SAGES 2009 Panel Report: Best Practices for the Surgical Treatment of Obesity

| August 17, 2009

by Jon Gould, MD, and Daniel Jones, MD
Dr. Gould is Associate Professor of Surgery at University of Wisconsin School of Medicine and Public Health. Dr. Jones is Associate Professor of Surgery at Harvard Medical School.

This article is a summary of a panel sponsored by the Society of American Gastrointestinal and Endoscopic Surgeons.

INTRODUCTION
As one of the fastest growing fields in medicine, bariatric surgery offers the allure of strong demand and good financial reward. Rapidly accelerating advances in surgical technologies and techniques have raised concerns about patient safety as well as levels of scrutiny by regulatory agencies, insurers, and public health officials. On April 24, 2009, in Phoenix, Arizona, at the annual Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) meeting, a panel of experts convened to provide updated information on patient safety and best practices in bariatric surgery.

BENCHMARKS FOR PATIENT SAFETY
Betsy Lehman Center for Patient Safety and Medical Error Reduction. The first half of this session featured five presentations on bariatric surgery and patient safety. Dan Jones, MD, Associate Professor of Surgery, Harvard Medical School, presented an overview of the Betsy Lehman Center for Patient Safety and Medical Error Reduction Expert Panel on Weight Loss Surgery (WLS). This expert panel was convened first in 2004 and again in 2007, with the mission of assessing bariatric surgical procedures, identifying issues related to patient safety, and developing evidence-based best practice recommendations to address those issues. We were fortunate that many of the experts to take part in the Betsy Lehman WLS sessions were able to participate in this SAGES session panel.

In the most recent Betsy Lehman WLS session, the 35-member Expert Panel was divided into 11 task groups: surgical care, multidisciplinary evaluation and treatment, behavior and psychological care, pediatric/adolescent, anesthetic perioperative care and pain management, nursing perioperative care, informed consent and patient education, policy and access (coding and reimbursement), specialized facilities and resources, data collection (registries)/future considerations, and endoscopic interventions. Participants were asked to provide recommendations based on the best available evidence, including randomized, controlled trials, observational studies, and expert opinion. A summary of these updated recommendations have been published in the journal Obesity.[1]

Surgical care: Levels of evidence. Phil Schauer, MD, Professor of Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, discussed levels of evidence regarding bariatric surgical care. Despite literally thousands of publications evaluating the outcomes of different WLS procedures, level 1 evidence supporting WLS is somewhat limited. A recent Cochrane review on surgery for obesity[2] includes three randomized, controlled trials and three prospective, cohort studies comparing WLS with nonsurgical management of obesity. Another 20 randomized, controlled trials comparing one WLS to another have been published at the time of this review (2009). The risk of bias in many of these trials is uncertain, and only five had adequate allocation concealment. The best data suggest that surgery results in greater weight loss than conventional treatment in moderate (BMI >30) as well as severe obesity. Reductions in comorbidities, such as diabetes and hypertension, also occur. Improvements in health-related quality of life occurred after two years, but effects at 10 years are less clear. Surgery is associated with complications, such as pulmonary embolism, and some postoperative deaths occur. Five different bariatric procedures were assessed, but some comparisons were assessed by just one trial. The limited evidence suggests that weight loss following gastric bypass is greater than vertical banded gastroplasty (VBG) or adjustable gastric banding (AGB), but similar to isolated sleeve gastrectomy and banded gastric bypass. Isolated sleeve gastrectomy appears to result in greater weight loss than AGB. Evidence comparing vertical banded gastroplasty with AGB is inconclusive. Data on the comparative safety of the bariatric procedures were limited. Weight loss and quality of life were similar between open and laparoscopic surgery. Conversion from laparoscopic to open surgery may occur.

Surgery appears to be more effective than conventional management of obesity. Certain procedures produce greater weight loss, but data are limited. The evidence on safety is even less clear. Due to limited evidence and poor quality of the trials, caution is required when interpreting comparative safety and effectiveness.

