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INDICATIONS FOR SURGERY (TOP OF ARTICLE)
SUMMARY OF REQUIREMENTS
BACKGROUND
    NATIONAL INSTITUTE OF HEALTH (NIH)
    THE AMERICAN COLLEGE OF SURGEONS (ACS)
    THE SOCIETY OF AMERICAN GASTROINTESTINAL ENDOSCOPIC SURGEONS (SAGES)
    THE AMERICAN SOCIETY OF BARIATRIC SURGEONS (ASBS)
Dr. BALLANTYNE'S GUIDELINES FOR PATIENT SELECTION FOR WEIGHT LOSS SURGERY
Co-MORBID CONDITIONS RELATED TO MORBID OBESITY

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WHO QUALIFIES FOR WEIGHT LOSS SURGERY?

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REGISTER TO ATTEND A FREE INFORMATION SESSION BY Dr. BALLANTYNE ABOUT WEIGHT LOSS SURGERY


INDICATIONS FOR SURGERY: The indications for Lap Band and Laparoscopic Gastric Bypass are identical.

SUMMARY OF REQUIREMENTS:
    1. AGE:
18 years of age or older.
    2. BMI: Body Mass Index (BMI) between 40 and 60;
             or Body Mass Index (BMI) of 35 or greater with significant co-morbid coinditions such as diabetes mellitus, sleep apnea, high cholesterol, the metabolic syndrome or infertility.
    3. PHYSICIAN or PROFESSIONALLY SUPERVISED WEIGHT LOSS PROGRAMS: The patient must have made a significant effort at weight loss by participating in Physician or Professionally supervised weight loss programs over a prolonged period of time and failed to have achieved sustained weight loss.

BACKGROUND: The Bariatric Surgery Center of Hackensack University Medical Center has based its criteria for patient selection for weight loss surgery on guidelines of the National Institute of Health and national surgical societies. The American College of Surgeons, Society of Gastrointestinal Endoscopic Surgeons (SAGES) and The American Society of Bariatric Surgeons have all offered guidelines for patient selection.

The National Heart, Lung, and Blood Institute in cooperation with The National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health (NIH) issued recommendations on patient selection for weight loss surgery in 1998. This updated the earlier National Institutes of Health Consensus Development Conference Statement of 1991. The 1998 recommendations were published as the Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report (NIH Publication No. 98-4083. September 1998. National Institute of Health). The NIH made the following recommendation:

"Weight loss surgery is an option for carefully selected patients with clinically severe obesity (Body Mass Index > 40 or > 35 with comorbid conditions) when less invasive methods of weight loss have failed and the patient is at high risk for obesity-associated morbidity or mortality." (p. 89)

This evidence based report also summarized available data regarding weight reduction after the age of 65. The Evidence Report recommended:

"A clinical decision to forgo obesity treatment in an older adult should be guided by an evaluation of the potential benefits of weight reduction for day-to-day functioning and reduction of the risk of future cardiovascular events, as well as the patient’s motivation for weight reduction. Care must be taken to ensure that any weight reduction program minimizes the likelihood of adverse effects on bone health or other aspects of nutritional status." (p. 91)

National surgical societies derived their recommendations from the NIH Evidence Report.

The America College of Surgeons published recommendations for "Recommendations for Facilities Performing Bariatric Surgery" (ST-34). In this policy statement, the American College of Surgeons wrote:

"Not all persons who are obese or who consider themselves overweight are candidates for bariatric surgery. These procedures are not for cosmesis but for prevention of the pathologic consequences of morbid obesity. The patient must be committed to the appropriate work-up for the procedure and for continuing long-term postoperative medical management, and understand and be adequately prepared for the potential complications of the procedure. Screening of the patients to ensure appropriate selection is a critical responsibility of the surgeon and the supporting health care team."

The American College of Surgeons stressed that the goal of weight loss surgery was to prevent the pathologic consequences of morbid obesity.

The American Society of Gastrointestinal Endoscopic Surgeons (SAGES) issued "The SAGES Guidelines for Laparoscopic and Conventional Surgical Treatment of Morbid Obesity". These guidelines offered more specific criteria:

"Surgical therapy should be considered for individuals who:
have a body mass index (BMI) of greater than 40 kg/m2

OR

have a BMI greater than 35 kg/m2 with significant co-morbidities.

AND

can show that dietary attempts at weight control have been ineffective."

