Weight loss surgery support groups southern california
Surgery for obesity, termed bariatric surgery, includes gastric restrictive procedures and gastric bypass. Children and adolescents are rapidly growing, and are therefore especially susceptible to adverse long-term consequences of nutritional deficiencies from the reduced nutrient intake and malabsorption that is induced by obesity surgery. The process of digestion is more or less normal. BMI exceeding 50 with one or more of the following less serious co-morbidities. 0 %, respectively), while the rate of incisional hernia is higher for open RGBY than laparoscopic RGBY (9. e. Severely obese persons are at increased risk of surgical complications. Since post-surgical biopsy is not widely available and has a significant risk, calculation of NAFLD fibrosis score is a simple tool to evaluate this evolution through a non-invasive approach. This device should not be used in patients who have had previous gastro-intestinal or bariatric surgery or who have been diagnosed with inflammatory intestinal or bowel disease, large hiatal hernia, symptoms of delayed gastric emptying or active H. In a prospective study, Zeinoddini (2014) evaluated safety and effectiveness of LGP on adolescents. The other end, leading from the gallbladder and pancreatic ducts, is connected onto the enteral limb at about 75 to 100 cm from the iliocecal valve. Primary efficacy outcome was achieved by 22. 7 %, 54. Although patients can have increased frequency of bowel movements, increased fat in their stools, and impaired absorption of vitamins, recent studies have reported good results. BMI exceeding 40 with one or more of the following serious co-morbidities. The panel recommended the Roux-en-Y gastric bypass method of surgery over the simpler, newer technique of implanting an adjustable gastric band since gastric bands are less effective and younger patients would probably need replacement as they age. The aim of this study was to determine the role of routine liver biopsy in managing bariatric patients. Regarding performing adjustable gastric banding as an open procedure, the CMS decision memorandum (2006) concluded that the evidence is not adequate to conclude that open adjustable gastric banding is reasonable and necessary and therefore this procedure remains noncovered for Medicare beneficiaries. The Task Group also noted that weight loss surgery is contraindicated in those who are unable to comprehend basic principles of weight loss surgery or follow operative instructions. CPB 0039 - Weight Reduction Medications and Programs. 3 % of their total body weight). The BPD was designed to address some of the drawbacks of the original intestinal bypass procedures, which resulted in unacceptable metabolic complications of diarrhea, hyperoxaluria, nephrolithiasis, cholelithiasis and liver failure. Although easier to perform than the RYGB, it has been shown to create a severe hazard in the event of any leakage after surgery, and seriously increases the risk of ulcer forrmation, and irritation of the stomach pouch by bile. 3 pounds on average (6. Weight loss surgery patients need to learn important new skills, including self-monitoring and meal planning. Given the importance of patient compliance in diet and self-care in improving patient outcomes after surgery, the appropriateness of obesity surgery in noncompliant patients should be questioned. Moreover, following surgery, patients have to follow a careful diet of nutritious, high-fiber foods in order to avoid nutritional deficiencies, dumping syndrome, and other complications. The authors concluded that bariatric surgery for weight loss is associated with alleviation of IIH symptoms and a reduction in intracranial pressure. Patients should be encouraged to remain non-smokers after weight loss surgery to reduce the negative long-term health effects of smoking. Studies have reported that many patients must undergo another revisional operation to obtain the results they seek. 2 % (10) with StomaphyX versus 3. The assessment found that open and laparoscopic RYGB induces similar amounts of weight loss. Requirement for Physician Supervision of Program Documented in Medical Record. 8 % of their total body weight) when the device was removed at 6 months, while the control group (who underwent an endoscopic procedure but were not given the device) lost an average of 7. 75 to 5 days (average of 2. The total weight loss from surgery can be enhanced if it is combined with a low-calorie diet. Two complications developed: (i) gastrogastric intussusception and (ii) tube kinking at the subcutaneous layer. Physician-supervised nutrition and exercise program: Member has participated in physician-supervised nutrition and exercise program (including dietician consultation, low calorie diet, increased physical activity, and behavioral modification), documented in the medical record at each visit. The patient must be committed to the appropriate work-up for the procedure and for continuing long-term post-operative medical management, and must understand and be adequately prepared for the potential complications of the procedure. The Roux-en-Y modification of the loop bypass was designed to divert bile downstream, several feet below the gastric pouch and esophagus to minimize the risk of reflux. Roux-en-Y Gastric Bypass (RYGB) and Vertical Banded Gastroplasty (VBG). They stated that additional prospective comparative trials and long-term follow-up are needed to further define the role of LGP in the surgical management of obesity. The Multidisciplinary Care Task Group recommended the use of patient selection criteria from the NIH Consensus Development Conference on Gastrointestinal Surgery for Severe Obesity, which are consistent with those of other organizations. Natural orifice transoral endoscopic surgery (NOTES) techniques for bariatric surgery including, but may not be limited to, the following. Laparoscopic adjustable gastric banded plication was performed using 5-port surgery. However, RYGB is associated with significantly more weight loss, and has become the procedure of choice for obesity surgery. The authors concluded that this treatment modality should be further investigated prospectively to analyze the rate of headache improvement with weight loss, the amount of weight loss needed for clinical improvement, and the possible correlation with improvement in papilledema. 