Bariatric and Metabolic Surgery Benefits, Challenges and Misperceptions

Stacy Brethauer, MD, is a staff physician in Cleveland Clinic’s Bariatric and Metabolic Institute. He addresses trends and challenges in bariatric surgery and what the kind of legacy he wants to leave in an interview as he assumes the role of President of the American Society of Metabolic and Bariatric Surgery (ASMBS).

Q: Are there any controversial areas you see the society addressing over the next year?

A: One of the most controversial things in our field is when a new procedure becomes acceptable for widespread use. New variations on older procedures [also] present a challenge: what level of evidence is sufficient to say that this should be covered and it’s a standard procedure? We have to be really diligent. Payers and patients pay attention when a society comes out and endorses a new procedure, and we want to make sure it’s safe and effective for the patient.

Q: Obesity affects a lot of different specialties in medicine. What surprises you most that other physicians don’t understand about bariatric surgery?

A: There is still a widespread perception that it’s a last resort, and quite the opposite is true. It should be considered earlier in the disease for obesity, diabetes and metabolic syndrome. We know that the earlier you intervene in a chronic disease, the more effective the treatment can be and the longer it can last. Other misperceptions about bariatric surgery are that it is very risky, it doesn’t work and it doesn’t last. There is a tremendous amount of evidence to the contrary. It is extremely safe, safer than many commonly performed surgical procedures.

Q: How do you address the whole scope of the field of bariatric surgery without bringing your own expertise into it?

A: That’s a great question. We are a society with about 2,000 surgeons and 2,000 integrated health professionals. We focus on prevention, less invasive treatments, and offering a full spectrum of therapy because it’s a chronic disease that affects millions and millions of people, and surgery is only going to touch a small fraction of those.

Q: What kind of goals do you want to accomplish during your time as ASMBS President?

A: One of my specific goals is around the State and Local Chapters Committee. These state and regional chapters that really serve as the lifeblood of the society and a lot of initiatives move forward at the state and regional meetings. I really want to highlight [that] activity and develop state chapter collaboratives for quality improvement.

The other thing I’m doing on a national level is the Enhanced Recovery Project. Our accreditation program, MBSAQIP (Metabolic and Bariatric Surgery Accreditation and Quality Improvement Project) is a national program with about 700 centers participating. We’re able to run these national quality improvement projects in conjunction with the American College of Surgeons. My project will be about implementing enhanced recovery pathways for bariatric programs that are in need of improvement in terms of their length of stay. We plan to run this initiative for the next 18 months to help standardize their enhanced recovery strategies. That’s an important thing we’re doing for patient care.

Q: Has the outgoing president offered any advice?

A: Not yet, but I’m sure he will. We have a strong Cleveland Clinic presence within the leadership of this society. The outgoing president is Raul Rosenthal, MD, who has been an excellent leader and provided a great example.

Q: How has working at Cleveland Clinic served you to now be able to represent this national society?

A: Cleveland Clinic is a big proponent of service and leadership, and helping those around you rise to their full potential. My leadership style is very collaborative, and it’s a style I’ve really learned at Cleveland Clinic that has served me well.

Q: There was a STAMPEDE study at Cleveland Clinic that assessed bariatric surgery to treat patients with Type 2 diabetes, including those with lower BMIs. Is that a growing trend?

A: It is. We’ve known for decades that diabetes can improve dramatically after bariatric surgery, but the level of evidence has greatly improved. It’s only been in the last five years that we’ve had … a dozen or so randomized, controlled trials that demonstrate that compared to medical therapies. The STAMPEDE trial is one of those and has the longest follow-up. It adds to the body of literature that supports the surgical treatment of diabetes.

Q: What do you hope you’ll be able to say at the end of your term as president?

A: I hope I will have left a mark in terms of enhanced recovery for the field of bariatric surgery on a large scale. This is really where things are going around value-based care — doing things that cost less, lead to a better patient experience, and have high-quality outcomes.

Follow Dr. Brethauer on Twitter @StacyBrethauer and follow the conversation with Cleveland Clinic physicians on Twitter via the hashtag #OW2016.