstructive sleep apnea, and socioeconomic and psychosocial impairment (1). The risk of developing one or more of these obesityrelated conditions is based on body mass index (BMI), with 25–30 kg/m 2 being low risk and 40 kg/m 2 being very high risk (2). The prevalence of obesity in the 18- to 29-yr-old group increased from 12% in 1991 to 18.9% in 1999 (3). Bariatric surgery encompasses a variety of surgical weight loss procedures used to treat morbid obesity. Obesity is clinically expressed in terms of BMI or Quetelet’s index (4), which is derived by dividing weight by the square of height to estimate the degree of obesity. Thus, BMI body weight (kg)/height 2 (m 2 ). Morbid obesity is a BMI more than 35 kg/m 2 , and super morbid obesity is BMI more than 55 kg/m 2 . The indications for surgical treatment of severe obesity, as outlined in the 1991 National Institutes of Health Consensus Development Conference Panel, include an absolute BMI more than 40 kg/m 2 or BMI more than 35 kg/m 2 in combination with lifethreatening cardiopulmonary problems or severe diabetes mellitus (1). Patients seeking surgical weight loss must have proven attempts at medically supervised weight loss. Documentation of loss of 5% to 10% excess body weight or weight gain after at least 6 mo of diet modification, exercise, and medical therapy or nonimprovement in comorbid conditions during this period indicates failure. Studies have shown that weight loss of 5%–10% of initial body weight improves glucose intolerance and Type II diabetes, hypertension, and dyslipidemia (5–7). The average expenditure is approximately $7000 per year per patient on weight loss programs and equipment. Unfortunately, long-term weight loss is the exception, and most patients regain weight, sometimes more than they initially lost.

Quo vadis?

Quo vadis?

Gallbladder management in obesity surgery.

In the 1980s, some surgeons recommended routine cholecystectomy for patients undergoing bariatric surgery. This was based on the high prevalence of gallstones in the obese and concern that rapid weight loss would increase the risk of gallbladder disease. Others recommended waiting for a lower weight and a definite need. With increasing prevalence and severity of obesity and increased use of gastric reduction surgery for weight control, it seemed appropriate to review the current standard of care for cholecystectomy. A survey was also made of ursodeoxycholic acid usage for prevention of gallstone formation. Data collected from active contributors for the 28th Report of the International Bariatric Surgery Registry (IBSR) were examined. Two questionnaires were also sent to members of the American Society for Bariatric Surgery (ASBS). The first (Q1) asked about the indications for cholecystectomy. The second (Q2) asked about ursodeoxycholic acid usage for prevention of gallstone formation during rapid weight loss following surgical treatment of obesity. There has been an increase in concurrent cholecystectomy during the last 15 years. Some of this is due to a shift from simple gastric restrictive operations to gastric bypass with gastric restriction. When the most extensive bypass of intestine is used, as in distal Roux-en-Y gastric bypass (RYGBP-X) or biliopancreatic diversion with a duodenal switch (BPD-DS), all patients were reported to have undergone cholecystectomy. Only 30% of surgeons performing standard Roux-en-Y gastric bypass (RYGBP) remove normal-appearing gallbladders. Ursodeoxycholic acid is used to prevent gallstone formation in one-third of patients when a normal-appearing gallbladder is left in place. Prophylactic cholecystectomy is left to the discretion of the surgeon when RYGBP is used. There has been an increase in cholecystectomy and malabsorptive operations during the last 15 years. When most of the small bowel is bypassed, all remaining gallbladders are removed. For patients with simple restriction operations, normal-appearing gallbladders are usually left in place. Urso-deoxycholic acid during rapid weight loss for prevention of gallstone formation is used in one-third of patients with remaining gallbladders.

19th Annual meeting of the American Society for Bariatric Surgery

19th Annual meeting of the American Society for Bariatric Surgery

American Society for Bariatric Surgery: 18th Annual Meeting, Call for Abstracts

American Society for Bariatric Surgery: 18th Annual Meeting, Call for Abstracts

Program, 17th Annual Meeting American Society for Bariatric Surgery

Program, 17th Annual Meeting American Society for Bariatric Surgery

Current practices in the prophylaxis of venous thromboembolism in bariatric surgery.

Morbidly obese patients undergoing bariatric surgery have commonly been concluded to be at high risk for the development of perioperative venous thromboembolism. Due to its clinically silent nature, primary prevention is the key to reduce morbidity and mortality. There is no clear consensus in the literature regarding the optimum approach to minimize this preventable phenomenon. Members of the American Society for Bariatric Surgery were surveyed regarding their current practices in the prophylaxis of venous thromboembolism in their bariatric patients. 31% of the members completed the survey. 62% were in private practice, and 38% practiced in an academic hospital. The number of bariatric surgeries done per year ranged from 5 to 325, with a mean of 85 procedures per member. The gastric bypass was the most commonly performed procedure at 61.7%, followed by vertical banded gastroplasty at 23.3%, biliary pancreatic diversion at 9.3%, laparoscopic gastroplasty at 4.0%, laparoscopic gastric bypass at 1.6%, and horizontal banded gastroplasty at 0.1%. 86% felt that their bariatric patients were at high risk for developing deep vein thrombosis (DVT) and pulmonary embolism (PE) with a self-reported incidence of 2.63% and 0.95%, respectively. 48% had at least one death due to PE. Routine prophylaxis is used by over 95% of members. 62% ranked the various methods of prophylaxis from most preferred to least preferred, while 38% used a combination of 2 or more prophylactic methods simultaneously. Low-dose heparin was the most preferred prophylaxis by 50% of members, followed by intermittent pneumatic compression stockings at 33%, low molecular weight heparins at 13%, and other methods at 4%. Over 83% indicated that safety with few complications, ease of administration, and effectiveness were the most important criteria for selecting their most preferred prophylactic method. Only 2% routinely performed testing to rule out venous thromboembolism before discharge, and 11% routinely discharged patients with prophylaxis. The prevailing opinion of members of the American Society for Bariatric Surgery is that morbidly obese patients are at high risk for developing perioperative venous thromboembolism. A vast majority routinely use prophylaxis. Despite these measures, fatal PE is still widespread. A lack of consensus in the method of prophylaxis was seen. A multicentric randomized controlled study comparing the efficacy of the various methods of prophylaxis will be the only manner to determine the best prophylaxis and its usefulness. This study will be costly and probably not warranted due to the low incidence of this condition in the morbidly obese patient.