7 % with isolated steatosis and just 7. Prospective data on patients undergoing Roux-en-Y gastric bypass (RYGBP) was analyzed. This physician-supervised nutrition and exercise program must meet all of the following criteria. 9 %), and a somewhat higher rate of bleeding (4. , adjustable gastric banding) result in the least amounts of weight loss. Garza (2003) explained that the patient should lose weight prior to surgery to reduce surgical risks. It is unclear what benefit there is from a temporary reduction in weight. A decision memorandum from the Centers for Medicare and Medicaid Services (CMS, 2006) concluded that the evidence is sufficient that open and laparoscopic RYGB is reasonable and necessary for Medicare beneficiaries who have a BMI greater than 35 and have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity. For adults aged 18 years or older, presence of persistent severe obesity, documented in contemporaneous clinical records, defined as any of the following. In addition, the intragastric balloon has been associated with potentially severe adverse effects, including gastric erosion, reflux, and obstruction. These included demographic data, pre- and post-operative symptoms, pre- and post-operative visual field deficits, bariatric procedure type, absolute weight loss, changes in BMI, and changes in cerebrospinal fluid (CSF) opening pressure. Patients who have this operation must have lifelong medical follow-up, since the side effects can be subtle, and can appear months to years after the surgery. 7 %). However, distension of the pouch, slippage of the band and entrapment of the foreign material by the stomach have been described and are worrisome. The duodenum is divided just beyond the pylorus. 0 %) and wound infections (11. Smoking cessation reduces the risk of pulmonary complications from surgery. 8 % to 74. Many forms of weight loss surgery require patients to take lifelong nutritional supplements and to have lifelong medical monitoring. Aetna considers open or laparoscopic vertical banded gastroplasty (VBG) medically necessary for members who meet the selection criteria for obesity surgery and who are at increased risk of adverse consequences of a RYGB due to the presence of any of the following co-morbid medical conditions. It offered insight into an early time course for symptom resolution, and explored the impact of weight-loss surgery on migraine headaches. One patient required replication 4 days post-operatively due to obstruction at the site of the last knot. Laparoscopic RGBY had a higher rate of postoperative anastomotic leaks than open RGBY (3. Changes in weight loss and BMI varied depending on the reported post-operative follow-up interval. Although the basic concept of gastric bypass remains intact, numerous variations are being performed at this time. The most progressive form of NAFLD is NASH. This method entails encircling the upper part of the stomach using bands made of synthetic materials, creating a small upper pouch that empties into the lower stomach through a narrow, non-stretchable stoma. Of the 6 patients who underwent GCP, the 6- and 12-month follow-up endoscopic examinations demonstrated a durable intraluminal fold, except for in 1 patient, with a partial disruption at the distal fold owing to a broken suture. Data from each relevant manuscript were gathered, analyzed, and compared. 4 % (1) with the sham procedure (p. Operative time ranged from 50 to 117. The degree and histopathological discordance is dependent upon zonal location and types of injury. Most recently, an assessment by the Canadian Agency for Drugs and Technologies in Health (CADTH) (Klarenbach et al, 2010) stated that their volume-outcome review found that higher surgical volumes were associated with better clinical outcomes. Body Mass Index as a Criterion for Candidacy for Obesity Surgery. Gentileschi et al (2002) systematically reviewed the published literature on open and bariatric laparoscopic obesity surgery and concluded that the available evidence indicates that laparoscopic VBG and laparoscopic RYGB are as effective as their open counterparts. Fifty-six (92 %) of 61 patients with recorded post-operative clinical history had resolution of their presenting IIH symptoms following bariatric surgery. For the 9 patients who underwent AP, the 6- and 12-month endoscopic evaluations demonstrated comparable-size plications over time, except for in 1 patient, who had a partially disrupted fold. Oliveira et al (2005) stated that pathogenesis of non-alcoholic fatty liver disease (NAFLD) remains incompletely known, and oxidative stress is one of the mechanisms incriminated. Although the long-term effectiveness of weight reduction programs has been questioned, the Institute of Medicine (1995) has reported the substantial short-term effectiveness of certain organized physician-supervised weight reduction programs. The data were collected and analyzed pre- and post-operatively. , RYGB), and restrictive procedures (e. They stated that further prospective randomized studies with control groups and a larger number of participants are lacking within the published studies to date. As a high incidence of gallbladder disease (28 %) has been documented after surgery for morbid obesity, Aetna considers routine cholecystectomy medically necessary when performed in concert with elective bariatric procedures. 