These guidelines focused on the differences in indication between patients with Type II Obesity (BMI 35 to <40 kg/m2) and patients with Type III Obesity (BMI > 40 kg/m2). The major difference was that patients with Type II Obesity must already have developed significant co-morbid conditions related to morbid obesity.

The American Society of Bariatric Surgeons (ASBS) offered the most detailed recommendations. The ASBS Guidelines stipulated:

"The option of surgical treatment should be offered to patients who are severely obese, well informed, motivated, and acceptable operative risks. The patient should be able to participate in treatment and long term follow-up. Some patients with manifest psychopathology that jeopardizes an informed consent and cooperation with long term follow up may need to be excluded. A decision to elect surgical treatment requires an assessment of the risk and benefit in each case. Increased abdominal fat or "central obesity" (apple shaped as opposed to pear shaped) is an important risk factor associated with the major complications of obesity. Functional impairments associated with obesity are also important deciding factors for surgical treatment. An important conclusion of the 1991 National Institutes Consensus Development Conference Statement on the surgical treatment of obesity was that "patients judged by experienced clinicians to have a low probability of success with non-surgical measures, as demonstrated, for example, by failure in established weight control programs or reluctance by the patient to enter such a program, may be considered for surgical treatment.

Patients whose BMI exceeds 40 are potential candidates for surgery if they strongly desire substantial weight loss, because obesity severely impairs the quality of their lives. They must clearly and realistically understand how their lives may change after operation.

In certain circumstances, less severely obese patients (with BMI's between 35 and 40) also may be considered for surgery. Included in this category are patients with high risk co-morbid conditions such as life threatening cardiopulmonary problems (e.g. severe sleep apnea, Pickwickian syndrome, obesity related cardiomyopathy, or severe diabetes mellitus). Other possible indications for patients with BMI's between 35 and 40 include obesity-induced physical problems that are interfering with lifestyle (e.g. musculoskeletal or neurologic or body size problems precluding or severely interfering with employment, family function and ambulation).

End stage obesity syndrome: Some candidates for surgical treatment of severe obesity have such impaired health that they must be hospitalized pre-operatively and undergo treatment to improve their operative risk."

This stressed the conclusions of the 1991 NIH Consensus Development Conference Statement that patients should have a low probability of success for achieving sustained weight loss using non-surgical measures. The ASBS Guidelines also illustrated the types of high risk co-morbid conditions related to morbid obesity that qualified patients with Type II Obesity for weight reduction surgery.

Dr. BALLANTYNE'S GUIDELINES FOR PATIENT SELECTION FOR WEIGHT LOSS SURGERY: We have used criteria directly derived from the NIH Evidence Report and national surgical societies to determine our guidelines for patient selections. Criteria fall in into six major categories:

1. Age;
2. Body mass index;
3. Family history of significant co-morbid medical conditions related to morbid obesity;
4. The development of significant co-morbid health conditions related to morbid obesity;
5. The failure of established weight control programs to achieve sustained weight loss; and
6. Mental competence to give informed consent to participate in long-term follow-up programs.

1. AGE: Patients should have an age of 18 years old to 65 years old. Patients with an age less than 18 must require rapid weight reduction because of life threatening co-morbid health conditions related to morbid obesity. Patients who are older than 65 years old should have significant co-morbid health conditions related to morbid obesity that are likely to impact adversely on life expectancy or quality of life. The expectation of improved life expectancy or quality of life should outweigh the risk of surgery.

2. BODY MASS INDEX: Patients should have a body mass index > 40 kg/m2 or a body mass index >35 and <40 kg/m2 with the presence of significant co-morbid conditions related to morbid obesity.

3. FAMILY HISTORY OF CO-MORBID HEALTH CONDITIONS RELATED TO MORBID OBESITY: As specified by the NIH Evidence Report, weight loss surgery is indicated in patients who are at "high risk for obesity-associated morbidity or mortality". As a result, weight loss surgery is may be indicated in patients with strong family histories of obesity-related health conditions. Weight loss surgery will often prevent the development of these co-morbid conditions and, thereby, spare the patients the morbidity and mortality of these diseases.

4. THE PRESENCE OF CO-MORBID HEATH CONDITIONS RELATED TO MORBID OBESITY: Weight loss surgery is appropriate in patients who have developed significant medical conditions related to morbid obesity. Weight loss surgery may cure or significantly improve these co-morbid diseases and prevent their associated morbidity and mortality.