Patient education and informed consent. Robert Fanelli, MD, Assistant Professor of Surgery at the University of Massachusetts Medical School and the Director of Surgical Endoscopy at Berkshire Medical Center, described patient education and informed consent. According to Dr. Fanelli, informed consent should include realistic risk estimates that take into account patient factors and relevant institutional and health provider characteristics that might affect risk (experience and outcomes for specific WLS procedures). Short- and long-term risks and complications and the potential for unknown or unforeseeable long-term risks should be discussed. Patients should receive realistic estimates of short- and long-term weight loss, including the potential for weight regain and modest benefits. They should also be informed if long-term data (>5 years) are unavailable. They should be advised of the long-term health benefits of weight loss produced by WLS, but also be made aware that not all pre-existing medical and psychosocial consequences of obesity (including eating disorders) will improve with WLS. Candidates for WLS should be given realistic estimates for health outcomes if they decline surgical treatment, and be advised of known factors and interventions that might optimize benefits. When creating the informed consent forms and educational programs for patients, the team should consider patient expectations, the value placed on different outcomes, and the risks each candidate is willing to accept. It should also address unrealistic expectations or other misconceptions patients might have.

Patients should be advised of required behavioral and dietary changes and other reasonable and foreseeable consequences of WLS that could affect health or quality of life in a substantive way, such as gastrointestinal symptoms, cosmetic effects (loose skin), and nutritional deficits. Patients should be advised about alternative WLS procedures and nonsurgical treatment options (medical and behavioral). They should be informed about them even if they are not available through the consenting health provider or institution. Each patient should have their comprehension of the risks, benefits, consequences, and alternatives to WLS evaluated. Confirmation of comprehension should be included as a protection for patients engaged in the informed consent process.

Future research is needed to better identify factors that affect short- and long-term outcomes so that patients can be cited appropriate and individualized outcome information. Research should focus on important gaps in knowledge on outcomes and consequences of WLS, and the different approaches that facilitate patient understanding of, and decision-making about, WLS.

Sleep apnea and anesthetic care. Stephanie Jones. MD, Associate Professor of Anesthesia, Harvard Medical School, discussed obstructive sleep apnea (OSA) and other aspects of anesthetic care in WLS patients. Mandatory polysomnography (PSG) for WLS patients has been advocated by some. Dr. Jones recommends that it be used in selected patients as indicated. When uncertain of the indication for such testing, clinical assessment should be supplemented to include gender, waist-to-hip ratio, and neck circumference, which are described risk factors for OSA. Preoperative continuous postive airway pressure (CPAP) treatment should be strongly considered for patients with a PSG diagnosis of moderate to severe OSA. Smoking cessation at least six weeks prior to surgery is encouraged. During the induction and emergence from anesthesia, the greater than or equal to 30-degree reverse Trendelenburg position prolongs the ability of patients with severe obesity to tolerate apnea during induction of and emergence from anesthesia. CPAP of approximately 10cmH2O may be considered during preoxygenation to prolong nonhypoxic apnea. Intubating laryngeal mask airway devices provide an alternative mechanical approach to securing the airway and may also improve success when attempting ventilation prior to securing the airway. Intubating laryngeal mask airway devices should be included among the alternative airway management devices immediately available in the operating room.

Postoperative nausea and vomiting (PONV) in laparoscopic WLS patients is related to the volume and rate of intraoperative fluid replacement. To reduce PONV, maintenance of euvolemia may be helpful.

Pharmacodynamic studies in patients with severe obesity have suggested optimal dosing requirements for different neuromuscular blocking agents. Laparoscopic WLS has been performed safely as 23-hour stay and outpatient procedures; however, patients with OSA should not be considered candidates for outpatient WLS. Adherence to the American Society of Anesthesiologists Practice Guidelines for the Perioperative Management of Patients with OSA is suggested. Based on new evidence of efficacy and safety specific to WLS patients, the use of opioid-sparing multimodal analgesic strategies, including local anesthetic wound infiltration and nonsteroidal anti-inflammatory medication use, is recommended, unless contraindicated.

