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Liver disease likely to become increasing indication for bariatric surgery
PHILADELPHIA – There is a long list of benefits from bariatric surgery in the morbidly obese, but prevention of end-stage liver disease and the need for a first or second liver transplant is likely to grow as an indication, according to an overview of weight loss surgery at Digestive Diseases: New Advances, held by Rutgers, the State University of New Jersey, and Global Academy for Medical Education.
“Bariatric surgery is associated with significant improvement not just in diabetes, dyslipidemia, hypertension, and other complications of metabolic disorders but for me more interestingly, it is effective for treating fatty liver disease where you can see a 90% improvement in steatosis,” reported Subhashini Ayloo, MD, chief of minimally invasive robotic hepato-pancreato-biliary surgery and liver transplantation at New Jersey Medical School, Newark.
Trained in both bariatric surgery and liver transplant, Dr. Ayloo predicts that these fields will become increasingly connected because of the obesity epidemic and the related rise in nonalcoholic fatty liver disease (NAFLD). Dr. Ayloo reported that bariatric surgery is already being used in her center to avoid a second liver transplant in obese patients who are unable to lose sufficient weight to prevent progressive NAFLD after a first transplant.
The emphasis Dr. Ayloo placed on the role of bariatric surgery in preventing progression of NAFLD to nonalcoholic steatohepatitis and the inflammatory process that leads to fibrosis, cirrhosis, and liver decompensation, was drawn from her interest in these two fields. However, she did not ignore the potential of protection from obesity control for other diseases.
“Obesity adversely affects every organ in the body,” Dr. Ayloo pointed out. As a result of weight loss achieved with bariatric surgery, there is now a large body of evidence supporting broad benefits, not just those related to fat deposited in hepatocytes.
“We have a couple of decades of experience that has been published [with bariatric surgery], and this has shown that it maintains weight loss long term, it improves all the obesity-associated comorbidities, and it is cost effective,” Dr. Ayloo said. Now with long-term follow-up, “all of the studies are showing that bariatric surgery improves survival.”
Although most of the survival data have been generated by retrospective cohort studies, Dr. Ayloo cited nine sets of data showing odds ratios associating bariatric surgery with up to a 90% reduction in death over periods of up to 10 years of follow-up. In a summary slide presented by Dr. Ayloo, the estimated mortality benefit over 5 years was listed as 85%. The same summary slide listed large improvements in relevant measures of morbidity for more than 10 organ systems, such as improvement or resolution of dyslipidemia and hypertension in the circulatory system, improvement or resolution of asthma and other diseases affecting the respiratory system, and resolution or improvement of gastroesophageal reflux disease and other diseases affecting the gastrointestinal system.
Specific to the liver, these benefits included a nearly 40% reduction in liver inflammation and 20% reduction in fibrosis. According to Dr. Ayloo, who noted that NAFLD is expected to overtake hepatitis C virus as the No. 1 cause of liver transplant within the next 5 years, these data are important for drawing attention to bariatric surgery as a strategy to control liver disease. She suggested that there is a need to create a tighter link between efforts to treat morbid obesity and advanced liver disease.
“There is an established literature showing that if somebody is morbidly obese, the rate of liver transplant is lower than when compared to patients with normal weight,” Dr. Ayloo said. “There is a call out in the transplant community that we need to address this and we cannot just be throwing this under the table.”
Because of the strong relationship between obesity and NAFLD, a systematic approach is needed to consider liver disease in obese patients and obesity in patients with liver disease, she said. The close relationship is relevant when planning interventions for either. Liver disease should be assessed prior to bariatric surgery regardless of the indication and then monitored closely as part of postoperative care, she said.
Dr. Ayloo identified weight control as an essential part of posttransplant care to prevent hepatic fat deposition that threatens transplant-free survival.
Global Academy and this news organization are owned by the same company. Dr. Ayloo reports no relevant financial relationships.
PHILADELPHIA – There is a long list of benefits from bariatric surgery in the morbidly obese, but prevention of end-stage liver disease and the need for a first or second liver transplant is likely to grow as an indication, according to an overview of weight loss surgery at Digestive Diseases: New Advances, held by Rutgers, the State University of New Jersey, and Global Academy for Medical Education.
“Bariatric surgery is associated with significant improvement not just in diabetes, dyslipidemia, hypertension, and other complications of metabolic disorders but for me more interestingly, it is effective for treating fatty liver disease where you can see a 90% improvement in steatosis,” reported Subhashini Ayloo, MD, chief of minimally invasive robotic hepato-pancreato-biliary surgery and liver transplantation at New Jersey Medical School, Newark.
Trained in both bariatric surgery and liver transplant, Dr. Ayloo predicts that these fields will become increasingly connected because of the obesity epidemic and the related rise in nonalcoholic fatty liver disease (NAFLD). Dr. Ayloo reported that bariatric surgery is already being used in her center to avoid a second liver transplant in obese patients who are unable to lose sufficient weight to prevent progressive NAFLD after a first transplant.
The emphasis Dr. Ayloo placed on the role of bariatric surgery in preventing progression of NAFLD to nonalcoholic steatohepatitis and the inflammatory process that leads to fibrosis, cirrhosis, and liver decompensation, was drawn from her interest in these two fields. However, she did not ignore the potential of protection from obesity control for other diseases.
“Obesity adversely affects every organ in the body,” Dr. Ayloo pointed out. As a result of weight loss achieved with bariatric surgery, there is now a large body of evidence supporting broad benefits, not just those related to fat deposited in hepatocytes.
“We have a couple of decades of experience that has been published [with bariatric surgery], and this has shown that it maintains weight loss long term, it improves all the obesity-associated comorbidities, and it is cost effective,” Dr. Ayloo said. Now with long-term follow-up, “all of the studies are showing that bariatric surgery improves survival.”
Although most of the survival data have been generated by retrospective cohort studies, Dr. Ayloo cited nine sets of data showing odds ratios associating bariatric surgery with up to a 90% reduction in death over periods of up to 10 years of follow-up. In a summary slide presented by Dr. Ayloo, the estimated mortality benefit over 5 years was listed as 85%. The same summary slide listed large improvements in relevant measures of morbidity for more than 10 organ systems, such as improvement or resolution of dyslipidemia and hypertension in the circulatory system, improvement or resolution of asthma and other diseases affecting the respiratory system, and resolution or improvement of gastroesophageal reflux disease and other diseases affecting the gastrointestinal system.
Specific to the liver, these benefits included a nearly 40% reduction in liver inflammation and 20% reduction in fibrosis. According to Dr. Ayloo, who noted that NAFLD is expected to overtake hepatitis C virus as the No. 1 cause of liver transplant within the next 5 years, these data are important for drawing attention to bariatric surgery as a strategy to control liver disease. She suggested that there is a need to create a tighter link between efforts to treat morbid obesity and advanced liver disease.
“There is an established literature showing that if somebody is morbidly obese, the rate of liver transplant is lower than when compared to patients with normal weight,” Dr. Ayloo said. “There is a call out in the transplant community that we need to address this and we cannot just be throwing this under the table.”
Because of the strong relationship between obesity and NAFLD, a systematic approach is needed to consider liver disease in obese patients and obesity in patients with liver disease, she said. The close relationship is relevant when planning interventions for either. Liver disease should be assessed prior to bariatric surgery regardless of the indication and then monitored closely as part of postoperative care, she said.
Dr. Ayloo identified weight control as an essential part of posttransplant care to prevent hepatic fat deposition that threatens transplant-free survival.
Global Academy and this news organization are owned by the same company. Dr. Ayloo reports no relevant financial relationships.
PHILADELPHIA – There is a long list of benefits from bariatric surgery in the morbidly obese, but prevention of end-stage liver disease and the need for a first or second liver transplant is likely to grow as an indication, according to an overview of weight loss surgery at Digestive Diseases: New Advances, held by Rutgers, the State University of New Jersey, and Global Academy for Medical Education.
“Bariatric surgery is associated with significant improvement not just in diabetes, dyslipidemia, hypertension, and other complications of metabolic disorders but for me more interestingly, it is effective for treating fatty liver disease where you can see a 90% improvement in steatosis,” reported Subhashini Ayloo, MD, chief of minimally invasive robotic hepato-pancreato-biliary surgery and liver transplantation at New Jersey Medical School, Newark.
Trained in both bariatric surgery and liver transplant, Dr. Ayloo predicts that these fields will become increasingly connected because of the obesity epidemic and the related rise in nonalcoholic fatty liver disease (NAFLD). Dr. Ayloo reported that bariatric surgery is already being used in her center to avoid a second liver transplant in obese patients who are unable to lose sufficient weight to prevent progressive NAFLD after a first transplant.
The emphasis Dr. Ayloo placed on the role of bariatric surgery in preventing progression of NAFLD to nonalcoholic steatohepatitis and the inflammatory process that leads to fibrosis, cirrhosis, and liver decompensation, was drawn from her interest in these two fields. However, she did not ignore the potential of protection from obesity control for other diseases.
“Obesity adversely affects every organ in the body,” Dr. Ayloo pointed out. As a result of weight loss achieved with bariatric surgery, there is now a large body of evidence supporting broad benefits, not just those related to fat deposited in hepatocytes.
“We have a couple of decades of experience that has been published [with bariatric surgery], and this has shown that it maintains weight loss long term, it improves all the obesity-associated comorbidities, and it is cost effective,” Dr. Ayloo said. Now with long-term follow-up, “all of the studies are showing that bariatric surgery improves survival.”
Although most of the survival data have been generated by retrospective cohort studies, Dr. Ayloo cited nine sets of data showing odds ratios associating bariatric surgery with up to a 90% reduction in death over periods of up to 10 years of follow-up. In a summary slide presented by Dr. Ayloo, the estimated mortality benefit over 5 years was listed as 85%. The same summary slide listed large improvements in relevant measures of morbidity for more than 10 organ systems, such as improvement or resolution of dyslipidemia and hypertension in the circulatory system, improvement or resolution of asthma and other diseases affecting the respiratory system, and resolution or improvement of gastroesophageal reflux disease and other diseases affecting the gastrointestinal system.
Specific to the liver, these benefits included a nearly 40% reduction in liver inflammation and 20% reduction in fibrosis. According to Dr. Ayloo, who noted that NAFLD is expected to overtake hepatitis C virus as the No. 1 cause of liver transplant within the next 5 years, these data are important for drawing attention to bariatric surgery as a strategy to control liver disease. She suggested that there is a need to create a tighter link between efforts to treat morbid obesity and advanced liver disease.
“There is an established literature showing that if somebody is morbidly obese, the rate of liver transplant is lower than when compared to patients with normal weight,” Dr. Ayloo said. “There is a call out in the transplant community that we need to address this and we cannot just be throwing this under the table.”
Because of the strong relationship between obesity and NAFLD, a systematic approach is needed to consider liver disease in obese patients and obesity in patients with liver disease, she said. The close relationship is relevant when planning interventions for either. Liver disease should be assessed prior to bariatric surgery regardless of the indication and then monitored closely as part of postoperative care, she said.
Dr. Ayloo identified weight control as an essential part of posttransplant care to prevent hepatic fat deposition that threatens transplant-free survival.
Global Academy and this news organization are owned by the same company. Dr. Ayloo reports no relevant financial relationships.
Open-capsule PPIs linked to faster ulcer healing after Roux-en-Y
The use of proton pump inhibitors in opened instead of closed capsules was associated with a nearly fourfold shorter median healing time among patients who developed marginal ulcers after Roux-en-Y gastric bypass, in a single-center retrospective cohort study.
In contrast, the specific class of proton pump inhibitor (PPI) did not affect healing times, wrote Allison R. Schulman, MD, and her associates at Brigham and Women’s Hospital, Boston. The report is in the April issue of Clinical Gastroenterology and Hepatology (doi: 10.1016/j.cgh.2016.10.015). “Given these results and the high prevalence of marginal ulceration in this patient population, further study in a randomized controlled setting is warranted, and use of open-capsule PPIs should be considered as a low-risk, low-cost alternative,” they added.
Roux-en-Y gastric bypass is one of the most common types of gastric bypass surgeries in the world, and up to 16% of patients develop postsurgical ulcers at the gastrojejunal anastomosis, the investigators noted. Acidity is a prime suspect in these “marginal ulcerations” because bypassing the acid-buffering duodenum exposes the jejunum to acid from the stomach, they added. High-dose PPIs are the main treatment, but there is no consensus on the formulation or dose of therapy. Because Roux-en-Y creates a small gastric pouch and hastens small-bowel transit, closed capsules designed to break down in the stomach “even may make their way to the colon before breakdown occurs,” they wrote.
They reviewed medical charts from patients who developed marginal ulcerations after undergoing Roux-en-Y gastric bypass at their hospital from 2000 through 2015. A total of 115 patients received open-capsule PPIs and 49 received intact capsules. All were followed until their ulcers healed.
For the open-capsule group, median time to healing was 91 days, compared with 342 days for the closed-capsule group (P less than .001). Importantly, capsule type was the only independent predictor of healing time (hazard ratio, 6.0; 95% confidence interval, 3.7 to 9.8; P less than .001) in a Cox regression model that included other known correlates of ulcer healing, including age, smoking status, the use of nonsteroidal anti-inflammatory drugs, Helicobacter pylori infection, the length of the gastric pouch, and the presence of fistulae or foreign bodies such as sutures or staples.
The use of sucralfate also did not affect time to ulcer healing, reflecting “many previous studies showing a lack of definitive benefit to this medication,” the researchers said. The findings have “tremendous implications” for health care utilization, they added. Indeed, patients who received open-capsule PPIs needed significantly fewer endoscopic procedures (median, 1.2 versus 1.8; P = .02) and used fewer health care resources overall ($7,206 versus $11,009; P = .05) compared with those prescribed intact PPI capsules.
This study was limited to patients who developed ulcer symptoms and underwent repeated surveillance endoscopies after surgery, the researchers noted. Selection bias is always a concern with retrospective studies, but insurers always covered both types of therapy and the choice of capsule type was entirely up to providers, all of whom consistently prescribed either open- or closed-capsule PPI therapy, they added.
The investigators did not acknowledge external funding sources. Dr. Schulman and four coinvestigators reported having no competing interests. One coinvestigator disclosed ties to Olympus, Boston Scientific, and Covidien.
Proton pump inhibitors (PPIs) are frequently employed to treat marginal ulcers after Roux-en-Y gastric bypass (RYGB). In a retrospective study, Schulman et al. compared intact vs. “open” PPI capsules. 
They state that “this may be overcome by use of a soluble form of PPI,” but don’t state what is meant by “soluble PPI” or how the open-capsule PPI was delivered. Among the PPIs they reported using to compare intact vs. open capsules was Protonix [pantoprazole] which is not produced as a capsule, and soluble Prevacid [lansoprazole], which is an orally disintegrating tablet that should provide characteristics similar to an “open capsule.”
PPI capsules provide PPI in enteric-coated granules, which are designed to protect the PPI from acid degradation in the stomach of individuals with intact gastrointestinal tracts and allow more of the PPI dose to reach the small intestine where it is absorbed. If capsules really fail to release their enteric-coated granules until very distally in RYGB patients, bypassing this step to allow earlier release of PPI makes intuitive sense; formulations such as suspensions and rapidly disintegrating tablets that deliver enteric-coated granules without capsules are currently available.
However, if this is an issue, administering a suspension of uncoated PPI with bicarbonate potentially might be the most attractive option, given more rapid absorption than PPI delivered as enteric-coated granules.
Loren Laine, MD, AGAF, professor of medicine, digestive diseases, Yale University, New Haven, Conn. He has no conflicts of interest.
Proton pump inhibitors (PPIs) are frequently employed to treat marginal ulcers after Roux-en-Y gastric bypass (RYGB). In a retrospective study, Schulman et al. compared intact vs. “open” PPI capsules.
