Data Driven:
Spotlight on ASMBS
Clinical Issues Committee

Published in June 2013 Issue             

An Interview with Stacy Brethauer, MD, FACS
ASMBS Clinical Issues Committee Chair

The 22-member strong ASMBS Clinical Issues Committee develops evidence-based guidelines and position statements to enhance patient care and to provide clarity around issues related to metabolic and bariatric surgery for ASMBS members and the health care community at large.

connect recently talked with Stacy Brethauer, MD, FACS, Staff Surgeon in the Section of Laparoscopic and Bariatric Surgery at Cleveland Clinic, who has been on the committee since 2006, the last three years as its chair. Dr. Brethauer describes the work of the committee and its role in providing expert guidance on issues of importance to the obesity community and
ASMBS members.

connect:  How does the committee determine which issues need position statements and which ones need to be updated?

Topics are identified and determined in several ways. They can come from Executive Council, Clinical Issues Committee Members, the general membership and in some cases, from patients, hospitals or other organizations. We determine which issues to develop position statements on based on urgency, changes in the state of the evidence, changes in policy, and emerging clinical needs. We recently formed a subcommittee to oversee the process of review and revision of existing statements and guidelines, which occurs at least once every two years (Algorithm for Review of Existing Statements & Guidelines).

connect: What position statements has the committee developed?

The most recent was an update to the position statement on Bariatric Surgery in Class 1 Obesity (BMI 30-35 kg/m2). This was issued in September 2012 in response to numerous inquiries made to ASMBS by patients, physicians, society members and hospitals. The committee concluded bariatric surgery should be an available option for patients with BMI 30-35 who do not achieve substantial and durable weight and comorbidity improvement with non-surgical methods. The statement went on to say that "there is no current justification on grounds of evidence of clinical effectiveness, cost-effectiveness, ethics or equity that this group should be excluded from life-saving treatment."

In 2011, the ASMBS issued its third position statement on Sleeve Gastrectomy as a Bariatric Procedure (Update) due to substantial changes in the number and quality of published literature. Substantial comparative and long-term data demonstrate durable weight loss, improved medical comorbidities, long-term patient satisfaction, and improved quality of life after sleeve gastrectomy. This led the ASMBS to recognize the procedure "as an acceptable option as a primary bariatric procedure and as a first stage procedure in high risk patients as part of a planned staged approach."

Other position statements include:

connect: What has been the impact of these statements?

The primary goals of all our statements are to improve patient care and contribute to best practices around the treatment of obesity with bariatric and metabolic surgery. In addition, statements like those for sleeve gastrectomy and preoperative supervised weight loss help policy makers come to more informed decisions about practices and protocols. After we updated the Position Statement on Sleeve Gastrectomy, Drs. John Morton and Matthew Brengman met with the Centers for Medicare and Medicaid Services (CMS), about revising its policy on the procedure. The position statement, which contained comprehensive data and expert opinion, was central to the discussion. Shortly after that meeting on August 30, 2012, CMS confirmed the removal of the Non-Covered status indicator for Sleeve Gastrectomy beginning October 1, 2012.

We believe the ASMBS position statement on Preoperative Supervised Weight Loss Requirements is also helping change policy among insurers regarding a requirement for documentation of prolonged preoperative diet efforts before approval of bariatric surgery services.

It was the society's view that "available Class II-IV data regarding acute weight loss prior to bariatric surgery are indeterminate and provide conflicting results leading to no clear consensus at this time" and that such a requirement for all patients "is inappropriate, capricious, and counter-productive." However, the statement also said individual surgeons and programs should be free to recommend preoperative weight loss based on the specific needs and circumstances of the patient. This position statement, accompanied by a letter from ASMBS was sent to insurance medical directors throughout the country and since that time a number of insurers including BlueCross BlueShield (BCBS) of Illinois, Texas, Oklahoma, and New Mexico have lifted the requirement and others are in considering doing the same.

connect: What is the process for developing a position statement once a topic has been approved?

As you can imagine, developing position statements requires a tremendous amount of research so we can best represent the state of the evidence and provide recommendations based on a comprehensive analysis.

Once a topic is approved, it is assigned to individuals on our committee to write the initial draft or we may work with another ASMBS committee who has specialized knowledge on the topic. An initial draft is typically completed within three months and submitted to our full committee for review and comment. If a committee member has recommendations, the draft is sent back to the subcommittee to incorporate recommended edits. Once the draft is approved by our committee, it is sent for legal review and any comments are considered or incorporated.

The draft is then sent to the Executive Committee of the Executive Council (ECEC) for review and comment. When the ECEC is satisfied with the draft, it is sent to the Executive Council for review and comment. Once the Executive Council approves the draft, the statement goes out to the entire ASMBS membership for comment via group e-mail and After the close of member comments, draft returns to Clinical Issues Committee for review of member comments and the incorporation of  appropriate edits. The ECEC once again reviews the document and if approved, it is forwarded again to the Executive Council and the statement is now ready for submission to SOARD for publication.

connect: What future evidence-based position statements are in development?

The committee is currently working on three position statements. We recently completed an update on the statement for Prophylactic Measures to Reduce the Risk of Venous Thromboembolism in Bariatric Surgery Patients, and the other two are on the impact of metabolic and bariatric surgery on bone changes and alcohol use after bariatric surgery.

connect: How can ASMBS members get more involved and submit recommended ideas for guidelines and position statements to the committee?

Members are encouraged to submit their ideas for statements anytime by emailing our ASMBS Staff Liason Susan Cox at

Dr. Brethauer recently presented a study in Indianapolis at the 133rd Annual Meeting of the American Surgical Association on improvements in diabetic status, glycemic control and cardiovascular risk up to nine years after surgery. Read about it in this month's General Surgery News.