Documenting nutritional status and risk-adjusted outcome. Matthew Hutter, MD, Assistant Professor in Surgery, Harvard Medical School,  talked about nutritional issues in pre- and postbariatric surgery patients and issues regarding risk-adjusted outcomes. According to Dr. Hutter, a good diet history is valuable prior to bariatric surgery for a variety of reasons. This history can help to identify those potential patients who may need significant pre-operative diet modification, such as binge eaters, sweet eaters, and emotional eaters. These history-taking sessions can also be valuable educational experiences for patients. Diet changes that will be important post-operatively can be reinforced. Some programs use the diet history to assist with preoperative weight loss. Many surgeons feel that modest preoperative weight loss (5–10% initial body weight) can lead to decreased operative time, lower liver volume, fewer conversions, and potentially lower operative risk. It is important that patients not be denied these WLS procedures because of a failure to lose 5 to 10 percent of their initial body weight, as there is relatively little evidence to suggest that this is a reasonable exclusion criterion. While it is common knowledge that many WLS patients can experience nutritional deficiencies postoperatively, what is less commonly appreciated is how often these patients are deficient prior to surgery, particularly in vitamin D, iron, and calcium.

When it comes to determining risk-adjusted outcomes for WLS patients, the quality of the data used to derive these adjustments is of paramount importance. Good data regarding WLS outcomes and patient risk are prospectively collected. They are risk adjusted with standardized definitions. They are collected by audited and trained data collectors, who are not part of the patient care team. These data are benchmarked, and sound statistical methods should be employed in analysis. Future considerations in data collection and risk assessment include a need to be able to compare and benchmark data across data collection systems, a need to determine what constitutes an outlier, a need to link data collection to quality improvement, and a need to collect data on new and novel therapies.

SPECIAL ISSUES AND CONTROVERSIES
Multidisciplinary team and bariatric program accreditation. The second half of this session involved discussions on special issues and controversies in bariatric surgery. Bruce Schirmer, MD, Professor of Surgery, University of Virginia, described the multidisciplinary bariatric patient care team and the bariatric program accreditation process. As the chair of the American College of Surgeons Bariatric Surgery Centers Network, Dr. Schirmer was uniquely qualified to give this talk. The multidisciplinary WLS team should include some key members including trained surgeon(s), a WLS program coordinator, nutritionist, primary care physician, medical subspecialists, and the OR team. Dr. Schirmer suggested that the optimal perioperative care of the WLS patient involve the use of multiple medical disciplines and the multidisciplinary team. For this reason, WLS should be focused at centers where these resources are readily available. The multidisciplinary WLS team is an important component of any bariatric surgery program for a variety of reasons. First of all, bariatric surgery patients have needs that are very different from patients undergoing other types of surgery. Education and behavior modification are import for WLS to succeed after surgery. These complex needs, coupled with an extremely low tolerance for bad outcomes (public scrutiny), the essentially elective nature of these operations, and a lack of sympathy for and bias against obesity create an environment where multidisciplinary programs and accreditation of these programs is essential.

There are currently two systems of accreditation for WLS programs not run by individual insurance companies. The American College of Surgeons Bariatric Surgery Centers Network and the Surgical Review Corporation Bariatric Surgery Center of Excellence Program (affiliated with the American Society of Metabolic and Bariatric Surgery) are similar in many ways. Both programs require specific resources (facilities and specialized equipment) and evaluate key personnel, the bariatric surgeon(s), the patient selection process, and patient education as well as outcomes and follow-up. There are some minor differences in terms of the data collection process, fees, and the fact that the ACS only accredits centers where the SRC accredits both surgeons and centers. As outcomes data from these accredited centers has accumulated over the years, it has become apparent that the morbidity and mortality rates for these centers is lower than expected based on published data. Future steps in the accreditation process include developing a risk-adjusted system where outcomes can replace surgical volume as a surrogate for excellence. It is likely that the future of bariatric surgery accreditation and reimbursement will take into account these outcomes.

