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through a port in the abdominal wall. One surgeon says the procedure could take off if patients can "get over the gross factor of flushing out the contents of their stomach, almost like medical bulimia." Laparoscopic gastric banding remains a viable option, though it seems to have fallen out of favor in recent years, likely due to the meteoric rise of the sleeve gastrectomy. "Most of my patients — I'd say 90% — want the sleeve gastrectomy," says Mustafa Ahmed, MD, FACS, a bariatric surgeon with Southern Nevada Bariatrics in Las Vegas. "Initially, nobody wants bypass because they know it's a more invasive procedure, but if someone has a con- traindication for the sleeve, I try to help them see that bypass may be their best option." If the patient has GERD or insulin-dependent diabetes, for example, bypass can essentially "cure" both conditions. Likewise, if the patient is severely obese, with a body mass index in the mid-50s or higher, Dr. Ahmed says gastric bypass may be more effective in helping the patient lose more of their excess weight than, say, the sleeve gastrec- tomy: 75% versus 55% to 65%. Obese patients have unique risks related to anesthesia and potential airway complications. As Dr. Brethauer puts it, surgical facilities that offer these procedures must have several "safety nets" in place. This would include agreements to transfer patients to a hospital if they require a higher level of care after any bariatric procedure, says Dr. Brethauer. Patient evaluation before any bariatric procedure must include a thor- ough medical assessment — including BMI analysis — to determine the risk for their procedure. The goal is to make the patient as "bulletproof" as possible, including identifying and addressing previously undiag- nosed illnesses. For operations such as the sleeve gastrectomy, patients must also undergo nutritional and psychological evaluations. 1 1 0 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • S E P T E M B E R 2 0 1 7