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?
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
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
Moderate
0
20
Very
Low
Low
25
Moderate
30
35
Very
High
High
40
BMI
Gray DS. Med Clin North Am. 1989;73(1):1–13.
Obesity Related Co-Morbidities
Type II Diabetes
Hyperlipidemia
Hypertension
Cardiac Disease
CAD/CHF/LVH
Respiratory Disease
Sleep apnea
Obesity hypoventilation
syndrome
Degenerative arthritis
Depression
Pseudotumor cerebri
GERD
Nephrotic syndrome
Pre-eclampsia
Infertility
Infectious complications
Stress incontinence
Venous stasis ulcers
Hernias
Medical Co-Morbidities Resolved
after Bariatric Surgery
Type 2 Diabetes
95%
Cholesterol
97%
Hypertension
92%
GERD
98%
Cardiac Function
Improvement
95%
Stress Incontinence
87%
Osteoarthritis
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

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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?
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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

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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
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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

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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


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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

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Weight loss
Reduction or improvement in comorbidities
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:

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intestinal leakage
acute gastric remnant dilatation
obstruction
cardiopulmonary
 MI, PE, pneumonia, atelectasis
Late complications:

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anastomotic stricture (5–10%)
anemia, B12 deficiency, Ca deficiency
Chapin 1996
How are good results achieved?
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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?

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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 PreAuthorize My Surgery?

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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?
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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