Ed. Leafing through your research work, I was inspired from an iterative topic “the ten golden rules of obesity anaesthesia…” Paraphrasing I shall continue with” the ten short questions” for the ESPCOP President.
Professor Mulier , may we start with you giving us some brief biographical information? How did you come into the profession? And how long have you been interested in obesity topics?
JM. At the age of 18 when I decided to become a physician and not an engineer, I assisted in the operating room for my father who is a surgeon and gynaecologist. At the operating table in 1977 I met my uncle Michel Mulier, who worked as anaesthesiologist and I got interested in his work. Anaesthesia was working with monitoring that required at that time a lot of technical expertise besides clinical expertise. The ability to measure the effect of your drugs and actions directly, opened the world of physiology to me. Surgery at that time seemed more manual work and internal medicine was descriptive. At that time monitoring was airway pressure, manual blood pressure and an ECG if available, but an explosion in monitoring technology was about to take place.
After several years of limited clinical experience I finally began my training in anaesthesia and became more focused on research. In my second year the first endoscope-mounted echo probe became available. My orthopaedic surgeon uncle was performing many total hip replacements and reconstructions and each year had several deaths due to hemodynamic reactions when inserting the prosthesis.
With the assistance of Prof Hugo Van Aken, we used an echo and found fat emboli circulating through the right heart and if there was an atrial defect, circulating to the brain. We solved the question and improved the surgical method by reducing drilling and large fluid rinsing before injecting the cement. This was my first experience on how anaesthesia can help surgeons improve the surgical outcome.
Trans-oesophageal echocardiography opened the path to cardiac anaesthesia and hemodynamic physiology when the echo quality improved and visualization of valves became possible. Echo made also volume calculations possible and therefore our Starling model became questionable. I assisted Karel Wesseling of TNO Netherlands to develop the pulse contour cardiac output, and in the animal lab we developed a mathematical model of the left ventricular pump function under the supervision of a famous cardiovascular bio-engineer, Abraham Noordergraaf at Penn University.
But before going to Penn I took one-year residency under Prof Miller at UCSF, again with the help of H Van Aken who envisioned the changes in anaesthesia that were to take place. Here I explored the cardio-respiratory interactions, and went to Medtronic to develop a pacemaker that would synchronise with respiration in heart failure. Whilst in the USA I caught up with my uncle Peter Mulier who was not a physician but a bio-engineer at Medtronic, working outside of the pacemaker activity. In my free time we started doing several non classical experiments based on new tools, new concepts and new disease questions. One of them was a cough assist device for intensive care, but that was too early to catch the market at that time.
After my PhD on “left ventricular pressure as a function of volume and flow” I worked further as cardiac anaesthesiologist. Echocardiography was a developing technique that allowed anaesthesiologist to improve the surgical results directly by analysing the reconstructive results, and indirectly by improving the hemodynamic.
In 1995 I moved to Sint Jan Bruges as chairman of the department of anaesthesiology. Although organization was my first task, I found an increasing number of bariatric procedures taking place at that time. A high morbidity and intensive care follow up rate seemed normal when performed by open laparotomy. When Bruno Dillemans started to perform these procedures laparoscopically and demanded better anaesthesia support I started to approach it scientifically with the motto: “The surgeon might be always correct, or the anaesthesiologist might be always correct, but probably each obese patient is different requiring a patient adapted approach. Therefore let us measure what happens and adapt in stages”. Indeed each obese patient is different and requires a special approach. We took more than one little step and again found how anaesthesia can improve surgical outcome.
Ed. In terms of the progression of your ideas, are there figures that came to be influencers as obviously your ideas and your thinking have evolved and changed?
JM. As mentioned before, A Noordergraaf taught me to invent models that describe physiology, Peter Mulier taught me to translate concepts into inventions and he showed me to communicate with patents, H Van Aken taught me how to give scientific lectures and to get things organised and done. My father taught me to work fast and efficiently, my uncle to improve your work each day by being a perfectionist and my grandfather showed me that working is teaching.
They were all three different (as surgeons!) but taught me to put the patient always first and to avoid surgery if not needed. I have had many other teachers in Anaesthesia, intensive care and emergency care and they all given me advice that I shall never forget.
