Qualifications for Gastric Surgery

Obesity profoundly affects quality of life, overall health, and life expectancy. Healthcare providers have sought safe and effective nonsurgical treatment strategies, but have had little reproducible long-term success. Surgical treatment for obesity, on the other hand, is very effective for the majority of patients; however, it is associated with significant risk. To determine whether a patient is a candidate for surgery requires a thoughtful calculation of the risk-to-benefit ratio of the procedure relative to no intervention. Several organizations have created criteria for patient selection including various medical societies, the National Institutes for Health, Medicare and Medicaid Services, and, perhaps most important, individual insurers. Qualifications for surgery thus are not uniform and differ slightly depending on prospective.

Most guidelines use body mass index (BMI) as the primary determinant for bariatric surgery candidacy. BMI is a person's weight in kilograms divided by the square of their height in meter. BMI is an accurate representation of adiposity in the morbidly obese and allows for comparisons between individuals by correcting for differences in patient height. Surgery is generally offered to patients whose BMI is 40 or greater or patients who have a BMI 35 or greater with serious weight-related medical comorbidities. Serious comorbidities may include the presence of diabetes, hypertension, and sleep apnea. A few insurers do not use BMI as a criterion. Some require a weight that is at least double one's ideal body weight, and others, a weight 100 pounds greater than ideal weight.

BMI is not the only criterion used to determine whether a patient is a candidate for bariatric surgery. Many other factors are equally important. A thorough psychosocial evaluation is often recommended as part of the preoperative workup of a morbidly obese patient. Surgery for obesity is significantly life altering and patients must be able to cope with these drastic changes. As such, important criteria for surgery includes the patient's ability to reasonably understand and assess the risks and benefits of surgery, and the patient's ability to maintain long-term follow-up with the bariatric surgery program. Most guidelines exclude a patient with severe mental retardation or unstable psychiatric disorders.

For example, depression, bipolar disease, and even schizophrenia are not absolute contraindications; however, someone who is suicidal, manic, or actively delusional should be in the care of a behavioral health specialist and stabilized before considering bariatric surgery. Patients with Prader-Willi syndrome would be considered an absolute contraindication by most surgeons. Last, the patient must have a reasonably supportive social network.

Obesity surgery at the extremes of age has been long controversial. Many bariatric centers restrict [Page 654]their practice to an age range between 18 and 65. Although numerous single institution series document the safety of obesity surgery in adolescent and elderly patients, the data are quite limited. Examination of large national databases suggests a significantly higher mortality rate in Medicare patients who are greater than 65 relative to younger Medicare patients. However, it is unclear if these patients who may be at highest risk from surgical complications are also the patients who may benefit the most. Medicare and Medicaid services currently offer bariatric surgery benefits to all of their members, regardless of age.

...