ATLANTA — Obesity Week 2013: The American Society for Metabolic and Bariatric Surgery (ASMBS) and the Obesity Society Joint Annual Scientific Meeting held earlier this month — provided some fresh insights into a number of key issues in bariatric surgery today.

These included the hot topic of accreditation of hospitals for these procedures, the issue of long-term outcomes for weight-loss surgery, and the possibility that some people are "nonresponders," experts told Medscape Medical News.

Also discussed was the changing landscape of US bariatric surgery, which is seeing an upward trend in sleeve gastrectomies at the expense of gastric bypass surgery, according to 2 surgeons.

Proof for Value of Accreditation Programs

The issue of accreditation has been in the spotlight since the decision 2 months ago by the US Centers for Medicare & Medicaid Services (CMS) to drop its requirement that Medicare patients who undergo bariatric surgery need to have the procedure performed in an accredited center.

Raul Rosenthal, MD, from the Cleveland Clinic in Weston, Florida, said this ruling is "difficult to understand," and he noted that the policy change was strongly opposed by the ASMBS, the Obesity Society, and others.

Two new studies reported at the meeting provide further evidence as to why accreditation and national performance standards are important, according toimmediate past president of the ASMBS, Jaime Ponce, MD, from Hamilton Medical Center, in Dalton, Georgia, and Memorial Hospital, in Chattanooga, Tennessee.

In one study, Alana Gebhart, from the University of California, Irvine School of Medicine, and colleagues showed that for complex operations that involve stapling — laparoscopic gastric bypass and laparoscopic sleeve gastrectomy — in-hospital mortality was almost 4-fold lower in centers that were accredited for bariatric surgery than nonaccredited centers (odds ratio, 3.7; P < 0.01). The findings are based on 2008 to 2010 data from 277,068 bariatric operations, where 88.1% of the operations had been performed in accredited centers.

Last year, the ASMBS and the American College of Surgeons combined their own respective accreditation programs and formed the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), which will be launched in January 2014.

In another study reported at Obesity Week, John Morton, MD, from the Stanford School of Medicine, California, and colleagues used benchmarks of patient care — determined from a precursor of MBSAQIP — to improve performance at their center. They identified 2 areas where they could do better — surgical-site infections and 30-day readmission rates — and then implemented procedures to address these weaknesses. As a result, from 2008 to 2012, the rate of surgical-site infections decreased from 2.5% to 1%, and the 30-day readmission rates decreased from 8% to 2%.

"Accreditation can provide for specific structures and processes that can enable centers to recognize complications earlier and ensure they have the necessary structure to care for the patient," Robin Blackstone, MD, from the Scottsdale Healthcare Bariatric Center, Arizona, told Medscape.

She added that she is looking forward to the launch of the MBSAQIP early next year.

Heterogeneity of Response to Surgery, but Good Long-term Outcomes

One of the big surprises at the meeting was work by Anita Courcoulas, MD, from the University of Pittsburgh Medical Center, Pennsylvania, and colleagues showing 3-year outcomes from the Longitudinal Assessment of Bariatric Surgery (LABS) study, which was published in the Journal of the American Medical Association just prior to the conference and then presented there.

Dr. Blackstone told Medscape Medical News that the trial results arrived like a "bombshell," because they revealed that patients were either responders or nonresponders to 2 types of bariatric surgery: Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding.

"This may indicate that obesity is more heterogeneous than we have believed," she said. "Many researchers came away from this meeting believing that we should pursue more investigation into which patient should have which procedure and why," she noted.

Dr. Ponce drew attention to 2 other studies presented at the meeting, which showed favorable long-term outcomes with bariatric surgery.

Ali Aminian, MD, from the Cleveland Clinic Foundation, Ohio, and colleagues reported results of a 6-year study of 131 diabetic obese patients who underwent gastric bypass surgery. They showed that, "along with remarkable control of diabetes, dyslipidemia, and hypertension, [bariatric surgery] is associated with a significant risk reduction for major complications including cardiovascular diseases…nephropathy, retinopathy, and cardiovascular mortality — in the range of 18% to 47%," Dr. Ponce explained.

And in other research, from the Swedish Obese Subjects (SOS) study, Lars Sjostrom, MD, from the Institution of Internal Medicine, Helsinki, Finland, and colleagues found that among obese individuals who had diabetes, 31% of those who underwent bariatric surgery no longer had diabetes 15 years later, which was superior to outcomes in the usual-care group. The surgical methods used in SOS — where vertical banded gastrectomy was the predominant procedure, used in 68% of cases  — do not reflect the current best practice, however.
Nevertheless, presentations such as these provide reassurances that bariatric surgery is safe and, moreover, that it can lead to improved control of diabetes and other diseases, Dr. Rosenthal observed.

Gastric Sleeve Aiming to Overtake Bypass?

Another presentation at the meeting, by Ranjan Sudan, MD, from Duke University Medical Center, Durham, North Carolina, and colleagues, based on the Bariatric Outcomes Longitudinal Database (BOLD), showed that from June 2007 to March 2102, among 1026 surgeons in 709 institutions in the United States, gastric bypass was the most common type of bariatric surgery being performed (49.36%), followed by adjustable band (35.77%), gastric sleeve (10.26%), and gastric reduction duodenal switch (0.93%).

However, Dr. Ponce and Dr. Rosenthal commented that more recent data are showing a shift toward sleeve gastrectomy.

In fact, this past April, the ASMBS, the Obesity Society, and the American Association of Clinical Endocrinologists (AACE) reclassified sleeve gastrectomy as a proven surgical option, rather than an investigational procedure, as it had previously been termed.

"There is no study published on this year's data yet, but the trends that we are seeing in the hospitals indicate that sleeve is becoming a more common procedure than bypass and bands," Dr. Ponce said.

Obesity Week 2013: The American Society for Metabolic and Bariatric Surgery and the Obesity Society Joint Annual Scientific Meeting. Abstracts A-109-OR, A-126-OR, A-102-OR, A-105-OR, A-142-OR. Presented November 13-14, 2013.


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