They state that “this may be overcome by use of a soluble form of PPI,” but don’t state what is meant by “soluble PPI” or how the open-capsule PPI was delivered. Among the PPIs they reported using to compare intact vs. open capsules was Protonix [pantoprazole] which is not produced as a capsule, and soluble Prevacid [lansoprazole], which is an orally disintegrating tablet that should provide characteristics similar to an “open capsule.”
PPI capsules provide PPI in enteric-coated granules, which are designed to protect the PPI from acid degradation in the stomach of individuals with intact gastrointestinal tracts and allow more of the PPI dose to reach the small intestine where it is absorbed. If capsules really fail to release their enteric-coated granules until very distally in RYGB patients, bypassing this step to allow earlier release of PPI makes intuitive sense; formulations such as suspensions and rapidly disintegrating tablets that deliver enteric-coated granules without capsules are currently available.
However, if this is an issue, administering a suspension of uncoated PPI with bicarbonate potentially might be the most attractive option, given more rapid absorption than PPI delivered as enteric-coated granules.
Loren Laine, MD, AGAF, professor of medicine, digestive diseases, Yale University, New Haven, Conn. He has no conflicts of interest.
Proton pump inhibitors (PPIs) are frequently employed to treat marginal ulcers after Roux-en-Y gastric bypass (RYGB). In a retrospective study, Schulman et al. compared intact vs. “open” PPI capsules.
They state that “this may be overcome by use of a soluble form of PPI,” but don’t state what is meant by “soluble PPI” or how the open-capsule PPI was delivered. Among the PPIs they reported using to compare intact vs. open capsules was Protonix [pantoprazole] which is not produced as a capsule, and soluble Prevacid [lansoprazole], which is an orally disintegrating tablet that should provide characteristics similar to an “open capsule.”
PPI capsules provide PPI in enteric-coated granules, which are designed to protect the PPI from acid degradation in the stomach of individuals with intact gastrointestinal tracts and allow more of the PPI dose to reach the small intestine where it is absorbed. If capsules really fail to release their enteric-coated granules until very distally in RYGB patients, bypassing this step to allow earlier release of PPI makes intuitive sense; formulations such as suspensions and rapidly disintegrating tablets that deliver enteric-coated granules without capsules are currently available.
However, if this is an issue, administering a suspension of uncoated PPI with bicarbonate potentially might be the most attractive option, given more rapid absorption than PPI delivered as enteric-coated granules.
Loren Laine, MD, AGAF, professor of medicine, digestive diseases, Yale University, New Haven, Conn. He has no conflicts of interest.
The use of proton pump inhibitors in opened instead of closed capsules was associated with a nearly fourfold shorter median healing time among patients who developed marginal ulcers after Roux-en-Y gastric bypass, in a single-center retrospective cohort study.
In contrast, the specific class of proton pump inhibitor (PPI) did not affect healing times, wrote Allison R. Schulman, MD, and her associates at Brigham and Women’s Hospital, Boston. The report is in the April issue of Clinical Gastroenterology and Hepatology (doi: 10.1016/j.cgh.2016.10.015). “Given these results and the high prevalence of marginal ulceration in this patient population, further study in a randomized controlled setting is warranted, and use of open-capsule PPIs should be considered as a low-risk, low-cost alternative,” they added.
Roux-en-Y gastric bypass is one of the most common types of gastric bypass surgeries in the world, and up to 16% of patients develop postsurgical ulcers at the gastrojejunal anastomosis, the investigators noted. Acidity is a prime suspect in these “marginal ulcerations” because bypassing the acid-buffering duodenum exposes the jejunum to acid from the stomach, they added. High-dose PPIs are the main treatment, but there is no consensus on the formulation or dose of therapy. Because Roux-en-Y creates a small gastric pouch and hastens small-bowel transit, closed capsules designed to break down in the stomach “even may make their way to the colon before breakdown occurs,” they wrote.
They reviewed medical charts from patients who developed marginal ulcerations after undergoing Roux-en-Y gastric bypass at their hospital from 2000 through 2015. A total of 115 patients received open-capsule PPIs and 49 received intact capsules. All were followed until their ulcers healed.
For the open-capsule group, median time to healing was 91 days, compared with 342 days for the closed-capsule group (P less than .001). Importantly, capsule type was the only independent predictor of healing time (hazard ratio, 6.0; 95% confidence interval, 3.7 to 9.8; P less than .001) in a Cox regression model that included other known correlates of ulcer healing, including age, smoking status, the use of nonsteroidal anti-inflammatory drugs, Helicobacter pylori infection, the length of the gastric pouch, and the presence of fistulae or foreign bodies such as sutures or staples.
The use of sucralfate also did not affect time to ulcer healing, reflecting “many previous studies showing a lack of definitive benefit to this medication,” the researchers said. The findings have “tremendous implications” for health care utilization, they added. Indeed, patients who received open-capsule PPIs needed significantly fewer endoscopic procedures (median, 1.2 versus 1.8; P = .02) and used fewer health care resources overall ($7,206 versus $11,009; P = .05) compared with those prescribed intact PPI capsules.
This study was limited to patients who developed ulcer symptoms and underwent repeated surveillance endoscopies after surgery, the researchers noted. Selection bias is always a concern with retrospective studies, but insurers always covered both types of therapy and the choice of capsule type was entirely up to providers, all of whom consistently prescribed either open- or closed-capsule PPI therapy, they added.
The investigators did not acknowledge external funding sources. Dr. Schulman and four coinvestigators reported having no competing interests. One coinvestigator disclosed ties to Olympus, Boston Scientific, and Covidien.
The use of proton pump inhibitors in opened instead of closed capsules was associated with a nearly fourfold shorter median healing time among patients who developed marginal ulcers after Roux-en-Y gastric bypass, in a single-center retrospective cohort study.
In contrast, the specific class of proton pump inhibitor (PPI) did not affect healing times, wrote Allison R. Schulman, MD, and her associates at Brigham and Women’s Hospital, Boston. The report is in the April issue of Clinical Gastroenterology and Hepatology (doi: 10.1016/j.cgh.2016.10.015). “Given these results and the high prevalence of marginal ulceration in this patient population, further study in a randomized controlled setting is warranted, and use of open-capsule PPIs should be considered as a low-risk, low-cost alternative,” they added.
Roux-en-Y gastric bypass is one of the most common types of gastric bypass surgeries in the world, and up to 16% of patients develop postsurgical ulcers at the gastrojejunal anastomosis, the investigators noted. Acidity is a prime suspect in these “marginal ulcerations” because bypassing the acid-buffering duodenum exposes the jejunum to acid from the stomach, they added. High-dose PPIs are the main treatment, but there is no consensus on the formulation or dose of therapy. Because Roux-en-Y creates a small gastric pouch and hastens small-bowel transit, closed capsules designed to break down in the stomach “even may make their way to the colon before breakdown occurs,” they wrote.
They reviewed medical charts from patients who developed marginal ulcerations after undergoing Roux-en-Y gastric bypass at their hospital from 2000 through 2015. A total of 115 patients received open-capsule PPIs and 49 received intact capsules. All were followed until their ulcers healed.
For the open-capsule group, median time to healing was 91 days, compared with 342 days for the closed-capsule group (P less than .001). Importantly, capsule type was the only independent predictor of healing time (hazard ratio, 6.0; 95% confidence interval, 3.7 to 9.8; P less than .001) in a Cox regression model that included other known correlates of ulcer healing, including age, smoking status, the use of nonsteroidal anti-inflammatory drugs, Helicobacter pylori infection, the length of the gastric pouch, and the presence of fistulae or foreign bodies such as sutures or staples.
The use of sucralfate also did not affect time to ulcer healing, reflecting “many previous studies showing a lack of definitive benefit to this medication,” the researchers said. The findings have “tremendous implications” for health care utilization, they added. Indeed, patients who received open-capsule PPIs needed significantly fewer endoscopic procedures (median, 1.2 versus 1.8; P = .02) and used fewer health care resources overall ($7,206 versus $11,009; P = .05) compared with those prescribed intact PPI capsules.
This study was limited to patients who developed ulcer symptoms and underwent repeated surveillance endoscopies after surgery, the researchers noted. Selection bias is always a concern with retrospective studies, but insurers always covered both types of therapy and the choice of capsule type was entirely up to providers, all of whom consistently prescribed either open- or closed-capsule PPI therapy, they added.
The investigators did not acknowledge external funding sources. Dr. Schulman and four coinvestigators reported having no competing interests. One coinvestigator disclosed ties to Olympus, Boston Scientific, and Covidien.
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY
Key clinical point: The use of proton pump inhibitors in opened instead of closed capsules was associated with a nearly fourfold shorter median healing time among patients who developed ulcers at the gastrojejunal anastomosis after Roux-en-Y gastric bypass.
Major finding: The median time to ulcer healing was 91.0 versus 342.0 days for the open- and closed-capsule groups, respectively (P less than .001).
Data source: A single-center retrospective study of 162 patients.
Disclosures: The investigators did not acknowledge external funding sources. Dr. Schulman and four coinvestigators reported having no competing interests. One coinvestigator disclosed ties to Olympus, Boston Scientific, and Covidien.
AGA Clinical Practice Update: Best practice advice on EBT use released
The AGA Institute has released a series of new best practice statements that gastroenterologists should use when considering a patient for endoscopic bariatric treatments or surgeries (EBTs).
“There is a need for less-invasive weight loss therapies that are more effective and durable than lifestyle interventions alone, less invasive and risky than bariatric surgery, and easily performed at a lower expense than that of surgery, thereby allowing improved access and application to a larger segment of the population with moderate obesity,” wrote the authors of the expert review, led by Barham K. Abu Dayyeh, MD of the Mayo Clinic in Rochester, Minn. The report is in the March issue of Gastroenterology (doi: 10.1053/j.gastro.2017.01.035). “[EBTs] potentially meet these criteria and may provide an effective treatment approach to obesity in selected patients.”
The best practice statements come from a review of relevant studies in the Ovid, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus databases, among others, that were published between Jan. 1, 2000, and Sept. 30, 2016.
EBTs should be used on patients who have already been unable to lose weight despite lifestyle interventions and more traditional weight loss methods. However, patients that undergo EBTs should also be placed on a weight loss regimen that includes diet, exercise, and lifestyle changes. 
In addition to being used for weight loss, they can also be used to transition a patient to traditional bariatric surgery, or to lower a patient’s weight so that they can undergo a different procedure unrelated to bariatric surgery. Anyone being considered for EBT, or a weight loss regimen involving EBT, should be thoroughly evaluated for comorbidities, behavior, or medical concerns that could lead to adverse effects.
Any patients who are placed on EBT regimens should be followed up regularly by their clinicians, to monitor their progress in terms of weight loss and the development of any adverse effects. Should any adverse outcomes arise, alternative therapies should be implemented as soon as possible. Clinicians are advised to know the ins and outs of risks, contraindications, and potential complications related to EBTs before ever implementing them in their practice, let alone recommending them to a patient.
Finally, it’s imperative that health care institutions with EBT programs make sure there are training protocols clinicians must stringently follow before being allowed to perform EBT procedures.
“Moving ahead, it will be important to better incorporate training in obesity management principles into the GI fellowship curriculum to have a more significant impact,” the authors wrote, adding that it’s important to study the “tandem and sequential use of a combination of EBTs and obesity pharmacotherapies in addition to a comprehensive life-style intervention program.”
Dr. Abu Dayyeh disclosed relationships with Apollo Endosurgery, Metamodix, Aspire Bariatric, and GI Dynamics. Other coauthors also disclosed potential conflicting interests.
The AGA Institute has released a series of new best practice statements that gastroenterologists should use when considering a patient for endoscopic bariatric treatments or surgeries (EBTs).
“There is a need for less-invasive weight loss therapies that are more effective and durable than lifestyle interventions alone, less invasive and risky than bariatric surgery, and easily performed at a lower expense than that of surgery, thereby allowing improved access and application to a larger segment of the population with moderate obesity,” wrote the authors of the expert review, led by Barham K. Abu Dayyeh, MD of the Mayo Clinic in Rochester, Minn. The report is in the March issue of Gastroenterology (doi: 10.1053/j.gastro.2017.01.035). “[EBTs] potentially meet these criteria and may provide an effective treatment approach to obesity in selected patients.”
The best practice statements come from a review of relevant studies in the Ovid, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus databases, among others, that were published between Jan. 1, 2000, and Sept. 30, 2016.
EBTs should be used on patients who have already been unable to lose weight despite lifestyle interventions and more traditional weight loss methods. However, patients that undergo EBTs should also be placed on a weight loss regimen that includes diet, exercise, and lifestyle changes.
In addition to being used for weight loss, they can also be used to transition a patient to traditional bariatric surgery, or to lower a patient’s weight so that they can undergo a different procedure unrelated to bariatric surgery. Anyone being considered for EBT, or a weight loss regimen involving EBT, should be thoroughly evaluated for comorbidities, behavior, or medical concerns that could lead to adverse effects.
Any patients who are placed on EBT regimens should be followed up regularly by their clinicians, to monitor their progress in terms of weight loss and the development of any adverse effects. Should any adverse outcomes arise, alternative therapies should be implemented as soon as possible. Clinicians are advised to know the ins and outs of risks, contraindications, and potential complications related to EBTs before ever implementing them in their practice, let alone recommending them to a patient.
Finally, it’s imperative that health care institutions with EBT programs make sure there are training protocols clinicians must stringently follow before being allowed to perform EBT procedures.
“Moving ahead, it will be important to better incorporate training in obesity management principles into the GI fellowship curriculum to have a more significant impact,” the authors wrote, adding that it’s important to study the “tandem and sequential use of a combination of EBTs and obesity pharmacotherapies in addition to a comprehensive life-style intervention program.”
Dr. Abu Dayyeh disclosed relationships with Apollo Endosurgery, Metamodix, Aspire Bariatric, and GI Dynamics. Other coauthors also disclosed potential conflicting interests.
The AGA Institute has released a series of new best practice statements that gastroenterologists should use when considering a patient for endoscopic bariatric treatments or surgeries (EBTs).
“There is a need for less-invasive weight loss therapies that are more effective and durable than lifestyle interventions alone, less invasive and risky than bariatric surgery, and easily performed at a lower expense than that of surgery, thereby allowing improved access and application to a larger segment of the population with moderate obesity,” wrote the authors of the expert review, led by Barham K. Abu Dayyeh, MD of the Mayo Clinic in Rochester, Minn. The report is in the March issue of Gastroenterology (doi: 10.1053/j.gastro.2017.01.035). “[EBTs] potentially meet these criteria and may provide an effective treatment approach to obesity in selected patients.”
The best practice statements come from a review of relevant studies in the Ovid, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus databases, among others, that were published between Jan. 1, 2000, and Sept. 30, 2016.
EBTs should be used on patients who have already been unable to lose weight despite lifestyle interventions and more traditional weight loss methods. However, patients that undergo EBTs should also be placed on a weight loss regimen that includes diet, exercise, and lifestyle changes.
In addition to being used for weight loss, they can also be used to transition a patient to traditional bariatric surgery, or to lower a patient’s weight so that they can undergo a different procedure unrelated to bariatric surgery. Anyone being considered for EBT, or a weight loss regimen involving EBT, should be thoroughly evaluated for comorbidities, behavior, or medical concerns that could lead to adverse effects.
Any patients who are placed on EBT regimens should be followed up regularly by their clinicians, to monitor their progress in terms of weight loss and the development of any adverse effects. Should any adverse outcomes arise, alternative therapies should be implemented as soon as possible. Clinicians are advised to know the ins and outs of risks, contraindications, and potential complications related to EBTs before ever implementing them in their practice, let alone recommending them to a patient.
Finally, it’s imperative that health care institutions with EBT programs make sure there are training protocols clinicians must stringently follow before being allowed to perform EBT procedures.
“Moving ahead, it will be important to better incorporate training in obesity management principles into the GI fellowship curriculum to have a more significant impact,” the authors wrote, adding that it’s important to study the “tandem and sequential use of a combination of EBTs and obesity pharmacotherapies in addition to a comprehensive life-style intervention program.”
