Hi;

I have tried multiple times to get the horizon bc/bs reps to send me the policy and requriements for bariatric surgery and have gotten nowhere. Here is a link to the application the doctor fills out, and lo and behold, there are the requirements.

Happy surfing...

http://www.horizon-bcbsnj.com/SiteGen/Uploads/Public/horizon_bcbsnj/pdf/3684.pdf

Thanks! Great info! I got denied for that "lack of" multi disciplinary approach. If you are serious, make sure you document food intake, exercise logs and make sure your PCP knows how to document your weight loss attempts. Obesitylaw.com helped me get my band approved after this denial.

I totally recommend fitday.com or something like that. Also if you go to a gym or something your receipts of monthly payments and exercise routines or whatever you do, make sure someone documents it. I got my boot camp guy to help me.

UPDATED INFO: I did not have to do the 5 year weight loss statement. I had to:

6 month diet with office notes and letter from doctor supervising weight loss-I did Medifast, which sucked but works if you can tolerate it.

psych eval-found my psych with google search.-cost me $200 for the testing and report (insurance did not cover, even though THEY require it. Would that be ironic or just stupid?), $10 co-pay

nutritional eval-found my nutritionist with google search too. she sends a report to doctor $10 co-pay

bariatric rehab class-at the local hospital, about what to expect and exercise. Pretty basic stuff. $55

seminar with surgeons-very informative-no cost

Best of luck, and I hope I get approved soon!

Here is the medical policy. The link was open one day so I copied it Does anyone understand D.....preprinted, check off forms are not acceptable. Does that mean my WW Book for the weekly weigh ins?

E-Mail Us

Medical_Policy@Horizon-bcbsnj.com

Horizon BCBSNJ

Uniform Medical Policy Manual

Section:

Surgery

Policy Number:

022

Effective Date:

06/10/2008

Original Policy Date:

06/22/2001

Last Review Date:

11/25/2008

Date Published to Web:

08/11/2008

Subject:

Surgery for Morbid Obesity

Description:

_______________________________________________________________________________________

IMPORTANT NOTE:

The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.

Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.

__________________________________________________________________________________________________________________________

As indicated by its name, morbid obesity is defined as an increase in weight over optimal weight, which results in significant complications and a shortened life span. For example, morbid obesity has a significant impact on cardiac risk factors, incidence of diabetes, obstructive sleep apnea, and various types of cancers (for men: colon, rectum, and prostate; for women: breast, uterus, and ovaries). The first treatment of morbid obesity is obviously dietary and life style changes. Although this strategy may be effective in some patients, frequently the weight loss is not durable with only 5%-10% of patients maintaining the weight loss for more than a few years.

When conservative measures fail, some patients may consider surgical approaches. A 1991 National Institutes of Health (NIH) Consensus Conference defined surgical candidates as those patients with a body mass index (BMI) of greater than 40 kg/m2, or greater than 35 kg/m2 in conjunction with severe comorbidities such as cardiopulmonary complications or severe diabetes. Super obesity has been described as a BMI greater than 50 kg/m2.

Surgery for morbid obesity, termed bariatric surgery, falls into three general categories; (1) gastric restrictive procedures that create a small gastric pouch, resulting in weight loss by producing early satiety and thus decreasing dietary intake; (2) malabsorptive procedures, which produce weight loss due to malabsorption by altering the normal transit of ingested food through the intestinal tract; and (3) combination of both restrictive and malabsorptive components. There are multiple variants of malabsorptive procedures, which differ in the lengths of the alimentary limb, the biliopancreatic limb, and the common limb, where the alimentary and biliopancreatic limbs are anastomosed. The degree of malabsorption is related to the length of the alimentary and common limbs. For example, a shorter alimentary limb (i.e., the greater the amount of intestine that is excluded from the nutrient flow) will be associated with malabsorption of a variety of nutrients, while a short common limb (i.e., the biliopancreatic juices are allowed to mix with nutrients for only a short segment) will primarily limit absorption of fat.

The following summarizes the different bariatric procedures.

