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Laparoscopic Procedures for Morbid Obesity

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Overview
ACS Guidelines
SAGES Guidelines
ASBS Guidelines
Patients Instructions
BMI Calculator
Coding - Billing
Consent
Bariatric Procedures
Lap V Band
Lap GBRY
LapBand
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Laparoscopic Bariatric Procedures
Laparoscopic Bariatric Procedures: Physician Section

NHLBI Obesity Education Initiative

Overview on Morbid Obesity

The impact of obesity on our society is best understood when  the following statistics are analyzed. In 1995, an estimated 52 billion US dollars was spent to treat patients with morbid obesity or 5,7% of all US health care expenditures. In 1999, this number was revised to 100 billion with over half of the population in the United States estimated to be overweight and 23%  morbidly obese. Furthermore, obesity as a disease of Western society is expected to continue to increase markedly over the next two decades. 

Obesity is classified as a disease as the overall mortality rate of the morbidly obese population has been demonstrated to be approximately double that of the normal weight population. More staggering is the realization that in the 25 to 34 year old male-age-group the same mortality rate is increased 12 fold. This increase in mortality is explained by the medical conditions or co-morbid factors frequently associated with morbid obesity, specifically the risks of hypertension (3.0 higher), the risk of diabetes (2.9 higher) and the risk of hypercholesterolemia (1.5 times higher). Most morbidly obese patients will also present with overwhelming psychological problems: poor body image, low self esteem, severe depression, poor quality of life, suicidal tendencies and extreme mood shifts. Some authors claim a number of these patients developed this disease after suffering severe, unresolved psychological trauma in their childhood. It has been documented extensive psychological support has not been effective in the treatment of these patient. In addition, conservative treatments for morbid obesity (diet, medical management, etc)  have an overall, dismal long-term success ranging between 9 to 15%.

Over the past century,  numerous surgical teams have attempted to design surgical procedures to successfully treat these patients. After introducing earlier techniques which resulted in horrifying long-term complications and side effects, newer, safer and well-standardized bariatric procedures finally became viable surgical interventions for this patient population. Advanced laparoscopy is now poised to revolutionize these procedures as surgeons have redesigned these techniques to be successfully performed via minimally invasive means.

Definition of the Obese Patient

Morbid obesity [ICD-9 Code: 278.01] has been categorized as being approximately 100 pounds over one's estimated ideal weight as provided in the 1983 Metropolitan Life Height and Weight Table or a Body Mass Index, BMI of 40. The American Society for Bariatric Surgery states that potential candidates for obesity surgery must have a BMI of at least 40 or a BMI of at least 35 with one or more co-morbid conditions.

BMI =Weight (Kg) divided by Height (M) squared = (w / h2) or (Kg / m2)

BMI CALCULATOR

Definition of Co-morbid Factors

Co-morbid factors are defined as medical conditions triggered or generated by excess body weight or morbid obesity.

The most common co-morbid factors are as follow::

bulletGERD
bulletHypertension
bulletDiabetes - T2
bulletSleep apnea
bulletOsteo-arthritis
bulletPickwickian syndrome
bulletSevere headaches
bulletAmmenorhea

 

Definition of a Surgical Candidate

The trigger point used by most bariatric surgeons is the BMI value at which the risks of potential complications from the bariatric procedure itself equals the risks generated by the excess weight of the patient. This trigger point is a BMI of 40, but this value is lowered if a co-morbid condition is identified.

Consequently, the indications for a bariatric surgical procedure are as follows:

bulletMorbid Obesity with BMI > or equal to 40. A BMI of 35 will be used if one or more serious co-morbid medical conditions are identified,
bulletDemonstrated, repeated failure at conservative treatments,
bulletNo history of significant psychiatric disorders.

 

The Laparoscopic Bariatric Procedures

Expert laparoscopic surgeons can now duplicate any standard, open bariatric procedure in optimal surgical conditions. However, some of these procedures are not favored by this surgical team and are simply not performed by personal choice. They have been championed by other authors who have reported acceptable outcomes. The laparoscopic bariatric procedures currently performed by our surgical team are as follow:

1. MALABSORPTIVE BARIATRIC SURGICAL PROCEDURES

Most surgeons no longer perform radical surgical malabsorptive bariatric surgical procedures. The most widely used procedure remains the Gastric Bypass with Roux-en-Y Limb and its laparoscopic version, the Laparoscopic Gastric Bypass with Roux-en-Y Limb. Originally described by Wittgrove and Clark in 1994, it remains the best available laparoscopic bariatric procedure. Technically challenging, it can be performed with different technical variations Standard 75 cm Roux Limb  or an Extralong Roux Limb (up to 200 cm for super obese patients). With an overall mortality rate of 0.5 to 1%, a morbidity rate of 10 to 15 % and an expected loss of 60 to 75% of excess weight, it is becoming the gold standard in laparoscopic bariatric surgery.