1 % versus 2. The report stated that the incidence of gastric sleeve dilatation appears to be an uncommon event, but the evidence is far from conclusive at this point. They placed Swedish bands using the pars flaccida method, divided the greater omentum, and performed gastric plication below the band to 3 cm from the pylorus using a single-row continuous suture. For these reasons, it is therefore best for patients to develop good eating and exercise habits before they undergo surgery. A Multidisciplinary Care Task Group (Saltzman et al, 2005) conducted a systematic review of the literature to to provide evidence-based guidelines for patient selection and to recommend the medical and nutritional aspects of multi-disciplinary care required to minimize peri-operative and post-operative risks in patients with severe obesity who undergo weight loss surgery. Bariatric surgery as a treatment for type-2 diabetes in persons with a BMI less than 35. The Fobi pouch, developed by California surgeon Mathias A. 5 %, respectively. The report found, on the other hand, that open surgery had higher rates of cardiopulmonary complications (2. It is not known whether the benefits of obesity surgery in children and adolescents outweigh the increased risks. Prevalence of NASH in bariatric patients is unknown. Aetna considers VBG experimental and investigational when medical necessity criteria are not met. Reduced-calorie diet program supervised by dietician or nutritionist. One non-randomized controlled clinical study that reported positive results reported that results were not maintained after gastric balloon removal (Ramhamadany et al, 1989). Hospital stay varied from 0. A total of 85 publications were identified, and after initial appraisal, 17 were included in the final review. Obesity makes many types of surgery more technically difficult to perform and hazardous. The authors concluded that the published Class IV evidence suggested that bariatric surgery may be an effective treatment for IIH in obese patients, both in terms of symptom resolution and visual outcome. They must also be able to understand, and be adequately prepared for, potential complications. In addition, VBG has a high rate of serious morbidity, including a re-operation rate of up to 30 % from stoma obstruction and staple-line disruption. In the study (Ponce et al, 2015), 187 individuals randomly selected to receive the ReShape Dual Balloon lost 14. Weight reduction reduces the size of the liver, making surgical access to the stomach easier. , biliopancreatic diversion (BPD)) result in the greatest amounts of weight loss, hybrid procedures are of intermediate effectiveness (e. The aim of this study was to evaluate the role of liver oxidative stress in NAFLD affecting morbidly obese patients. Candidates for obesity surgery should begin a weight reduction diet prior to surgery. The group with the routine liver biopsies showed a statistically significant larger preponderance of NASH (37 % versus 32 %). g. The loop gastric bypass developed years ago has generally been abandoned by most bariatric surgeons as unsafe. Furthermore, an improvement was observed in patients where conventional treatments, including neurosurgery, were ineffective. Plication of the greater curvature produces a restrictive mechanism that causes weight loss. , San Clemente, CA) to treat obesity without the need for invasive surgery. A total of 13 patients were operated on (7 women). The ReShape Dual Balloon device is delivered into the stomach via the mouth through a minimally invasive endoscopic procedure. Weight loss prior to surgery makes the procedure easier to perform. 9 %, 41. Fobi, is a modification of gastric bypass surgery. Anderin et al (2015) found that weight loss before bariatric surgery is associated with marked reduction of risk of postoperative complications. These researchers planned for 120 patients to be randomized 2:1 to multiple full-thickness plications within the gastric pouch and stoma using the StomaphyX device with SerosFuse fasteners or a sham endoscopic procedure and followed up for 1 year. NASH was defined as steatohepatitis without alcoholic or viral hepatitis. It is meant to be temporary and should be removed 6 months after it is inserted. The assessment noted that, due to limited evidence and poor quality of the trials comparing each pair of procedures, these conclusions should be viewed with caution. Nevertheless, a 25-mm biopsy specimen without zone 3 cellular ballooning or fibrosis appears adequate to exclude the diagnosis of NASH. A number of studies have demonstrated a relationship between surgical volumes and outcomes of obesity surgery. The National Institutes of Health Consensus Statement (1998) states that all smokers should be encouraged to quit, regardless of weight. Arun et al (2007) stated that NAFLD is a chronic condition that can progress to cirrhosis and hepatocellular cancer. The authors concluded that routine liver biopsy documented significant liver abnormalities in a larger group of patients compared with selective liver biopsies, thereby suggesting that liver appearance is not predictive of NASH. Oxidative stress was measured by concentration of hydroperoxides (CEOOH) in liver tissue. Even