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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

        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


 Ratio      1.5

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

                                            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
Respiratory Disease
                           Infectious complications
 Sleep apnea               Stress incontinence
 Obesity hypoventilation   Venous stasis ulcers
Degenerative arthritis
  Medical Co-Morbidities Resolved
       after Bariatric Surgery
                                   Type 2 Diabetes
       Cholesterol                                                       Hypertension
          97%                                                                92%

     GERD                                                                     Cardiac Function
      98%                                                                      Improvement

Stress Incontinence                                                    Osteoarthritis
        87%                                                                82%

                                     Sleep Apnea

                     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
   Medical co-morbidities are
   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
   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
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
                 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-
   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

   Each insurance plan has its own provisions and
   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
   Life-long commitment for patient access and
   Multidisciplinary resources for post-surgical needs
   Results will be pooled and compared to national
   Internet community and private bulletin boards for
   Emphasis on SAFETY and RESULTS!
            Final Words…
* Surgery is only a tool
* Patients must commit to lifelong changes in
  and behavior
* Think seriously about options
* We are here to help