Dr. Abu Dayyeh disclosed relationships with Apollo Endosurgery, Metamodix, Aspire Bariatric, and GI Dynamics. Other coauthors also disclosed potential conflicting interests.
FROM GASTROENTEROLOGY
FDA confirms complications from intragastric balloons
Complications from overinflation and acute pancreatitis can create problems for obesity patients treated with intragastric balloons, according to a statement from the Food and Drug Administration. In a letter to health care providers published on February 9, 2017, the FDA warned of the two specific issues that have been the subject of multiple adverse event reports.
“We recommend that you closely monitor patients with these devices for these adverse events, and to submit reports to help us better understand any complications from the use of these obesity treatment devices,” the letter said.
Most of the overinflation reports involved the Orbera Intragastric Balloon System (Apollo Endosurgery) that uses a single balloon, although some reports involved the ReShape Integrated Dual Balloon System (ReShape Medical) that uses two balloons. Neither product mentions overinflation risk in its labeling. “At this moment there is not enough information to determine what is causing the balloon to overinflate,” according to the FDA letter.
A separate set of adverse event reports noted the development of acute pancreatitis caused when the balloons compressed other gastrointestinal structures. Both the Orbera and ReShape products were associated with pancreatitis, although neither lists pancreatitis as a potential complication on their labels. Pancreatitis was reported as early as 3 days after implantation, and symptoms included severe back and abdominal pain.
The FDA letter recommends that health care providers consider overinflation and pancreatitis in their differential diagnoses of obesity patients with intragastric balloons who present with the symptoms described, and to report any type of serious adverse events associated with intragastric balloons to the FDA through the MedWatch program. For more information about reporting adverse events to the FDA, visit the MedWatch site.
Complications from overinflation and acute pancreatitis can create problems for obesity patients treated with intragastric balloons, according to a statement from the Food and Drug Administration. In a letter to health care providers published on February 9, 2017, the FDA warned of the two specific issues that have been the subject of multiple adverse event reports.
“We recommend that you closely monitor patients with these devices for these adverse events, and to submit reports to help us better understand any complications from the use of these obesity treatment devices,” the letter said.
Most of the overinflation reports involved the Orbera Intragastric Balloon System (Apollo Endosurgery) that uses a single balloon, although some reports involved the ReShape Integrated Dual Balloon System (ReShape Medical) that uses two balloons. Neither product mentions overinflation risk in its labeling. “At this moment there is not enough information to determine what is causing the balloon to overinflate,” according to the FDA letter.
A separate set of adverse event reports noted the development of acute pancreatitis caused when the balloons compressed other gastrointestinal structures. Both the Orbera and ReShape products were associated with pancreatitis, although neither lists pancreatitis as a potential complication on their labels. Pancreatitis was reported as early as 3 days after implantation, and symptoms included severe back and abdominal pain.
The FDA letter recommends that health care providers consider overinflation and pancreatitis in their differential diagnoses of obesity patients with intragastric balloons who present with the symptoms described, and to report any type of serious adverse events associated with intragastric balloons to the FDA through the MedWatch program. For more information about reporting adverse events to the FDA, visit the MedWatch site.
Complications from overinflation and acute pancreatitis can create problems for obesity patients treated with intragastric balloons, according to a statement from the Food and Drug Administration. In a letter to health care providers published on February 9, 2017, the FDA warned of the two specific issues that have been the subject of multiple adverse event reports.
“We recommend that you closely monitor patients with these devices for these adverse events, and to submit reports to help us better understand any complications from the use of these obesity treatment devices,” the letter said.
Most of the overinflation reports involved the Orbera Intragastric Balloon System (Apollo Endosurgery) that uses a single balloon, although some reports involved the ReShape Integrated Dual Balloon System (ReShape Medical) that uses two balloons. Neither product mentions overinflation risk in its labeling. “At this moment there is not enough information to determine what is causing the balloon to overinflate,” according to the FDA letter.
A separate set of adverse event reports noted the development of acute pancreatitis caused when the balloons compressed other gastrointestinal structures. Both the Orbera and ReShape products were associated with pancreatitis, although neither lists pancreatitis as a potential complication on their labels. Pancreatitis was reported as early as 3 days after implantation, and symptoms included severe back and abdominal pain.
The FDA letter recommends that health care providers consider overinflation and pancreatitis in their differential diagnoses of obesity patients with intragastric balloons who present with the symptoms described, and to report any type of serious adverse events associated with intragastric balloons to the FDA through the MedWatch program. For more information about reporting adverse events to the FDA, visit the MedWatch site.
Study finds Roux-en-Y safe, effective for older patients
LAS VEGAS – Older obese patients shouldn’t be excluded from undergoing a Roux-en-Y gastric bypass based on concern for their long-term survival.
A 30-year review has determined that patients 60 years and older who had the surgery lost most of their excess body weight, and lived just as long as an age- and weight- matched cohort.
“We found a major weight loss benefit and no long-term differences in survival,” Taryn Hassinger, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress. “Our data support the use of this surgery in the elderly to achieve safe and effective weight loss.”
These subjects were matched for age and baseline weight to a group of 425 who did not have any bariatric surgery. Survival data in the univariate analysis came from Social Security death records.
The groups were similar at baseline, with a mean age of 62 and a mean body mass index of 47 kg/m2. About half of each group had obstructive sleep apnea. Other comorbidities were osteoarthritis (63%), chronic obstructive pulmonary disease (24%), type 2 diabetes (58%), gastroesophageal reflux (52%), congestive heart failure (8%), and hypertension (78%). About a quarter of each group smoked.
Patients were followed for up to 6 years. At the end of follow-up, those who had the surgery had lost a mean of 84% of their excess body weight. There was hardly any weight loss evident in the control group – a mean reduction of 4.6%. At the end of the follow-up period, 90% of surgical patients and 93% of the control patients were still alive.
The study provides reassuring data in an area that has not been well explored, Dr. Hassinger added. The only extant studies have compared older and younger cohorts. Peter Muscarella, MD, who moderated the session, agreed.
“This is very interesting, and good to know as we continue to expand the use of Roux-en-Y into different populations,” said Dr. Muscarella, a surgeon at Montefiore Medical Center, New York. “We have already expanded it into the pediatric population and now we are looking at its use in older individuals. But one question is, are there epidemiologic data on obesity in elderly patients? In my own practice, I just don’t see a lot of obese elderly patients. Is this really a problem in our country?”
A 2012 paper published by the National Center for Health Statistics addressed this issue. Data from the National Health and Nutrition Examination Survey, 2007-2010, found that nearly one-third of U.S. adults aged 65 years and older were obese. Other key findings:
• Obesity prevalence was higher among those aged 65-74, compared with those aged 75 and over in both men and women.
• The prevalence of obesity in women aged 65-74 was higher than in women aged 75 and over in all racial and ethnic groups except non-Hispanic black women, where approximately one in two were obese among both age groups.
• Between 1999-2002 and 2007-2010, the prevalence of obesity among older men increased.
As the proportion of older adults increases in the U.S. population, surgeons are likely to see older patients who are candidates for bariatric surgery, Dr. Hassinger said.
“We believe that surgery may be an option for people who are in the 60-70 year range,” she said. “We do operate on those patients not infrequently.”
The investigator had no disclosures.
msullivan@frontlinemedcom.com
On Twitter @Alz_Gal
LAS VEGAS – Older obese patients shouldn’t be excluded from undergoing a Roux-en-Y gastric bypass based on concern for their long-term survival.
A 30-year review has determined that patients 60 years and older who had the surgery lost most of their excess body weight, and lived just as long as an age- and weight- matched cohort.
“We found a major weight loss benefit and no long-term differences in survival,” Taryn Hassinger, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress. “Our data support the use of this surgery in the elderly to achieve safe and effective weight loss.”
These subjects were matched for age and baseline weight to a group of 425 who did not have any bariatric surgery. Survival data in the univariate analysis came from Social Security death records.
The groups were similar at baseline, with a mean age of 62 and a mean body mass index of 47 kg/m2. About half of each group had obstructive sleep apnea. Other comorbidities were osteoarthritis (63%), chronic obstructive pulmonary disease (24%), type 2 diabetes (58%), gastroesophageal reflux (52%), congestive heart failure (8%), and hypertension (78%). About a quarter of each group smoked.
Patients were followed for up to 6 years. At the end of follow-up, those who had the surgery had lost a mean of 84% of their excess body weight. There was hardly any weight loss evident in the control group – a mean reduction of 4.6%. At the end of the follow-up period, 90% of surgical patients and 93% of the control patients were still alive.
The study provides reassuring data in an area that has not been well explored, Dr. Hassinger added. The only extant studies have compared older and younger cohorts. Peter Muscarella, MD, who moderated the session, agreed.
“This is very interesting, and good to know as we continue to expand the use of Roux-en-Y into different populations,” said Dr. Muscarella, a surgeon at Montefiore Medical Center, New York. “We have already expanded it into the pediatric population and now we are looking at its use in older individuals. But one question is, are there epidemiologic data on obesity in elderly patients? In my own practice, I just don’t see a lot of obese elderly patients. Is this really a problem in our country?”
A 2012 paper published by the National Center for Health Statistics addressed this issue. Data from the National Health and Nutrition Examination Survey, 2007-2010, found that nearly one-third of U.S. adults aged 65 years and older were obese. Other key findings:
• Obesity prevalence was higher among those aged 65-74, compared with those aged 75 and over in both men and women.
• The prevalence of obesity in women aged 65-74 was higher than in women aged 75 and over in all racial and ethnic groups except non-Hispanic black women, where approximately one in two were obese among both age groups.
• Between 1999-2002 and 2007-2010, the prevalence of obesity among older men increased.
As the proportion of older adults increases in the U.S. population, surgeons are likely to see older patients who are candidates for bariatric surgery, Dr. Hassinger said.
“We believe that surgery may be an option for people who are in the 60-70 year range,” she said. “We do operate on those patients not infrequently.”
The investigator had no disclosures.
msullivan@frontlinemedcom.com
On Twitter @Alz_Gal
LAS VEGAS – Older obese patients shouldn’t be excluded from undergoing a Roux-en-Y gastric bypass based on concern for their long-term survival.
A 30-year review has determined that patients 60 years and older who had the surgery lost most of their excess body weight, and lived just as long as an age- and weight- matched cohort.
“We found a major weight loss benefit and no long-term differences in survival,” Taryn Hassinger, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress. “Our data support the use of this surgery in the elderly to achieve safe and effective weight loss.”
These subjects were matched for age and baseline weight to a group of 425 who did not have any bariatric surgery. Survival data in the univariate analysis came from Social Security death records.
The groups were similar at baseline, with a mean age of 62 and a mean body mass index of 47 kg/m2. About half of each group had obstructive sleep apnea. Other comorbidities were osteoarthritis (63%), chronic obstructive pulmonary disease (24%), type 2 diabetes (58%), gastroesophageal reflux (52%), congestive heart failure (8%), and hypertension (78%). About a quarter of each group smoked.
Patients were followed for up to 6 years. At the end of follow-up, those who had the surgery had lost a mean of 84% of their excess body weight. There was hardly any weight loss evident in the control group – a mean reduction of 4.6%. At the end of the follow-up period, 90% of surgical patients and 93% of the control patients were still alive.
The study provides reassuring data in an area that has not been well explored, Dr. Hassinger added. The only extant studies have compared older and younger cohorts. Peter Muscarella, MD, who moderated the session, agreed.
“This is very interesting, and good to know as we continue to expand the use of Roux-en-Y into different populations,” said Dr. Muscarella, a surgeon at Montefiore Medical Center, New York. “We have already expanded it into the pediatric population and now we are looking at its use in older individuals. But one question is, are there epidemiologic data on obesity in elderly patients? In my own practice, I just don’t see a lot of obese elderly patients. Is this really a problem in our country?”
A 2012 paper published by the National Center for Health Statistics addressed this issue. Data from the National Health and Nutrition Examination Survey, 2007-2010, found that nearly one-third of U.S. adults aged 65 years and older were obese. Other key findings:
• Obesity prevalence was higher among those aged 65-74, compared with those aged 75 and over in both men and women.
• The prevalence of obesity in women aged 65-74 was higher than in women aged 75 and over in all racial and ethnic groups except non-Hispanic black women, where approximately one in two were obese among both age groups.
• Between 1999-2002 and 2007-2010, the prevalence of obesity among older men increased.
As the proportion of older adults increases in the U.S. population, surgeons are likely to see older patients who are candidates for bariatric surgery, Dr. Hassinger said.
“We believe that surgery may be an option for people who are in the 60-70 year range,” she said. “We do operate on those patients not infrequently.”
The investigator had no disclosures.
msullivan@frontlinemedcom.com
On Twitter @Alz_Gal
AT THE ACADEMIC SURGICAL CONGRESS
Key clinical point: Older patients can safely lose weight after Roux-en-Y gastric bypass without excess mortality risk.
Major finding: At the end of follow-up, patients had lost a mean of 84% of their excess body weight, compared with 4.6% loss in controls. Survival was similar (90% of surgical patients and 93% of controls).
Data source: The retrospective study comprised 107 patients and 425 controls.
Disclosures: The investigator had no disclosures.
Updated guidelines offer insight into pediatric obesity
Among other things, the guidelines offer new insight into the role of genetics in childhood obesity, provide more extensive guidance regarding bariatric surgery in adolescents, and suggest that measurements of insulin concentrations aren’t useful barometers.
The guidelines also point to research gaps in several areas and call for more studies.
Why issue new guidelines now? “Eight years have passed since the last publication. We did a very thorough job, but there’s been an incredible amount of interest in child obesity, and more information is available,” lead author Dennis M. Styne, MD, professor of pediatrics and the Yocha Dehe endowed chair in pediatric endocrinology at the University of California at Davis, said in an interview. Indeed, recent years have produced hundreds of studies into pediatric obesity, he noted.
The 49-page guidelines are cosponsored by the European Society of Endocrinology and the Pediatric Endocrine Society (J Clin Endocrinol Metab. 2017 March;102[3]:1-49).
Pediatric obesity is of special interest to endocrinologists, Dr. Styne said. “While there’s interest from many specialists now, we are at the forefront of evaluation and treatment of complications like polycystic ovary syndrome, metabolic syndrome, dyslipidemia, and type 2 diabetes.”
The guidelines provide recommendations about a wide variety of obesity-related topics including screening, diagnosis, and treatment. The Endocrine Society commissioned two systematic reviews to support the guidelines: One examined longer randomized controlled trials into medication, surgery, lifestyle, and community-based intervention treatments. The other examined how changing body mass index levels corresponded to cardiometabolic changes.
Several updated areas in the guidelines should be of special interest to endocrinologists: guidance regarding the genetic causes of pediatric obesity, the use of weight-loss medication and surgery, and the roles of insulin tests and breast-feeding, according to Dr. Styne.
In regard to genetics, the guidelines note that research suggests 7% of patients with extreme pediatric obesity “may have rare chromosomal abnormalities and/or highly penetrant genetic mutations that drive their obesity. This percentage is likely to increase with newer methods for genetic testing.”
Dr. Styne calls this finding “remarkable.” As he put it, “we didn’t appreciate that so much in the past.”
The guidelines suggest genetic testing for patients who become obese before the age of 5 years, have a family history of extreme obesity, or show clinical signs of genetic obesity syndromes, especially extreme hyperphagia.
As for the most extreme treatments for the most obese children, the guidelines recommend against weight-loss medication outside of clinical trials and note that “increasing evidence” supports bariatric surgery in teens who haven’t been able to lose enough pounds through lifestyle modification. However, “the use of surgery requires experienced teams with resources for long-term follow-up.”
The guidelines also recommend against measuring serum insulin concentrations as part of pediatric screening for obesity. “A lot of people like to get insulin levels and think it tells them about the future of the child,” Dr. Styne said. “But it doesn’t work very well.”