if the patient has not been able to keep weight off long-term with prior dieting, the patient may be able to lose significant weight short term prior to surgery in order to improve the outcome of surgery. The published literature was reviewed using manual and electronic search techniques. Consecutive liver biopsies were compared to those liver biopsies selected because of grossly fatty livers. By contrast, the liver enlarges and becomes increasingly infiltrated with fat when weight is gained prior to surgery. Both groups had a similar prevalence of cirrhosis. These investigators enrolled 26 patients from May 2009 to August 2010. The average age of the patients was 45 years and all but 4 patients were women. These researchers investigated the discordance of paired liver biopsies in individuals undergoing gastric bypass. These investigators performed a comprehensive literature search using the following databases: MEDLINE, EMBASE, PubMed, Scopus, Web of Sciences, and the Cochrane Library. 3 and a 5-year history of severe headaches and moderate papilledema due to IIH. However, it remains unclear if weight loss following LGP is durable in the long-term. Similarly, however, less pronounced risk reductions were found when comparing patients in the 50th with those in the 25th percentile of pre-operative weight loss. 0 % versus 4. Some Aetna plans entirely exclude coverage of surgical treatment of obesity. This causes vomiting, which can tear out the staple line and destroy the operation. 4 %). In a prospective, single-center, randomized, single-blinded study, Eid et al (2014) examined the safety and effectiveness of endoscopic gastric plication with the StomaphyX device versus a sham procedure for revisional surgery in RYGB (performed at least 2 years earlier) patients to reduce regained weight. Rationale for Six-Month Nutrition and Exercise Program Prior to Surgery. This team should include experienced surgeons and physicians, skilled nurses, specialty-educated nutritionists, experienced anesthesiologists, and, as needed, cardiologists, pulmonologists, rehabilitation therapists, and psychiatric staff. The mini-gastric bypass has not been subjected to a prospective clinical outcome study in peer-reviewed publication. Clinically significant obstructive sleep apnea (i. ), an endoluminal fastener and delivery system used to tighten esophageal tissue. 4 % with follow-up from 6 months to 24 months. The outpatient procedure usually takes less than 30 minutes while a patient is under mild sedation. These studies were from a single group of investigators, raising questions about the generalization of the findings. 1 % of the patients. The two groups were similar in age, gender, and BMI. Aetna considers open or laparoscopic short or long-limb Roux-en-Y gastric bypass (RYGB), open or laparoscopic sleeve gastrectomy, open or laparoscopic biliopancreatic diversion (BPD) with or without duodenal switch (DS), or laparoscopic adjustable silicone gastric banding (LASGB) medically necessary when the selection criteria listed below are met. 7 % of those with NASH. Levin and colleagues (2015) stated that IIH occurs most frequently in young, obese women. Shalhub et al (2004) noted that non-alcoholic steatohepatitis (NASH) commonly occurs in obese patients and predisposes to cirrhosis. Peri-operative data were collected from each study and recorded. Prevalence of NASH was 26 % in Group 1 and 32 % in Group 2. Minimal standards in these areas are set by the institution and maintained under the direction of a qualified surgeon who is in charge of an experienced and comprehensive bariatric surgery team. 3 % versus 1. The primary efficacy end-point was reduction in pre-RYGB excess weight by 15 % or more excess BMI (calculated as weight in kilograms divided by height in meters squared) loss and BMI less than 35 at 12 months after the procedure. Ideally, the surgical center where surgery is to be performed should be accomplished in bariatric surgery with a demonstrated commitment to provide adequate facilities and equipment, as well as a properly trained and funded appropriate bariatric surgery support staff. According to the available literature, patients who have this procedure seldom experience any satisfaction from eating, and tend to seek ways to get around the operation by eating more. , affect surgical risk. 2 % excess weight loss with RYGB at 5, 10, and 14 years, respectively, in a large series with 95 % follow-up. The mini-gastric bypass uses a jejunal loop directly connected to a small gastric pouch, instead of a Roux-en-Y anastomosis. 9 pounds of the 14. Ideally patients selected for surgery should have no major perioperative risk factors, a stable personality, no eating disorders, and have lost some weight prior to surgery. 0 % versus 0 %). Both patients were at a high risk and could not undergo another open or laparoscopic surgery to correct the leaks that were not healing. L. The claimed advantage of LASGB is the adjustability of the band, which can be inflated or deflated percutaneously according to weight loss without altering the anatomy of the stomach. Overall, clinical studies have shown that about 40 % of persons who have this operation do not achieve loss of more than half of their excess body weight. 7 % versus 1. Cazzo et al (2014) stated that non-alcoholic fatty liver disease (NAFLD) is common among subjects who undergo bariatric surgery and its post-surgical improvement has been reported.