Ed. What has been the greatest achievement of your career to date?
JM. The understanding and the message to others that anaesthesia is more than putting a patient to sleep and that we have a real impact on surgical outcome.
To have that impact you need to see the problems, look for the ways to solve them and you should accept changes in your behaviour. The last is the most difficult and we all tend to keep things as they are.
Ed. How do you see a perfect day in your life?
JM. A perfect day does not exist. Hard work and having more than one task at a time is normal; If you wait until you have time things will never get done. Therefore you stay alert and take every moment possible to do research, as this is the work that is easily delayed.
Ed. If you were to write an autobiography, what would the title be?
JM.“Quality is more than fighting for rules and controlling them.”
Open your eyes to see the problems around you, seek ways to solve them and be happy if one of them can be fixed without a rule. If a change in behaviour is also needed it might take a generation before it becomes standardised.
Ed. How did you become involved with the ESPCOP? Could you tell us a little bit about its history and why do you think it is important to anaesthetists in general?
JM. Adrian Alvarez of Buenos Aires and Jay Brodsky of Stanford envisioned that the problem of obesity for anaesthesiologists is not a disaster if you prepare for it. IFSO and bariatric surgery were in existence. Therefore they started the international society for the peri-operative care of the obese patient to support the anaesthesiologists. Many surgeons who started this type of surgery moved at an early stage from universities to private clinics leaving the first anaesthesiologists trained in obesity behind. Therefore ISPCOP had a difficult time to get sufficient support.
In Europe bariatric surgery was also booming, first in Italy and Belgium and later followed in many other countries. The ESA was looking to collaborate with specialist societies who had a European membership and therefore I took the initiative to talk with colleagues in Italy and England. England however was moving forward with a UK society and found it important to be UK based. Therefore we made the plan to have the SOBA as UK based society but to integrate it with the European ESPCOP. At the same time we promised to link the ESPCOP with the ISPCOP when this society would re-start again, with support of SOBA and ESPCOP.
Ed. What projects are you involved in within ESPCOP at the moment? Do you envisage any development in the near future?
JM. ESPCOP gives lectures during the ESA and IFSO meetings and has its own society meeting every year now. Many members are actively involved in scientific research in obesity and the support of this remains important. Best poster prizes are now awarded every year. More local training in every country on the key points of anaesthesia in the obese patients should be organised and working together with the SOBA seems here important.
Ed. For the purpose of these projects are there significant institutions and organizations as well as people who can contribute to enhancing ESPCOP?
JM.As already discussed like IFSO, ESA, the sister organisations SOBA, ISPCOP and now the Australian group, ASPCOP.
Ed. Moving to a broader perspective,…I was wondering if you had observed any particular trends in the popularity and progress of different techniques for and approaches to obese anaesthesia and care ? Any trends or changes over the time that you’ve been in this field?
JM. Initially we thought that we needed stronger tables, ventilators and other equipment but this was not always true. The idea that ventilators with larger tidal volumes and higher pressures were needed was wrong. The equipment should support higher loads, but ventilators need to give protective lung ventilation with higher PEEP, plus pressure support and CPAP modes.
Morbidly obese patients are not really more difficult or pose higher risks if both patient and operator are well prepared. And the same is becoming true for post operative care, in that intensive care is not more frequently needed if anaesthesia is adapted to be short with less side effects
Having expertise to deal with obese patients is very important. This is also true for bariatric surgeons and for new bariatric centres it is important to start with obese and not super obese patients first, to get that needed expertise.
We have more water soluble drugs available now making the IBW and LBW more useful for calculations than the total body weight.
Ed. And I’ve got one last question for you, which is of a much more speculative nature, just wondering what thoughts you might have on the next 20….years for ESPCOP?
JM. Morbid obesity will further increase, certainly in the south of Europe, and therefore the need for clinical skills and information on obesity management will remain. More research is still needed in the many areas of anaesthesiology and intensive care where obesity changes the physiology and the pharmacology. Obesity should become a basic part of anaesthesia training and ESPCOP a scientific committee inside the ESA.