1. Vertical Banded Gastroplasty

The stomach is segmented along its vertical axis. To create a durable reinforced and rate-limiting stoma at the distal end of the pouch, a plug of stomach is removed and a propylene collar is placed through this hole and then stapled to itself. Because the normal flow of food is preserved, metabolic complications are rare. Complications include esophageal reflux, dilation or obstruction of the stoma, with the latter two requiring reoperation. Dilation of the stoma is a common reason for weight regain. Vertical-banded gastroplasty may be performed using an open or laparoscopic approach.

2. Adjustable Gastric Banding

This is the most commonly performed restrictive procedure. Adjustable gastric banding involves placing a gastric band around the exterior of the stomach. The band is attached to a reservoir that is implanted subcutaneously in the rectus sheath. Injecting the reservoir with saline will alter the diameter of the gastric band; therefore the rate limiting stoma in the stomach can be progressively narrowed to induce greater weight loss, or expanded if complications develop. Because the stomach is not entered, the surgery and any revisions, if necessary, are relatively simple. Complications include slippage of the external band or band erosion through the gastric wall. Adjustable gastric banding has been widely used in Europe. Currently, the Lap-Band Adjustable Gastric Banding System made by BioEnterics Corporation is an approved device by the U.S. Food and Drug Administration (FDA) for marketing in the United States. Another FDA-approved device is the REALIZE Adjustable Gastric Band For Morbid Obesity which is manufactured by Ethicon-Endo-Surgery, Inc. [Please refer to specific benefit coverage under the Federal Employees Health Benefits Program (FEHBP).]

3. Gastric Bypass with Short-Limb (150 cm or less) Roux-en-Y Anastomosis

The original gastric bypass surgeries were based on the observation that post-gastrectomy patients tended to lose weight. The current procedure involves division of the stomach into a smaller upper (called the pouch) and larger lower sections in association with a Roux-en-Y procedure (i.e., a gastrojejunal and a jejujejunal anastomoses). Thus the flow of food bypasses the duodenum and proximal small bowel. The procedure may also be associated with an unpleasant "dumping syndrome," in which a large osmotic load delivered directly to the jejunum from the stomach produces abdominal pain and/or vomiting. The dumping syndrome may further reduce intake, particularly in "sweets eaters." Operative complications include leakage and marginal ulceration at the anastomotic site. Because the normal flow of food is disrupted, there are more metabolic complications compared to other gastric restrictive procedures, including Iron deficiency anemia, Vitamin B-12 deficiency, and hypocalcemia, all of which can be corrected by oral supplementation. Another concern is the ability to evaluate the "blind" bypassed portion of the stomach. Gastric bypass may be performed with either an open or laparoscopic technique.

4. Mini-Gastric Bypass

Recently, a variant of the gastric bypass, called the mini-gastric bypass, has been popularized. Using a laparoscopic approach, the stomach is segmented, similar to a traditional gastric bypass, but instead of creating a Roux-en-Y anastomosis, the jejunum is anastomosed directly to the stomach, similar to a Billroth II procedure. This unique aspect of this procedure is not based on its laparoscopic approach but rather the type of anastomosis used.

5. Sleeve Gastrectomy

A sleeve gastrectomy has been proposed to be an alternative approach that can be performed on its own, or in combination with malabsorptive procedures (most commonly biliopancreatic diversion with duodenal switch). In this procedure, the greater curvature of the stomach is resected from the angle of HIS to the distal antrum, resulting in a stomach remnant shaped like a tube or sleeve. The pyloric sphincter is preserved, resulting in a more physiologic transit of food from the stomach to the duodenum, and avoiding the dumping syndrome (overly rapid transport of food through the stomach into the intestines) that is seen with distal gastrectomy. This procedure is relatively simple to perform, and can be done by the open or laparoscopic technique. Some surgeons have proposed this procedure as the first in a 2-stage procedure for very high-risk patients including those who are “super” obese (BMI>50). Weight loss following sleeve gastrectomy may improve a patient’s overall medical status, and thus, reduce the risk of a subsequent more extensive malabsorptive procedure, such as biliopancreatic diversion.

