Accredited bariatric surgery centers have fewer postoperative complications

Eight of 11 studies that evaluated postoperative complications found that undergoing a bariatric operation in an accredited facility reduced the odds of experiencing a serious complication by 9 percent to 39 percent (odds ratios of 1.09 to 1.39), the researchers reported.

A population-based analysis of use and outcomes of laparoscopic bariatric surgery across socioeconomic groups in Taiwan

BACKGROUND

With the growing development of minimally invasive techniques for the treatment of morbid obesity, laparoscopic bariatric surgery (LBS) is increasingly performed. This study aimed to assess the association between patients' socioeconomic status (SES) and the likelihood of undergoing LBS and related outcomes in Taiwan.

METHODS

This nationwide population-based study was conducted by using data from Taiwan's National Health Insurance Research Database. A total of 3678 morbidly obese patients aged 18 years and older who underwent conventional open bariatric surgery or LBS were identified between 2004 and 2011. Regression analyses were performed using generalized estimating equation (GEE) models to account for the nesting of patients within physician to assess patients' SES category associated with the use of LBS and related outcomes. Odds ratios (ORs) and 95 % confidence intervals (CIs) were estimated.

RESULTS

Compared with those with medium and low SES (84.6 % and 80.2 %), patients with high SES (88.1 %) had the highest percentage of undergoing LBS (P < 0.001). After adjusting for patient demographics, institution and surgeon characteristics, the multivariate GEE analysis revealed that the highest likelihood of undergoing LBS was noted in morbidly obese patients with high SES (OR = 1.45, 95 % CI 1.10-1.90), followed by those with medium SES (OR = 1.27, 95 % CI 1.04-1.56). In addition, patients with high SES had slightly lower length of hospital stay (LOS; OR = 0.90, 95 % CI 0.82-0.99) and hospital treatment cost (OR = 0.93, 95 % CI 0.87-0.99) than their counterparts after adjustment.

CONCLUSIONS

The increased likelihood of undergoing LBS and lower LOS and hospital treatment cost were noted among morbidly obese patients with higher SES. This finding suggests there is the need to improve clinical practice and reduce health disparities in the surgical treatment of morbidly obese patients.

Obesity in children: bariatric surgery

INTRODUCTION

The prevalence of childhood obesity in the UK and in many countries worldwide remains high. Behavioural interventions to modify lifestyle, such as diet and physical activity, usually form part of weight management strategies for obese children. Whether or not surgical interventions are effective and safe in treating childhood obesity is unclear.

METHODS AND OUTCOMES

We conducted a systematic overview, aiming to answer the following clinical question: What are the effects of surgical interventions for the treatment of childhood obesity? We searched Medline, Embase, The Cochrane Library, and other important databases up to August 2014 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this overview).

RESULTS

At this update, after deduplication and removal of conference abstracts, 67 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 19 studies and the further review of 48 full publications. Of the 48 full articles evaluated, two systematic reviews were included at this update.

CONCLUSIONS

In this systematic overview, we categorised the efficacy for two comparisons based on information about the effectiveness and safety of bariatric surgery versus no intervention and different types of bariatric surgery versus each other.

Bariatric and metabolic surgery: a shift in eligibility and success criteria

The obesity epidemic, combined with the lack of available and effective treatments for morbid obesity, is a scientific and public health priority. Worldwide, bariatric and metabolic surgeries are increasingly being performed to effectively aid weight loss in patients with severe obesity, as well as because of the favourable metabolic effects of the procedures. The positive effects of bariatric surgery, especially with respect to improvements in type 2 diabetes mellitus, have expanded the eligibility criteria for metabolic surgery to patients with diabetes mellitus and a BMI of 30-35 kg/m(2). However, the limitations of BMI, both in the diagnosis and follow-up of patients, need to be considered, particularly for determining the actual adiposity and fat distribution of the patients following weight loss. Understanding the characteristics shared by bariatric and metabolic surgeries, as well as their differential aspects and outcomes, is required to enhance patient benefits and operative achievements. For a holistic approach that focuses on the multifactorial effects of bariatric and metabolic surgery to be possible, a paradigm shift that goes beyond the pure semantics is needed. Such a shift could lead to profound clinical implications for eligibility criteria and the definition of success of the surgical approach.