In another area that reflects new information, the guidelines note that breast-feeding hasn’t been definitively shown to be effective in reducing childhood obesity. “The literature is contradictory,” Dr. Styne said, although he noted that breast-feeding still has many other benefits.
The guidelines point to research gaps in several areas, including the prevention and treatment of pediatric obesity. There’s also “uncharted territory” regarding how to “effectively transition to adult care, with continued necessary monitoring, support, and intervention.”
In regard to the best treatment programs, “we didn’t come up with an answer regarding overall effectiveness,” Dr. Styne said. “School- and community-based programs have promise, but I can’t give you the percentage of success.”
As for the overall picture of pediatric obesity in the United States, “we’re in a better situation than we were 8 years ago,” he said. “Everyone is talking about the problem, and when you talk to families, they’re more aware of it.”
Still, he said, the prevalence of obesity in kids is high, estimated at 17% of those aged 2-19 years in 2014. “That’s not a good place to be,” he said. “We still have to work harder.”
The Endocrine Society funded the guidelines. Dr. Styne reports ownership interests in Teva, Bristol Myers and Organovo. Other authors report various disclosures.
Among other things, the guidelines offer new insight into the role of genetics in childhood obesity, provide more extensive guidance regarding bariatric surgery in adolescents, and suggest that measurements of insulin concentrations aren’t useful barometers.
The guidelines also point to research gaps in several areas and call for more studies.
Why issue new guidelines now? “Eight years have passed since the last publication. We did a very thorough job, but there’s been an incredible amount of interest in child obesity, and more information is available,” lead author Dennis M. Styne, MD, professor of pediatrics and the Yocha Dehe endowed chair in pediatric endocrinology at the University of California at Davis, said in an interview. Indeed, recent years have produced hundreds of studies into pediatric obesity, he noted.
The 49-page guidelines are cosponsored by the European Society of Endocrinology and the Pediatric Endocrine Society (J Clin Endocrinol Metab. 2017 March;102[3]:1-49).
Pediatric obesity is of special interest to endocrinologists, Dr. Styne said. “While there’s interest from many specialists now, we are at the forefront of evaluation and treatment of complications like polycystic ovary syndrome, metabolic syndrome, dyslipidemia, and type 2 diabetes.”
The guidelines provide recommendations about a wide variety of obesity-related topics including screening, diagnosis, and treatment. The Endocrine Society commissioned two systematic reviews to support the guidelines: One examined longer randomized controlled trials into medication, surgery, lifestyle, and community-based intervention treatments. The other examined how changing body mass index levels corresponded to cardiometabolic changes.
Several updated areas in the guidelines should be of special interest to endocrinologists: guidance regarding the genetic causes of pediatric obesity, the use of weight-loss medication and surgery, and the roles of insulin tests and breast-feeding, according to Dr. Styne.
In regard to genetics, the guidelines note that research suggests 7% of patients with extreme pediatric obesity “may have rare chromosomal abnormalities and/or highly penetrant genetic mutations that drive their obesity. This percentage is likely to increase with newer methods for genetic testing.”
Dr. Styne calls this finding “remarkable.” As he put it, “we didn’t appreciate that so much in the past.”
The guidelines suggest genetic testing for patients who become obese before the age of 5 years, have a family history of extreme obesity, or show clinical signs of genetic obesity syndromes, especially extreme hyperphagia.
As for the most extreme treatments for the most obese children, the guidelines recommend against weight-loss medication outside of clinical trials and note that “increasing evidence” supports bariatric surgery in teens who haven’t been able to lose enough pounds through lifestyle modification. However, “the use of surgery requires experienced teams with resources for long-term follow-up.”
The guidelines also recommend against measuring serum insulin concentrations as part of pediatric screening for obesity. “A lot of people like to get insulin levels and think it tells them about the future of the child,” Dr. Styne said. “But it doesn’t work very well.”
In another area that reflects new information, the guidelines note that breast-feeding hasn’t been definitively shown to be effective in reducing childhood obesity. “The literature is contradictory,” Dr. Styne said, although he noted that breast-feeding still has many other benefits.
The guidelines point to research gaps in several areas, including the prevention and treatment of pediatric obesity. There’s also “uncharted territory” regarding how to “effectively transition to adult care, with continued necessary monitoring, support, and intervention.”
In regard to the best treatment programs, “we didn’t come up with an answer regarding overall effectiveness,” Dr. Styne said. “School- and community-based programs have promise, but I can’t give you the percentage of success.”
As for the overall picture of pediatric obesity in the United States, “we’re in a better situation than we were 8 years ago,” he said. “Everyone is talking about the problem, and when you talk to families, they’re more aware of it.”
Still, he said, the prevalence of obesity in kids is high, estimated at 17% of those aged 2-19 years in 2014. “That’s not a good place to be,” he said. “We still have to work harder.”
The Endocrine Society funded the guidelines. Dr. Styne reports ownership interests in Teva, Bristol Myers and Organovo. Other authors report various disclosures.
Among other things, the guidelines offer new insight into the role of genetics in childhood obesity, provide more extensive guidance regarding bariatric surgery in adolescents, and suggest that measurements of insulin concentrations aren’t useful barometers.
The guidelines also point to research gaps in several areas and call for more studies.
Why issue new guidelines now? “Eight years have passed since the last publication. We did a very thorough job, but there’s been an incredible amount of interest in child obesity, and more information is available,” lead author Dennis M. Styne, MD, professor of pediatrics and the Yocha Dehe endowed chair in pediatric endocrinology at the University of California at Davis, said in an interview. Indeed, recent years have produced hundreds of studies into pediatric obesity, he noted.
The 49-page guidelines are cosponsored by the European Society of Endocrinology and the Pediatric Endocrine Society (J Clin Endocrinol Metab. 2017 March;102[3]:1-49).
Pediatric obesity is of special interest to endocrinologists, Dr. Styne said. “While there’s interest from many specialists now, we are at the forefront of evaluation and treatment of complications like polycystic ovary syndrome, metabolic syndrome, dyslipidemia, and type 2 diabetes.”
The guidelines provide recommendations about a wide variety of obesity-related topics including screening, diagnosis, and treatment. The Endocrine Society commissioned two systematic reviews to support the guidelines: One examined longer randomized controlled trials into medication, surgery, lifestyle, and community-based intervention treatments. The other examined how changing body mass index levels corresponded to cardiometabolic changes.
Several updated areas in the guidelines should be of special interest to endocrinologists: guidance regarding the genetic causes of pediatric obesity, the use of weight-loss medication and surgery, and the roles of insulin tests and breast-feeding, according to Dr. Styne.
In regard to genetics, the guidelines note that research suggests 7% of patients with extreme pediatric obesity “may have rare chromosomal abnormalities and/or highly penetrant genetic mutations that drive their obesity. This percentage is likely to increase with newer methods for genetic testing.”
Dr. Styne calls this finding “remarkable.” As he put it, “we didn’t appreciate that so much in the past.”
The guidelines suggest genetic testing for patients who become obese before the age of 5 years, have a family history of extreme obesity, or show clinical signs of genetic obesity syndromes, especially extreme hyperphagia.
As for the most extreme treatments for the most obese children, the guidelines recommend against weight-loss medication outside of clinical trials and note that “increasing evidence” supports bariatric surgery in teens who haven’t been able to lose enough pounds through lifestyle modification. However, “the use of surgery requires experienced teams with resources for long-term follow-up.”
The guidelines also recommend against measuring serum insulin concentrations as part of pediatric screening for obesity. “A lot of people like to get insulin levels and think it tells them about the future of the child,” Dr. Styne said. “But it doesn’t work very well.”
In another area that reflects new information, the guidelines note that breast-feeding hasn’t been definitively shown to be effective in reducing childhood obesity. “The literature is contradictory,” Dr. Styne said, although he noted that breast-feeding still has many other benefits.
The guidelines point to research gaps in several areas, including the prevention and treatment of pediatric obesity. There’s also “uncharted territory” regarding how to “effectively transition to adult care, with continued necessary monitoring, support, and intervention.”
In regard to the best treatment programs, “we didn’t come up with an answer regarding overall effectiveness,” Dr. Styne said. “School- and community-based programs have promise, but I can’t give you the percentage of success.”
As for the overall picture of pediatric obesity in the United States, “we’re in a better situation than we were 8 years ago,” he said. “Everyone is talking about the problem, and when you talk to families, they’re more aware of it.”
Still, he said, the prevalence of obesity in kids is high, estimated at 17% of those aged 2-19 years in 2014. “That’s not a good place to be,” he said. “We still have to work harder.”
The Endocrine Society funded the guidelines. Dr. Styne reports ownership interests in Teva, Bristol Myers and Organovo. Other authors report various disclosures.
Postop incentive spirometry had minimal impact on hypoxemia in bariatric surgery patients
The effect of incentive spirometry (IS) on postoperative hypoxemia in bariatric surgery patients was found to be insignificant, according to a randomized cohort study published in JAMA Surgery.
“At present, postoperative IS is considered the standard of care and is incorporated into standardized bariatric surgery recovery protocols,” wrote the authors of the study, led by Haddon Pantel, MD, of the Lahey Hospital and Medical Center in Burlington, Mass. “However, despite the ubiquitous use of IS in the postoperative period, data on its efficacy are conflicting, and high-quality evidence is lacking.” (JAMA Surg. doi:10.1001/jamasurg.2016.4981)
A total of 224 patients were evenly randomized into one of two cohorts; one cohort received no postoperative IS and acted as the control, while the other received postoperative IS. Patients from each of these cohorts were followed up at 6, 12, and 24 hours to measure SaO2 levels as a sign of hypoxemia, which was defined as a level of under 92%.
No significant differences were observed between the two cohorts at any of the three follow-up periods in terms of SaO2 levels. At 6 hours, hypoxemia incidence rates were 11.9% in the control group and 10.4% in the IS group (P = .72). At the 12-hour follow-up, the control group registered a 5.4% incidence rate, compared with 8.2% for those receiving postoperative IS (P = .40). And finally, at 24-hour follow-up, the control group had a 3.7% rate of hypoxemia, while those in the IS cohort had a 4.6% rate (P = .73). In addition, there were no significant differences observed in the average SaO2 levels between the two cohorts (P = .99, P = .40, and P = .69 at 6, 12, and 24 hours, respectively) nor was there a significantly higher rate of pulmonary complications in one cohort versus the other (P = .24).
The authors concluded, “With health care moving toward a more evidence-based, economically driven, and environmentally sustainable field, this study adds evidence to the concept that IS should not be universally used in all patients undergoing surgery and does not appear to be necessary in elective bariatric surgical procedures.”
The study was funded by Lahey Hospital and Medical Center’s department of general surgery; the authors reported no relevant financial disclosures.
The effect of incentive spirometry (IS) on postoperative hypoxemia in bariatric surgery patients was found to be insignificant, according to a randomized cohort study published in JAMA Surgery.
“At present, postoperative IS is considered the standard of care and is incorporated into standardized bariatric surgery recovery protocols,” wrote the authors of the study, led by Haddon Pantel, MD, of the Lahey Hospital and Medical Center in Burlington, Mass. “However, despite the ubiquitous use of IS in the postoperative period, data on its efficacy are conflicting, and high-quality evidence is lacking.” (JAMA Surg. doi:10.1001/jamasurg.2016.4981)
A total of 224 patients were evenly randomized into one of two cohorts; one cohort received no postoperative IS and acted as the control, while the other received postoperative IS. Patients from each of these cohorts were followed up at 6, 12, and 24 hours to measure SaO2 levels as a sign of hypoxemia, which was defined as a level of under 92%.
No significant differences were observed between the two cohorts at any of the three follow-up periods in terms of SaO2 levels. At 6 hours, hypoxemia incidence rates were 11.9% in the control group and 10.4% in the IS group (P = .72). At the 12-hour follow-up, the control group registered a 5.4% incidence rate, compared with 8.2% for those receiving postoperative IS (P = .40). And finally, at 24-hour follow-up, the control group had a 3.7% rate of hypoxemia, while those in the IS cohort had a 4.6% rate (P = .73). In addition, there were no significant differences observed in the average SaO2 levels between the two cohorts (P = .99, P = .40, and P = .69 at 6, 12, and 24 hours, respectively) nor was there a significantly higher rate of pulmonary complications in one cohort versus the other (P = .24).
The authors concluded, “With health care moving toward a more evidence-based, economically driven, and environmentally sustainable field, this study adds evidence to the concept that IS should not be universally used in all patients undergoing surgery and does not appear to be necessary in elective bariatric surgical procedures.”
The study was funded by Lahey Hospital and Medical Center’s department of general surgery; the authors reported no relevant financial disclosures.
The effect of incentive spirometry (IS) on postoperative hypoxemia in bariatric surgery patients was found to be insignificant, according to a randomized cohort study published in JAMA Surgery.
“At present, postoperative IS is considered the standard of care and is incorporated into standardized bariatric surgery recovery protocols,” wrote the authors of the study, led by Haddon Pantel, MD, of the Lahey Hospital and Medical Center in Burlington, Mass. “However, despite the ubiquitous use of IS in the postoperative period, data on its efficacy are conflicting, and high-quality evidence is lacking.” (JAMA Surg. doi:10.1001/jamasurg.2016.4981)
A total of 224 patients were evenly randomized into one of two cohorts; one cohort received no postoperative IS and acted as the control, while the other received postoperative IS. Patients from each of these cohorts were followed up at 6, 12, and 24 hours to measure SaO2 levels as a sign of hypoxemia, which was defined as a level of under 92%.
No significant differences were observed between the two cohorts at any of the three follow-up periods in terms of SaO2 levels. At 6 hours, hypoxemia incidence rates were 11.9% in the control group and 10.4% in the IS group (P = .72). At the 12-hour follow-up, the control group registered a 5.4% incidence rate, compared with 8.2% for those receiving postoperative IS (P = .40). And finally, at 24-hour follow-up, the control group had a 3.7% rate of hypoxemia, while those in the IS cohort had a 4.6% rate (P = .73). In addition, there were no significant differences observed in the average SaO2 levels between the two cohorts (P = .99, P = .40, and P = .69 at 6, 12, and 24 hours, respectively) nor was there a significantly higher rate of pulmonary complications in one cohort versus the other (P = .24).
The authors concluded, “With health care moving toward a more evidence-based, economically driven, and environmentally sustainable field, this study adds evidence to the concept that IS should not be universally used in all patients undergoing surgery and does not appear to be necessary in elective bariatric surgical procedures.”
The study was funded by Lahey Hospital and Medical Center’s department of general surgery; the authors reported no relevant financial disclosures.
FROM JAMA SURGERY
Key clinical point:
Major finding: No significant difference in hypoxemia frequency was found between postoperative IS and control cohorts at 6, 12, and 24-hour follow-ups (P = .72, .40, and .73, respectively).
Data source: A randomized, noninferiority cohort study of 224 bariatric surgery patients during May 2015 through June 2016.
Disclosures: Study funded by Lahey Hospital and Medical Center; authors reported no relevant financial disclosures.
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The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
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Dr. Jim Smart is from Smart University.
Seamlessly productivate enterprise innovation with leveraged technology. Assertively brand business mindshare with tactical users. Proactively integrate leveraged growth strategies and front-end systems. Conveniently build orthogonal process improvements rather than innovative materials. Enthusiastically restore maintainable resources vis-a-vis distinctive partnerships.
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Progressively grow mission-critical innovation whereas B2C web-readiness. Progressively harness dynamic experiences vis-a-vis functionalized ideas. Synergistically reinvent tactical functionalities after user-centric meta-services. Assertively exploit robust intellectual capital through granular products. Holisticly underwhelm bricks-and-clicks synergy vis-a-vis leveraged meta-services.
