Bringing Creativity to Bariatric and Metabolic Care

One thing an economic recession will do is instill discipline in virtually every sector, public or private. Investors become ever more discriminating about their money. Research budgets are drastically trimmed with greater stipulations attached. Financial institutions are intolerant of risks. Organizations, especially healthcare and nonprofits, streamline their processes to optimize efficiency and lower costs. However, despite the tight scrutiny during sluggish economies, innovations still happen. We could even argue that when times are lean, only the best innovations—defined as doing an excellent job at lowest cost—survive the “valley of death”a that is common among new discoveries. Even “luxury” services or high-priced items are forced to define the value they are providing their clients.

For the care of our patients, we have seen very interesting and exciting innovations coming out of the difficult economic times following the recession of 2008. We have seen the release of several endoscopic modalities (e.g., suturing, clipping, stenting) that help us treat postsurgical complications with good results. There are other transoral devices in various stages of development that are intended to perform internal gastroplasties for gastric volume reduction. In January of this year, the United States Food and Drug Administration (FDA) approved the VBLOC (EnteroMedics, Minneapolis, MN) system for vagal signaling blockade to disrupt hunger signals sent to the brain—a development that has been ongoing for more than a decade. In Europe, the Obalon capsule (Obalon Therapeutics, San Diego, CA) is swallowed by the patient and then inflates in the patient's stomach to become a volume-occupying balloon to induce satiety. The rumor around the coffee break room is that other satiety balloons will also be available for our patients soon. I am most excited about a balloon that dissolves on its own without having to remove it. Be warned that these are rumors and some border on fantasy.

I do believe that a different type of innovation is creating fresh offerings for our patients that do not solely rely on surgery—especially when patients do not want, or are not fit, for surgery. Let's face it: bariatric surgery is fantastically effective for many patients, but the surgical options are really only restrictive, malabsorptive, or a combination of the two. A program that is organized under one system is hard to do, since we are accustomed to operating within independent silos. Who will pay for the exercise physiologist in a plastic surgeon's office, for example? Who should see the patient first for satiety balloon placement—the surgeon or the gastroenterologist? However, a program that can harness different options and existing resources will probably do best in an environment where patients want ease of access, affordability, options, and convenience. In the book The Power of Pull, ¹ John Hagel talks about how successful small businesses are able to capitalize the merger of information, creativity, and capabilities in an increasingly interdependent world where borders are blurred. For example, a Fortune 500 company works with a bariatric medical group to start a healthy living program for its employees, but finds low compliance because activities happen during the busy working day when millions of dollars are changing hands. The creative team decides to enter into the lives of the employees during off-hours and, in doing so, helps whole families understand healthy living and eating.

At Emory, we have started a transition care program where children who have been cared for at the Children's Hospital transition to the adult program after 21 years of age. In essence, this system takes on a patient, and sometimes the family, for life. We have used the term “metabolic aesthetics” by combining dietetic counseling, nonsurgical weight loss treatment with our aesthetic surgery program knowing that liposculpturing in an overweight patient works best if the patient loses 5–8 body mass index (BMI)s. Here's another easy place to start: remind your patients who meet screening criteria to have their colonoscopies and arrange it with your in-house endoscopist (gastroenterologist or otherwise). For the surgeon skeptic who thinks this is a lot of work for patients who would not eventually have surgery—it is. But remember that we surgeons only have a few surgical options at our disposal, and we can usually only use each once. As surgery goes, only a fixed set of patients meet the criteria. What about the patients with BMIs between 30 and 40? Furthermore, a basic business formula for growth in a competitive environment for the same patients is to grow the size of the “pie” (or increase the client pool). Our interventional radiologists, having interest in health and fitness, are exploring gastric fundus embolization as adjuncts to weight loss. And yes, surgeons are probably the best drivers for these innovative programs for our patients because we are procedure based and, when we choose to, we can converse in non-surgical arenas as well. Finally, surgeons understand the upper limits of how much we can do for a patient.

So, I find the near future exciting for bariatric and metabolic care because there are entities around us that want to offer patients great care but are frustrated by isolation and limited patient offerings. It takes creativity and passion to look and bring these resources together for our patients.