6. Endoscopic Gastric Reduction or Transoral Endoluminal Gastroplasty

The EndoGastric Solutions StomaphyX endoluminal fastener and delivery system was approved by the FDA on March 3, 2007 through the 510(k) marketing clearance as substantially equivalent to its predicate device, the Bard EndoCinch Suturing System. It is specifically indicated for use in endoluminal trans-oral tissue approximation and ligation of the GI Tract. The device uses vacuum to invaginate tissue through a port into a chamber and fasten it using H shaped polypropylene fasteners. It has been investigated as a possible minimally-invasive endoscopic procedure for patients who gain weight after bariatric surgery (e.g., due to a dilated gastrojejunal anastomoses after a Roux-en-Y procedure).

7. Biliopancreatic Bypass Procedure (also known as the Scopinaro procedure)

The biliopancreatic bypass (BPB) procedure, developed and used extensively in Italy, was designed to address some of the drawbacks of the original intestinal bypass procedures that have been abandoned due to unacceptable metabolic complications. Many of the complications were thought to be related to bacterial overgrowth and toxin production in the blind, bypassed segment. In contrast, BPB consists of a subtotal gastrectomy and diversion of the biliopancreatic juices into the distal ileum by a long Roux-en-Y procedure. The procedure consists of the following components.

A. A distal gastrectomy functions to induce a temporary early satiety and/or the dumping syndrome in the early postoperative period, both of which limit food intake.

B. A 200-cm long "alimentary tract" consists of 200 cm of ileum connecting the stomach to a common distal segment.

C. A 300- to 400-cm "biliary tract," which connects the duodenum, jejunum, and remaining ileum to the common distal segment.

D. A 50- to 100-cm "common tract," where food from the alimentary tract mixes with biliopancreatic juices from the biliary tract. Food digestion and absorption, particularly of fats and starches, are therefore limited to this small segment of bowel, i.e., creating a selective malabsorption. The length of the common segment will influence the degree of malabsorption.

E. Because of the high incidence of cholelithiasis associated with the procedure, patients typically undergo an associated cholecystectomy.

There are many potential metabolic complications related to biliopancreatic bypass, including most prominently iron deficiency anemia, Protein malnutrition, hypocalcemia, and bone demineralization. Protein malnutrition may require treatment with total parenteral nutrition. In addition, there have been several case reports of liver failure resulting in death or liver transplant.

8. Biliopancreatic Bypass with Duodenal Switch

The duodenal switch procedure is essentially a variant of the biliopancreatic bypass described above. However, instead of performing a distal gastrectomy, a "sleeve" gastrectomy is performed along the vertical axis of the stomach, preserving the pylorus and initial segment of the duodenum, which is then anastomosed to a segment of the ileum, similar to the above procedure, to create the alimentary segment. Preservation of the pyloric sphincter is designed to be more physiologic. The sleeve gastrectomy decreases the volume of the stomach and also decreases the parietal cell mass, with the intent of decreasing the incidence of ulcers at the duodenoileal anastomosis. However, the basic principle of the procedure is similar to that of the biliopancreatic bypass; i.e., producing selective malabsorption by limiting the food digestion and absorption to a short common ileal segment.

9. Long Limb Gastric Bypass (i.e., >150 cm)

Recently, variations of gastric bypass procedures have been described, consisting primarily of long limb Roux-en-Y procedures. For example, the stomach may be divided with a long segment of the jejunum (instead of ileum) anastomosed to the proximal gastric stump, creating the alimentary limb. The remaining pancreaticobiliary limb, consisting of stomach remnant, duodenum, and length of proximal jejunum is then anastomosed to the ileum, creating a common limb of variable length in which the ingested food mixes with the pancreaticobiliary juices. The stomach may be bypassed in a variety of ways, i.e., either by resection/division or stapling along the horizontal or vertical axis. Unlike the traditional gastric bypass, which is essentially a gastric restrictive procedure, these very long limb Roux-en-Y gastric bypasses combine gastric restriction with some degree of malabsorption, depending on the location of the anastomoses.

Policy:

[iNFORMATIONAL NOTE: When significant weight loss is achieved such as is typically the case after bariatric procedures for morbid obesity, it is not uncommon for the patients to be left with a significant amount of redundant skin (e.g., in the abdomen, breasts, thighs and arms). Procedures to remove the redundant skin are typically considered to be cosmetic. The eligibility of procedures and/or services related to, or resulting from, a prior surgical procedure for morbid obesity is determined by the patient’s specific contract benefits.