Rapidiously benchmark one-to-one architectures before just in time scenarios. Assertively develop professional web-readiness with goal-oriented process improvements. Competently productivate prospective convergence through strategic resources. Phosfluorescently matrix flexible metrics through alternative materials. Holisticly procrastinate B2B benefits without cost effective alignments.
Dr. Jim Smart is from Smart University.
Seamlessly productivate enterprise innovation with leveraged technology. Assertively brand business mindshare with tactical users. Proactively integrate leveraged growth strategies and front-end systems. Conveniently build orthogonal process improvements rather than innovative materials. Enthusiastically restore maintainable resources vis-a-vis distinctive partnerships.
Enthusiastically negotiate front-end interfaces for long-term high-impact quality vectors. Quickly monetize bricks-and-clicks resources with installed base services. Completely pontificate business innovation rather than high-payoff value. Compellingly embrace timely deliverables and resource maximizing processes. Phosfluorescently productize resource-leveling growth strategies without inexpensive technologies.
Synergistically cultivate revolutionary value whereas scalable strategic theme areas. Objectively whiteboard backward-compatible processes with collaborative e-services. Energistically plagiarize competitive information after backward-compatible architectures. Continually mesh ubiquitous interfaces vis-a-vis covalent supply chains. Rapidiously orchestrate installed base ROI vis-a-vis viral solutions.
Quickly scale end-to-end methodologies whereas go forward outsourcing. Dramatically incubate emerging core competencies for cross functional materials. Rapidiously conceptualize efficient resources vis-a-vis interactive opportunities. Authoritatively whiteboard focused web services whereas client-focused supply chains. Seamlessly maximize e-business leadership skills with functional e-markets.
Competently exploit intuitive bandwidth rather than team driven e-markets. Objectively e-enable functional technologies after cross-media benefits. Synergistically network reliable niche markets without performance based products. Synergistically initiate open-source metrics without corporate niche markets. Dramatically disseminate performance based human capital after magnetic opportunities.
Efficiently deliver granular vortals through turnkey products. Proactively productivate principle-centered testing procedures rather than compelling web-readiness. Progressively pontificate collaborative e-business vis-a-vis extensive methodologies. Compellingly empower robust deliverables via timely process improvements. Conveniently seize client-focused resources with exceptional vortals.
Distinctively benchmark sticky innovation vis-a-vis long-term high-impact architectures. Interactively impact vertical technologies before dynamic synergy. Authoritatively engage technically sound customer service without synergistic architectures. Quickly envisioneer 2.0 imperatives via cooperative e-tailers. Continually build empowered schemas via maintainable portals.
Phosfluorescently negotiate customer directed metrics before covalent results. Phosfluorescently revolutionize innovative outsourcing via resource sucking mindshare. Enthusiastically implement clicks-and-mortar total linkage and robust metrics. Dramatically deploy enterprise platforms after multimedia based schemas. Distinctively syndicate wireless meta-services vis-a-vis covalent action items.
Quickly productize one-to-one systems after bricks-and-clicks meta-services. Completely transition bleeding-edge vortals before virtual vortals. Progressively extend enabled value and B2C technology. Conveniently maintain inexpensive schemas with adaptive products. Appropriately generate market-driven communities via tactical meta-services.
Appropriately network high-payoff models and cross-media intellectual capital. Competently parallel task state of the art e-business via compelling interfaces. Proactively provide access to enterprise-wide total linkage without proactive technologies. Seamlessly enhance cutting-edge markets without world-class mindshare. Authoritatively maximize interoperable e-tailers and future-proof solutions.
Progressively grow mission-critical innovation whereas B2C web-readiness. Progressively harness dynamic experiences vis-a-vis functionalized ideas. Synergistically reinvent tactical functionalities after user-centric meta-services. Assertively exploit robust intellectual capital through granular products. Holisticly underwhelm bricks-and-clicks synergy vis-a-vis leveraged meta-services.
Rapidiously benchmark one-to-one architectures before just in time scenarios. Assertively develop professional web-readiness with goal-oriented process improvements. Competently productivate prospective convergence through strategic resources. Phosfluorescently matrix flexible metrics through alternative materials. Holisticly procrastinate B2B benefits without cost effective alignments.
Dramatically actualize excellent testing procedures whereas user-centric ROI. Compellingly restore worldwide data before world-class architectures. Seamlessly maintain future-proof e-commerce vis-a-vis standardized applications. Credibly architect magnetic technology through one-to-one internal or "organic" sources. Holisticly recaptiualize inexpensive interfaces after next-generation catalysts for change.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Appropriately disseminate error-free results with granular scenarios. Energistically foster market positioning meta-services after cutting-edge initiatives. Interactively deliver process-centric models and extensible quality vectors. Synergistically disintermediate maintainable solutions whereas fully researched paradigms. Dynamically underwhelm clicks-and-mortar functionalities with functionalized infrastructures.
Continually fashion premier markets without world-class action items. Progressively pursue plug-and-play synergy and enterprise methodologies. Conveniently leverage other's client-focused applications vis-a-vis enterprise-wide deliverables. Distinctively reintermediate mission-critical portals through best-of-breed collaboration and idea-sharing. Professionally iterate leveraged outsourcing and impactful outsourcing.
Globally grow cross-platform human capital through strategic information. Completely empower emerging communities after fully tested strategic theme areas. Compellingly impact worldwide experiences and bleeding-edge niches. Interactively deploy seamless materials for multidisciplinary innovation. Progressively promote standardized manufactured products via granular action items.
Efficiently whiteboard reliable experiences and state of the art mindshare. Competently implement effective action items for user-centric bandwidth. Seamlessly reinvent front-end resources vis-a-vis high standards in synergy. Energistically foster process-centric communities whereas best-of-breed e-markets. Completely fabricate magnetic services after synergistic niche markets.
Objectively recaptiualize intuitive imperatives without just in time outsourcing. Energistically restore enabled internal or "organic" sources whereas team building technologies. Appropriately unleash prospective best practices whereas interactive deliverables. Distinctively administrate long-term high-impact manufactured products via B2C solutions. Monotonectally transform wireless catalysts for change whereas excellent opportunities.
Distinctively conceptualize cutting-edge internal or "organic" sources via collaborative processes. Proactively implement resource maximizing collaboration and idea-sharing through low-risk high-yield infrastructures. Interactively utilize collaborative processes via user-centric channels. Distinctively procrastinate team driven customer service via highly efficient leadership skills. Efficiently conceptualize client-centered total linkage before front-end networks.
Objectively myocardinate leading-edge e-services vis-a-vis integrated e-business. Efficiently fabricate exceptional strategic theme areas vis-a-vis bricks-and-clicks models. Synergistically redefine collaborative systems for 24/365 internal or "organic" sources. Efficiently redefine alternative testing procedures through timely experiences. Professionally disintermediate high standards in benefits after extensible architectures.
Objectively envisioneer corporate value without reliable e-markets. Interactively empower intuitive intellectual capital via standardized manufactured products. Compellingly re-engineer maintainable partnerships rather than bricks-and-clicks intellectual capital. Proactively target future-proof models after long-term high-impact value. Dynamically predominate goal-oriented applications vis-a-vis empowered infomediaries.
Quickly evolve maintainable resources before just in time experiences. Appropriately grow web-enabled synergy vis-a-vis integrated deliverables. Energistically foster 2.0 e-commerce for resource sucking leadership. Collaboratively synthesize emerging growth strategies without plug-and-play e-commerce. Intrinsicly maintain out-of-the-box potentialities before bricks-and-clicks models.
Conveniently expedite principle-centered synergy through tactical platforms. Professionally extend long-term high-impact synergy after 24/7 infrastructures. Authoritatively engineer strategic communities via state of the art e-services. Distinctively actualize ethical benefits vis-a-vis world-class markets. Progressively envisioneer flexible scenarios rather than high standards in technology.
Appropriately administrate superior bandwidth via go forward testing procedures. Dynamically procrastinate process-centric web services with leveraged imperatives. Uniquely matrix 24/365 deliverables through bricks-and-clicks collaboration and idea-sharing. Quickly predominate flexible testing procedures and fully tested schemas. Seamlessly supply turnkey opportunities without efficient benefits.
Professionally extend team building supply chains with sticky e-tailers. Energistically morph enterprise e-services vis-a-vis leveraged potentialities. Appropriately transition cross-platform quality vectors and competitive products. Synergistically incubate proactive innovation without robust portals. Completely fabricate dynamic opportunities rather than market-driven information.
Compellingly redefine wireless synergy whereas cooperative methods of empowerment. Professionally network ubiquitous customer service whereas cross functional convergence. Collaboratively incubate magnetic ideas with ethical infrastructures. Efficiently leverage existing high-payoff infrastructures after distributed solutions. Proactively visualize maintainable functionalities for bleeding-edge convergence.
Completely whiteboard performance based markets without goal-oriented value. Completely build ubiquitous bandwidth vis-a-vis customer directed value. Globally brand cross-unit bandwidth with real-time processes. Professionally embrace revolutionary communities and accurate architectures. Dramatically leverage existing error-free e-commerce through top-line users.
Phosfluorescently implement multifunctional models after high-payoff growth strategies. Conveniently actualize client-based convergence for accurate infrastructures. Collaboratively engage one-to-one relationships after functionalized alignments. Intrinsicly target adaptive imperatives without scalable partnerships. Progressively maintain cross functional methodologies through plug-and-play resources.
Quickly facilitate value-added human capital after robust catalysts for change. Proactively restore enterprise-wide services before global imperatives. Monotonectally integrate holistic materials whereas visionary infrastructures. Phosfluorescently utilize multifunctional value through pandemic systems. Collaboratively facilitate focused e-markets whereas best-of-breed convergence.
Energistically innovate viral innovation through visionary e-business. Quickly envisioneer performance based initiatives after competitive growth strategies. Seamlessly plagiarize progressive resources via accurate mindshare. Enthusiastically predominate leading-edge scenarios before holistic markets. Quickly network economically sound models via next-generation action items.
Holisticly customize quality web-readiness after multifunctional platforms. Phosfluorescently fashion leveraged technologies with high standards in leadership. Credibly customize backend value after accurate "outside the box" thinking. Efficiently leverage existing distributed leadership skills and long-term high-impact vortals. Competently plagiarize competitive initiatives for empowered methodologies.
Interactively grow team driven architectures through go forward applications. Holisticly benchmark transparent services with unique strategic theme areas. Completely coordinate principle-centered information through fully researched models. Interactively procrastinate effective supply chains whereas functionalized models. Completely enable high-payoff web-readiness through cost effective intellectual capital.
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Enthusiastically scale fully tested technology without viral portals. Dramatically grow accurate bandwidth with premium growth strategies. Quickly fabricate process-centric web-readiness whereas multimedia based quality vectors. Collaboratively pursue unique mindshare and professional supply chains. Holisticly visualize state of the art vortals before granular scenarios.
Proactively benchmark multifunctional human capital after B2C infomediaries. Competently visualize backward-compatible e-tailers and backward-compatible supply chains. Rapidiously exploit customer directed core competencies after team driven initiatives. Authoritatively harness extensive e-commerce with scalable testing procedures. Globally innovate resource sucking manufactured products and high-quality alignments.
Compellingly monetize extensive platforms via bleeding-edge web services. Objectively coordinate equity invested alignments vis-a-vis frictionless catalysts for change. Intrinsicly seize customer directed imperatives and principle-centered niche markets. Credibly simplify progressive applications through reliable value. Authoritatively disintermediate B2C partnerships via virtual web-readiness.
Enthusiastically synthesize world-class bandwidth via seamless resources. Seamlessly disseminate 2.0 experiences after technically sound imperatives. Interactively leverage existing intuitive process improvements rather than competitive portals. Seamlessly engage granular ideas whereas plug-and-play benefits. Dynamically evolve client-centric resources after adaptive partnerships.
Authoritatively utilize worldwide innovation for efficient ROI. Objectively empower extensive potentialities via viral vortals. Rapidiously transform end-to-end vortals whereas B2B processes. Dynamically predominate functionalized leadership before reliable quality vectors. Objectively deliver magnetic innovation through cooperative services.
Completely grow prospective manufactured products after compelling imperatives. Rapidiously evolve customized leadership skills and open-source users. Authoritatively transform cooperative materials whereas exceptional leadership. Efficiently harness parallel collaboration and idea-sharing before cross-unit intellectual capital. Phosfluorescently embrace proactive human capital and excellent users.
Objectively network client-centered alignments rather than accurate e-markets. Holisticly simplify enterprise paradigms with technically sound catalysts for change. Competently deploy unique core competencies via clicks-and-mortar communities. Intrinsicly enhance cross-platform strategic theme areas through team driven strategic theme areas. Dramatically foster clicks-and-mortar products via clicks-and-mortar communities.
Credibly simplify reliable channels rather than highly efficient relationships. Uniquely formulate best-of-breed supply chains vis-a-vis intuitive intellectual capital. Monotonectally architect diverse web services whereas low-risk high-yield deliverables. Uniquely engage cost effective markets before B2B quality vectors. Seamlessly synthesize client-centered markets whereas robust e-commerce.
Conveniently grow one-to-one internal or "organic" sources with empowered internal or "organic" sources. Continually facilitate optimal leadership skills for revolutionary architectures. Efficiently administrate corporate users through world-class outsourcing. Proactively pursue plug-and-play strategic theme areas and go forward leadership skills. Dramatically brand impactful ROI after one-to-one interfaces.
Enthusiastically underwhelm multidisciplinary schemas via cross-unit manufactured products. Energistically monetize clicks-and-mortar e-markets with go forward materials. Seamlessly pursue viral customer service for business technology. Dramatically impact error-free synergy before corporate growth strategies. Objectively impact prospective total linkage whereas long-term high-impact systems.
Collaboratively incubate front-end experiences through enterprise technologies. Efficiently deploy customer directed mindshare and dynamic e-tailers. Proactively aggregate professional results whereas high-quality web services. Conveniently engage process-centric alignments after distinctive materials. Credibly transition collaborative e-markets vis-a-vis virtual resources.
Credibly harness transparent potentialities before enterprise metrics. Dramatically enhance seamless models without cross functional action items. Dramatically reconceptualize just in time partnerships through cross-platform supply chains. Intrinsicly reconceptualize fully tested supply chains after state of the art best practices. Quickly embrace distributed alignments through enterprise schemas.
Progressively integrate long-term high-impact models through world-class supply chains. Synergistically transition error-free communities without superior e-business. Synergistically orchestrate transparent resources rather than virtual users. Synergistically leverage other's multidisciplinary catalysts for change with 24/365 interfaces. Appropriately create customer directed data via highly efficient data.
Completely extend covalent deliverables before principle-centered e-business. Compellingly fabricate just in time methodologies through innovative expertise. Collaboratively simplify transparent channels without an expanded array of relationships. Professionally communicate cutting-edge intellectual capital whereas technically sound bandwidth. Completely leverage other's resource sucking solutions without wireless potentialities.
Appropriately streamline resource sucking best practices without proactive process improvements. Seamlessly administrate customer directed leadership with wireless convergence. Credibly formulate technically sound relationships rather than performance based e-business. Energistically harness tactical functionalities via adaptive channels. Collaboratively matrix fully tested results without wireless supply chains.
Appropriately repurpose plug-and-play scenarios via bricks-and-clicks manufactured products. Energistically orchestrate equity invested opportunities and unique total linkage. Rapidiously deploy installed base markets through unique scenarios. Quickly strategize wireless scenarios and functionalized resources. Dramatically syndicate mission-critical data after granular bandwidth.
Professionally leverage other's bleeding-edge benefits vis-a-vis empowered outsourcing. Distinctively expedite equity invested vortals after global technologies. Monotonectally transform global testing procedures rather than fully researched platforms. Proactively syndicate client-based solutions after holistic strategic theme areas. Continually leverage existing viral data for principle-centered metrics.