However this last point will not happen as the number of scientific committees is considered enough. It will sadly remain difficult for ESPCOP as society to get a large membership (in comparison with surgical societies) and this has to do with the fact that surgeons have to show their patients that they are qualified, whilst anaesthesiologist do not yet need to come out with these qualification. But whilst there is no requirement to demonstrate specialisation with such qualifications in anaesthesia today, perhaps this will change over the coming …20 years
Ed. It seems I've cheated a bit, asking more than one question on behalf of one of the ten; but all's well that ends well, for the sake of the Newsletter readers.
Thank you very much, Prof. Mulier
5th ESPCOP Meeting, Saturday,December 20th 2014, Ghent – Belgium
How do the morbidly obese patients perform in non-bariatric settings? This meeting will address some aspects of morbidly obese patients in situations and pathologies others than bariatric surgery.
- Morbidly obese patients and protective lung ventilation.
P. Pelosi, Genova, Italy
- Morbidly obese patients in thoracic surgery
Mert Senturk, istanbul, Turkey
- Morbidly obese patients in cardiology and cardiosurgery
Michel De Pauw, Ghent, Belgium
- Morbidly obese patients in transplantation/ liversurgery
Luc De Baerdemaeke, Ghent, Belgium
- Morbidly obese patients and kidney function
E. Hoste, Ghent Belgium
- Morbidly obese patients in hepatology.
Jules Wendon, Kings College, UK
- Difficult intubation in the ICU
to be confirmed
- Rapid sequence induction in morbidly obese
Yigal Leykin, Pordenone, Italy
- Sedation of morbidly obese patients in remote locations
Jan Paul Mulier , Brugge, Belgium
- Morbids and echo-guided nerveblocks: help or hell?
Daniela Godoroja, Bucharest, Romania
- The obesity paradox in ICU patients
T. Gaszynski, Lodz, Poland
- Morbidly obese patients and inflammation
Roman Schumann,Boston, USA
- OSAS and outcome
to be confirmed
- Morbidly obese patients and surgery: what’s new?
Yves van Nieuwenhove,Ghent Belgium
- Morbidly obese patients in the emergency unit
Mike Margarson, Chichester, UK
- Morbidly obese patients and the brain.
C. Dedeyne, ZOL, Belgium
The growing epidemic of obesity, an increasing burden throughout the world, is perfectly expressed by the term "globesity".
The medical, social and economic implications of morbid obesity have over the last decades highlighted the limitations of non-interventional medical treatment.
Today laparoscopic bariatric/metabolic surgery provides the most reliable and durable benefits for the obese patient with severe co-morbidities, leading to resolution of type 2 diabetes, sleep apnoea and cardiovascular disease in the majority of cases.
The "globesity" challenge requires the efforts of a multidisciplinary team to offer the best standard of care and to guarantee the safe and effective peri-operative management of the obese patient, both for bariatric and for general surgical procedures.
In this international workshop we will share the experience of European bariatric centres of excellence and update interdisciplinary guidelines for perioperative management of the obese patient.
The programme of this workshop has been designed by leading experts, focusing on pre-operative work up, intra-operative and postoperative management. Plenty of time will be reserved for discussions during the scientific sessions.
We are looking forward to welcoming you in Latina
Save the date : Friday September 26, 2014
Sapienza University of Rome – Polo`Pontino,Rome, Italy
Division of General Surgery,
Director Bariatric Center of Excellence,
Sapienza University of Rome-Polo Pontino
Department of Medical- Surgical Sciences,
Section of Anesthesiology,
Sapienza University of Rome-Polo Pontino
Neil E. Hutcher, MD, FACSr
Chief Medical Officer and Vice President of Clinical Compliance,
Surgical Review Corporation
I’m not an anesthesiologist. Does this disqualify me to present my opinions regarding anesthesia excellence?
I don’t think so. I’m a general surgeon with 37 busy clinical years before devoting myself full time to patient safety. During those years, I treated my anesthesia colleagues with respect and admiration, exercising open and often frank communication that I will now continue.
The last 20 years of my clinical practice were devoted to metabolic/bariatric surgery. In the early 2000s, this specialty was in danger of extinction due to inconsistent and sometimes disastrous outcomes, intense scrutiny by the media, and the inability of patients, referring physicians and payers to identify those providing high-quality care and results.