2. RESTRICTIVE BARIATRIC SURGICAL PROCEDURES:

bullet

The Laparoscopic V-Band or Laparoscopic Vertical Banded Gastroplasty

bullet

The Adjustable Implantable LAP-BANDô

 

A Common Misconception

Most patients as well as some surgical teams are under the wrong impression that having a morbidly obese patient undergo a bariatric surgical procedure will generate a inevitable, controlled weight loss. It is our belief a bariatric surgical procedure is only a instrument given to morbdily obese patients to initiate a rewarding and effective weight loss program. Greatest success is achieved with surgical patients who meticulously comply with a 12 to 18 month rigorous and regular monitoring protocol. During that critical post-operative period faulty eating habits will need to be re-formatted to a "three meals a day, no snacking" formula. Local long term post-operative follow-up with support group network is indeed essential for an optimal outcome.

 

Standard Pre-operative evaluation of the Bariatric Patient

This pre-operative evaluation is a multidisciplinary evaluation. The morbidly obese patient should undergo the following assessment:

bulletDietary - Nutritional Evaluation: Eating habits, nutrition, eating disorders, etc.
bulletPsycho-social: Behavior - Eating disorders, disruptive lifestyle, abusive relationships, etc.
bulletMedical - Identifying all co-mordid conditions, sleep apnea, etc.
bulletSurgical - Previous surgeries, GI problems.

During this evaluation, the surgeon should understand the expectations of the patients and should give the patients a realistic assessment and correction of their expectations if needed. The patient should have a clear understanding of basic nutrition. If not, further nutritional counseling by a licensed nutritionist will be ordered. In addition, the patient should understand the risks and benefits of this procedure as well as the radical changes of his or her future eating habits.

 
The Disclosure Documents

The patient about to undergo a bariatric surgical procedure should be an educated patient. It is essential for the surgeon to accurately disclose the surgical risks of the proposed surgical intervention (mortality. morbidity rate, etc.) as well as the expected results, long-term side effects, impact of post-operative life style. A detailed comparison to other available bariatric procedures should also be given. In turn, the patient should reiterate his or her commitment to life-long follow-up and monitoring.

Lastly, extensive written documentation or disclosure documents should be given to the patient.

 
Standard Guidelines

Welcome to SAGES!

  [SAGES GUIDELINES]

 [ AMERICAN COLLEGE OF SURGEONS GUIDELINES ]

American Society for Bariatric Surgery

[ AMERICAN SOCIETY FOR BARIATRIC SURGERY ]

 
The Issue of Advanced Age

Usual age range guidelines for performing open or laparoscopic procedures are from 18 to 55 years old. Some malpractice insurers actually have included these age criteria in their bariatric riders. However because of  the superior outcomes being achieved with the laparoscopic gastric bypass with the Roux Y Limb we have informally increased our upper age limit in some cases up to 65 years old. These cases should be critically reviewed on an individual basis and we sometimes insist these patients get a second corroborating opinion.

Surgical Indications

The general indications used by our surgical team for laparoscopic bariatric procedures are as follows and should be clearly documented in each patient's chart.

bulletAverage Age Range: 18 to 55 years old.
bulletpatients must have a BMI of 40 or 35 if one or more co-morbid factors are documented.
bulletpatient must have undergone a standard bariatric psycho-social and nutritional evaluation,
bulletundergone a basic endocrine evaluation and medical evaluation,
bullethave a documented long history of failed medical weight loss regimen,
bullethave a documented history (over 5 years) of stable morbid obesity,
bulletunderstand the risks, benefits and impact of the procedure and willing to comply to pre-operative and post-operative instructions.


       

Essential websites on  Morbid Obesity

> Basics about overweight and Obesity: NIH CDC Consensus

> Obesity and Genetics: CDC Update

> Body Mass index Classification and Calculation: Adult and Children

> Obesity trends

> Nutrition and Physical Activities: CDC Website

Statistics Related to Overweight and Obesity

> Weight Control Information Network: A NIH Product

American Obesity Association

> American Obesity Association



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