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Indications contraindications

Diagnosis of morbid obesity (BMI >40) is the basic prerequisite to indicate surgical treatment. The Body Mass Index (BMI) is the most commonly used tool. Indications in accordance with Swiss legislation are listed below in Table 17.

  1. Consultation with a physician of choice
  2. Age < 60 years
  3. BMI > 40 kg/m2
  4. An adequate weight-reduction therapy of two years that failed
  5. Diagnosis of one of the following secondary diseases:
    - arterial hypertension
    - diabetes
    - sleep apnoea
    - disorders of fat metabolism (dyslipidaemia, e.g. high cholesterol)
    - degenerative mutation of the musculosceletal system
    - heart disease
    - infertility combined with hyperandrogenism
    - polycystic ovaries in females of childbearing age
  6. Surgery in a clinical centre providing interdisciplinary staff with the required level of experience (surgery, psychotherapy, nutritional counselling, internal medicine)
  7. The hospital must maintain an evaluation register.

 
Tab.17: Indications of bariatric surgery according to “Krankenpflege-
Leistungsverordnung (KLV 1.1.2000, Regulations on patient care)

Adiposity-anamnesis over several years (reference point approx. 5 years). Indication is not limited to a stable adiposity with constant excess weight. Typically body weight varies strongly depending on age and length of morbid adiposity, and is also influenced by the diets at the time (yo-yo effect), mostly though the general tendency is rising (see Conservative Therapy). Along with the weight criteria, verification of an adequate conventional therapy monitored by a physician is required. To some extent it is better if patients suffer the mental anguish of multiple unsuccessful diets of diets as then they will see surgery in its full scope as a last and final opportunity and be willing to cooperate to the utmost extent. Morbid adiposity cannot be successfully treated with conventional treatments due to the nature of its causes, which augments indication of surgery. In order to make the decision for surgical therapy, all contraindications must be carefully evaluated (Table 18).
There are controversial discussions about the age aspect. In Switzerland the age limit was set to 60yrs from January 2000 on (previously 50yrs). Our own results in the age group 50 – 60 are positive. Adolescents younger than 18 years may in fact show good results (Hell, 1998), but from a legal perspective and regarding the specific situation of puberty and adolescence, surgical therapy of these patients should be considered very carefully and only in centres with adequate paediatric departments.

  1. Lack of cooperation
     - low level of compliance: Insufficient patient cooperation caused by mental   factors and inadequate psycho-social environment
    - severe, uncontrollable eating disorders (see Behaviour and Psychology)
    - psychosis (schizophrenia, cyclothymia)
    - addictions (alcohol, drugs)
  2. Gastrointestinal diseases
    - oesophageal conditions
    - gastric ulcer
    - inflammatory bowel disease (Crohn’s Disease, Ulcerative Colitis)
    - congenital abnormalities of the upper gastrointestinal tract
  3. Endocrine diseases (hormones)
    - thyroid diseases (especially hypothyroidism combined with hormone  deficiency)
    - Cushing’s syndrome (increased production of cortisol by the adrenal glands)
    - hormone producing tumours (e.g. pituitary gland)
  4. Malign tumours
    - regardless of location of all carcinoma
  5. Specific drugs
    - cortisol (steroids)
    - cytostatics
  6. Diseases of the connective tissue
    - autoimmune diseases, systemic lupus erythematosus, scleroderma
  7. Surgical risk too high (risk-benefit analysis, previous treatment)
    - pulmonary embolism
    - unstable coronary disease
    - severe liver disease: hepatitis/liver cirrhosis
    – consumptive diseases (tuberculosis, immune deficiency)
  8. Pregnancy
    - pregnancy can only be planned postoperatively after evidence of constant   physiological conditions and weight (approx. 2 years)
  9. Dental conditions operation only after dental cleanup
  10. Silicone allergy (gastric banding only)
    - very rare
Tab.18: Absolute and relative contraindications (exclusion criteria)