Citizens Receives Weight Loss Surgery Certification

Victoria Texas
March 6, 2006
PATRICK BRENDEL - Victoria Advocate

The Citizens Bariatric Center gained special certification just in time to comply with new Medicare guidelines that surgeon B. Dean McDaniel feels will help lead to better care for the extremely obese, most of whom have no recourse to weight loss but surgery.

However, McDaniel, who is medical director of the Bariatric Center, cautioned that surgery alone cannot solve the growing obesity problem in the United States and the world, and that the only viable solution is to engage in healthy behaviors before obesity manifests itself.

The Centers for Medicare and Medicaid Services determined on Feb. 21 that three bariatric surgery procedures will now be covered for Medicare beneficiaries.

Medicare will only cover the operation if the patient has a Body Mass Index of greater than 35, has at least one co-morbidity related to obesity, and has been previously unsuccessful with medical treatment for obesity.

Body Mass Index, or BMI, is the result of a formula relating your height to your weight. A person who is 6 feet tall and 258 pounds has a BMI of 35.

In addition, procedures must be performed at facilities that are certified by the American College of Surgeons as a Level 1 Bariatric Surgery Center; or certified by the American Society for Bariatric Surgery as a Bariatric Center of Excellence.

The Bariatric Center was designated a Center of Excellence on Jan. 30, just beating the certification deadline of Feb. 15 set by Medicare.

In addition to strict guidelines on facilities and staff, designation as a Center of Excellence requires that the center perform more than 125 surgeries per year, collect and analyze data on an annual basis, and demonstrate positive outcomes with patients, McDaniel said.

“The Bariatric Center is practically the only one of its kind in South Texas,” McDaniel said, adding that his patient base extends from Laredo to McAllen to Corpus Christi.

The majority of McDaniel’s patients come from more than 100 miles from Victoria, he said, with some people traveling from as far away as New Mexico, the Carolinas, Puerto Rico and Korea.

The Medicare announcement in itself does not really affect the Bariatric Center at Citizens, he said because only a small percentage of his patients are eligible for Medicare.

Also, the Bariatric Center has stricter regulations for bariatric surgery than Medicare, requiring that patients have a BMI of more than 40, (a 6-foot-tall person weighing 295 pounds).

Yet, McDaniel said he does not expect a sudden influx of people looking for a free and effortless way to lose weight because of the Bariatric Center’s extensive screening process that includes documentation of each patient’s medical problems and history of weight loss attempts.

“Most of the time we stop them with a phone call,” McDaniel said of non-qualified candidates for bariatric surgery.

Rather, the utilization of the Medicare determination lies in its implications.

“It’s stating that high-volume, accredited weight-loss facilities should be doing bariatric surgery,” McDaniel said, adding that private insurance companies will probably soon follow Medicare’s lead.

Centers that perform a large number of procedures demonstrate a lower mortality and greater success rate than non-specialized surgical centers, McDaniel said.

“If you do it in the right place, you have minimal risk.”

Similar to how arthroscopic surgery has supplanted open surgery on knee injuries to athletes, laparoscopy has revolutionized bariatric procedures, which used to involve a sternum-to-navel incision, lengthy convalescence and risk of infection.

In a laparoscopic procedures, a fiber-optic camera (laparoscope) is inserted into a “keyhole-type incision” next to the patient’s belly button, McDaniel said.

Using laparoscopy, an entire procedure involves a total of four to six incisions of less than 1 inch in length. Standard recovery time from laparoscopic bariatric surgery is two days in the hospital and two weeks off work, McDaniel said.

There has been a steady increase in the number of bariatric surgeries since 2002, he said, mostly due to laparoscopic surgery eliminating many of the complications associated with open surgery.

While laparoscopy has made bariatric surgery safer, certain surgical techniques have arisen to make bariatric surgery more effective.

The three procedures recognized by Medicare are Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, and open and laparoscopic biliopancreatic diversion with duodenal switch.

At the Bariatric Center, McDaniel and fellow surgeon Craig G. Chang only perform the Roux-en-Y gastric bypass procedure and laparoscopic adjustable gastric banding.

“Those are associated with the greatest weight loss and the least amount of risk.”

Roux-en-Y gastric bypass is considered the “gold standard” of bariatric surgery - the operation by which all other operations are judged,” McDaniel said.

Roux-en-Y gastric bypass leads to a weight loss of at least 100 pounds and is by far the most popular bariatric surgery procedure performed at the Bariatric Center. He estimated that anywhere from 80 to 95 percent of all bariatric surgeries he performs are Roux-en-Y gastric bypasses.

The other Medicare-approved procedure performed by McDaniel, laparoscopic adjustable gastric banding, involves no cutting of the stomach and leads to a weight loss of 50 to 60 pounds, he said.

McDaniel credits the creation of high-volume bariatric centers, advancements in technology, and better surgical procedures with the decrease in mortality rates associated with bariatric surgery, currently at 0.2 percent at Citizens Bariatric Center.

McDaniel said he considers 2 in 1,000 patients to be an acceptable risk in any surgery, and especially so with regard to bariatric surgery, because the vast majority of the morbidly obese cannot lose weight except through surgery.

Once a person is more than 100 pounds overweight, McDaniel said, he or she has only about a 1 or 2 percent chance of losing weight successfully with diet and exercise.

“Surgery is the mainstay therapy for obesity,” McDaniel said, but he highlighted the importance that candidates for bariatric surgery must have tried diet and exercise before surgery.

“It helps put a person in the right mental frame of mind for surgery, helps them ready for a lifestyle change,” he said. “If they have not tried dieting, they might not be prepared to do it.”

Yet, however safe, convenient, and effective bariatric surgery has become, McDaniel said surgery is not the solution to the country’s struggle with obesity.

“This is a complex disease,” he said.

Patrick Brendel is a reporter for the Advocate. Contact him at 361-580-6535 or pbrendel@vicad.com, or comment on this story at www.VictoriaAdvocate.com.

Tags: gastric bypass, bariatric surgery, weight loss surgery, obesity surgery, lapband, obesity research, sleep apnea