To protect the profession, the American Society for Bariatric Surgery (now the American Society for Metabolic and Bariatric Surgery) founded Surgical Review Corporation (SRC) in 2003 as an independent, nonprofit organization whose charge was to develop a Center of Excellence program that would improve the safety, efficacy and efficiency of bariatric surgery care. SRC collaborated with the Society and the specialty’s stakeholders (e.g., leading surgeons, hospital administrators, allied health professionals, patient advocates, payers) to determine the program’s designation requirements. The organization then developed the processes for application, surgeon and facility site review, designation, and continued designation.
It was imperative to couple the Center of Excellence program with meaningful outcomes data collection to support program compliance, quality improvement and research. The result was what we call the 10 “pillars of excellence”:
- Institutional commitment to excellence
- Procedure volume and outcomes*
- Designated medical director
- Consultative services
- Appropriate equipment and instruments
- Surgeon dedication and qualified call coverage
- Clinical pathways and standardized operating procedures
- Nurses, physician extenders and program coordinator
- Patient support/education
- Long-term patient follow-up and outcomes data
*Outcomes benchmarks added later based on data-driven evidence
The implementation of these principles resulted in a greater than two-thirds decrease in bariatric surgery mortality and complications for the 800+ Center of Excellence participants in the United States. Our international program has participants in more than 20 countries with equally outstanding initial outcomes.
You may be asking, “How does this relate to anesthesia?” We and others quickly recognized that these 10 pillars transcend geographic, specialty and even professional boundaries. SRC now manages Center of Excellence programs worldwide for minimally invasive gynecology and hernia surgery, and each has its own outcomes database specific to the needs of the specialty. Nearly 200 hospitals and 600 surgeons in 16 countries are currently participating in the minimally invasive gynecologic surgery program, which is administered on behalf of the AAGL, the specialty’s leading professional society; we recently certified the first two hernia surgery designees, both located in the Czech Republic.
So what about a program for anesthesia? From my experience performing thousands of surgeries, reviewing more than 1,000 programs in three specialties and visiting programs around the world, here’s a few of my thoughts:
- Even the best can get better.
- Outcomes data is essential. The mere collection of it improves quality. The physician’s data is their data, and it must be kept confidential.
- There are established “best practices” for anesthetic management of the obese patient, but are they always used and can we prove it through documentation?
- Experience is crucial in the management of the obese patient’s complex needs. How can this experience be translated into a lifetime volume requirement to earn designation, and what annual volume should be required to maintain it?
- Meeting the needs of the obese patient requires a commitment and investment from facility administration that extends beyond bariatric surgery, as an increasing percentage of all hospitalized patients are obese.
- Standardization of processes (pathways) is key. Pathways should be developed with input from those involved in the execution of the process and adhered to without exception. Data must be collected that can be used to evaluate the effectiveness of the process. Pathways should be implemented for all aspects of preoperative evaluation, perioperative management, immediate/intermediate postoperative care as well as short- and longer-term pain management.
Anesthesiologists providing excellent care deserve recognition for their efforts, and those who do not meet the established criteria should be given a framework for quality improvement that will enable them to do so. We believe the requirements for a Center of Excellence program should be developed by SRC in close concert with leaders of the various anesthesia societies devoted to the obese patient, but it is important for the designation process to be independent from the societies. Medical societies have frequent changes in leadership, are inherently political, and present issues regarding restraint of trade and confidentiality. SRC is a patient safety organization, which exists to benefit the patient; societies are focused on the welfare of their members, which can result in a tension of purpose. Center of Excellence programs must yield tangible benefits for all stakeholders, but the benefit to patients is paramount.
- SRC is an independent, nonprofit patient safety organization with 11 years of experience developing Center of Excellence programs and the outcomes databases that support them. We currently manage programs for bariatric and metabolic surgery, hernia surgery, and minimally invasive gynecology, and have participants in more than 30 countries.
- The best can always get better!
- Bariatric surgery patients deserve the same level of excellence from anesthesia as they do from their surgeon.
- There remain unanswered questions regarding anesthetic care for the obese. Many of these questions can be answered with a well-designed registry.
- Center of Excellence programs should be independent from but supported/endorsed by medical societies.
- SRC is dependent on anesthesia input to develop credible requirements and data elements. We will move forward only if we receive your enthusiastic support.
