BARIATRIC SURGERY - Health Plan of Nevada

weight loss. A history of sexual abuse correlated with poorer weight loss, whereas intrinsic
motivational factors appeared to predict greater weight loss after surgery (Ray et al., 2003). Although
research supports the association of psychological problems such as depression and personality
disorder with less successful obesity surgery outcomes, rarely are the psychological problems cited as
contraindications for surgery (Greenberg et al., 2005). Furthermore, the goal of psychological
assessment should be the development of pre- and postsurgical treatment plans that address
psychosocial barriers to postoperative success. Professional consensus is that bariatric surgery should
be performed only in motivated, educated patients who have participated in a combined
multidisciplinary assessment and only after behavior-based interventions have failed (Bachman et al.,
2005).
Weight loss therapy is not appropriate for most pregnant or lactating women.
Absolute contraindications include patients with active substance abuse. A signed physician statement
indicating that the patient is substance free is recommended.
The following conditions should be considered relative contraindications to bariatric surgery: Major
mental disorders, such as schizophrenia, uncontrolled depression, active suicidal ideation or
personality disorders can interfere with the ability to comprehend informed consent for bariatric
surgery and/or to comply with the recommended post-surgical follow-up. A variety of serious illnesses
could be exacerbated by caloric restriction, including anorexia nervosa or bulimia nervosa.
Gastric Bypass (Roux-en-Y; Gastrojejunal Anastomosis)
The Roux-en-Y bypass (RYGB) procedure involves restricting the size of the stomach by stapling shut
90% of the lower stomach. In addition, the proximal intestinal anatomy is rearranged, thereby
bypassing the duodenum resulting in a malabsorptive effect. This can be an open or laparoscopic
procedure.
Long-limb Roux-en-Y gastric bypass (LLRGB) is similar to standard RYGBP, except that the "Roux"
limb (through which only food passes) is greater than 100 cm instead of the usual 45 to 100 cm.
Consequently, the common limb (which empties both food and digestive fluids) is shorter, thereby
permitting less food absorption. Several authors assert that this procedure should be performed for
patients with a BMI of greater than 50 instead of the RYGB.
In an 18 year retrospective cohort study by Adams et al. (2007), 9949 patients who had undergone
gastric bypass surgery and 9628 severely obese persons who applied for driver's licenses were studied.
From these subjects, 7925 surgical patients and 7925 severely obese control subjects were matched for
age, sex, and body-mass index. The authors concluded that long-term total mortality after gastric
bypass surgery, particularly deaths from diabetes, heart disease, and cancer, was significantly reduced.
However, the rate of death from causes other than these diseases was higher in the surgery group than
in the control group. Review of the data showed that a substantial number of severely obese persons
have unrecognized presurgical mood disorders or post-traumatic stress disorder or have been victims
of childhood sexual abuse. This is leading some bariatric surgery centers to recommend that all
patients undergo psychological evaluation and, if necessary, treatment before surgery and
psychologically related surveillance postoperatively. Despite an improved quality of life after gastric
bypass surgery, certain unrecognized presurgical conditions may reappear after surgery. Therefore,
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