Interdisciplinary European guidelines on metabolic and bariatric surgery

In 2012, an expert panel composed of presidents of each of the societies, the European Chapter of the International Federation for the Surgery of Obesity (IFSO-EC), and of the European Association for the Study of Obesity (EASO), as well as of the chair of EASO Obesity Management Task Force (EASO OMTF) and other key representatives from IFSO-EC and EASO, devoted the joint Medico-Surgical Workshop of both institutions to the topic of metabolic surgery in advance of the 2013 European Congress on Obesity held in Liverpool. This meeting was prompted by the extraordinary advancement made in the field of metabolic and bariatric surgery during the past decade. It was agreed to revise and update the 2008 Interdisciplinary European Guidelines on Surgery of Severe Obesity produced by focusing in particular on the evidence gathered in relation to the effects on diabetes and the changes in the recommendations of patient eligibility criteria. The expert panel allowed the coverage of key disciplines in the comprehensive management of obesity and obesity-associated diseases, aimed specifically at updating the clinical guidelines to reflect current knowledge, expertise and evidence-based data on metabolic and bariatric surgery.

Adolescent bariatric surgery program characteristics: the Teen Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study experience

The number of adolescents undergoing weight loss surgery (WLS) has increased in response to the increasing prevalence of severe childhood obesity. Adolescents undergoing WLS require unique support, which may differ from adult programs. The aim of this study was to describe institutional and programmatic characteristics of centers participating in Teen Longitudinal Assessment of Bariatric Surgery (Teen-LABS), a prospective study investigating safety and efficacy of adolescent WLS. Data were obtained from the Teen-LABS database, and site survey completed by Teen-LABS investigators. The survey queried (1) institutional characteristics, (2) multidisciplinary team composition, (3) clinical program characteristics, and (4) clinical research infrastructure. All centers had extensive multidisciplinary involvement in the assessment, pre-operative education, and post-operative management of adolescents undergoing WLS. Eligibility criteria and pre-operative clinical and diagnostic evaluations were similar between programs. All programs have well-developed clinical research infrastructure, use adolescent-specific educational resources, and maintain specialty equipment, including high weight capacity diagnostic imaging equipment. The composition of clinical team and institutional resources is consistent with current clinical practice guidelines. These characteristics, coupled with dedicated research staff, have facilitated enrollment of 242 participants into Teen-LABS.

Bariatric surgery for obese children and adolescents: a review of the moral challenges

BACKGROUND

Bariatric surgery for children and adolescents is becoming widespread. However, the evidence is still scarce and of poor quality, and many of the patients are too young to consent. This poses a series of moral challenges, which have to be addressed both when considering bariatric surgery introduced as a health care service and when deciding for treatment for young individuals. A question based (Socratic) approach is applied to reveal underlying moral issues that can be relevant to an open and transparent decision making process.

DISCUSSION

A wide range of moral issues with bariatric surgery for children and adolescents is identified in the literature. There is a moral imperative to help obese minors avoiding serious health problems, but there is little high quality evidence on safety, outcomes, and cost-effectiveness for bariatric surgery in this group. Lack of maturity and family relations poses a series of challenges with autonomy, informed consent, assent, and assessing the best interest of children and adolescents. Social aspects of obesity, such as medicalization, prejudice, and discrimination, raise problems with justice and trust in health professionals. Conceptual issues, such as definition of obesity and treatment end-points, present moral problems. Hidden interests of patients, parents, professionals, industry, and society need to be revealed.

SUMMARY

Performing bariatric surgery for obese children and adolescents in order to discipline their behavior warrants reflection and caution. More evidence on outcomes is needed to be able to balance benefits and risks, to provide information for a valid consent or assent, and to advise minors and parents.

Bariatric surgery complications before vs after implementation of a national policy restricting coverage to centers of excellence

IMPORTANCE

Starting in 2006, the Centers for Medicare & Medicaid Services (CMS) has restricted coverage of bariatric surgery to hospitals designated as centers of excellence (COE) by 2 major professional organizations.

OBJECTIVE

To evaluate whether the implementation of the COE component of the national coverage decision was associated with improved bariatric surgery outcomes in Medicare patients.

DESIGN, SETTING, AND PATIENTS

Retrospective, longitudinal study using 2004-2009 hospital discharge data from 12 states (n = 321,464 patients) of changes in outcomes in Medicare patients undergoing bariatric surgery (n = 6723 before and n = 15,854 after implementation of the policy). A difference-in-differences analytic approach was used to evaluate whether the national coverage decision was associated with improved outcomes in Medicare patients above and beyond existing time trends in non-Medicare patients (n = 95,558 before and n = 155,117 after implementation of the policy).

MAIN OUTCOME MEASURES

Risk-adjusted rates of any complication, serious complications, and reoperation.