5. THE FAILURE of ESTABLISHED NON-SURGICAL WEIGHT LOSS PROGRAMS TO ACHIEVE SUSTAINED WEIGHT LOSS: Surgical treatment of morbid obesity is appropriate only in patients in whom success with established weight loss programs seems unlikely. In order to qualify, patients must have made sustained efforts in organized weight loss programs over a substantial time period. Appropriate programs include, but are not limited to, physician supervised programs, Weight Watchers, Over Eaters Anonymous, Jenny Craig, Nutri System, "Fat Farms", hypnosis, jaw wiring, R. Simons Deal a Meal, the Atkins Diet, the Scarsdale Diet, and the South Beach Diet. Caloric restriction diets directed by nutritionists, dieticians or diabetes centers also qualify as established non-surgical weight loss programs. Similarly, intense exercise programs directed by an exercise therapist or other qualified professional also may play an important role as an established non-surgical weight loss program.

6. MENTAL COMPETENCE: Patients must be mentally competent to give informed consent. Patients with a significant psychosis may not be able to adhere to the prolonged follow-up programs associated with excellent outcomes following weight reduction surgery.

SIGNIFICANT CO-MORBID HEALTH CONDITIONS RELATED TO MORBID OBESITY: The NIH Evidence Report enumerates the co-morbid conditions associated with morbid obesity (pp. 12-20). These include:

1. Type 2 Diabetes Mellitus;
2. Obstructive sleep apnea;
3. Asthma;
4. Hypertension;
5. Hypercholesterolemia;
6. Hypertriglyceridemia;
7. Metabolic syndrome (Syndrome X);
8. Coronary artery disease;
9. Congestive heart failure;
10. Gastro-Esophageal Reflux Disease (GERD);
11. Gallstones;
12. Urinary stress incontinence;
13. Dysmenorrhea or amenorrhea;
14. Infertility;
15. Osteoarthritis;
16. Deep venous thrombosis;
17. Depression;
18. Stroke;
19. Colon cancer;
20. Breast cancer;
21. Endometrial cancer; and
22. Gallbladder cancer.


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LEARN MORE ABOUT Dr. BALLANTYNE, HIS PROFESSIONAL STAFF,
HOW HE EVALUATES PATIENTS & WEIGHT LOSS SURGERY

LAPAROSCOPIC GASTRIC BYPASS LAPAROSCOPIC ADJUSTABLE
GASTRIC BANDING: "LAP BAND"
MEET Dr. BALLANTYNE'S OFFICE STAFF WHAT IS THE BARIATRIC SURGERY CENTER?
HOW DOES Dr. BALLANTYNE EVALUATE HIS PATIENTS? DATES OF UPCOMING INFORMATION SEMINARS
DATES OF UPCOMING
PATIENT SUPPORT GROUP MEETINGS
Dr. BALLANTYNE'S RECENT AWARDS
Dr. BALLANTYNE'S RECENT BARIATRIC PRESENTATIONS BEFORE SURGERY & AFTER SURGERY
PHOTOS OF Dr. BALLANTYNE'S PATIENTS

SURGICAL SOCIETIES & NATIONAL INSTITUTE OF HEALTH
GUIDELINES & STATEMENTS
ON WEIGHT LOSS SURGERY

NIH CONSENSUS STATEMENT ON THE HEALTH IMPLICATIONS OF OBESITY

AMERICAN SOCIETY FOR BARIATRIC SURGERY GUIDELINES

AMERICAN COLLEGE OF SURGEONS RECOMMENDATIONS FOR FACILITIES PERFORMING BARIATRIC SURGERY

SAGES GUIDELINES FOR BARIATRIC SURGERY

NIH: GASTROINTESTINAL SURGERY FOR SEVERE OBESITY

LINKS TO OTHER BARIATRIC WEB SITES


GARTH H. BALLANTYNE, M.D., M.B.A.
F.A.C.S., F.A.S.C.R.S.
SURGEON IN CHIEF

BOARD CERTIFIED IN:
GENERAL SURGERY & COLON AND RECTAL SURGERY

OFFICE
4 SHAW'S COVE
SUITE #201
NEW LONDON, CT 06320

CURRENT POSITIONS
SURGEON IN CHIEF
LAWRENCE & MEMORIAL HOSPITAL
NEW LONDON, CT 06320

 

PRACTICE LIMITED TO LAPAROSCOPIC SURGERY


CONTACT US AT:
1-860-444-7675