Bariatric Surgery: Who Qualifies?

 

      Definition of Morbid Obesity

 

Patients are morbidly obese if their weight is more than 100 pounds in excess of the Ideal Body Weight (IBW).  An accurate and standardized method to define morbid obesity is to use the Body Mass Index (BMI).  The BMI is calculated as follows:

BMI = weight (kg)/height (m2) weight (expressed in kilograms) divided by the square of height (expressed in meters)

 

Obesity Class                                      BMI

Underweight                                    < 18.5

Normal                                          18.5 - 24.5

Overweight                                     25 - 29.9

Obese Class I                                   30 - 34.9

Obese Class II                                  35 - 39.9

Morbidly Obese Class III                   >40

 

      Definition of the Surgical Patient and Indications for Surgery

 

·         Surgical therapy should be routinely considered for individuals with:

 

 Body mass index (BMI) greater than 40 kg/m2

     OR

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

     AND

Proven failed attempts with dietary weight-control

 

Co-morbidities include but are not limited to:

·                    Cardiac disease

·                    Diabetes mellitus – Type 2

·                    Obstructive sleep apnea

·                    Hypertension

·                    Dyslipidemia

·                    Gastro-esophageal reflux disease

·                    Stress urinary incontinence

·                    Arthritis of weight-bearing joints

·                    Infertility

·                    Some cancers

 

Lapband Placement in Patients with BMI 30 to 35 can be considered if associated with major co-morbid conditions. There is since 2012 some evidence that bariatric surgery can be beneficial for patients with Class 1 Obesity or with a BMI of 30-35 [see findings, position, and recommendations]. However, most insurance companies will not cover bariatric surgery for patients with Class 1 Obesity and Class 1 Obesity is not an indication for Bariatric Surgery in Center of Excellence.

 

      Impact of Morbid Obesity

 

Morbid obesity is a disease. Morbidly obese patients have significantly higher rates of associated medical problems.  Although the medical complications of obesity may occur in moderately obese individuals, the frequency of these associated medical problems or co-morbid factors (such as heart disease, high blood pressure, diabetes, premature death, etc.) increases dramatically as weight increases. For example, morbidly obese men between the ages of 25-35 have a 12-times greater risk of dying prematurely compared to their normal-weight counterparts. In addition, there are now numerous studies demonstrating a marked decrease in the life expectancy of morbidly obese patients.

 

The medical conditions commonly caused or exacerbated by morbid obesity are as follows:

 

• Cardiac - high blood pressure, coronary artery disease, etc.

• Pulmonary - obstructive sleep apnea, obesity hypoventilation syndrome, gastro-esophageal reflux induced asthma or aspiration.

• Gastrointestinal, Abdominal – gallstones, (usually associated with cyclic weight loss/gain), gastro-esophageal reflux disease, recurrent ventral hernias, stress urinary incontinence, etc.

• Endocrine - diabetes, menstrual irregularity, infertility, hirsutism, hyperlipidemia, hypercholesterolemia.

• Genitourinary, reproductive – recurrent urinary tract infections, stress urinary incontinence, irregular menstruation, infertility, etc.

• Musculoskeletal – degenerative disorders of the knees and hips, intervertebral disc herniation, low back pain, etc.

• Skin – venous stasis, etc.

• Cancer risk - breast, endometrium, colon, prostate.

 

 

      Deciding to Become a Surgical Candidate

 

The decision to undergo bariatric surgery is complex, intensely personal, and of great magnitude.  It will, dramatically and irrevocably, change your life.  Together, you and your surgeon must agree whether or not weight-loss surgery is indeed the most appropriate therapeutic option. 

 

The decision to become a surgical candidate for a bariatric surgical procedure is based on the following: 

 

·        Weight:  Surgery is only offered to patients who have a BMI greater than 40, or a BMI of 35 or greater if the patient has an associated co-morbid factor (associated medical condition as diabetes, hypertension, etc.).

 

·        Ability to comply with therapy: The patient must be able to follow the advice and instructions of his/her surgeon especially regarding diet and exercise after surgery. Changes in lifestyle, eating habits, and exercise are required for success after the surgery.  Your surgeon will determine whether you are a candidate for this procedure based on your ability to understand and comply with its requirements.

 

·        Surgery as the last therapeutic option: The patient must have demonstrated multiple failed attempts at medical regimens (diets, controlled behavior, etc.).

 

·        Other medical conditions: Morbidly obese patients’ excess weight may have generated significant and permanent damage to one or more organ systems resulting in associated diseases. The most commonly affected organs are the lungs (sleep apnea, gastroesophageal reflux), the heart (congestive failure, coronary artery disease), and the kidneys (diabetes, high blood pressure).  These medical problems increase the risks of any major surgical procedure including bariatric surgery, but they also validate the need for weight loss.  Thus, significant medical problems require careful consideration but are not necessarily a contraindication to surgery.

 

·        Age: Our surgical performance has dramatically increased the age range for these procedures. Patients younger than 21 must demonstrate exceptional maturity to become good candidates for a bariatric surgical procedure.  

 

·        Reaction of Family and Friends:  Some of our patients tell us that when they decide to undergo a bariatric procedure they are accused of "taking the easy way out."  Friends and family may ask why the patient doesn't simply "take control of his/her life" and lose weight by dieting.  Few people will realize that weight-loss surgery or bariatric surgery is not “the easy way out.” It is a difficult decision that requires rigorous behavior modification.  Those who choose surgery (after all other options have been exhausted) are in fact doing what is necessary to regain control of their lives.

 

·        The Type of Procedure:  Selecting the correct bariatric surgical procedure for each patient is essential. Your surgeon and his bariatric team will explain the benefits and risks of each type of procedure.