The authors concluded that the results demonstrate that significant sampling variability exists in class 2 and 3 obese individuals undergoing screening liver biopsies for NAFLD. Surgery should only be performed at facilities that are equipped to collect long-term data on clinical outcomes. 2 pounds (3. 7 %). Bariatric surgery as a treatment for idiopathic intracranial hypertension. , person meets the criteria for treatment of obstructive sleep apnea set forth in. The CMS decision memorandum found that short-and-long-term mortality associated with both LASGB and RYGB were low (less than 2 %) in this younger age group. Gastric bypass surgery has been used to treat morbid obesity and its co-morbidities, and IIH has recently been considered among these indications. The Task Group stated that registered dietitians are best qualified to provide nutritional care, including pre-operative assessment and post-operative education, counseling, and follow-up. They stated that prospective, controlled studies are needed for better elucidation of its role. The authors concluded that laparoscopic adjustable gastric banded plication provides both restrictive and reductive effects and is reversible. 3 %, 55. After institutional review board approval, 2 methods were used to achieve laparoscopic gastric volume reduction. The mean operative time was 87. In March 2007, the FDA granted 510(k) pre-marketing clearance to the StomaphyX (EndoGastric Solutions, Inc. Specifically, performing a loop, rather than a Roux-en-Y, anastomosis to a small gastric pouch in the stomach may permit reflux of bile and digestive juice into the esophagus where it can cause esophagitis and ulceration, and may thus increase the risk of esophageal cancer. Aetna considers surgery to correct complications from bariatric surgery medically necessary, such as obstruction, stricture, erosion, or band slippage. The reduced capacity of the pouch and the restriction caused by the band diminish caloric intake, depending on important technical details, thus producing weight loss comparable to vertical gastroplasties, without the possibility of staple-line disruption and lesser incidence of infectious complications. This study was poorly reported, failing to discuss inclusion criteria for the trial and adverse events associated with the procedures. A problem with the traditional procedure is that the staples can break down, causing the stomach to regain its original shape -- and patients to start gaining weight again. Recent data demonstrate that surgeons are moving from simple gastroplasty procedures, favoring the more complex gastric bypass procedures as the surgical treatment of choice for the severely obese patient. No mortality was reported in these studies and the rate of major complications requiring re-operation ranged from 0 % to 15. The evidence for the mini gastric bypass has come from a single investigator, thus raising questions about the generalization and validity of the reported findings. g. The gastric restrictive procedures include vertical banded gastroplasty accompanied by gastric banding which attempt to induce weight loss by creating an intake-limiting gastric pouch by segmenting the stomach along its vertical axis. 0 % and 2. For patients in the highest range of body mass index (BMI), the risk reduction associated with pre-operative weight loss was statistically significant for all analyzed complications, whereas corresponding risk reductions were only occasionally encountered and less pronounced in patients with lower BMI. Eleven (92 %) of 12 patients who had undergone pre- and post-operative formal visual field testing had complete or nearly complete resolution of visual field deficits, and the remaining patient had stabilization of previously progressive vision loss. It is associated with a minimal risk of leakage, bleeding, and nutritional deficiency. A fatty liver is heavy, brittle, and more likely to suffer injury during surgery. Handley et al (2015) systematically reviewed the effect of bariatric weight reduction surgery as a treatment for IIH. The technique is safe, feasible, and reproducible and can be used as an alternative bariatric procedure. The modifications to gastric bypass surgery are designed to prevent post-surgical enlargement of the gastric pouch and stoma. Liver biopsy remains the gold-standard for diagnosing NASH. Laparoscopic RYGB is a less invasive approach that results in a shorter hospital stay and earlier return to usual activities. The authors concluded that early reports with LGP were promising with a favorable short-term safety profile. g. The results of the first cases where this technique has been applied in this hospital were presented. There is a lack of data on the durability of the results with the ReShape Integrated Dual Balloon System. There is active collaboration with multiple patient care disciplines including nutrition, anesthesiology, cardiology, pulmonary medicine, orthopedic surgery, diabetology, psychiatry, and rehabilitation medicine. Vertical banded gastroplasty (VBG), a purely restrictive procedure, has fallen into disfavor because of inadequate long-term weight loss. Obesity surgery is not indicated for persons with transient increases in weight (Collazo-Clavell, 1999). Once the device is placed in the stomach, patients may experience vomiting, nausea, abdominal pain, gastric ulcers, and feelings of indigestion. The authors concluded that as previously reported by studies in which post-surgical biopsies were performed, RYGB leads to a great resolution rate of liver fibrosis. More recently, a review of the literature by the Veterans Health Administration Technology Assessment Program (Adams, 2008) found no new literature that would not alter the conclusions of the ANZHSN review. The greater and lesser curvatures were approximated to create an intraluminal fold of the stomach. The negative