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					            What Is Obesity?
   A life-long, progressive, life-threatening,
    costly, genetically-related, multi-factorial
    disease of excess fat storage with multiple
    co-morbidities




                                                   ASBS
        What Is Morbid Obesity?

   Clinically severe obesity at which point
    serious medical conditions occur as a direct
    result of the obesity
   Defined as >200% of ideal weight, >100 lb
    overweight, or a Body mass index of 40
Obesity and Mortality Risk
            2.5


            2.0

Mortality
 Ratio      1.5


            1.0
                              Very                                                     Very
                  Moderate    Low         Low     Moderate             High            High
             0
                         20          25         30              35               40

                                            BMI
                                            Gray DS. Med Clin North Am. 1989;73(1):1–13.
Obesity Related Co-Morbidities
Type II Diabetes           Depression
Hyperlipidemia             Pseudotumor cerebri
Hypertension               GERD
Cardiac Disease            Nephrotic syndrome
                           Pre-eclampsia
 CAD/CHF/LVH
                           Infertility
Respiratory Disease
                           Infectious complications
 Sleep apnea               Stress incontinence
 Obesity hypoventilation   Venous stasis ulcers
 syndrome
                           Hernias
Degenerative arthritis
  Medical Co-Morbidities Resolved
       after Bariatric Surgery
                                   Type 2 Diabetes
                                        95%
       Cholesterol                                                       Hypertension
          97%                                                                92%




     GERD                                                                     Cardiac Function
      98%                                                                      Improvement
                                                                                    95%




Stress Incontinence                                                    Osteoarthritis
        87%                                                                82%

                                     Sleep Apnea
                                         75%



                     Wittgrove AC,Clark GW. Laparoscopic Gastric bypass roux-n-y-500 patients. Obes Surg 2000. And others.
Non-Medical Co-Morbidities

       Physical
       Economic
       Psychological
       Social
               Why Surgery?
   Diet and exercise are not effective
    long term in the morbidly obese
   Surgery is an accepted and effective
    approach
   Medical co-morbidities are
    improved/resolved
   Surgical risk is acceptable vs. risk of long-
    term obesity
NIH Consensus Conference 1991

   Surgery is an accepted and effective
    approach that provides consistent,
    permanent weight loss for morbidly obese
    patients
   Surgery indicated in patients with:
     BMI of 40 or over
     BMI of 35-40 with significant co-morbidity

     documented dietary attempts ineffective
Who Is a Surgical Candidate?
   Meets NIH criteria
   No endocrine cause of obesity
   Acceptable operative risk
   Understands surgery and risks
   Absence of drug or alcohol problem
   No uncontrolled psychological conditions
   Consensus after bariatric team evaluation:
     Surgeon/Dietician/Psychologist/Consultant
   Dedicated to life-style change and follow-up
Roux-en-Y Gastric Bypass

                 Combination
                 Most frequently
                  performed bariatric
                  procedure in the US
                 First done in 1967
                 Laparoscopically
                  since 1993
                 60-70% EBW 14yr
                  follow-up
                                   ASBS
How Does the Roux-en-Y Work?
     Surgery factors:
       restriction of meal size
       “dumping syndrome”
       some malabsorption
       decreased appetite

     Patient factors:
       calorie intake
       calorie expenditure
       Results of Gastric Bypass*
   Longest and most thorough follow-up
   Significant and durable weight loss
   Control of adult onset diabetes mellitus
   Control of hypertension
   Long term improvement in health and
    physical functioning

                    *Results achieved in most but not all cases. Degree of improvements vary by individual
Laparoscopic Adjustable Gastric
          Banding
                 Restrictive
                 Good results in Europe
                  and Australia
                 Inamed Lap Band™
                  FDA approved 6/01
                 40-55% EBW Loss
     How does the Band work?
Surgery Factors:
 Restriction of meal size

 Decreased appetite



Patient Factors:
 Decreased calorie intake

 Increased calorie expenditure
      Advantages of Laparoscopy
   Fewer wound complications/infection
   Decreased rate of incisional hernias
   Less pain and faster recovery
   Surgeon has better view of the anatomy
   Quicker return to work/activities
   Shorter hospitalization
                              Nguyen 2001, Wittgrove 2000, Schauer 2000, Watson 1997
             Hospital Course
   Laparoscopic Bypass 2-3 days
   Open Bypass         4-7 days
   Gastric Band        overnight stay

Swallow study performed day 1-3
Liquid diet started
Home when able to tolerate 3-4 oz/hour
Results of Bariatric Surgery
   Weight loss
   Reduction or improvement in co-
    morbidities
   Increased longevity
   Improved Quality of Life
     health
     social
     personal
     work
    Lifetime supplements are
     necessary to prevent…

   Iron Deficiency Anemia
   Folate Deficiency
   Vitamin B-12 Deficiency
Complications of Gastric Bypass
   Early complications:
       intestinal leakage
       acute gastric remnant dilatation
       obstruction
       cardiopulmonary
           MI, PE, pneumonia, atelectasis

   Late complications:
       anastomotic stricture (5–10%)
       anemia, B12 deficiency, Ca deficiency   Chapin 1996
    How are good results achieved?
   Follow ASBS recommendations
   Surgeon and Hospital commitment
   Dedicated bariatric team
   Comprehensive care
   Lifelong follow up
   Database management
Weight Loss Program Team
   Surgeon
   Nurse Practicioner
   Bariatric Coordinator
   Registered Dietician
   Clinical psychologist
   Exercise Specialist
   Office support staff
    Will My Insurance Pay for This
             Procedure?

   Each insurance plan has its own provisions and
    exclusions
   Contact your employer and ask if your insurance
    has coverage for treatment of morbid obesity
   What does “coverage” really mean?
    What Happens if My Insurance
    Company Denies My Request?

   You have the right to appeal
   Use supportive documentation from your
    PCP and surgeon (receipts, programs, gym
    memberships, ect.)
    How Long Does it Take to Pre-
       Authorize My Surgery?

   Each insurance company has their own set
    of rules
   They commonly request more information
    before approving or disapproving
   The process takes from 1 hour to 2 weeks,
    and as long as months
            What Makes
    Sacramento Bariatric Different?
   Integrated program modeled after NIH and ASBS
    criteria.
   Life-long commitment for patient access and
    follow-up
   Multidisciplinary resources for post-surgical needs
   Results will be pooled and compared to national
    data
   Internet community and private bulletin boards for
    patients.
   Emphasis on SAFETY and RESULTS!
            Final Words…
* Surgery is only a tool
* Patients must commit to lifelong changes in
 diet
  and behavior
* Think seriously about options
* We are here to help

				
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