Robotics, protocol for the fast track perioperative management of the obese patient, role of the Guidelines, of the diagnostic-therapeutic care pathways and of the Care Networks in ensuring safety and quality of bariatric surgery. These are the themes at the center of the 32nd Sicob national congress – Italian Society of Obesity Surgery, entitled “Obesity: in search of a new therapeutic alliance”, underway at Giardini di Naxos (Messina) where the scientific community met Italian dedicated to the treatment of obesity.
The congress constituted an important moment of discussion on the most innovative aspects of the obesity topic. First of all the state of the art of robotics in bariatric surgery. In this regard – a note reports – it should be highlighted that, compared to traditional laparoscopy, robotics has made significant progress on several fronts. First of all, it allows the surgeon to work in 3D and in some cases with an “immersive” vision. It therefore allows for more precise and more calibrated interventions on the individual patient. Second, robotics reduces the learning curve: the surgeon learns to use the platform faster than he learns to perform laparoscopic surgery. Another advantage is the absolute stability of the platform. In fact, with laparoscopy even the slightest instability of the hand is also transmitted to the operating instrument. This doesn’t happen with the robot.
Soon artificial intelligence – which is currently used essentially for training – will be able to help the surgeon by predicting errors. There is great anatomical variability from subject to subject and the reason for some surgical errors can be traced back to the surgeon’s incorrect perception of what is in front of him. This perception – we read – can in fact differ from reality because the real anatomical image corresponds to a variant compared to normal anatomy. Not only. AI will help the surgeon recognize real anatomy and avoid these perception errors. The tools available today allow for self-improvement, educational and networking.
Currently, there are various elements that contribute to protecting the bariatric patient by guaranteeing safety and quality of care. First of all, the Guidelines of the Italian Society of Obesity Surgery – emerges from the congress – These have recently been published, with Grade methodology and therefore with a highly impactful level of evidence, according to the parameters dictated by the National System of Guidelines of the Higher Institute of Health. The Guidelines – the note details – define a standard of care: that is, they constitute the roadmap that obesity specialists must follow to guarantee optimal quality of service. They are updated at regular intervals and, for this reason, do not constitute a “static” reality. They therefore represent the first, fundamental point of reference for the specialist who, if he deviates from it, must justify his choice.
“Through the Guidelines it has been possible to extend the indication for bariatric surgery to class I obesity with complications (with body mass index between 30 and 35), to adolescents and the elderly without age limits (obviously evaluating their fragility) – says Maurizio De Luca, director of the Surgical Department of Rovigo Hospital – Considering the severity of the Grade methodology, the Ifso (International federation for the surgery of obesity and metabolic disorders) asked Sicob to publish them in English in an international journal for in order to acquire the methodological process for expressing certain recommendations”.
Another important tool is the Diagnostic Therapeutic Care Path (PDTA). This is a flow chart – Sicob says – which outlines the path that public and private healthcare companies must guarantee to the patient in the treatment of obesity when he comes into contact with the healthcare system or through the general practitioner, either through the specialist or through a healthcare facility.
The current system then includes clinical-care networks, which connect professionals, structures and services that provide healthcare interventions. The Regions that are equipped with them – the note reports – send questionnaires to the healthcare facilities to assess the possession of requirements in organizational-structural terms, personnel and in relation to the equipment available and decide whether the facility can provide the medical service. First level centers or hubs and second level centers or spokes are thus identified. The former can take charge of the more complex cases, the latter those with a lower degree of complexity.
“Modern medicine is of interdisciplinary necessity, to guarantee adequate care of the patient and his care needs – underlines Mirto Foletto, director of Uosd Bariatric Surgery at the University of Padua Hospital – To be effective, the in charge must make use of the various skills available in the territory. This implies that the healthcare facilities located in this territory are connected to each other within a healthcare network that allows rational use of increasingly scarce resources and the provision of services. of an adequate level. To ensure adequate integration between the various structures and between the professionals of the Network – continues the professor – it is necessary to develop a common and shared language to be expressed in a defined clinical-assistance path (Pdta), which assigns the stages for the patient and the skills for the various health professionals, with undeniable advantages from the point of view of perceived quality and professional enhancement”.
To date, only 2 regions have established approved and recognized healthcare networks: Veneto and Sicily. In these cases – concludes the note – bariatric surgery operations can only be carried out by centers recognized at regional level. Even in this case we are not faced with a crystallized reality, but each year a “window period” is identified in which one can apply for accreditation. In all regions where there is no healthcare network, Sicob has equipped itself with an accreditation system which is made up of affiliated, accredited and excellent centres. Sicob has taken responsibility for identifying the minimum criteria that identify the different levels of accreditation and issues the qualification of an accredited center to carry out bariatric surgery following verification of the requirements.
The Eras Society has promoted a global accreditation program for certified centers that follow the Eras (Enhanced Recovery After Surgery) protocol. The proposal to adapt the protocol to the characteristics of the Italian healthcare system emerged from the Sicob congress. We aim to identify items from which to choose those that can be implemented more easily in Italy. The ultimate aim is to build an accreditation system managed by the Company both from the training point of view and with regard to verification procedures.
“Our aim must be to ensure public health – comments Giuseppe Navarra, president of Sicob – For this reason it is necessary first of all to spread the concept that obesity is not a fault but a chronic pathology and that fortunately there are multiple therapeutic approaches. The decision on the path must therefore be taken by a multidisciplinary team, following the Sicob Guidelines, the Pdta and moving within Care Networks. All this allows us to increase the number of patients treated and guarantee high quality and safety of care.”
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