The medical malpractice risk associated with bariatric surgery.

Bariatric surgery has been classified as high risk by the medical malpractice industry, but it is unclear what data support this classification. When a small group of physicians is separated from their peers and asked to support their malpractice claims, their premiums will often rise unfairly in relation to the outcome of the claims. This report outlines the results of a survey sent to the members of the American Society for Bariatric Surgery (ASBS) asking for information on malpractice claims. Surveys were mailed to the 285 ASBS members requesting which bariatric operations were performed, how many procedures were completed each year, details of any suits filed against the member including final outcome, and information on whether the members also performed gastric surgery for ulcer disease. Surveys were returned by 165 members (58%) from surgeons in 33 states and Washington, D.C. Malpractice claims had been made after 107 bariatric procedures and three ulcer procedures with the risk of a suit being filed for a bariatric procedure being approximately 1.6/1,000 cases. The average monetary award was $88,667. Of the suits that resulted in a jury trial, 14% agreed with the plaintiff. Over half the cases that had been resolved were either dropped or dismissed before trial. The incidence of suit being brought against ASBS members performing bariatric procedures is low. Once filed, most cases do not reach a jury trial. Settlements are usually under $100,000. These data suggest that this group of bariatric surgeons do not represent a disproportionately large risk pool for medical malpractice insurance companies.

American Society for Bariatric Surgery<BR></BR> NEW MEMBERS

American Society for Bariatric Surgery<BR></BR> NEW MEMBERS

American Society for Bariatric Surgery<BR></BR> Executive Council and Committees 1998-l999

American Society for Bariatric Surgery<BR></BR> Executive Council and Committees 1998-l999

American Society for Bariatric Surgery<BR></BR> 1999 Annual Meeting, Call for Abstracts

American Society for Bariatric Surgery<BR></BR> 1999 Annual Meeting, Call for Abstracts

Past, present, and future of obesity surgery.

At the meeting 1 year ago, Mary Lou Walen asked the author to provide a brief luncheon talk about the past, present, and future of obesity surgery for the Allied Health Sciences members who meet in conjunction with the annual meeting of the American Society for Bariatric Surgery. This led the author to examine the surgical treatment of severe obesity as it relates to our times and society. Edward O. Wilson has recommended that bariatric surgeons enlarge their view of the work they are engaged in, to include a more universal perspective. From this review, the following talk was presented.

The American Society For Bariatric Surgery (ASBS) Statement on Bariatric Surgeon Qualifications, October 12, 1997

The American Society For Bariatric Surgery (ASBS) Statement on Bariatric Surgeon Qualifications, October 12, 1997

American Society For Bariatric Surgery<BR></BR> Executive Council and Committees 1997-1998

American Society For Bariatric Surgery<BR></BR> Executive Council and Committees 1997-1998

Fifteenth Annual Meeting of the American Society for Bariatric Surgery<BR></BR> June 24-27 1998<BR></BR> Orlando, Florida

Fifteenth Annual Meeting of the American Society for Bariatric Surgery<BR></BR> June 24-27 1998<BR></BR> Orlando, Florida

Gastric bypass for morbid obesity: a standard surgical technique by consensus.

The gastric bypass operation has evolved since 1966 when it was first introduced. The purpose of this study was to determine the present state of gastric bypass by consensus among the members of the American Society for Bariatric Surgery (ASBS). A questionnaire was sent to all members of the ASBS. Forty-three percent responded reporting over 41,200 cases. Results were analyzed by using chi2 tests with a null hypothesis. Surgeons agreed on several technical aspects, preferring a vertical to a horizontal stapleline; estimating, rather than measuring, the pouch volume at an average of 22 cc. Few surgeons divide the short gastric vessels, and only 25% of surgeons polled use a restrictive ring or band proximal to the gastroenterostomy. Most surgeons calibrate the gastroenterostomy, reporting a preferred average diameter of 12.3cm. There was no consensus regarding forming the gastroenterostomy, 58% preferring hand-sewn and 42% stapled anastomoses. There was no consensus regarding dividing the gastric pouch from the bypassed stomach: The preferred gastric bypass is vertical, with the pouch estimated at 20-25 cc, and the gastroenterostomy calibrated at 12 mm diameter. The short gastric vessels need not be divided, and restrictive bands or rings are not preferred. This technique of gastric bypass should be used as the control procedure when modifications are tested in future trials. Randomized prospective studies are suggested to probe the benefits of division of the stomach pouch from the bypassed stomach.