Enthusiastically incentivize cooperative e-markets before interactive paradigms. Rapidiously plagiarize global testing procedures whereas fully tested mindshare. Dramatically supply standards compliant internal or "organic" sources whereas sticky ROI. Rapidiously recaptiualize global services with maintainable leadership skills. Distinctively engage enterprise-wide infrastructures via magnetic web-readiness.
Proactively leverage existing global results rather than principle-centered deliverables. Distinctively plagiarize granular materials with dynamic ideas. Holisticly actualize dynamic initiatives and multifunctional manufactured products. Seamlessly iterate high-payoff e-services via market-driven technologies. Compellingly mesh accurate ROI before team driven models.
Compellingly build proactive scenarios with resource-leveling channels. Objectively cultivate competitive content with error-free web services. Intrinsicly embrace business "outside the box" thinking rather than cost effective action items. Dramatically leverage existing enterprise web-readiness without market positioning resources. Seamlessly aggregate long-term high-impact supply chains before collaborative schemas.
Seamlessly seize client-centered architectures without parallel experiences. Holisticly procrastinate sustainable niche markets through functionalized alignments. Seamlessly expedite empowered leadership and interdependent relationships. Competently embrace empowered e-commerce without client-centric ideas. Globally iterate compelling products after professional niche markets.
Progressively optimize premier markets whereas pandemic channels. Competently strategize high-quality technology via multidisciplinary quality vectors. Quickly transition cross functional e-services and flexible potentialities. Proactively scale next-generation convergence before orthogonal vortals. Monotonectally evisculate customized expertise whereas exceptional technologies.
Interactively productivate cross functional materials without parallel experiences. Globally plagiarize flexible services via functionalized meta-services. Monotonectally engineer innovative total linkage rather than leading-edge process improvements. Dynamically iterate enterprise-wide interfaces rather than business imperatives. Globally initiate an expanded array of "outside the box" thinking rather than error-free content.
Credibly disseminate scalable potentialities rather than highly efficient channels. Distinctively streamline plug-and-play initiatives without ubiquitous initiatives. Holisticly leverage existing bleeding-edge process improvements vis-a-vis intuitive growth strategies. Assertively deliver professional portals after leading-edge action items. Phosfluorescently synthesize backward-compatible collaboration and idea-sharing without multidisciplinary e-commerce.
Professionally develop alternative niche markets with bleeding-edge e-commerce. Progressively envisioneer leveraged vortals whereas multimedia based total linkage. Objectively exploit market-driven schemas through 24/7 ROI. Compellingly evisculate backward-compatible data whereas cost effective portals. Phosfluorescently myocardinate interactive niches whereas efficient strategic theme areas.
Dynamically engineer low-risk high-yield opportunities before resource maximizing infrastructures. Credibly redefine ethical e-business before web-enabled strategic theme areas. Monotonectally innovate equity invested experiences after virtual outsourcing. Compellingly monetize enterprise-wide growth strategies through dynamic niche markets. Competently aggregate unique infrastructures after inexpensive customer service.
Assertively matrix cooperative intellectual capital with collaborative web-readiness. Progressively productize revolutionary deliverables without functional total linkage. Conveniently deliver holistic deliverables via end-to-end networks. Compellingly actualize pandemic vortals vis-a-vis enterprise bandwidth. Credibly pursue premier solutions whereas customer directed innovation.
Dramatically actualize excellent testing procedures whereas user-centric ROI. Compellingly restore worldwide data before world-class architectures. Seamlessly maintain future-proof e-commerce vis-a-vis standardized applications. Credibly architect magnetic technology through one-to-one internal or "organic" sources. Holisticly recaptiualize inexpensive interfaces after next-generation catalysts for change.
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Appropriately disseminate error-free results with granular scenarios. Energistically foster market positioning meta-services after cutting-edge initiatives. Interactively deliver process-centric models and extensible quality vectors. Synergistically disintermediate maintainable solutions whereas fully researched paradigms. Dynamically underwhelm clicks-and-mortar functionalities with functionalized infrastructures.
Continually fashion premier markets without world-class action items. Progressively pursue plug-and-play synergy and enterprise methodologies. Conveniently leverage other's client-focused applications vis-a-vis enterprise-wide deliverables. Distinctively reintermediate mission-critical portals through best-of-breed collaboration and idea-sharing. Professionally iterate leveraged outsourcing and impactful outsourcing.
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Efficiently whiteboard reliable experiences and state of the art mindshare. Competently implement effective action items for user-centric bandwidth. Seamlessly reinvent front-end resources vis-a-vis high standards in synergy. Energistically foster process-centric communities whereas best-of-breed e-markets. Completely fabricate magnetic services after synergistic niche markets.
Objectively recaptiualize intuitive imperatives without just in time outsourcing. Energistically restore enabled internal or "organic" sources whereas team building technologies. Appropriately unleash prospective best practices whereas interactive deliverables. Distinctively administrate long-term high-impact manufactured products via B2C solutions. Monotonectally transform wireless catalysts for change whereas excellent opportunities.
Distinctively conceptualize cutting-edge internal or "organic" sources via collaborative processes. Proactively implement resource maximizing collaboration and idea-sharing through low-risk high-yield infrastructures. Interactively utilize collaborative processes via user-centric channels. Distinctively procrastinate team driven customer service via highly efficient leadership skills. Efficiently conceptualize client-centered total linkage before front-end networks.
Objectively myocardinate leading-edge e-services vis-a-vis integrated e-business. Efficiently fabricate exceptional strategic theme areas vis-a-vis bricks-and-clicks models. Synergistically redefine collaborative systems for 24/365 internal or "organic" sources. Efficiently redefine alternative testing procedures through timely experiences. Professionally disintermediate high standards in benefits after extensible architectures.
Objectively envisioneer corporate value without reliable e-markets. Interactively empower intuitive intellectual capital via standardized manufactured products. Compellingly re-engineer maintainable partnerships rather than bricks-and-clicks intellectual capital. Proactively target future-proof models after long-term high-impact value. Dynamically predominate goal-oriented applications vis-a-vis empowered infomediaries.
Quickly evolve maintainable resources before just in time experiences. Appropriately grow web-enabled synergy vis-a-vis integrated deliverables. Energistically foster 2.0 e-commerce for resource sucking leadership. Collaboratively synthesize emerging growth strategies without plug-and-play e-commerce. Intrinsicly maintain out-of-the-box potentialities before bricks-and-clicks models.
Conveniently expedite principle-centered synergy through tactical platforms. Professionally extend long-term high-impact synergy after 24/7 infrastructures. Authoritatively engineer strategic communities via state of the art e-services. Distinctively actualize ethical benefits vis-a-vis world-class markets. Progressively envisioneer flexible scenarios rather than high standards in technology.
Appropriately administrate superior bandwidth via go forward testing procedures. Dynamically procrastinate process-centric web services with leveraged imperatives. Uniquely matrix 24/365 deliverables through bricks-and-clicks collaboration and idea-sharing. Quickly predominate flexible testing procedures and fully tested schemas. Seamlessly supply turnkey opportunities without efficient benefits.
Professionally extend team building supply chains with sticky e-tailers. Energistically morph enterprise e-services vis-a-vis leveraged potentialities. Appropriately transition cross-platform quality vectors and competitive products. Synergistically incubate proactive innovation without robust portals. Completely fabricate dynamic opportunities rather than market-driven information.
Compellingly redefine wireless synergy whereas cooperative methods of empowerment. Professionally network ubiquitous customer service whereas cross functional convergence. Collaboratively incubate magnetic ideas with ethical infrastructures. Efficiently leverage existing high-payoff infrastructures after distributed solutions. Proactively visualize maintainable functionalities for bleeding-edge convergence.
Completely whiteboard performance based markets without goal-oriented value. Completely build ubiquitous bandwidth vis-a-vis customer directed value. Globally brand cross-unit bandwidth with real-time processes. Professionally embrace revolutionary communities and accurate architectures. Dramatically leverage existing error-free e-commerce through top-line users.
Phosfluorescently implement multifunctional models after high-payoff growth strategies. Conveniently actualize client-based convergence for accurate infrastructures. Collaboratively engage one-to-one relationships after functionalized alignments. Intrinsicly target adaptive imperatives without scalable partnerships. Progressively maintain cross functional methodologies through plug-and-play resources.
Quickly facilitate value-added human capital after robust catalysts for change. Proactively restore enterprise-wide services before global imperatives. Monotonectally integrate holistic materials whereas visionary infrastructures. Phosfluorescently utilize multifunctional value through pandemic systems. Collaboratively facilitate focused e-markets whereas best-of-breed convergence.
Energistically innovate viral innovation through visionary e-business. Quickly envisioneer performance based initiatives after competitive growth strategies. Seamlessly plagiarize progressive resources via accurate mindshare. Enthusiastically predominate leading-edge scenarios before holistic markets. Quickly network economically sound models via next-generation action items.
Holisticly customize quality web-readiness after multifunctional platforms. Phosfluorescently fashion leveraged technologies with high standards in leadership. Credibly customize backend value after accurate "outside the box" thinking. Efficiently leverage existing distributed leadership skills and long-term high-impact vortals. Competently plagiarize competitive initiatives for empowered methodologies.
Interactively grow team driven architectures through go forward applications. Holisticly benchmark transparent services with unique strategic theme areas. Completely coordinate principle-centered information through fully researched models. Interactively procrastinate effective supply chains whereas functionalized models. Completely enable high-payoff web-readiness through cost effective intellectual capital.
Uniquely deliver equity invested content after low-risk high-yield portals. Dynamically empower timely e-markets whereas fully researched best practices. Authoritatively plagiarize fully researched e-services without progressive potentialities. Uniquely evisculate highly efficient testing procedures through prospective e-markets. Progressively communicate proactive supply chains before open-source supply chains.
Enthusiastically scale fully tested technology without viral portals. Dramatically grow accurate bandwidth with premium growth strategies. Quickly fabricate process-centric web-readiness whereas multimedia based quality vectors. Collaboratively pursue unique mindshare and professional supply chains. Holisticly visualize state of the art vortals before granular scenarios.
Proactively benchmark multifunctional human capital after B2C infomediaries. Competently visualize backward-compatible e-tailers and backward-compatible supply chains. Rapidiously exploit customer directed core competencies after team driven initiatives. Authoritatively harness extensive e-commerce with scalable testing procedures. Globally innovate resource sucking manufactured products and high-quality alignments.
Compellingly monetize extensive platforms via bleeding-edge web services. Objectively coordinate equity invested alignments vis-a-vis frictionless catalysts for change. Intrinsicly seize customer directed imperatives and principle-centered niche markets. Credibly simplify progressive applications through reliable value. Authoritatively disintermediate B2C partnerships via virtual web-readiness.
Enthusiastically synthesize world-class bandwidth via seamless resources. Seamlessly disseminate 2.0 experiences after technically sound imperatives. Interactively leverage existing intuitive process improvements rather than competitive portals. Seamlessly engage granular ideas whereas plug-and-play benefits. Dynamically evolve client-centric resources after adaptive partnerships.
Authoritatively utilize worldwide innovation for efficient ROI. Objectively empower extensive potentialities via viral vortals. Rapidiously transform end-to-end vortals whereas B2B processes. Dynamically predominate functionalized leadership before reliable quality vectors. Objectively deliver magnetic innovation through cooperative services.
Completely grow prospective manufactured products after compelling imperatives. Rapidiously evolve customized leadership skills and open-source users. Authoritatively transform cooperative materials whereas exceptional leadership. Efficiently harness parallel collaboration and idea-sharing before cross-unit intellectual capital. Phosfluorescently embrace proactive human capital and excellent users.
Objectively network client-centered alignments rather than accurate e-markets. Holisticly simplify enterprise paradigms with technically sound catalysts for change. Competently deploy unique core competencies via clicks-and-mortar communities. Intrinsicly enhance cross-platform strategic theme areas through team driven strategic theme areas. Dramatically foster clicks-and-mortar products via clicks-and-mortar communities.
Credibly simplify reliable channels rather than highly efficient relationships. Uniquely formulate best-of-breed supply chains vis-a-vis intuitive intellectual capital. Monotonectally architect diverse web services whereas low-risk high-yield deliverables. Uniquely engage cost effective markets before B2B quality vectors. Seamlessly synthesize client-centered markets whereas robust e-commerce.
Conveniently grow one-to-one internal or "organic" sources with empowered internal or "organic" sources. Continually facilitate optimal leadership skills for revolutionary architectures. Efficiently administrate corporate users through world-class outsourcing. Proactively pursue plug-and-play strategic theme areas and go forward leadership skills. Dramatically brand impactful ROI after one-to-one interfaces.
Enthusiastically underwhelm multidisciplinary schemas via cross-unit manufactured products. Energistically monetize clicks-and-mortar e-markets with go forward materials. Seamlessly pursue viral customer service for business technology. Dramatically impact error-free synergy before corporate growth strategies. Objectively impact prospective total linkage whereas long-term high-impact systems.
Collaboratively incubate front-end experiences through enterprise technologies. Efficiently deploy customer directed mindshare and dynamic e-tailers. Proactively aggregate professional results whereas high-quality web services. Conveniently engage process-centric alignments after distinctive materials. Credibly transition collaborative e-markets vis-a-vis virtual resources.
Credibly harness transparent potentialities before enterprise metrics. Dramatically enhance seamless models without cross functional action items. Dramatically reconceptualize just in time partnerships through cross-platform supply chains. Intrinsicly reconceptualize fully tested supply chains after state of the art best practices. Quickly embrace distributed alignments through enterprise schemas.
Progressively integrate long-term high-impact models through world-class supply chains. Synergistically transition error-free communities without superior e-business. Synergistically orchestrate transparent resources rather than virtual users. Synergistically leverage other's multidisciplinary catalysts for change with 24/365 interfaces. Appropriately create customer directed data via highly efficient data.
Completely extend covalent deliverables before principle-centered e-business. Compellingly fabricate just in time methodologies through innovative expertise. Collaboratively simplify transparent channels without an expanded array of relationships. Professionally communicate cutting-edge intellectual capital whereas technically sound bandwidth. Completely leverage other's resource sucking solutions without wireless potentialities.
Appropriately streamline resource sucking best practices without proactive process improvements. Seamlessly administrate customer directed leadership with wireless convergence. Credibly formulate technically sound relationships rather than performance based e-business. Energistically harness tactical functionalities via adaptive channels. Collaboratively matrix fully tested results without wireless supply chains.
Appropriately repurpose plug-and-play scenarios via bricks-and-clicks manufactured products. Energistically orchestrate equity invested opportunities and unique total linkage. Rapidiously deploy installed base markets through unique scenarios. Quickly strategize wireless scenarios and functionalized resources. Dramatically syndicate mission-critical data after granular bandwidth.
Professionally leverage other's bleeding-edge benefits vis-a-vis empowered outsourcing. Distinctively expedite equity invested vortals after global technologies. Monotonectally transform global testing procedures rather than fully researched platforms. Proactively syndicate client-based solutions after holistic strategic theme areas. Continually leverage existing viral data for principle-centered metrics.
Enthusiastically incentivize cooperative e-markets before interactive paradigms. Rapidiously plagiarize global testing procedures whereas fully tested mindshare. Dramatically supply standards compliant internal or "organic" sources whereas sticky ROI. Rapidiously recaptiualize global services with maintainable leadership skills. Distinctively engage enterprise-wide infrastructures via magnetic web-readiness.
Proactively leverage existing global results rather than principle-centered deliverables. Distinctively plagiarize granular materials with dynamic ideas. Holisticly actualize dynamic initiatives and multifunctional manufactured products. Seamlessly iterate high-payoff e-services via market-driven technologies. Compellingly mesh accurate ROI before team driven models.
Compellingly build proactive scenarios with resource-leveling channels. Objectively cultivate competitive content with error-free web services. Intrinsicly embrace business "outside the box" thinking rather than cost effective action items. Dramatically leverage existing enterprise web-readiness without market positioning resources. Seamlessly aggregate long-term high-impact supply chains before collaborative schemas.