Obesity Epidemic: The Medical Profession Fights Back
“The UK is the fat man of Europe”. So states Professor Terence Stephenson, Chair of the Academy of Medical Royal College (AoMRC) in his forward to the AoMRC report “Measuring Up”. Few could argue! The UK lies third in the world table of obesity prevalence gaining ground on the United States and leaving the rest of Europe behind. The impact of obesity on the general health of the UK population is well documented and is a constant source of both medical and popular news stories.
Yet we have been here before. In the 1960’s and 70’s the UK was undergoing a similar threat to the health of the nation: Smoking. The response of the medical profession to the smoking epidemic was admirable. One of the leaders in this was the Royal College of Physicians (RCP) whose campaign “Action on Smoking and Health” (ASH) in 1971 sought to tie together the many diverse strands of healthcare into a unified front that inspired radical changes in government policy, medical education and medical research, developing a coordinated strategy across all areas of healthcare. The result saw smoking effectively demonized and led directly to decreasing rates of smoking related deaths and disease.
Roll on 45 years and we appear to be at the beginning of a similar approach to our new nemesis, with the past year seeing the publication of three reports on obesity whose aims are all identical.
In January 2013 the RCP London produced “Action on Obesity: Comprehensive Care for All”, in February of the same year the AoMRC published “Measuring up. The Medical Professions Prescription for the Nations Obesity Crisis” and finally in February of this year the National Obesity Forum (NOF) released its report “State of the Nations Waistline. Obesity in the UK: Analysis and Expectations.”
All three reports are from respected national bodies comprising the leaders in medical education and in the case of the NOF, a multi-disciplinary group comprising doctors, academics, politicians and figures from business. The three reports could almost be read as a single item as all have the same message: The UK is getting more obese and the answer cannot simply be the government of the day saying we all need to eat less and exercise more.
The answer is of course the same as that which worked so effectively in the 60’s and 70’s with smoking; that we can only tackle this problem if we look at it from every angle. The AoMRC and RCP reports look at medical education and are quite blunt in their assertion that managing obesity is poorly taught in every branch of medical training, yet obesity impacts on virtually every branch of medicine. Efforts need to be made to improve medical education in this area at both undergraduate and post-graduate level. The fact that we live in an obesogenic environment also comes in for scrutiny. The AoMRC and NOF reports give direction to government bodies on increasing exercise (for example by reversing the trend of closing school playing fields) and of legislation to promote a so-called “sugar tax”. The RCP call for the development of obesity leads in both primary and secondary care with the establishment of an MDT approach to the management of the obese patient. The list goes on, indeed to a total of 47 recommendations between the three reports.
Taken as a whole, the reports show a change in tack in the way we are looking at the obesity epidemic. As with most environmental issues, no one treatment will bring about a cure, we need to deal with every aspect of care. It worked for us once before so will it work again?
All three reports are freely available online, and I recommend them to anyone with an interest in developing multi-disciplinary approach to the obesity crisis. The UK is leading the way when it comes to obesity prevalence; perhaps we are also leading the way in how to tackle it!
Measuring up, The Academy of Medical Royal Colleges: www.aomrc.org.uk/doc_details/9673-measuring-up.
Action on Obesity, The Royal College of Physicians: http://www.rcplondon.ac.uk/resources/action-obesity-comprehensive-care-all
The State of the Nations Waistline, The National Obesity Forum: PDF
Research & Education Lead,
The Society for Obesity and Bariatric Anaesthesia (SOBA).
Jan Paul Mulier ,Bruges, Belgium
Luc De Baerdemaeker ,Gent, Belgium
- What is different in the pre-operative preparation of a morbidly obese patient? Claire Nightingale, London, United Kingdom
- What is different in the induction and intubation of a morbidly obese patient? Michael Margarson, Chichester, United Kingdom
- What is different in the ventilation of a morbidly obese patient? Paolo Pelosi, Genova, Italy
- What is different in the awakening and extubation of a morbidly obese patient? Tomasz Gaszynski, Lodz, Poland
- What is different in the postoperative treatment of a morbidly obese patient? Yigal Leykin, Pordenone, Italy
- Panel discussion on “What are the key points that are different when giving anaesthesia for morbidly obese patients”
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