When the patient’s contract does not specifically exclude such procedures and/or services, they are subject to review for medical necessity. Medical policies pertaining to the covered person’s condition should be consulted, as applicable (e.g., Policy #025 on Abdominoplasty, Policy #028 on Reduction Mammaplasty, and Policy #001 on Cosmetic Procedures including excision of excessive skin and subcutaneous tissue and suction assisted lipectomy, under the Surgery Section). The approval of a bariatric procedure for medical necessity should not be interpreted to be an automatic approval for procedures that address the sequelae of significant weight loss, nor should it create the expectation that such procedures will be approved.]

I. Contract exclusions and/or limitations for surgery for morbid obesity (bariatric surgery) will determine the available benefit.

[iNFORMATIONAL NOTE: Some contracts specifically exclude surgery for morbid obesity (bariatric surgery). Please refer to the group’s or individual member’s contract benefit language to determine benefit availability.]

II. If it is NOT specifically excluded by the member's contract, surgery for morbid obesity (bariatric surgery) is considered medically necessary when all of the following lettered criteria are met:

A. The surgical procedure is one of the following types:

• 
  
  • 
    
    • Laparoscopic adjustable gastric banding;
      [iNFORMATIONAL NOTE: Please refer to specific benefit coverage for adjustable gastric banding under the Federal Employees Health Benefits Program (FEHBP).]
      
    • Vertical-banded gastroplasty;
      
    • Gastric bypass with short-limb (i.e., 150 cm or less) or long-limb (i.e., greater than 150 cm) Roux-en-Y anastomosis;
      
    • Biliopancreatic diversion and duodenal switch.
      

[iNFORMATIONAL NOTE: According to the Consensus Conference Panel Statement presented at the Georgetown University Conference Center, Washington, DC, May 2004, "Standard of care for bariatric surgery includes use of laparoscopic and open techniques.]

B. The member is at least 18 years of age and/or has reached full skeletal growth. Bariatric surgery is considered NOT medically necessary for members under 18 years of age unless the member has already achieved full skeletal growth and has a life threatening co-morbidity (i.e., pseudotumor cerebri, severe sleep apnea, uncontrollable hypertension, incapacitating musculoskeletal disease, etc.).

[iNFORMATIONAL NOTE: According to published medical literature, bone age can be objectively assessed with radiographs of the hand and wrist.]

C. The member has morbid obesity. Morbid obesity is defined as either:

1. A body mass index (BMI) greater than 40 kg/m2; or

2. A BMI between 35 kg/m2 and 40 kg/m2 with one or more of the following life-threatening, obesity-related co-morbidities which is (are) being treated or managed, and is (are) generally expected to be improved, curtailed, or reversed by obesity surgical management:

• 
  
  • 
    
    • 
      
      • coronary artery disease
        
      • obesity-related cardiomyopathy
        
      • congestive heart failure
        
      • obstructive sleep apnea
        
      • Pickwickian syndrome
        
      • insulin resistance or frank diabetes mellitus
        
      • clinically significant asthma
        
      • chronic venous insufficiency of the lower extremities
        
      • gastroesophageal reflux disease (GERD)
        
      • pain and limitation of motion in any weight-bearing joint or the spine
        
      • hypertension
        
      • pseudotumor cerebri
        
      • polycystic ovarian syndrome
        
      • metabolic syndrome
        
      • hyperlipidemia (hypercholesterolemia and/or hypertriglyceridemia)
        
      • non-alcoholic fatty liver (NASH)
        
      • osteoarthritis
        
      • depression.
        

[iNFORMATIONAL NOTE: BMI is calculated by dividing a patient’s weight (in kilograms) by height (in meters) squared.

• 
  
  • 
    
    • 
      
      • To convert pounds to kilograms, multiply pounds by 0.45
        
      • To convert inches to meters, multiply inches by .0254]
        

D. Within the 12 months prior to the time of surgery, the member must meet all of the following requirements:

1. Documentation of successful completion of at least 6 consecutive months of supervised conservative weight loss program, diet programs/plans (e.g., Weight Watchers, Jenny Craig), or the Horizon Obesity Disease Management Program.

