IH Newsletter - Spring 2016
The facts about Mettias v. US:
by: Livia Kogan, RPA-C | Clinical Coordinator | Bellevue Hospital Center
When news broke about the verdict in this case, I wondered if and how our program should change in response. To help figure out where to go from here, I reviewed the court docket online. There are facts that people have not regularly mentioned when discussing the case, but are pertinent to the verdict.
- The patient’s approximate BMI upon referral and entry into the program was 41 with no obesity related co-morbidities, dropping down to about 36 at the time of surgery, with a ~34 lbs weight loss.
- The patient was started on Orlistat while her BMI was <40, with consistent weight loss in the healthy lifestyle program provided by the bariatric program
- Her BMI at the time of booking with the bariatric surgeon was recorded as 34.35, but this was calculated with the incorrect height. Her actual BMI at the time of surgery booking was 36.6.
- The incorrect height was used again on the day of surgery for a BMI of 34.3. Her actual BMI on this day was 36.
- The hospital’s website states that a patient’s weight on the day of surgery is the weight that will qualify the patient for bariatric surgery.
From reviewing the details of the case, one of the key points of contention between the two sides appears to be this: at what point during a patient’s evaluation process should the BMI be calculated to determine eligibility for bariatric surgery? Put more simply, which weight counts? Is it the weight upon initial entrance into the program? When meeting with the surgeon? When booked and given a date for surgery? Or is it the patient’s weight on the day of surgery, which often occurs months after the patient’s first visit to the bariatric program that should be used?
It is imperative that the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) and the American Society for Metabolic and Bariatric Surgery (ASMBS) come to a consensus on this issue. The current IFSO position statement is that as long as the BMI requirement is met upon admission into a bariatric program, this qualifies the patient for surgery and the BMI does not need to be revisited on the day of surgery or otherwise. This statement has yet to be adopted by the ASMBS.
After seven years of working with a bariatric program that now operates on nearly 1000 patients a year, I believe that a patient’s BMI that should be used to establish eligibility for bariatric surgery should be calculated on the day of booking. This is when the procedures are thoroughly explained to the patient, the risks and benefits discussed, and when the patient has the opportunity to ask questions about the surgery.
This early preoperative visit is also when we talk with our patients about the importance of starting to change their dietary habits and their lifestyle in order to prepare them for what is to come after surgery. We actively encourage our patients to start losing weight through diet and exercise prior to surgery, both because it mentally readies them for the operation and because it has been shown to decrease the risk of surgical complications. This is in fact the premise behind putting patients on a liquid diet for two weeks preoperatively – this has been demonstrated to decrease the size of the liver and thus make the gastroesophageal junction more accessible to the surgeon. Thus, preoperative weight loss should be encouraged in bariatric patients. If we were to accept the position that the patient’s BMI on the day of surgery should determine their eligibility, we would in effect be penalizing the patient who enrolled into a bariatric program at a qualifying BMI who then successfully lost some weight preoperatively through nonsurgical means. If patients’ surgeries are cancelled due to excess preoperative weight loss, the natural and undesirable consequence will be that patients will not attempt to lose weight prior to surgery.
It was argued in the court case that when the patient’s BMI decreased to less than 35 prior to surgery, that the risks in having bariatric surgery at that point exceeded the benefits. It is unclear to me why this statement was made, as there have been studies demonstrating significant health benefits with bariatric surgery in patients with a BMI between 30 and 35. Weight loss through non-surgical means is rarely sustainable in the long term, as both scientific inquiry and the anecdotal evidence of fad and yo-yo dieters has shown. Bariatric surgery, despite its inherent risks, has been demonstrated to provide many patients with the best chance of sustainable weight loss, as well as improvement in co-morbidities such as diabetes.
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Poster on Best Practices displayed at the Obesity Week Conference in November 2015.
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