SurgiStrategies spoke with Kent Sasse, MD, medical director of Western Bariatric Institute, and Partner at the Surgery Center of Reno, to evaluate some key points in a successful bariatric program. Q: Can you review some of the most common techniques in bariatric procedures? More investigational techniques? Today, there are two primary bariatric surgical techniques, both of which have long-term data and well researched, highly successful, short-and long-term weight loss results. The two dominant procedures are the laparoscopic adjustable gastric band (LAGB) and the laparoscopic Roux-en-Y gastric bypass (LRYGB). Both of these procedures are now widely performed throughout the United States and the rest of the world. Numerous long-term studies demonstrate that people undergoing the procedures live longer lives and suffer less diabetes, heart disease, hypertension and multiple other medical conditions. Both procedures are minimally invasive or laparoscopic procedures usually performed with five small incisions measuring less than half an inch. They are done as an outpatient or same-day procedure in the case of the banding, and with an overnight or two-night stay with the bypass. More recently a third procedure called the laparoscopic sleeve gastrectomy (LSG) has come on the scene and has won some devotees. A small fraction of the bariatric surgeons now use this as their primary procedure. It is the only procedure that involves removal of organs or tissues, as the surgeon trims the large capacity stomach down to a long, narrow, tube-like organ and induces the same type of satiety and gastric restriction as the above procedures. Time will tell if the long-term results will match those of the LAGB or LRYGB. Q: A bariatric program requires a tremendous amount of planning before you make the first cut. Do you have some tips for building a bariatric ASC? Building a bariatric ASC is best done after some careful planning. There are several key components to a successful bariatric surgical weight loss center, and the first of these centers around the proper equipment. To provide high-quality bariatric surgical services a center must have high-quality bariatric surgical equipment. Because the surgery is performed for overweight and obese individuals, it is imperative that all operating tables and other equipment be suitable for handling high-weight capacity. Operating tables and exam tables are the obvious ones, but waiting room chairs, toilets and other office furniture are sometimes overlooked. Today’s modern bariatric surgery is performed with a laparoscopic technique and requires a high-quality laparoscopic system. Time spent modernizing the laparoscopic surgical equipment will pay dividends with smoother surgical procedures and turnovers. For the most part, few specialized instruments are required beyond that of standard laparoscopic instrument trays, but a few, low cost, unique instruments can make the surgery more efficient and successful. In addition, it’s important to work with the surgeons and carrying inventory for the endoscopic staplers and bands that are preferred, as there is competition with these disposable devices. Participation in buy-in groups allows for better pricing on the bands (an approximately $3,000) as well as the linear endoscopic stapler instruments, which constitute a significant expense for the procedures. Q: How are health plans and Medicare covering obesity surgery and how are physicians clearing the insurance hurdle? Medicare and nearly all of the public health plans including Tricare and most state Medicaid plans do cover bariatric surgery, albeit at rates which are not very favorable to surgical practices. These plans continue to follow the guidelines that were originally set forth in the 1991 NIH Consensus Conference Statement. At that time the BMI criteria recommended bariatric surgery for anyone with a BMI over 40 and for patients with a BMI of 35-39 who had obesity related comorbid conditions. Commercial plans have largely followed suit with some exceptions. Regrettably, a few commercial payors have offered specious reasoning for strict limitations in coverage or for denials of coverage for bariatric surgery. As the evidence has continued to mount that weight loss surgery is highly effective, safe and produces survival and disease free advantage, it has become increasingly difficult for insurance carriers to deny this type of coverage in most standard health insurance plans. More recently, employer-directed or self-insured programs have begun to look at the data surrounding weight loss surgery and conclude that it is cost effective for them to cover weight loss surgery as an insurance benefit. Several studies have demonstrated now that the plan and employer group stands to benefit financially due to decreases in medical absenteeism and obesity related health conditions when weight loss surgery is a covered benefit. Restrictions can still be onerous, however. A number of plans have created difficult hurdles that patients must jump over, most notably the three-or six-month medically supervised weight loss plan, which must precede authorization for bariatric surgery. Until such plans are eventually eliminated as discriminatory, surgeons and weight loss providers must navigate a complex pathway toward insurance coverage for weight loss surgery. The best results after weight loss surgery stem from committed patients participating in a structures weight loss program combined with weight loss surgery. The American Society of Metabolic and Bariatric Surgery created a system for identification of National Centers of Excellence, but the insurance reimbursement process is still in evolution. Bariatric surgery and obese patients suffer from the fact that weight loss surgery is still not as fully accepted as other medical treatments and as such, faces some more difficult challenges. Q: Beyond the bypass procedure there must be education, support and exercise for patients. What are some key factors to a successful pre-operative program? Beyond the weight loss surgical procedure there must be a structured program for pre-operative education and post-operative support, vitamin testing, band adjustments and exercise. Studies show the best results for weight loss and improved health and longevity stemmed from weight loss surgery combined with a structured program that incorporates all of these elements. The best programs in the country have taken a holistic approach toward long-term weight loss and have chosen to “partner” with patients on a lifelong journey of weight loss and weight maintenance. These programs focus on surgery, but incorporate a team of practitioners including dietary counselors, nurses, physician assistants, medical assistants, exercise and fitness trainers and support group leaders. Regular weekly and monthly support groups provide an outlet for patients to share challenges and successes and compare notes on individual day-today strategies. Routine weigh-ins with the clinic holds patients accountable over the long term and provides a mechanism for feedback, coaching and encouragement. Finally, the medical component allows for testing of vitamin deficiencies – necessary for gastric bypass patients – as well as band adjustments and evaluations by practitioners who are familiar with obesity related disease. Often a weight loss surgical practice finds itself in the best possible position to diagnose obesity related disease such as obstructive sleep apnea and make the appropriate referrals to other sub-specialists. Frequent follow-up, long term commitment and involvement of many levels of health practitioners provides a winning formula for long term success of the patients in a cost conscious practice environment. Reproduced with permission from SurgiStrategies Magazine, December 2010 issue. ©2010 Virgo Publishing. All Rights Reserved.