Expert Commentary: Daniel Farkas, M.D. FACS 9/24/2009

As disclosure, I'll preface by saying that my hospital is NOT a center of excellence. This has been an area of interest for the last few years. Not just in bariatric surgery, but in all sorts of specialized surgery, for example pancreas surgery. Most studies will show that high volume centers have better outcomes.

I agree with this finding. There is no doubt that on the average, a center that does a lot of a certain procedure, will do it better than a center that does fewer. In this particular study I’m not sure how they rated “five star” hospitals. However, I do believe that Centers of Excellence will – on the average – have better results.

One issue is access to care. And so in complex pancreatic cancer surgery, which is not as common, one might suggest that we refer patients to high volume centers. But in bariatric surgery, where there are over a million potential patients in the country, there isn’t really enough space at the high volume centers to accommodate them. (And that is not taking into account other economic factors, such as many high volume centers not accepting Medicaid, for example.)

And so it is my belief that we don’t limit these surgeries to these centers. There should probably be some limitations in place, say for example that we ensure that the surgeon has undergone specialized training. But more than that would be prohibitive. If for example we decided that only surgeons who performed 50 bariatric surgeries a year would be allowed – then no new surgeons could do bariatric surgery!

If you think about it, I’m certain that if we studied the first few of anything, we’d find similar results. Let’s say we looked at any given surgeon’s first ten colon resections, and compared them with how they did after ten years of practice. I’m certain there will be more complications in those first few. Does that mean that we should not allow surgeons without ten years of experience to do colon resections?

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