Editorial Message: Overcoming insurance coverage barriers for laparoscopic sleeve gastrectomy and follow-up bariatric procedures—hope for 2010

| February 18, 2010

Dear Readers:

As I write this message, I am preparing for the 9th Annual Surgery of the Foregut Symposium being held February 14 to 17, 2010, in Coral Gables, Florida.

This month’s issue of Bariatric Times is a special one for those of us who are passionate about bariatric surgery.

First, Dr. Gregg Jossart gives us a wonderful overview of how laparoscopic sleeve gastrectomy (LSG) has evolved from a primary procedure to a component of another surgery, such as the duodenal switch, then became a step approach, and back to a primary procedure again. Dr. Alex Gandsas follows with an excellent article reviewing his initial experience after nearly 300 cases of LSG. I am sure we will continue to read more articles describing different techniques, indications, and results on LSG. I cannot emphasize more emphatically my opinion that LSG is a great operation with the strong advantage of having minimal to no long-term complications. While it is indeed technically simple, it has excellent short- and mid-term results when it comes to rapid weight loss and resolution of comorbidities.

Next, Dr. Ninh Nguyen reviews the implications of bleeding in patients that underwent gastric bypass surgery. This is a complex clinical scenario because these patients can bleed into the abdominal cavity or into the gastrointestinal tract. There can be multiple bleeding sites from the upper or the lower gastrointestinal tract (staple lines and anastomosis) to excluded areas, such as the gastric remnant. Because of the difficulty we have in identifying and treating these patients, we should maximize prevention, which is no easy task. We must balance our decisions between choosing the right staple height (green, blue, or white cartridges), buttressing or not buttressing the staple line, and deciding when and how anticoagulation will be implemented. I learned a long time ago from my dear colleague, Gisselle Hamad, to start anticoagulation with heparin every eight hours for the first postoperative day and then switch to low molecular heparin once the patient is “out of the woods.” I enjoyed reading this great article from Dr. Ninh and learned a lot about gastrointestinal bleeding after Roux-en-Y gastric bypass.

In our second installment of “Ask the Experts: Dilammas in Bariatric Surgery,” Dr. Alan Wittgrove discusses the difficult case of a young woman with short gut syndrome and dumping due to internal herniation and bowel necrosis after undergoing a gastric bypass with closure of mesenteric defects. What a conundrum case. To me, the most upsetting aspect in this case was the long period that this patient had to wait before getting her last surgery approved because of insurance barriers. I have had several “peer-to-peer” discussions with medical directors of insurance companies and have explained to them the urgency of patient cases complicated by line sepsis, malnutrition, and other problems. Despite my efforts to explain that the surgery in question is a follow up of the first procedure and treatment of complication, I get the same answer that the patient is approved for one bariatric procedure only. In my experience, the only solution to getting the follow-up procedure approved is for the patient to switch to an insurance company that covers it.

I am hoping that 2010 will be a year in which more medical insurance companies will approve LSG for the treatment of morbid obesity as well as follow-up procedures to treat complications in the bariatric surgery patient.

I hope you enjoy this month’s issue of Bariatric Times.

Sincerely,

Raul J. Rosenthal, MD, FACS
Editor, Bariatric Times

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