we did observe that the average MMP patient waited over 3 months longer for surgery
than the non-MMP patients. There were several unique aspects of our study that further
our understanding of MMPs. The current literature investigating the benefits of MMPs is
sparse and is hampered by confounding factors such as multiple surgeons, ill-defined
weight loss metrics, and heterogeneous, unstructured medical weight loss programs.
Our study was limited to a single surgeon, and our MMP patients underwent a standardized
medical program for at least 6 months at our bariatric center. In addition, regardless of
insurance criteria, all patients underwent nutritional counseling with a team of two “surgical”
dieticians at our center and were placed on a standardized low-calorie, 2-week preoperative
liquid diet. Furthermore, we clearly defined the time intervals before surgery and the method for
calculating %EWL. Finally, our investigation is, to our knowledge, the only published
study that compares weight loss outcomes between MMP and non MMP groups during
the pre and postoperative phase for both LRYGB and LAGB.
Our study has some limitations. First, our follow-up did not go beyond 1 year. This may
be insufficient to fully examine weight loss in LAGB patients, as the weight nadir in this
group is thought to be 2 to 3 years after surgery. In addition, our follow-up period was
insufficient to formulate any conclusions about the effect of MMPs on prevention of
weight regain after LRYGB. Furthermore, our study did not examine the effect of MMPs
on preoperative attrition, complications or resolution of comorbid conditions. Finally, although
larger than most published studies, our LAGB patient population size was
limited, especially in the 12-month follow up LAGB group.
Morbid obesity is a complex disease that can involve abnormalities in behavior,
metabolism and neural and endocrine pathways. While effective, surgery is not for
everyone and most surgeons support the concept of thorough psychological and
nutritional counseling before surgery. The duration and type of preoperative therapy and
evaluations should be individualized, and there are clearly patients who benefit from a
prolonged period of intensive behavioral and psychological preoperative therapy.
However, we disagree with the practice of arbitrarily requiring all patients to undergo a
fixed time period, mandated medical program before surgery. Physicians, as opposed to
the insurance industry, should determine if and when a patient is ready for surgery.
Finally, because MMPs prolong the preoperative phase, it is likely that they increase
health care utilization and inflate the costs associated with bariatric surgery.
Many insurance companies require patients to participate in a medical weight loss
program before surgery. According to our data, MMPs do not significantly improve
weight loss before or after LRYGB or LAGB; however, they significantly increase the
wait time for surgery. Thus, we believe that the insurance industry should abandon the
practice of mandating preoperative medical weight loss programs. In addition, further
research is necessary to determine the effect of MMPs on the durability of bariatric
surgery and health care utilization and costs.
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