predictive values from Group 1 liver biopsies for NASH and portal fibrosis were only 83 % and 67 %, respectively. It also found that VBG shows substantial weight loss efficacy but less than that for RYGB. The pre-operative surgical preparatory regimen should include cessation counseling for smokers. The outlet of this pouch is restricted by a band of synthetic mesh, which slows its emptying, so that the person having it feels full after only a few bites of food. Results of the morbidity, mortality and weight loss were presented. The assessment found that the estimated mortality rate was low for both procedures, but somewhat lower for laparoscopic surgery than open surgery (0. Laparoscopic gastric plication was performed in 12 adolescents (9 females and 3 males). Because the normal flow of food is disrupted, available literature indicates that there is a greater potential for metabolic complications compared to gastric restrictive surgeries, including iron deficiency anemia, vitamin B-12 deficiency and hypocalcemia, all of which can be corrected by oral supplementation. Vagus nerve blocking (e. g. Factors such as blood glucose control, hypertension, etc. Plication of the gastric greater curvature was performed under general anesthetic and by laparoscopy using 3 lines of sutures and with an orogastric probe as a guide. The American College of Surgeons (ACS) has stated that the surgeon performing the bariatric surgery be committed to the multidisciplinary management of the patient, both before and after surgery. The trend towards use of Roux-en-Y and away from loop gastric bypass was based on sound surgical experience of multiple surgeons with large series of patients. Available brands of LASGB include the Lap-Band System (Allergan, Inc. There is established evidence that medical supervision of a nutrition and exercise program increases the likelihood of success (Blackburn, 1993). Therefore, the appropriateness of obesity surgery in non-compliant patients should be questioned. 9 %) and anastomotic problems (8. The small bowel is then divided, and the end going to the cecum of the colon is connected to the short stump of the duodenum. Aetna considers each of the following procedures experimental and investigational because the peer-reviewed medical literature shows them to be either unsafe or inadequately studied. Roux-en-Y gastric bypass as a treatment for gastroesophageal reflux in non-obese persons. A randomized controlled clinical trial comparing short-term (1-year) outcomes of laparoscopic sleeve gastrectomy to laparoscopic RYGB found comparable reductions in body weight and BMI (Karamanakos et al, 2008). The CTAF assessment found few comparative studies of sleeve gastrectomy. All of the published literature has been limited to descriptive articles, case series, and a prospective non-randomized controlled study. Sampling discordance was greatest for portal fibrosis (26 %), followed by zone 3 fibrosis (13 %) and ballooning degeneration (3 %). Biliopancreatic Diversion (BPD) (Jejunoilieal Bypass, Scorpinaro Procedure) and Duodenal Switch (DS) Procedures. An assessment of laparoscopic RYGB by the BlueCross BlueShield Association Technology Evaluation Center (BCBSA, 2005) stated that among available bariatric surgical procedures, RYGB appears to have the most favorable risk-to-benefit ratio, and that the overall risk-to-benefit ratio of laparoscopic RGBY is similar to that of open RGBY. However, the assessment found that the profile of adverse events differs between the two approaches. A Multidisciplinary Care Task Group (Saltzman et al, 2005) recommended that operative candidates must be committed to the appropriate work-up for the procedure and to continued long-term post-operative medical management. , the VBLOC device, also known as the Maestro Implant or the Maestro Rechargeable System). Once in place, the balloon device is inflated with a sterile solution, which takes up room in the stomach. Liver cirrhosis was present in 11. Recent advances in laparoscopy have renewed the interest in gastric banding techniques for the control of severe obesity. , Irvine, CA) and the Realize Adjustable Gastric Band (Ethicon Endo-Surgery, Cincinnati, OH). This new device is intended to facilitate weight loss in obese adult patients by occupying space in the stomach, which may trigger feelings of fullness, or by other mechanisms that are not yet understood. These procedures are not for cosmesis but for prevention of the pathologic consequences of morbid obesity. The CTAF assessment reported that the results of multiple case series and retrospective studies have suggested that sleeve gastrectomy as a primary procedure is associated with a significant reduction in excess weight loss. One pathologist graded all liver biopsies as mild, moderate or severe steatohepatitis. The patient may be able to lose significant weight prior to surgery in order to improve the outcome of surgery. 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. Therefore, the evidence supports the overall superiority of RYGB over VBG in safety and efficacy for bariatric surgery. A decision memorandum from the Centers for Medicare and Medicaid Services (CMS, 2006) concluded that open or laparoscopic BPD with or without DS are reasonable and necessary for Medicare beneficiaries. BMI greater than 35 in conjunction with any of the following severe co-morbidities. Bariatric Surgery for the Treatment of Idiopathic Intracranial Hypertension. Regarding long-term adverse events, the rates of reoperation (9. Brethauer et al (2011) presented the results of a feasibility study using laparoscopic gastric plication for weight loss achieved without stapling or banding. , persons with BMI greater than 50) because of the substantial weight loss induced by this procedure. However, they stated that large well-designed studies with long-term follow-up are needed. 