Successful completion means formal documentation or photocopies/print-outs of progress notes of at least monthly follow-up by the supervising physician, other health care provider, or program coordinator including the patient’s weight and progress relative to the goals set at the start of the program.

(NOTE: Pre-printed check-off forms and summary letters are NOT acceptable documentation for this requirement.)

[iNFORMATIONAL NOTE: Programs supervised by a registered dietitian may not be a covered service under a member's contract.]

2. Documentation of participation in an organized multidisciplinary surgical preparatory regimen in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the member's ability to comply with post-operative medical care and dietary restrictions. The regimen should provide guidance on diet, physical activity, and behavioral and social support prior to and after the surgery.

Documentation should include physician's initial assessment of the member, and the physician's assessment of the member's progress at the completion of the multidisciplinary surgical preparatory regimen.

3.Documentation of pre-operative psychological evaluation provided by a licensed mental health care professional familiar with the implications of weight reduction surgery. (Please note that psychological testing is NOT included in this requirement.)

[iNFORMATIONAL NOTE: It should be noted that all bariatric surgeries require a high degree of patient compliance. For gastric restrictive procedures the weight loss is primarily due to reduced caloric intake, and thus the patient must be committed to eating small meals, reinforced by early satiety. For example, gastric restrictive surgery will not be successful in patients who consume high volumes of calorie rich liquids. In addition, patients must adhere to a balanced diet, including proper micronutrient supplementation, to avoid metabolic complications. (Micronutrients are defined as Vitamins, minerals, and trace elements.)

The high potential for metabolic complications requires life-long follow-up. Therefore, patient selection is a critical process, often requiring psychiatric evaluation and a multidisciplinary team approach.]

III. The following procedures are considered investigational:

• 
  
  • Mini-gastric bypass
    
  • Sleeve gastrectomy (either as a sole procedure or as one step in a staged procedure);
    
  • Endoscopic Gastric Reduction (also known as transoral endoluminal gastroplasty).
    

[iNFORMATIONAL NOTE: There is limited data published in the medical literature to evaluate outcomes of sleeve gastrectomy as a stand-alone procedure and to compare its efficacy with other procedures. Furthermore, the published data on outcomes following completion of both stages of a 2-stage operation are limited to case reports and case series with very small number of patients. According to the ECRI Health Technology Assessment Information Service Custom Hotline Response on Laparoscopic Sleeve Gastrectomy for Morbid Obesity (last updated 01/22/2007), “None of the studies reported weight loss at three years or more after the operation, which we consider the most important outcome measure for these studies to report. Earlier follow-up periods may not provide data indicative of the eventual results of the surgery and do not provide sufficient time to assess the possible long-term complications of this surgery”.]

IV. Repeat bariatric surgery or any subsequent modification should be handled on an individual case basis and reviewed by the medical director. Supporting documentation should at least include a clear explanation of the clinical circumstances as to why the procedure failed, the member’s BMI, and the results of any diagnostic tests or studies performed.

Since members are expected to be compliant with the postoperative requirements, members who have failed bariatric surgery because of noncompliance and wish to be considered for revision surgery must be actively reintegrated into an established multidisciplinary bariatric program. These patients must demonstrate compliance to the bariatric surgeon through enrollment in a multidisciplinary bariatric program including psychological intervention nutritional counseling, and support group attendance.

A distinction between clinical failure and technical failure must be established.

A. A clinical failure is defined as weight regain, inspite of an intact, functional operation. In these instances, reintegration into a multidisciplinary bariatric program and psychological re-evaluation are required. If the member is able to demonstrate the probability of complying with the postoperative requirements (e.g., diet , physical activity, etc.), repeat bariatric surgery or any subsequent modification of the original bariatric surgery may be considered medically necessary. Otherwise, any further surgical intervention is considered not medically necessary.

B. A technical failure is defined as a breakdown of the operation itself (i.e., staple line disruption, fistula formation, dilatation of the pouch, marginal ulceration, band slippage, anastomotic dilatation, etc.). In these instances, psychological re-assessment of the patient is not mandatory.

[iNFORMATIONAL NOTE: Band adjustment is a regular part of follow-up for adjustable gastric banding. All adjustments done within 90 days from band implantation are considered part of the global surgical service. Any subsequent adjustment beyond this period is eligible for separate reimbursement if the band implantation was deemed medically necessary.]

