I was recently asked the intriguing question above by a patient. As follows the dilemma in the individual’s own words:
I am looking for advice, I am a gastric band patient and had my band fitted in 2009
Whilst I lost a significant amount of weight, I was never without heartburn, reflux or vomiting (I have had a fill under x-ray to rule out any complications).I have not reached my desired weight and am contemplating further surgery. The bypass is the gold standard and if I am going to the cost and hassle of further surgery I want to make sure it will work
However, as my BMI is around 26 – which technically makes me overweight – I am having difficulties organising this. It appears that I can have a gastric sleeve but not a bypass In fact asking for a bypass is like asking someone to sew another head on me. Could you be more specific with the risks of bypass at a lower BMI?
I don’t understand that at a BMI of 35 (and say with hypertension) it is not possible but one point up to 36 and it’s ethical. If you’re overweight with a background of poor weight control would it not make sense?
Before I comment on the rationale for the guidelines regarding the BMI cut-off, I would just like to point out some of the inaccurate perceptions above. First, neither sleeve nor bypass would be an option at a BMI 26. In fact none of the bariatric procedures would be offered at a BMI which is just slightly over an ideal BMI of 25. Second, a band can be offered at a BMI of 30 or above, sleeve and bypass at a BMI of 35 and above with any obesity related co-morbidity.
Now that we’ve got the facts out of the way, I would honestly have to say that I fully understand and appreciate the point this person is trying to make. Obviously, the gastric band has worked and led to successful weight loss, however at a price. Constant reflux, heartburn and occasional vomiting are quality of life issues which can be frustrating but are common with band and to a lesser extent sleeve. The solution could possibly be conversion to a bypass. Not at a BMI of 26 though. This brings us to the inevitable dilemma of explaining the guidelines.
BMI guidelines
BMI guidelines were put into place to acknowledge the risk posed by surgery in the face of a condition which historically was not seen as a disease (although some countries have recently classified obesity as a disease). So the benefit-risk ratio is unfavourable at any BMI up to 35, bands are allowed at lower BMIs as the risk profile of surgery is very small. This has nothing to do with cost-effectiveness.
In the future two things may happen to change the guideline BMI downwards; the risk profile for surgery such as sleeve and bypass will continue to improve and research may show that operating on lower BMI patients has clear benefits in reversing but also preventing the occurrence of obesity related conditions such as type 2 diabetes.
Until that happens, don’t blame your surgeon if they turn you down. They are only acting in your best interests.