Pediatric/adolescent care and concerns. Janey Pratt, MD, General and Bariatric Surgeon, Massachusetts General Hospital, talked about issues regarding bariatric surgery in children and adolescents. According to Dr. Pratt, laparoscopic Roux-en-Y gastric bypass is considered a safe and effective option for adolescents who are extremely obese as long as appropriate long-term follow-up is provided. The adjustable gastric band (AGB) has not been approved by the FDA for use in adolescents and, therefore, should be considered investigational. Off-label use can be considered, if done in an IRB-approved study. Biliopancreatic diversion and duodenal switch procedures cannot be recommended in adolescents. Current data suggest substantial risks of protein malnutrition, bone loss, and micronutrient deficiencies. These nutritional risks are of particular concern during pregnancy. In addition, several late maternal deaths have been reported. Sleeve gastrectomy should be considered investigational; existing data are not sufficient to recommend widespread and general use in adolescents.

Strong indications for WLS in adolescents include established type 2 diabetes, moderate to severe OSA with apnea hypopnea index (AHI) ≥15, severe and/or progressive nonalcoholic steatohepatitis (NASH), and pseudotumor cerebri. Other indications for WLS in adolescents include mild OSA, mild NASH, hypertension, dyslipidemia, and significantly impaired quality of life. All adolescents with obesity should be formally assessed for depression. Depression should be treated prior to WLS. The presence of eating disturbances is not an exclusion criterion for WLS, but adolescents with such disorders should be treated prior to surgery.

When combination procedures are used in adolescents, physical maturity (completion of 95% of adult stature based on radiographic study) should be documented. In most cases, this criterion will limit surgery to children over age 12. Psychological maturity, demonstrated by understanding of the surgery, mature motivations for the operation, and adherence with preoperative therapy, should be assessed prior to WLS. BMI cut-off points in children and adolescents who meet other criteria should be greater than or equal to 35 with major comorbidities (type 2 diabetes mellitus, moderate to severe sleep apnea, pseudotumor cerebri, or severe NASH) and greater than or equal to 40 with other comorbidities.

There are no data available to suggest that prolonged preoperative weight management programs are of benefit to adolescents who undergo WLS. However, children and adolescents should demonstrate the ability to adhere with treatment regimens and medical monitoring before WLS. In many cases, consistent attendance in a prolonged weight management program will provide important assurance of postoperative adherence.

Individuals with mental retardation vary in their capacity to demonstrate knowledge, motivation, and adherence; they should, therefore, be evaluated for WLS on a case-by-case basis. For these children, an ethicist should be included on the multidisciplinary evaluation team. Others who should be screened on a case-by-case basis include patients with syndromic obesity, endocrine disorders, obesity that appears to be related to the use of weight-promoting medications, and those in whom obesity cannot be controlled through medical interventions and/or carefully designed environmental and behavioral management. Very limited information is available about the outcomes of WLS for such patients. Patients with uncontrolled psychosis (presence of hallucinations and delusions), bipolar disorder (extreme mood lability), or substance use disorders can be considered for WLS on a case-by-case basis after they have been in remission for one year.

Although few hospitals have sufficient volume for a stand-alone pediatric surgical center, the ideal WLS team should include a minimum of 4 to 5 professionals who are located in the same center. At least one preoperative face-to-face meeting should be conducted to prepare a treatment plan for each patient. Staff should include a surgeon (an experienced adult bariatric surgeon or a pediatric surgeon with bariatric fellowship or the equivalent experience), a pediatric specialist (an internist or pediatrician with adolescent and obesity training and experience), a registered dietician (with weight management certificate and experience in treating obesity and working with children and families), a mental health professional (with specialty training in child, adolescent, and family treatment and experience treating eating disorders and obesity), and a program coordinator (RN, social worker, or one of the other team members who has the responsibility of coordinating each child or adolescent’s care and assuring adherence and follow-up). The ideal setting would be in an adult/pediatric hospital, with a pediatric program partnered with an adult program that has full access to pediatric specialists. A comprehensive family-based evaluation should be provided to parents seeking surgery for their adolescent children.

