Bariatric surgery

Gastric bypass PAR for Contra Costa Health plan

Advice on referring patients, per Kim Haglund, surgical registrar, September 2008:

Where for whom:
  • No one at CCRMC does weight-loss surgery. Thus, all patients who qualify for weight-loss surgery will be referred out.
  • CCHP/BAC patients usually end up with Dr. Dat Nguyen at Valley Care in Pleasanton.
    • It is relatively easy to get CCHP/BAC patients through the hoops and operated on. I’ve had several CCHP/BAC patients get surgery.
  • Straight MediCal patients can go to UCSF.
    • It is next to impossible for UCSF (in my limited experience). UCSF won’t operate on patients who are over 450 lbs and really prefer that patients lose down to 400 lbs before surgery. They will get patients involved in a diet/exercise program over there to try to achieve that, but if patient doesn’t lose any weight in the program, they will probably not operate. Given the distances involved and the frequency with which they want participants to go over to be weighed, do group activities, etc, I haven’t had a single patient succeed with weight loss or get surgery over there.
Surgical options
There are currently 2 main choices in surgery:
  • Lap band
    • An adjustable band is placed around the stomach to make its capacity smaller, but where no permanent alteration of anatomy happens. If the patient has intolerance of the lap band, it can be removed if necessary and patient returns to status quo ante.
  • Roux-en-Y gastrojejunostomy
    • The stomach is divided permanently. A very small pouch made of the proximal stomach is then attached to a loop of jejunum. The rest of the stomach is left in the body, but it usually can’t be reattached if the patient is unhappy with the results of the surgery.
    • This kind of surgery has risks of some quite unpleasant long-term consequences, such as afferent limb syndrome, dumping syndrome, SBO, malabsorption of nutrients
    • However, this surgery also has much more reliable and permanent weight loss.
Things that should give one pause before embarking on a quest for weight loss surgery
  • Serious psychiatric disease
    • Patients who are on antipsychotics or anticonvulsants may have serious obesity problems as a side effect of their meds. Thus, unless/until they can get off the meds, their weight is going to be a problem. If they can be switched to other meds maybe they won’t even need surgery.
  • Disordered/binge eating
    • Not likely to benefit from surgery, high likelihood of complications
    • Treating the eating disordered with psychotherapy specifically directed at eating behaviors (rather than, say, depression in general) may be more effective.
  • Unrealistic expectations
    • Patient will not be a supermodel even if loses a lot of weight. Patients will have often large pannus of redundant skin even if normal weight achieved; plastic surgery to improve this is not necessarily covered. Patients who are looking to surgery to help them in their efforts to find a partner, a job, a better sex life are likely to be disappointed. Patients who go into surgery hoping for better health, longer life, less need for medication are more likely to be happy with their results and accepting of the concomitant inconveniences of the post-op life.
Hoops to go through
No one will get surgery quickly. Plan on a year to have the patient get all their boxes checked and hoops jumped through. Thus, before you go down this path, you might want to discuss with patients to make sure that surgery is really the right choice for them.
If the patients can’t comply with these requirements, the theory is, they will be unlikely to comply with all the lifestyle changes necessary after surgery (drastic change in eating habits—lifelong if they get Roux-en-Y bypass; frequent labs to monitor for deficiencies needed lifelong; unable to take certain meds including NSAIDs after surgery, etc)
Step 1: DOCUMENT in the chart the patient’s weight history, dieting history, and current amount of exercise. Document their current eating habits: sodas? juice? nonfat milk? dessert or sweets how often? fast-food and restaurant food how many meals/week? portion size? Do they eat high-fiber foods? Lots of simple carbs? Only veg potatoes and squash? Also document any health problems attributable to obesity: knee/hip problems, menstrual irregularity/infertility, diabetes, hypercholesterolemia, etc. On all subsequent visits, continue to document your recommendations to pt in terms of diet & exercise as well as their successes or failures in those arenas.
Step 2: RECOMMEND some initial lifestyle changes and follow up on patient’s results with these changes. Things I suggest: get rid of your dinner plates and use 7-inch salad plates for meals; cover ½ your plate with green veg, ¼ with protein, ¼ with carb for each meal; drink only water—even diet soda trains your palate to expect sweet flavor; no fast food ever—putting a yogurt and an apple in a bag is faster than the fastest fast food; exercise 45 min a day at least 5 days a week—many will have to work up to this if have been sedentary a long time.
Step 3: REFER to dietician and Weight Watchers/Food Addicts/Overeaters Anonymous. Patients must have 2 visits to dietician at least 30 days apart and must have 6 months attendance at an organized weight loss program (eg Weight Watchers) before they will get insurance authorization for surgery. They also need monthly weight checks documented in chart for 6 months. Losing at least 15-20% of goal weight loss makes authorization go more smoothly.
Step 4: CHECK LABS: TSH, CBC, BUN, Cr, fasting glucose, LFTs, Lipids
Step 5: GET PSYCH CLEARANCE: No sooner than 6 months after weight loss efforts begun, you can submit a request for authorization to CCHP. On this form you must note the dates that all the above steps were completed (counseling, Weight Watchers or equivalent, normal labs, dietician visits). CCHP will then clear pt to be screened by psych. CCHP will direct you where to send pt for the psych eval. The purpose of this psych eval is to make sure patients don’t have unrealistic expectations, disordered eating, serious psych barriers to following pre/post-op instructions.
Step 6: Once psych clears patient, CCHP will give the green light for patient to make appt with the bariatric surgeon CCHP designates (usually Dr. Nguyen). Patient calls and makes own appointment. The ball is in the court of patient and surgeon from then on; you usually only get involved again for pre-op H&P and post-op labs. Dr. Nguyen will send a nice post-op pack with labs you should check, how often, what post-op diet/med restrictions are.