________________________________________________________________________________________

Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

___________________________________________________________________________________________________________________________

Index:

Surgery for Morbid Obesity

Adjustable Gastric Banding

Banding, Gastric

Bariatric Surgery

Biliopancreatic Bypass Procedure

Biliopancreatic Diversion

Bypass, Biliopancreatic

Bypass, Gastric

Duodenal Switch, Biliopancreatic Bypass with

Endoluminal Gastroplasty, Transoral

Endoscopic Gastric Reduction

Gastrectomy, Sleeve

Gastric Banding

Gastric Bypass

Gastric Reduction, Endoscopic

Gastric Restrictive Surgery

Gastroplasty

Lap-Band Adjustable Gastric Banding System

Laparoscopic Adjustable Gastric Banding

Laparoscopic Gastric Bypass

Laparoscopic Mini-Gastric Bypass

Laparoscopic Sleeve Gastrectomy

Long Limb Gastric Bypass

Malabsorptive Procedures

Morbid Obesity, Surgery for

Mini-Gastric Bypass

Obesity, Morbid, Surgery for

Scopinaro Procedure

Sleeve Gastrectomy

Transoral Endoluminal Gastroplasty

Vertical Banded Procedures

References:

1. Blue Cross and Blue Shield Association. Medical Policy Reference Manual: Surgery for Morbid Obesity. 5:2006: Policy #7.01.47 (and its associated references).

2. ECRI. Health Technology Trends. FDA clears stomach band for obesity. Vol.13 No.7. July 2001.

3. Weiner R, Bockhorn H, Rosenthal R, et al. A prospective randomized trial of different laparoscopic gastric banding techniques for morbid obesity. Surg Endosc. 2001 Jan;15(1):63-68.

4. Cadiere G, Himpens J, Vertruyen M, et al. Laparoscopic Gastroplasty (Adjustable Gastric Banding). Semin Laparosc Surg. 2000 Mar;7(1):55-65.

5. Fielding GA, Rhodes M, Nathanson LK. Laparoscopic gastric banding for morbid obesity. Surgical outcomes in 335 cases. Surg Endosc. 1999 Jun;13(6):550-554.

6. Dargent J. Laparoscopic Adjustable Gastric Banding: Lessons from the First 500 Patients in a Single Institution. Obes Surg. 1999 Oct;9(5):446-452.

7. Belachew M, Legrand M, Vincent V, et al. Laparoscopic Adjustable Gastric Banding. World J Surg. 1998 Sep;22:955-963.

8. Improvement of physical functioning of morbidly obese patients who have undergone a Lap-Band operation: one-year study. Obes Surg. 1999 Aug;9(4):399-402.

9. Furbetta F, Gambinotti G, Robortella EM. 28-month experience with the lap-band technique; results and critical points of the method. Obes Surg. 1999 Feb;9(1):56-58.

10. DeMaria EJ, Sugerman HJ, Meador JG, et al. High Failure Rate After Laparoscopic Adjustable Silicone Gastric Banding for Treatment of Morbid Obesity. Annals of Surgery. 2001 Jun;233(6):809-818.

11. National Institutes of Health. Consensus Development Conference Panel. Gastrointestinal surgery for severe obesity. Ann Int Med 1991;115:956-61.

12. MacLean LD, Rhode BM, Forse RA. Late results of vertical banded gastroplasty for morbid and super obesity. Surgery 1990;107:20-27.

13. Willbanks OL. Long term results of silicone elastomer ring vertical gastroplasty for the treatment of morbid obesity. Surgery 1987;101:606-10.

14. Brolin RE. Results of obesity surgery. Gastroenterol Clin North Am 1987;16:317-35.

15. Kolanowski J. Gastroplasty for morbid obesity: The internist’s view. Int J Obesity 1995;19(suppl):S61-S65.

16. Melissas J, Christodoulakis M, Spyridakis et al. Disorders with clinically severe obesity: Significant improvement after surgical weight loss. Sout Med J 1998;91:1143-48.

17. Griffen WO, Printen KJ eds. Gastric bypass in surgical management of surgical obesity. New York, NY. Marcel Dekker, Inc, 1987:27-45.