RESULTS

Bariatric surgery outcomes improved during the study period in both Medicare and non-Medicare patients; however, this change was already under way prior to the CMS coverage decision. After accounting for patient factors, changes in procedure type, and preexisting time trends toward improved outcomes, there were no statistically significant improvements in outcomes after (vs before) implementation of the CMS national coverage decision for any complication (8.0% after vs 7.0% before; relative risk [RR], 1.14 [95% CI, 0.95-1.33]), serious complications (3.3% vs 3.6%, respectively; RR, 0.92 [95% CI, 0.62-1.22]), and reoperation (1.0% vs 1.1%; RR, 0.90 [95% CI, 0.64-1.17]). In a direct assessment comparing outcomes at hospitals designated as COEs (n = 179) vs hospitals without the COE designation (n = 519), no significant differences were found for any complication (5.5% vs 6.0%, respectively; RR, 0.98 [95% CI, 0.90-1.06]), serious complications (2.2% vs 2.5%; RR, 0.92 [95% CI, 0.84-1.00]), and reoperation (0.83% vs 0.96%; RR, 1.00 [95% CI, 0.86-1.17]).

CONCLUSIONS AND RELEVANCE

Among Medicare patients undergoing bariatric surgery, there was no significant difference in the rates of complications and reoperation before vs after the CMS policy of restricting coverage to COEs. Combined with prior studies showing no association of COE designation and outcomes, these results suggest that Medicare should reconsider this policy.

[Standardize and pragmatism- the key to promote the healthy development of obesity and metabolic surgery in China]

After more than half a century of development, obesity and metabolic surgery in western countries has become a complete surgical specialties, but the introduction of obesity and metabolic surgery was only 10 years old in China. The surgical treatment of obesity and related metabolic diseases, especially obesity of type 2 diabetes has been recognized and acknowledgd by the majority of surgical colleagues and patients as a new direction of development. The current trend of obesity and metabolic surgery is favorable, but there are many problems in the development of obesity and metabolic surgery in China, for example, the surgery nomenclature is not standardized, surgical indications are loosened, the surgical procedure is modified arbitrarily, the evaluation criteria is confusing, the postoperative follow-up protocol is not unified, etc. These problems require the majority of surgical colleagues to work together to make the standards scientifically a nd objectively in accordance with the actual situatioin of our country, so as to promote the healthy development of obesity and metabolic surgery in China.

A culture of safety: a business strategy for medical practices

Physician practices can enhance their economics by taking patient safety to a new level within their practices. Patient safety has a lot to do with systems and processes that occur not only at the hospital but also within a physician's practice. Historically, patient safety measures have been hospital-focused and -driven, largely due to available resources; however, physician practices can impact patient safety, efficiently and effectively, with a methodical plan involving assessment, prioritization, and compliance. With the ever-increasing focus of reimbursement on quality and patient safety, physician practices that implement a true culture of safety now could see future economic benefits using this business strategy.

Bariatric surgery for diabetes: the International Diabetes Federation takes a position

Type 2 diabetes (T2D) and obesity are both complex and chronic medical disorders, each with an escalating worldwide prevalence. When obesity is severe, and/or available medical therapies fail to control the diabetes, bariatric surgery becomes a cost-effective therapy for T2D. When there are other major comorbidities and cardiovascular risk, the option of bariatric surgery becomes even more worthy of consideration. National guidelines for bariatric surgery need to be developed and implemented for people with T2D. With this in mind, the International Diabetes Federation convened a multidisciplinary working group to develop a position statement. The key recommendations cover describing those eligible for surgery and who should be prioritized, incorporating bariatric surgery into T2D treatment algorithms, performing surgery in centers with multidisciplinary teams that are experienced in the management of both obesity and diabetes, and developing bariatric surgery registries and reporting standards.

Quality control in gastrointestinal surgery

We analyzed the Mexican legal framework, identifying the vectors that characterize quality and control in gastrointestinal surgery. Quality is contemplated in the health protection rights determined according to the Mexican Constitution, established in the general health law and included as a specific goal in the actual National Development Plan and Health Sector Plan. Quality control implies planning, verification and application of corrective measures. Mexico has implemented several quality strategies such as certification of hospitals and regulatory agreements by the General Salubrity Council, creation of the National Health Quality Committee, generation of Clinical Practice Guidelines and the Certification of Medical Specialties, among others. Quality control in gastrointestinal surgery must begin at the time of medical education and continue during professional activities of surgeons, encouraging multidisciplinary teamwork, knowledge, abilities, attitudes, values and skills that promote homogeneous, safe and quality health services for the Mexican population.