Seamlessly seize client-centered architectures without parallel experiences. Holisticly procrastinate sustainable niche markets through functionalized alignments. Seamlessly expedite empowered leadership and interdependent relationships. Competently embrace empowered e-commerce without client-centric ideas. Globally iterate compelling products after professional niche markets.
Progressively optimize premier markets whereas pandemic channels. Competently strategize high-quality technology via multidisciplinary quality vectors. Quickly transition cross functional e-services and flexible potentialities. Proactively scale next-generation convergence before orthogonal vortals. Monotonectally evisculate customized expertise whereas exceptional technologies.
Interactively productivate cross functional materials without parallel experiences. Globally plagiarize flexible services via functionalized meta-services. Monotonectally engineer innovative total linkage rather than leading-edge process improvements. Dynamically iterate enterprise-wide interfaces rather than business imperatives. Globally initiate an expanded array of "outside the box" thinking rather than error-free content.
Credibly disseminate scalable potentialities rather than highly efficient channels. Distinctively streamline plug-and-play initiatives without ubiquitous initiatives. Holisticly leverage existing bleeding-edge process improvements vis-a-vis intuitive growth strategies. Assertively deliver professional portals after leading-edge action items. Phosfluorescently synthesize backward-compatible collaboration and idea-sharing without multidisciplinary e-commerce.
Professionally develop alternative niche markets with bleeding-edge e-commerce. Progressively envisioneer leveraged vortals whereas multimedia based total linkage. Objectively exploit market-driven schemas through 24/7 ROI. Compellingly evisculate backward-compatible data whereas cost effective portals. Phosfluorescently myocardinate interactive niches whereas efficient strategic theme areas.
Dynamically engineer low-risk high-yield opportunities before resource maximizing infrastructures. Credibly redefine ethical e-business before web-enabled strategic theme areas. Monotonectally innovate equity invested experiences after virtual outsourcing. Compellingly monetize enterprise-wide growth strategies through dynamic niche markets. Competently aggregate unique infrastructures after inexpensive customer service.
Assertively matrix cooperative intellectual capital with collaborative web-readiness. Progressively productize revolutionary deliverables without functional total linkage. Conveniently deliver holistic deliverables via end-to-end networks. Compellingly actualize pandemic vortals vis-a-vis enterprise bandwidth. Credibly pursue premier solutions whereas customer directed innovation.
From JAMA
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Bariatric surgery quality improvement project ‘DROPs’ readmissions
NEW ORLEANS – A significant reduction in 30-day all-cause hospital readmissions after sleeve gastrectomy was accomplished through the first-ever joint national quality improvement collaboration between the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery, John M. Morton, MD, reported at Obesity Week 2016.
The quality improvement program, known as DROP, for Decreasing Readmissions through Opportunities Provided, was developed by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). It was put to the test in a year-long study conducted in 128 nationally representative U.S. hospitals. The study involved a comparison of the participating hospitals’ 30-day all-cause readmission rates following bariatric surgery in the year prior to vs. the year after launch of the DROP project.
Overall, the 30-day all-cause readmission rate after primary laparoscopic adjustable gastric banding, laparoscopic sleeve gastrectomy, or laparoscopic Roux-en-Y gastric bypass dropped only modestly, from 4.76% to 4.61%, a relative reduction of 3.2%. But that’s not the whole story. Hidden within that modest overall result were major improvements, Dr. Morton said at the meeting, presented by the Obesity Society of America and the American Society for Metabolic and Bariatric Surgery.
Of particular interest was the finding that the readmission rate following laparoscopic sleeve gastrectomy decreased from 4.02% to 3.54%, a 12% reduction. That’s an important finding, because sleeve gastrectomy is now by far the most frequently performed type of bariatric surgery in the United States. Indeed, it accounted for 54% of the estimated 196,000 bariatric surgery procedures performed in the country in 2015. Roux-en-Y gastric bypass was a distant second at 23%, followed by surgical revisions at 13.6%.
Moreover, the impact of the DROP initiative appeared to accelerate over time. The initiative as tested consisted of a comprehensive bundle of numerous components addressing preoperative, in-hospital, and postoperative care, and it took a while for hospitals to implement. The 30-day readmission rate following laparoscopic sleeve gastrectomy actually increased by 9.2% in the first 3 months following launch of the DROP initiative. But the readmission rate then took a U-turn, declining by 13.2% in the second quarter compared to the year-before rate, by 16.9% in the third quarter, and falling by 27.1% in the final 3 months of the study.
Mean length of stay for patients undergoing laparoscopic sleeve gastrectomy fell significantly, from 1.9 days pre-DROP to 1.79 days. The DROP intervention also achieved a significant decrease in length of stay for laparoscopic adjustable gastric banding, from 0.5 to 0.42 days.
The rate of readmission within 24 hours post discharge in laparoscopic sleeve gastrectomy patients decreased significantly by 19% after introduction of the DROP program. The trend was favorable, albeit not statistically significant, for the other two bariatric procedures studied.
Of note, hospitals in the two quartiles with the lowest preintervention 30-day all-cause readmission rates post bariatric surgery, with rates of 1.34% and 3.15%, respectively, didn’t derive any further reduction by participating in the DROP program. They already were performing many of the elements included in the intervention. But hospitals in the third quartile significantly improved their 30-day readmission rate from 4.84% to 4.13%, and those in the fourth quartile improved from 7.31% preintervention to 4.47% under the DROP program.
The program had no impact on postoperative leak rates or other surgical complications. However, patient satisfaction scores improved after introduction of the DROP intervention.
The preoperative components of the DROP readmission prevention bundle included a standardized 5-minute educational video featuring a surgeon, nutritionist, pharmacist, and psychologist or psychiatrist, with advice on key issues related to the upcoming operation. That’s also when the visits with the surgeon and a nutritionist were to be scheduled for within 30 days post surgery, and when the patient received phone numbers for the clinic and on-call surgeon in case questions arose later.
The in-hospital elements of the DROP intervention included provision of a clinical roadmap to guide patient expectations, as well as a nutritional consultation. The postoperative components included a day-after-discharge phone call from a nurse or physician assistant, a letter sent to the referring physician containing a discharge summary and recommendations, and a system to make sure that the scheduled follow-up appointments with the surgeon and nutritionist actually take place.
Since adherence to the various components of the DROP bundle varied from hospital to hospital, it was possible for Dr. Morton and his coinvestigators to determine which elements made the most difference in improving 30-day readmission rates. They found that the key difference makers were the nurse’s phone call on the day following discharge and the postoperative visits with the surgeon and nutritionist within the first several weeks.
Asked whether the study findings mean that hospitals that already have a 30-day all-cause readmission rate in the lower half of the national average don’t need to adopt the DROP program, Dr. Morton replied: “One size does not fit all. Maybe some centers don’t need to do all this.”
Thirty-day all-cause readmissions were selected for the first quality improvement project by the MBSAQIP in part because the Centers for Medicare & Medicaid Services has identified it as a priority area for surgery in general. Also, Dr. Morton was a coinvestigator in a study that found many readmissions after bariatric surgery are tied to preventable causes, including dietary indiscretions resulting in nausea and vomiting or dehydration, medication side effects, and inappropriate patient expectations (J Gastrointest Surg. 2016 Nov;20[11]:1797-1801).
“I think readmissions are a good outcome to study, because they incorporate many different elements of the patient experience, including patient safety and satisfaction. No surgeon wants to have a patient come back to the ER and be readmitted. And finally, there’s the cost,” Dr. Morton observed.
He noted that members of the MBSAQIP developed the DROP project in a highly efficient and cost-effective manner through a series of webinars and conference calls without the need for face-to-face meetings. The group plans to follow the same approach to its future quality improvement programs.
The DROP study was funded without industry support. Dr. Morton reported serving on advisory boards for Allurion and Novo Nordisk.
NEW ORLEANS – A significant reduction in 30-day all-cause hospital readmissions after sleeve gastrectomy was accomplished through the first-ever joint national quality improvement collaboration between the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery, John M. Morton, MD, reported at Obesity Week 2016.
The quality improvement program, known as DROP, for Decreasing Readmissions through Opportunities Provided, was developed by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). It was put to the test in a year-long study conducted in 128 nationally representative U.S. hospitals. The study involved a comparison of the participating hospitals’ 30-day all-cause readmission rates following bariatric surgery in the year prior to vs. the year after launch of the DROP project.
Overall, the 30-day all-cause readmission rate after primary laparoscopic adjustable gastric banding, laparoscopic sleeve gastrectomy, or laparoscopic Roux-en-Y gastric bypass dropped only modestly, from 4.76% to 4.61%, a relative reduction of 3.2%. But that’s not the whole story. Hidden within that modest overall result were major improvements, Dr. Morton said at the meeting, presented by the Obesity Society of America and the American Society for Metabolic and Bariatric Surgery.
Of particular interest was the finding that the readmission rate following laparoscopic sleeve gastrectomy decreased from 4.02% to 3.54%, a 12% reduction. That’s an important finding, because sleeve gastrectomy is now by far the most frequently performed type of bariatric surgery in the United States. Indeed, it accounted for 54% of the estimated 196,000 bariatric surgery procedures performed in the country in 2015. Roux-en-Y gastric bypass was a distant second at 23%, followed by surgical revisions at 13.6%.
Moreover, the impact of the DROP initiative appeared to accelerate over time. The initiative as tested consisted of a comprehensive bundle of numerous components addressing preoperative, in-hospital, and postoperative care, and it took a while for hospitals to implement. The 30-day readmission rate following laparoscopic sleeve gastrectomy actually increased by 9.2% in the first 3 months following launch of the DROP initiative. But the readmission rate then took a U-turn, declining by 13.2% in the second quarter compared to the year-before rate, by 16.9% in the third quarter, and falling by 27.1% in the final 3 months of the study.
Mean length of stay for patients undergoing laparoscopic sleeve gastrectomy fell significantly, from 1.9 days pre-DROP to 1.79 days. The DROP intervention also achieved a significant decrease in length of stay for laparoscopic adjustable gastric banding, from 0.5 to 0.42 days.
The rate of readmission within 24 hours post discharge in laparoscopic sleeve gastrectomy patients decreased significantly by 19% after introduction of the DROP program. The trend was favorable, albeit not statistically significant, for the other two bariatric procedures studied.
Of note, hospitals in the two quartiles with the lowest preintervention 30-day all-cause readmission rates post bariatric surgery, with rates of 1.34% and 3.15%, respectively, didn’t derive any further reduction by participating in the DROP program. They already were performing many of the elements included in the intervention. But hospitals in the third quartile significantly improved their 30-day readmission rate from 4.84% to 4.13%, and those in the fourth quartile improved from 7.31% preintervention to 4.47% under the DROP program.
The program had no impact on postoperative leak rates or other surgical complications. However, patient satisfaction scores improved after introduction of the DROP intervention.
The preoperative components of the DROP readmission prevention bundle included a standardized 5-minute educational video featuring a surgeon, nutritionist, pharmacist, and psychologist or psychiatrist, with advice on key issues related to the upcoming operation. That’s also when the visits with the surgeon and a nutritionist were to be scheduled for within 30 days post surgery, and when the patient received phone numbers for the clinic and on-call surgeon in case questions arose later.
The in-hospital elements of the DROP intervention included provision of a clinical roadmap to guide patient expectations, as well as a nutritional consultation. The postoperative components included a day-after-discharge phone call from a nurse or physician assistant, a letter sent to the referring physician containing a discharge summary and recommendations, and a system to make sure that the scheduled follow-up appointments with the surgeon and nutritionist actually take place.
Since adherence to the various components of the DROP bundle varied from hospital to hospital, it was possible for Dr. Morton and his coinvestigators to determine which elements made the most difference in improving 30-day readmission rates. They found that the key difference makers were the nurse’s phone call on the day following discharge and the postoperative visits with the surgeon and nutritionist within the first several weeks.
Asked whether the study findings mean that hospitals that already have a 30-day all-cause readmission rate in the lower half of the national average don’t need to adopt the DROP program, Dr. Morton replied: “One size does not fit all. Maybe some centers don’t need to do all this.”
Thirty-day all-cause readmissions were selected for the first quality improvement project by the MBSAQIP in part because the Centers for Medicare & Medicaid Services has identified it as a priority area for surgery in general. Also, Dr. Morton was a coinvestigator in a study that found many readmissions after bariatric surgery are tied to preventable causes, including dietary indiscretions resulting in nausea and vomiting or dehydration, medication side effects, and inappropriate patient expectations (J Gastrointest Surg. 2016 Nov;20[11]:1797-1801).
“I think readmissions are a good outcome to study, because they incorporate many different elements of the patient experience, including patient safety and satisfaction. No surgeon wants to have a patient come back to the ER and be readmitted. And finally, there’s the cost,” Dr. Morton observed.
He noted that members of the MBSAQIP developed the DROP project in a highly efficient and cost-effective manner through a series of webinars and conference calls without the need for face-to-face meetings. The group plans to follow the same approach to its future quality improvement programs.
The DROP study was funded without industry support. Dr. Morton reported serving on advisory boards for Allurion and Novo Nordisk.
NEW ORLEANS – A significant reduction in 30-day all-cause hospital readmissions after sleeve gastrectomy was accomplished through the first-ever joint national quality improvement collaboration between the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery, John M. Morton, MD, reported at Obesity Week 2016.
The quality improvement program, known as DROP, for Decreasing Readmissions through Opportunities Provided, was developed by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). It was put to the test in a year-long study conducted in 128 nationally representative U.S. hospitals. The study involved a comparison of the participating hospitals’ 30-day all-cause readmission rates following bariatric surgery in the year prior to vs. the year after launch of the DROP project.
Overall, the 30-day all-cause readmission rate after primary laparoscopic adjustable gastric banding, laparoscopic sleeve gastrectomy, or laparoscopic Roux-en-Y gastric bypass dropped only modestly, from 4.76% to 4.61%, a relative reduction of 3.2%. But that’s not the whole story. Hidden within that modest overall result were major improvements, Dr. Morton said at the meeting, presented by the Obesity Society of America and the American Society for Metabolic and Bariatric Surgery.
Of particular interest was the finding that the readmission rate following laparoscopic sleeve gastrectomy decreased from 4.02% to 3.54%, a 12% reduction. That’s an important finding, because sleeve gastrectomy is now by far the most frequently performed type of bariatric surgery in the United States. Indeed, it accounted for 54% of the estimated 196,000 bariatric surgery procedures performed in the country in 2015. Roux-en-Y gastric bypass was a distant second at 23%, followed by surgical revisions at 13.6%.
Moreover, the impact of the DROP initiative appeared to accelerate over time. The initiative as tested consisted of a comprehensive bundle of numerous components addressing preoperative, in-hospital, and postoperative care, and it took a while for hospitals to implement. The 30-day readmission rate following laparoscopic sleeve gastrectomy actually increased by 9.2% in the first 3 months following launch of the DROP initiative. But the readmission rate then took a U-turn, declining by 13.2% in the second quarter compared to the year-before rate, by 16.9% in the third quarter, and falling by 27.1% in the final 3 months of the study.
Mean length of stay for patients undergoing laparoscopic sleeve gastrectomy fell significantly, from 1.9 days pre-DROP to 1.79 days. The DROP intervention also achieved a significant decrease in length of stay for laparoscopic adjustable gastric banding, from 0.5 to 0.42 days.
The rate of readmission within 24 hours post discharge in laparoscopic sleeve gastrectomy patients decreased significantly by 19% after introduction of the DROP program. The trend was favorable, albeit not statistically significant, for the other two bariatric procedures studied.
Of note, hospitals in the two quartiles with the lowest preintervention 30-day all-cause readmission rates post bariatric surgery, with rates of 1.34% and 3.15%, respectively, didn’t derive any further reduction by participating in the DROP program. They already were performing many of the elements included in the intervention. But hospitals in the third quartile significantly improved their 30-day readmission rate from 4.84% to 4.13%, and those in the fourth quartile improved from 7.31% preintervention to 4.47% under the DROP program.