Early WLS may reduce obesity-related mortality and morbidity. However, early timing must be weighed against the patient’s possible psychological immaturity and the risk of decreased adherence and long-term follow-up. All adolescents undergoing WLS should be included in prospective longitudinal data collection to improve the evidence base for evaluating the risks and benefits of WLS in this age group. Emphasis on adherence strategies, careful monitoring of vitamin and mineral intake, and periodic laboratory surveillance to detect deficiencies is crucial in pediatric and adolescent bariatric surgery patients. Adolescent girls are particularly vulnerable to nutritional deficiencies; this group is at substantial risk of developing iron-deficiency anemia and vitamin B deficiencies during menstruation and pregnancy, and should receive special attention. The risk of pregnancy in adolescents may increase after WLS. All female adolescents should be informed about increased fertility following weight loss and possible risks associated with pregnancy during the first 18 months after surgery. They should be counseled to avoid pregnancy during this period and offered appropriate contraception. In addition to risks for deficiencies of iron, calcium, and vitamin B12 after WLS, adolescents may also be at particular risk for osteopenia and thiamine deficiency.

Informed assent by the adolescent should be obtained separately from the parents to avoid coercion (as in other pediatric chronic illnesses that require surgical intervention). The patient’s knowledge of the risks and benefits of the procedure and the importance of postoperative follow-up should be formally evaluated to ensure true informed assent. The parental permission process should include discussion of the risks of adult obesity, available medical treatments, surgical alternatives, and the specific risks and outcomes of the proposed WLS in the proposed institution.

NOTES and endoscopic weight loss frontiers. James Ellsmere, MD, presented the latest developments in endoscopic weight loss procedures. The use of endoscopic interventions for the treatment of obesity is in its infancy, but will eventually provide valuable approaches to presurgical weight loss, postsurgical revision of previous WLS procedures, and primary WLS procedures. Such interventions may offer economical, minimally invasive outpatient options for growing numbers of WLS patients. Their investigation and development should be a high priority.

Gastrojejunostomy anastomotic complications can often be addressed with endoscopic therapies. Stomal stenosis responds well to endoscopic balloon dilation. Selected cases of staple line complications may respond to endoscopic covered stents. On the more experimental side, primary endoscopic weight loss procedures are emerging. Favorable safety and efficacy outcomes have been documented with an endoscopically delivered and retrieved duodenal-jejunal bypass sleeve. Recently reported are some preliminary and encouraging results from pilot trials with the TOGA System, a set of transoral endoscopically guided staplers that are being used to create a stapled, restrictive pouch along the lesser curve of the stomach. Duodenal electrical stimulation has been used to slow gastric emptying and reduce water intake in healthy human volunteers. The BioEnterics Intragastric Balloon (BIB) has not been approved by the Food and Drug Administration for use in the United States. However, studies outside the United States have shown favorable outcomes with its use for temporary weight reduction for mild or moderate obesity, or for preoperative weight loss for severe obesity.

For all endoluminal procedures targeted to WLS, there is a need for the development of definitive outcome measures and for the design and execution of prospective, double-blind, controlled studies.