3 mins without any intra-operative complications. The Roux-en-Y gastric bypass was the most common bariatric procedure performed. CADTH was not, however, able to identify specific thresholds for surgical volume that were associated with better clinical outcomes. 2 %, and 59. The mean excess weight loss at 1, 3, 6, 9, and 12 months after surgery was 21. Note: The presence of depression due to obesity is not normally considered a contraindication to obesity surgery. The nutrition and exercise program may be administered as part of the surgical preparative regimen, and participation in the nutrition and exercise program may be supervised by the surgeon who will perform the surgery or by some other physician. One-year follow-up was completed by 45 patients treated with StomaphyX and 29 patients in the sham treatment group. It is a reproducible and reversible technique with results and indications still to be validated. 3 pounds they lost. 7 % with normal liver. 9 cmH2 O in the 12 patients who had this recorded. Roux-en-Y Gastric Bypass (RYGB), Laparoscopic Adjustable Silicone Gastric Banding (LASGB), Sleeve Gastrectomy, Biliopancreatic Diversion (BPD) and Duodenal Switch (DS) Procedures. The Task Group recommended to decide on a case-by-case basis whether to proceed with surgery in patients who are unable to lose weight. Also, the stomach opening that leads into the intestines, which in surgery is made smaller to allow less food to pass through, often stretches as the years go by. According to the recommendations by the expert panel, potential candidates for bariatric surgery should be referred to centers with multi-disciplinary weight management teams that have expertise in meeting the unique needs of overweight adolescents. An assessment by the Institute for Clinical Systems Improvement (ICSI, 2005) found that large studies have shown that RYGB may result in weight loss of 60 % to 70 % of excess weight. Smoking cessation is especially important in obese persons, as obesity places them at increased risk for cardiovascular disease. A total of 242 patients underwent open and laparoscopic RYGBP from 1998 to 2001. Histology showed fatty liver in 92. Neither BMI nor liver enzymes predicted the presence or severity of NASH. The authors recommended routine liver biopsy during bariatric operations to determine the prevalence and natural history of NASH, which will have important implications in directing future therapeutics for obese patients with NASH and for patients undergoing bariatric procedures. It is often the first step in a 2-stage procedure when performing RYGB or duodenal switch. Dramatic improvement in IIH headaches occurred by 4 months post-procedure and was maintained at 1 year, when she reached her weight plateau with a BMI of 35. 9 %, 31. Measured parameters included %EWL, percentage of BMI loss (%BMIL), obesity related co-morbidities, operative time, and length of hospitalization and complications. 7 %, and 49. For maximal benefit, dieting should occur proximal to the time of surgery, and not in the remote past to reduce surgical risks and improve outcomes. The gastric bypass operation can be modified, to alter absorption of food, by moving the Roux-en-Y-connection distally down the jejunum, effectively shortening the bowel available for absorption of food. Intragastric balloon is intended to reduce gastric capacity, causing satiety, making it easier for patients to take smaller amounts of food. 3 %, including 43. No restrictions were placed on these searches, including the date of publication. Pories et al (1995) reported 57. On July 28, 2015, the Food and Drug administration (FDA) approved the ReShape Integrated Dual Balloon System (ReShape Medical Inc. 1 %). Pujol Gebelli et al (20110 stated that laparoscopic gastric plication is a new technique derived from sleeve gastrectomy. Patients are advised to follow a medically supervised diet and exercise plan to augment their weight loss efforts while using the ReShape Dual Balloon and to maintain their weight loss following its removal. A total of 71 patients underwent sclerotherapy at their gastrojejunostomy from July 2004 to August 2006. In a sense, this procedure combines the least desirable features of the gastric bypass with the most troublesome aspects of the biliopancreatic diversion. 9 mins (average of 79. Resolution was statistically associated with female gender, percentage of excess weight loss, post-surgical BMI, post-surgical platelet count, and diabetes resolution. Complications were noted in 9. A total of 11 relevant publications (including 6 individual case reports) were found, reporting on a total of 62 patients. Some have advocated use of the DS procedure in the super-obese (i. This study aimed to determine the evolution of liver disease evaluated through NAFLD fibrosis score 12 months after surgery. While appropriate surgical procedures for severe obesity primarily produce weight loss by restricting intake, intestinal bypass procedures produce weight loss by inducing a malabsorptive effect. The Task Group also recommended a pre-operative assessment for micronutrient deficiencies. It is thought that these patients lose restriction because of the dilated gastrojejunostomy and thus overeat. Six months following the device removal, patients treated with the ReShape Dual Balloon device kept off an average of 9. 