The program had no impact on postoperative leak rates or other surgical complications. However, patient satisfaction scores improved after introduction of the DROP intervention.
The preoperative components of the DROP readmission prevention bundle included a standardized 5-minute educational video featuring a surgeon, nutritionist, pharmacist, and psychologist or psychiatrist, with advice on key issues related to the upcoming operation. That’s also when the visits with the surgeon and a nutritionist were to be scheduled for within 30 days post surgery, and when the patient received phone numbers for the clinic and on-call surgeon in case questions arose later.
The in-hospital elements of the DROP intervention included provision of a clinical roadmap to guide patient expectations, as well as a nutritional consultation. The postoperative components included a day-after-discharge phone call from a nurse or physician assistant, a letter sent to the referring physician containing a discharge summary and recommendations, and a system to make sure that the scheduled follow-up appointments with the surgeon and nutritionist actually take place.
Since adherence to the various components of the DROP bundle varied from hospital to hospital, it was possible for Dr. Morton and his coinvestigators to determine which elements made the most difference in improving 30-day readmission rates. They found that the key difference makers were the nurse’s phone call on the day following discharge and the postoperative visits with the surgeon and nutritionist within the first several weeks.
Asked whether the study findings mean that hospitals that already have a 30-day all-cause readmission rate in the lower half of the national average don’t need to adopt the DROP program, Dr. Morton replied: “One size does not fit all. Maybe some centers don’t need to do all this.”
Thirty-day all-cause readmissions were selected for the first quality improvement project by the MBSAQIP in part because the Centers for Medicare & Medicaid Services has identified it as a priority area for surgery in general. Also, Dr. Morton was a coinvestigator in a study that found many readmissions after bariatric surgery are tied to preventable causes, including dietary indiscretions resulting in nausea and vomiting or dehydration, medication side effects, and inappropriate patient expectations (J Gastrointest Surg. 2016 Nov;20[11]:1797-1801).
“I think readmissions are a good outcome to study, because they incorporate many different elements of the patient experience, including patient safety and satisfaction. No surgeon wants to have a patient come back to the ER and be readmitted. And finally, there’s the cost,” Dr. Morton observed.
He noted that members of the MBSAQIP developed the DROP project in a highly efficient and cost-effective manner through a series of webinars and conference calls without the need for face-to-face meetings. The group plans to follow the same approach to its future quality improvement programs.
The DROP study was funded without industry support. Dr. Morton reported serving on advisory boards for Allurion and Novo Nordisk.
Key clinical point:
Major finding: In a large national study, the 30-day all-cause readmission rate after laparoscopic sleeve gastrectomy improved by 12% in the year after introduction of a quality improvement program targeting that outcome.
Data source: The DROP study involved a comparison of 30-day all-cause readmission rates after bariatric surgery at 128 nationally representative hospitals during the year prior to vs. the year following launch of a comprehensive package of quality improvement steps.
Disclosures: The DROP study received no industry funding. Dr. Morton reported serving on advisory boards for Allurion and Novo Nordisk.
Malpractice issues tied to bariatric surgery explored
NEW ORLEANS – The first-ever analysis of medical malpractice closed claims involving bariatric surgeons spotlights key opportunities for improvement for the surgical specialty, Eric J. DeMaria, MD, declared at Obesity Week 2016.
Four of the nation’s largest medical malpractice insurance companies agreed to allow members of an American Society for Metabolic and Bariatric Surgery task force to make site visits to their corporate offices, where the surgeons sat in closed rooms to read and take notes on a total of 175 cases closed during 2010-2015. Those case notes were later shared with the full task force, which sifted through the details in order to identify common causal themes and opportunities for improvement, explained Dr. DeMaria, a bariatric surgeon in Suffolk, Va.
Among the key findings:
• The defense prevailed in 63% of cases. The mean expense for defending a lawsuit was $91,836.
• In the 37% of cases involving monetary awards, the mean figure was $293,500, ranging from $20,000 to $8 million.
• Mortality was involved in 35% of cases. Other notable complications resulting in lawsuits included leak in 18% of cases, bowel obstruction in 10%, bleeding in 5.3%, retained foreign body in 5.3%, and vascular injury from access in 4.4%.
• Preoperative issues such as informed consent and disclosure of information were rare.
• The defendant surgeon was a foreign medical graduate in 27.5% of cases, board certified in 75.9%, and only 43% of the hospitals where the surgery took place were accredited. All those figures are at odds with national norms.
• The panel determined that the cause of the complication was provider-related in 50% of cases, system-related in 29%, and intrinsic to the patient’s disease in 21%.
• In the panel’s view, the complication was preventable by the surgeon in nearly 60% of cases and not preventable by the surgeon in 20%, with the remainder of cases deemed impossible to judge.
• Better preoperative care would have prevented the complication in 20% of cases, in the panel’s view. Better postoperative care would have prevented the complication in 45%.
• Just over 5% of the malpractice claims involved nonstandard malabsorptive operations. “Some of them I’d never heard of before,” according to Dr. DeMaria.
• Care was deemed by the panel to be appropriate in roughly 21% of the malpractice cases and grossly negligent or incompetent in 8%. Twenty-three percent of lawsuits involved preventable error of such magnitude that significant coaching and instruction would be required in order to prevent a recurrence.
Dr. DeMaria observed that this analysis of closed claims suggests that in order to reduce future malpractice claims against bariatric surgeons, it makes sense to focus on a few key areas of practice where most of the serious problems occur.
“We found the same themes repeated over and over; for example, delays in diagnosis and treatment of leaks,” he said.
A substantial number of the lawsuits could have been prevented through the use of preinsufflation and optical trocars, or access away from the midline, he added.
But the number one theme to emerge from the lawsuit analysis was poor communication with the health care team and/or family. The experts on the task force considered the communication performance to be appropriate in only 20% of cases.
“I would emphasize the strong contribution of communication issues, and the strong contribution of coverage and handoff issues,” Dr. DeMaria said. “One example of an intervention that might be introduced would be to standardize the language used in the operating room just before you start to staple the stomach, very similar to what airplane pilots do in their communication. We saw cases over and over again where the anesthesia person was asked to take out the [nasogastric] tube didn’t realize that meant the esophageal stethoscope, too.
“We need to do a better job of not just making sure a coverage person has been identified, but actually communicating with that person and doing a standardized handoff procedure,” Dr. DeMaria continued. “Management of postoperative phone calls is another important area: Who answers the phone? What are they supposed to do with that information? How do you get patients to appropriate care?”
Discussant Ramsey M. Dallal, MD, congratulated Dr. DeMaria and his fellow ASMBS task force members on “the massive amount of work” entailed in this project. And he urged his colleagues to take to heart the lessons learned.
“People hear the word ‘malpractice’ and they get fearful. They think of lawyers and of being attacked. The reality is this is not a malpractice study; this is a patient safety study. A study like this is an excellent way to improve patient safety. The problem with registry data is we don’t get the details – and it’s the case details that point out problems and potential solutions,” said Dr. Dallal, director of bariatrics and vice chair of the department of surgery at the Einstein Healthcare Network in the Philadelphia area.
The closed claims analysis was conducted free of commercial support. Dr. DeMaria reported serving as a consultant to Covidien and Ethicon.
NEW ORLEANS – The first-ever analysis of medical malpractice closed claims involving bariatric surgeons spotlights key opportunities for improvement for the surgical specialty, Eric J. DeMaria, MD, declared at Obesity Week 2016.
Four of the nation’s largest medical malpractice insurance companies agreed to allow members of an American Society for Metabolic and Bariatric Surgery task force to make site visits to their corporate offices, where the surgeons sat in closed rooms to read and take notes on a total of 175 cases closed during 2010-2015. Those case notes were later shared with the full task force, which sifted through the details in order to identify common causal themes and opportunities for improvement, explained Dr. DeMaria, a bariatric surgeon in Suffolk, Va.
Among the key findings:
• The defense prevailed in 63% of cases. The mean expense for defending a lawsuit was $91,836.
• In the 37% of cases involving monetary awards, the mean figure was $293,500, ranging from $20,000 to $8 million.
• Mortality was involved in 35% of cases. Other notable complications resulting in lawsuits included leak in 18% of cases, bowel obstruction in 10%, bleeding in 5.3%, retained foreign body in 5.3%, and vascular injury from access in 4.4%.
• Preoperative issues such as informed consent and disclosure of information were rare.
• The defendant surgeon was a foreign medical graduate in 27.5% of cases, board certified in 75.9%, and only 43% of the hospitals where the surgery took place were accredited. All those figures are at odds with national norms.
• The panel determined that the cause of the complication was provider-related in 50% of cases, system-related in 29%, and intrinsic to the patient’s disease in 21%.
• In the panel’s view, the complication was preventable by the surgeon in nearly 60% of cases and not preventable by the surgeon in 20%, with the remainder of cases deemed impossible to judge.
• Better preoperative care would have prevented the complication in 20% of cases, in the panel’s view. Better postoperative care would have prevented the complication in 45%.
• Just over 5% of the malpractice claims involved nonstandard malabsorptive operations. “Some of them I’d never heard of before,” according to Dr. DeMaria.
• Care was deemed by the panel to be appropriate in roughly 21% of the malpractice cases and grossly negligent or incompetent in 8%. Twenty-three percent of lawsuits involved preventable error of such magnitude that significant coaching and instruction would be required in order to prevent a recurrence.
Dr. DeMaria observed that this analysis of closed claims suggests that in order to reduce future malpractice claims against bariatric surgeons, it makes sense to focus on a few key areas of practice where most of the serious problems occur.
“We found the same themes repeated over and over; for example, delays in diagnosis and treatment of leaks,” he said.
A substantial number of the lawsuits could have been prevented through the use of preinsufflation and optical trocars, or access away from the midline, he added.
But the number one theme to emerge from the lawsuit analysis was poor communication with the health care team and/or family. The experts on the task force considered the communication performance to be appropriate in only 20% of cases.
“I would emphasize the strong contribution of communication issues, and the strong contribution of coverage and handoff issues,” Dr. DeMaria said. “One example of an intervention that might be introduced would be to standardize the language used in the operating room just before you start to staple the stomach, very similar to what airplane pilots do in their communication. We saw cases over and over again where the anesthesia person was asked to take out the [nasogastric] tube didn’t realize that meant the esophageal stethoscope, too.
“We need to do a better job of not just making sure a coverage person has been identified, but actually communicating with that person and doing a standardized handoff procedure,” Dr. DeMaria continued. “Management of postoperative phone calls is another important area: Who answers the phone? What are they supposed to do with that information? How do you get patients to appropriate care?”
Discussant Ramsey M. Dallal, MD, congratulated Dr. DeMaria and his fellow ASMBS task force members on “the massive amount of work” entailed in this project. And he urged his colleagues to take to heart the lessons learned.
“People hear the word ‘malpractice’ and they get fearful. They think of lawyers and of being attacked. The reality is this is not a malpractice study; this is a patient safety study. A study like this is an excellent way to improve patient safety. The problem with registry data is we don’t get the details – and it’s the case details that point out problems and potential solutions,” said Dr. Dallal, director of bariatrics and vice chair of the department of surgery at the Einstein Healthcare Network in the Philadelphia area.
The closed claims analysis was conducted free of commercial support. Dr. DeMaria reported serving as a consultant to Covidien and Ethicon.
NEW ORLEANS – The first-ever analysis of medical malpractice closed claims involving bariatric surgeons spotlights key opportunities for improvement for the surgical specialty, Eric J. DeMaria, MD, declared at Obesity Week 2016.
Four of the nation’s largest medical malpractice insurance companies agreed to allow members of an American Society for Metabolic and Bariatric Surgery task force to make site visits to their corporate offices, where the surgeons sat in closed rooms to read and take notes on a total of 175 cases closed during 2010-2015. Those case notes were later shared with the full task force, which sifted through the details in order to identify common causal themes and opportunities for improvement, explained Dr. DeMaria, a bariatric surgeon in Suffolk, Va.
Among the key findings:
• The defense prevailed in 63% of cases. The mean expense for defending a lawsuit was $91,836.
• In the 37% of cases involving monetary awards, the mean figure was $293,500, ranging from $20,000 to $8 million.
• Mortality was involved in 35% of cases. Other notable complications resulting in lawsuits included leak in 18% of cases, bowel obstruction in 10%, bleeding in 5.3%, retained foreign body in 5.3%, and vascular injury from access in 4.4%.
• Preoperative issues such as informed consent and disclosure of information were rare.
• The defendant surgeon was a foreign medical graduate in 27.5% of cases, board certified in 75.9%, and only 43% of the hospitals where the surgery took place were accredited. All those figures are at odds with national norms.
• The panel determined that the cause of the complication was provider-related in 50% of cases, system-related in 29%, and intrinsic to the patient’s disease in 21%.
• In the panel’s view, the complication was preventable by the surgeon in nearly 60% of cases and not preventable by the surgeon in 20%, with the remainder of cases deemed impossible to judge.
• Better preoperative care would have prevented the complication in 20% of cases, in the panel’s view. Better postoperative care would have prevented the complication in 45%.
• Just over 5% of the malpractice claims involved nonstandard malabsorptive operations. “Some of them I’d never heard of before,” according to Dr. DeMaria.
• Care was deemed by the panel to be appropriate in roughly 21% of the malpractice cases and grossly negligent or incompetent in 8%. Twenty-three percent of lawsuits involved preventable error of such magnitude that significant coaching and instruction would be required in order to prevent a recurrence.
Dr. DeMaria observed that this analysis of closed claims suggests that in order to reduce future malpractice claims against bariatric surgeons, it makes sense to focus on a few key areas of practice where most of the serious problems occur.
“We found the same themes repeated over and over; for example, delays in diagnosis and treatment of leaks,” he said.
A substantial number of the lawsuits could have been prevented through the use of preinsufflation and optical trocars, or access away from the midline, he added.
But the number one theme to emerge from the lawsuit analysis was poor communication with the health care team and/or family. The experts on the task force considered the communication performance to be appropriate in only 20% of cases.
“I would emphasize the strong contribution of communication issues, and the strong contribution of coverage and handoff issues,” Dr. DeMaria said. “One example of an intervention that might be introduced would be to standardize the language used in the operating room just before you start to staple the stomach, very similar to what airplane pilots do in their communication. We saw cases over and over again where the anesthesia person was asked to take out the [nasogastric] tube didn’t realize that meant the esophageal stethoscope, too.
“We need to do a better job of not just making sure a coverage person has been identified, but actually communicating with that person and doing a standardized handoff procedure,” Dr. DeMaria continued. “Management of postoperative phone calls is another important area: Who answers the phone? What are they supposed to do with that information? How do you get patients to appropriate care?”
Discussant Ramsey M. Dallal, MD, congratulated Dr. DeMaria and his fellow ASMBS task force members on “the massive amount of work” entailed in this project. And he urged his colleagues to take to heart the lessons learned.
“People hear the word ‘malpractice’ and they get fearful. They think of lawyers and of being attacked. The reality is this is not a malpractice study; this is a patient safety study. A study like this is an excellent way to improve patient safety. The problem with registry data is we don’t get the details – and it’s the case details that point out problems and potential solutions,” said Dr. Dallal, director of bariatrics and vice chair of the department of surgery at the Einstein Healthcare Network in the Philadelphia area.
The closed claims analysis was conducted free of commercial support. Dr. DeMaria reported serving as a consultant to Covidien and Ethicon.
Key clinical point:
Major finding: Communication with the health care team and the patient’s family was deemed appropriate in only 20% of a large series of medical malpractice lawsuits filed against bariatric surgeons.
Data source: This analysis of malpractice insurers’ files on 175 closed malpractice claims against bariatric surgeons was conducted by an American Society for Metabolic and Bariatric Surgery task force.
Disclosures: The study was conducted free of industry support.