SAGES Educational Offerings
Steven Schwaitzberg, MD, described the SAGES educational offerings that bariatric surgeons may find useful. SAGES Pearls are narrated videos of specific commonly performed laparoscopic procedures. A Pearl describing laparoscopic Roux-en-Y gastric bypass has been created, with contributions from multiple expert bariatric surgeons. SAGES Pearls differ from standard narrated videos in that a standard surgical video is generally one author presenting one case, or a particular technique, and is edited for time. SAGES Pearls offer multiple examples of the salient points for a technique from the perspective of multiple expert operators. Each procedure is broken down into core steps. Each step reveals one or more methods as performed by the masters of laparoscopic surgery. Specially prepared commentaries are included to enhance understanding of each Pearl. In this program, the laparoscopic Roux-en-Y gastric bypass procedure has been broken down into 13 basic steps: port placement, dissection of Angle of His, liver retraction, access to lesser sac, creation of gastric pouch and gastrojejunostomy with linear stapler, creation of gastric pouch and gastrojejunostomy with EEA stapler, creation of gastric pouch and gastrojejunostomy handsewn, identification of ligament of Treitz and creation of Roux-limb, creation of jejunojejunostomy, closure of jejunojejunostomy, route of the Roux-limb, closure of defects, and testing GJ anastomosis. Upcoming Pearls videos from SAGES include laparoscopic adjustable gastric band placement and a Pearl on sleeve gastrectomy.

SAGES also offers several additional WLS-related educational products. A narrated video description of both the laparoscopic Roux-en-Y gastric bypass and the laparoscopic adjustable gastric band placement is included as a part of the collection entitled SAGES Top 14 Procedures Every Practicing Surgeon Should Know.

SAGES Grand Rounds is an innovative, new concept designed to deliver current information on topics in the field of minimally invasive surgery. Each episode in this series is dedicated to a specific disease or disorder and is filled with the latest information from leading experts on treatments, techniques, and complications, culminating in case discussions. Grand Rounds Episode VI is entitled Bariatric Surgery. The stated objectives of this episode are to understand the surgical options and techniques for weight reduction surgery, to discuss the evidence-based outcomes of laparoscopic bariatric surgery, and to review common complications of laparoscopic bariatric surgery. Chapters include laparoscopic gastric bypass, laparoscopic AGB, laparoscopic duodenal switch, an evidence-based comparison of bariatric procedures, a panel discussion, and managing bariatric surgery complications.

Select panel discussions from previous SAGES meetings have been recorded and are available for purchase. The SAGES Postgraduate course entitled Complications in Bariatric Surgery and How to Manage Them features nationally respected experts discussing a broad spectrum of bariatric complications, from minor to life threatening. Emphasis is placed on evaluation and management of early sepsis and chronic abdominal pain, as well as practical application of evidence-based clinical medicine. Ask the Experts and Roundtable Discussions from the meeting are also included on the DVD. Topics include diagnosis and management of early postoperative sepsis, evaluation and management of abdominal pain and vomiting in the postoperative patient, nontechnical complications (e.g., deep vein thrombosis, pulminary embolism, respiratory issues), Lap-Band complications, managing patients with morbid obesity in the ICU, long-term nutritional complications, management of weight loss failure, and legal ramifications of bariatric complications. Finally, the 2007 SAGES panel Safety in Bariatric Surgery is available as an audiocast.

All of this material can be ordered online at www.cine-med.com/sages. Active SAGES members are eligible for a significantly discounted price. When hard copies of the DVD or CD-ROM are purchased, unlimited online access to the video for one year following the purchase date is customary.

Policy and Access
Jon Gould, MD, Associate Professor of Surgery, University of Wisconsin School of Medicine and Public Health, discussed issues relating to policy and access in bariatric surgery. As Dr. Gould describes, it is important that public health policy be aligned with long-term goals for the treatment of severe obesity. Barriers to WLS in populations with a high prevalence of severe obesity should be identified and eliminated, and there should be uniform standards of coverage for all WLS candidates. Advocacy for increased access to WLS for underserved regions and populations is necessary. Public education about the obesity epidemic and the risks as well as the benefits of WLS should be undertaken. A recent and sharp increase in childhood obesity lends urgency to the need to address this problem. Policy initiatives to identify pediatric and adolescent populations most likely to benefit from surgical treatment of obesity are needed. Surgical treatment should be considered a potentially effective option for appropriately selected individuals, and there should be uniform standards of coverage for adolescent patients. There is a need to educate legislators, community leaders, and other stakeholders on the costs and benefits of WLS for extremely obese adolescents, and to leverage opportunities for collaboration between teachers, parents, and community leaders.