2 mins). The authors concluded that laparoscopic gastric plication is a new surgical technique which gives equivalent short-term results as vertical gastrectomy. Thirty-four (97 %) of 35 patients who had undergone pre- and post-operative funduscopy were found to have resolution of papilledema post-operatively. If this goal is achieved, further weight loss can be attempted, if indicated through further evaluation. The early weight loss results have been encouraging, with better weight loss in patients who underwent GCP. 0 %) may be higher for laparoscopic RGBY than for open RGBY (6. A synthetic band is placed around the stomach opening to keep it from stretching. In 2008, Loewen and Barba evaluated the injection of morrhuate sodium as sclerotherapy to decrease the diameter of the gastrojejunostomy anastomosis following gastric bypass. The 1st patient in the GCP group required re-operation and plication reduction owing to gastric obstruction. Fridley et al (2011) reviewed the literature on the effectiveness of bariatric surgery for obese patients with idiopathic intracranial hypertension (IIH) with regard to both symptom resolution and resolution of visual deficits. The study also found that sleeve gastrectomy was associated with more severe complications than LASGB. After a waxing and waning course and various medical treatments, the patient underwent laparoscopic Roux-en-Y gastric bypass surgery with anterior repair of hiatal hernia. The NIH Consensus Conference (1998) states that the combination of a reduced calorie diet and increased physical activity can result in substantial improvements in blood pressure, glucose tolerance, lipid profile, and cardiorespiratory fitness. Enrollment was closed prematurely because preliminary results indicated failure to achieve the primary efficacy end-point in at least 50 % of StomaphyX-treated patients. In 13 patients both pre- and post-operative CSF pressures were recorded, with an average post-operative pressure decrease of 254 mm H(2)O. Procedures that are mainly diversionary (e. The weight loss effect is then a combination of the very small stomach, which limits intake of food, with malabsorption of the nutrients, which are eaten, reducing caloric intake even further. These investigators presented a case report of a 29-year old female with a maximum BMI of 50. Huang et al (2012) noted that the laparoscopic adjustable gastric band has been widely accepted as 1 of the safest bariatric procedures to treat morbid obesity. The percentage of EWL (% EWL) for LGP varied from 31. The most frequently found morbidity was nausea and vomiting. 4 days). The Task Group recommended that smokers should be encouraged to stop, preferably at least 6 to 8 weeks before surgery (Saltzman et al, 2005). 4 % (average of 3. 6 % with NASH, 48. Ji et al (2014) conducted a systematic review of the currently available literature regarding the outcomes of laparoscopic gastric plication (LGP) for the treatment of obesity. There is rarely a good reason why obese patients (even super obese patients) can not delay surgery in order to undergo behavioral modification to improve their dietary and exercise habits in order to reduce surgical risks and improve surgical outcomes. Post-operative lumbar puncture opening pressure was shown to decrease by an average of 18. When comparing patients in the 75th with those in the 25th percentile of pre-operative weight loss, the risk of complications was reduced by 13 %. Note: Most Aetna HMO and QPOS plans exclude coverage of surgical operations, procedures or treatment of obesity unless approved by Aetna. It is a prospective cohort study which evaluated patients immediately before and 12 months following Roux-en-Y gastric bypass (RYGB). Australia has reported that the costs of band adjustments with LASGB has exceeded the costs of the primary LASGB procedure. The Task Group stated that registered dietitians are best qualified to provide nutritional care, including pre-operative assessment and nutritional education and counseling. e. This added to the small number of case reports and retrospective analyses of the successful treatment of IIH with gastric bypass surgery, and brought this data from the surgical literature into the neurological domain. Dedicated dietitians can help patients during their pre-operative education on new dietary requirements and stipulations and their post-surgical adjustment to those requirements. In a traditional gastric bypass procedure, surgeons create a smaller stomach by stapling off a large section. However, because of variations in the results and the complications that tend to arise from port adjustment, alternative procedures are needed. 6 % versus 1. Findings of cirrhosis on frozen section changed the operation from a distal to a proximal RYGBP. A retrospective review was performed of this group, including chart review, follow-up data with weight checks, and telephone interview findings. Overall improvement in symptoms of IIH after bariatric surgery was observed in 60 of the 65 patients observed (92 %). The intragastric balloon (also known as the silicone intragastric balloon or SIB) has been developed as a temporary aid for obese patients who have had unsatisfactory results in their clinical treatment for obesity and super obese patients with higher surgical (Fernandes et al, 2004). The authors concluded that LGP has the potential of being an ideal weight loss surgery for adolescents, resulting in excellent weight loss and minimal psychological disruption. The assessment concluded that the evidence is not adequate to conclude that open or laparoscopic vertical banded gastroplasty is reasonable and necessary and they are therefore non-covered for all Medicare beneficiaries.
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