18. Pories WJ, Swanson MS, MacDonald KG, et al. Who would have thought it? An operation proves to be the most effective therapy for adult onset diabetes mellitus. Ann Surg 1995;222:339-52.

19. Flickinger EG, Sinar DR, Swanson M. Gastric bypass. Gastroenterol Clin North Am 1987;16:283-92.

20. Cowan GSM, Buffington CK. Significant changes in blood pressure, glucose and lipids with gastric bypass surgery. World J Surg 1998;22:987-92.

21. Sugarman HJ, Starkey JV, Birkenhauer R. A randomized prospective trial of gastric bypass versus vertical banded gastroplasty for morbid obesity and their effects on sweets versus non-sweet eaters. Ann Surg 1987;205:618-24.

22. Fobi MA, Fleming AW. Vertical banded gastroplasty vs. gastric bypass in the treatment of obesity. J Natl Med Assoc 1988;78:1091-98.

23. Doherty C, Maher JW, Heitshusen DS. Prospective investigation of complications, reoperations and sustained weight loss with an adjustable gastric banding device for treatment of morbid obesity. J Gastrointest Surg 1998;2:102-08.

24. Doherty C, Maher JW, Heitshusen DS. An interval report on prospective investigations of adjustable silicone gastric banding devices for the treatment of severe obesity. Eur J Gastroenterol Hepatol 1999;11:115-19.

25. Miller K, Hell E. Laparoscopic adjustable gastric banding: a prospective 4 year follow up study. Obesity Surg 1999;9:183-87.

26. Suter M, Giusti V, Heraief E, et al. Eary results of laparoscopic gastric banding compared with open vertical banded gastroplasty. Obesity Surg 1999;9:374-80.

27. Scopinaro N, Gianetta E, Adami GF. Biliopancreatic diversion for treatment of morbid obesity: Experience in 180 consecutive cases. Obesity Surg 1999;9:161-65.

28. Nanni G, Balduzzi GF, Capuluongo R, et al. Biliopancreatic diversion: Clinical experience. Obesity Surg 1997;7:26-29.

29. Murr MM, Balsiger BM, Kennedy FP, et al. Malabsorptive procedures for severe obesity; Comparison of pancreaticobiliary bypass and very long limb Roux-en-Y gastric bypass. J Gastrointest Surg 1999;3:607-12.

30. Grimm IS, Schindler W, Halusza O. Steatohepatitis and fatal hepatic failure after biliopancreatic diversion. Am J Gastroenterol 1992;87:775-79.

31. Langdon DE, Leffingwell T, Rank D. Hepatic failure after biliopancreatic diversion. Am J Gastroenterol 1993;88:321.

32. Sugarman HJ, Kellum JM, DeMaria EJ. Conversion of proximal to distal gastric bypass for failed gastric bypass for superobesity. J Gastrointest Surg 1997;1:517-25.

33. Marceau P, Hould FD, Simrad S, et al. Biliopancreatic diversion with duodenal switch. Word J Surg 1998;22:947-54.

34. Hess DS, Hess DW. Biliopancreatic bypass with a duodenal switch. Obes Surg 1998;8:267.

35. Baltasar A, Del Rio J, Excriva C, et al. Preliminary results of the duodenal switch. Obesity Surg 1997;7:500-04.

36. Mason EE, Doherty C, Maher JW, et al. Super obesity and gastric reduction procedures. Gastroenterol Clin North Am 1997;16:495-502.

37. Brolin RE. Results of obesity surgery. Gastroenterol Clin North Am 1987;16:317-336.

38. Angrisani L, Furbetta F, Doldi SB et al. Lap Band adjustable gastric banding system. Surg Endosc 2002 Dec 4;[epub ahead of print].

39. Vertruyen M. Experience with Lap-band System up to 7 years. Obes Surg 2002 Aug;12(4):569-72.

40. Belachew M, Belva PH, Desaive C. Long-term results of laparoscopic adjustable gastric banding for the treatment of morbid obesity. Obes Surg 2002 Aug;12(4):564-8.

41. Rubensteing RB. Laparoscopic adjustable gastric banding at a U.S. center with up to 3-year follow-up. Obes Surg