Monday, August 26, 2013

Nuts and Bolts of Band Revisional Surgery, Part 2

Photo by M Clock
So, in keeping with the theme of the unexpected-

We went on a charter fishing trip out of Rock Harbor in Cape Cod recently.  We had a great time, caught some nice Bluefish and Sea Bass.  I came across a sticker that some may find unusual.

Why is the Captain against seals on Cape Cod?  You would think that he would be pro-sea life in general, not just certain kinds of sea inhabitants.

There is a good reason he's anti-seal of late, and you may be aware of at least part of the problem, as it involves increasing numbers of Great White sharks off of Chatham, and some of the outer Cape beaches.

Since the seals are included in a congressional act passed a number of years ago that protects them and other endangered sea life, it seems that the program has been in some ways essentially too successful.  Seals are becoming quite a nuisance, given their bloated numbers on Monmoy, and are not only an attractant to Great White Sharks, but also eating up the fish in the Bay, as well as terrorizing the commercial fisherman in the Cape Cod Bay's catch, and hence their livelihood.  More info can be found at this link to a recent NBC news report from this month.

Anyway, back to the issue at hand - Band revisional surgery.  You might want to grab a cup of coffee or tea...this one will take a little to get through.

Part 2

So, we have come to the conclusion that a patient needs a Band revisional procedure.  The next step is putting all the needed components together to assure the best chance at post operative success.  Just as important, and somewhat out of order in this discussion, is the question as to whether insurance will even cover the procedure in the first place.

There are a number of questions to ask to be able to assure insurance reimbursement, which is imperative to both the patient and ourselves, the surgical group that will do the procedure.  There are a few relatively hard and fast rules, and then a number of other variables to keep in mind. There is also the reality that things do change as far as insurance company coverage goes, and we frequently find these out in retrospect as "new" ground rules.

The easy part are the main concepts that are fairly constant.  'Covered' revisional procedures usually stem from a mechanical failure of one of the components of the Band (Band itself, or access port), or the occasional acute or chronic issues that are not able to be remedied through fluid adjustments or conservative means.  Chronic and severe reflux, recurrent gastric prolapse, and Gastric erosion falls into this category.

For the 'failure to lose weight' category, it gets a little more sticky.  Firstly, we need to screen these folks to assure that they have given the post operative care a reasonable try with regular visits, dietary adherence, exercise schedules, and adequate time from surgery (usually around 2 years).  The behavioral component by the patient will be required no matter what procedure we are converting their Band to, and weight loss and maintenance of that loss is very directly related to compliance on those behavioral variables to be successful.

Secondly, the insurance again comes in to play.  Most, but certainly not all, insurance plans follow the initial guidelines of BMI and comorbidites to 're-qualify' a patient, (BMI 35-39 with comorbidities, BMI of 40 or greater)but some consider those same standards a bit more strictly, perhaps looking for a reason not to reimburse the revisional procedure.

For example, we had a patient who didn't qualify for surgery with a BMI of 38 even with OSA recently, as the Pulmonary consult note characterized the OSA as "mild, yet still requiring an appliance" (C Pap).  We have also had experiences with patients having HTN and DM2 who were denied in the recent past due to the 'controlled' nature of their diseases, due to the fact they were only on 1 medicine (HTN) and not on insulin yet (DM 2).  The majority of our previous experience was that OSA, DM 2, and usually HTN, were relatively absolute qualifiers for insurance coverage for surgery, but not so anymore, especially when a revision is on the table.

One commonly-held local / regional HMO is adamant that no revisional procedure will be approved without a peer to peer review, and most of these remain unapproved even with that level of interaction and 'expected' qualification for surgery.

I do understand the position of the insurance company to a degree.  First, the dramatic increase in Bariatric surgeries over the past 8-10 years, and now another potential wave of 're-do's" that may need to be done.  Difficult to budget for from their perspective, and difficult to get excited about, as there truly is a paucity of evidenced-based data out there, thus far, on the likelihood of success after undergoing such a procedure.

Additionally, with some of the patients, it could be argued that there is a significant behavioral component to their failure, and it is furthermore difficult to predict who will likely do well after a revisional Band procedure.

Sorry for the lengthy insurance diversion, but it is necessary to review potential barriers to access to surgery, for better and for worse.

And lastly, from a semantics standpoint, we do require the patient to go through a majority of the same initial process that they participated in the first time, getting to their first surgical procedure.  They will need to see Psych again, their PCP for clearance, likely lose some weight (5-10%) before surgery,  get a full battery of labs tests and possibly an EGD, as well as seeing the Dietitian again to discuss both their lack of weigh loss after their last procedure in addition to the education involved in their new procedure of choice.

It is stressed throughout this pathway, essentially from the start as we entertain the possibility of a revision, that revisional surgeries are not a walk in the park.  They generally take a number of hours more to do, nationally have a 30% higher likelihood of complications, and are not guaranteed on their own to finally get the patient to lose weight long term and keep it off.

Having the patient understand that a revision is not "the easy way out", a guarantee of long term success, or a whimsical choice because "the Band isn't working for me" is key to getting off to a good start as we pursue this kind of surgery.

All the above being said, we do Band revisional surgeries with some frequency.  We have had a number of successful conversions from Band to Bypass or Sleeve.  And,  especially in the cases where patients have complications from their Bands, they are very happy to have their revisional procedures done, ameliorate their complaints, and get back to the business of losing weight and keeping it off..





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