Controversial issues affecting bariatric surgery coverage include required documentation of prior weight loss attempts through more conservative means and proof of extreme obesity for at least five years. Access to WLS for those with a BMI of 35 to 40 is also inconsistent and controversial. To address these issues and inconsistencies, it is advisable to consider routine examination of weight loss histories during behavioral evaluation to determine whether additional attempts at nonsurgical weight loss are advisable. Coverage of WLS for those with a BMI of 35 to 40 and comorbid conditions that require ongoing treatment (e.g., CPAP, medication) should be routine.

Ongoing research to characterize weight loss histories of surgical candidates and to explore the relation between dieting history and postoperative outcomes will be invaluable in determining the utility of some of these preoperative requirements employed by insurers. Collection and dissemination of data on WLS costs, risks, and benefits, and finally collaborative efforts between government, industry, and other stakeholders to promote safe and effective delivery of WLS will be important to resolve these wide regional disparities in WLS access.
Data demonstrates that obesity is linked to higher healthcare costs than smoking or drinking, and plays a major role in disability. Accurate short and long-term cost savings for employers and insurance companies need to be collected and disseminated. Clinical pathways that reduce unnecessary costs to providers should also be developed. Legislators need to be apprised of the personal and economic costs of obesity in the communities they serve. Dissemination of evidence-based information on the risks, benefits, and cost effectiveness of WLS can bring these issues to their attention.

The highest BMI groups are the fastest growing and the most stigmatized. To address this problem, targeted education campaigns, community-level public information/education, and sensitivity training for hospital personnel should be employed. Hospitals should also acquire obese-appropriate products (e.g., gowns, chairs, commodes).

The Centers for Medicare and Medicaid Services allow national coverage for Roux-en-Y gastric bypass (open and laparoscopic), laparoscopic adjustable gastric banding (LAGB), and biliopancreatic diversion with duodenal switch (BPD) (open and laparoscopic). Nationally covered procedures and new 2006 CPT codes are available. Reimbursement policies should reflect the importance of comprehensive, multidisciplinary care. There should be full coverage for medical, nutritional, and psychological preoperative evaluation as well as pre-, peri-, and postoperative care required by insurers. CPT codes for WLS should be updated to reflect current practice. New CPT Category I codes should be requested and approved as evidence accumulates in favor of new procedures (e.g., vertical sleeve gastrectomy, endoscopic interventions). T codes should be considered for evolving technologies, and procedures. The use of T codes may create a pathway for reimbursement by supporting consistent data collection and development of evidence. Evidence indicating that a promising technology or new procedure leads to improved health outcomes could support conversion of Category III codes to Category I codes. There should be support for the development of appropriate CPT codes for each component of multidisciplinary care (exercise therapy, pre- and postoperative support groups). All of the discussed factors can help to increase access, raise awareness, and eliminate inconsistencies in different areas of the country and for varied patient populations for WLS.

Conclusions
WLS is a field that is evolving and adapting to multiple external pressures. Safety concerns along with increasing public scrutiny have led to a systematic approach to defining best practices, creating standards of care, and identifying mechanisms to ensure that patients consistently receive the best and most effective care possible. In many ways, bariatric surgery and multidisciplinary bariatric surgery programs may serve as a model for other programs and surgical specialties in the near future.

References
1.    Betsy Lehman Center Weight Loss Surgery Expert Panel. Commonwealth of Massachusetts. Betsy Lehman Center for Patient Safety and Medical Error Reduction. Expert Panel on Weight Loss Surgery: executive report: Update 2007. Obesity. 2009;17(5):839–841
2.    Colquitt JL, Picot J, Loveman E, Clegg AJ. Surgery for obesity. Cochrane Database Syst Rev. 2009; 15(2): CD003641.

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