What Is Obesity?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?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

BMIGray DS. Med Clin North Am. 1989;73(1):1–13.

Obesity and Mortality Risk2.5

2.0

1.5

1.0

020 25 30 35 40

MortalityRatio

Moderate VeryLow Low Moderate HighHigh Very

High

Obesity Related Co-Obesity Related Co-MorbiditiesMorbidities

Type II DiabetesHyperlipidemiaHypertensionCardiac Disease CAD/CHF/LVHRespiratory Disease Sleep apnea Obesity hypoventilation

syndrome

Degenerative arthritis

DepressionPseudotumor cerebriGERDNephrotic syndromePre-eclampsiaInfertilityInfectious

complicationsStress incontinenceVenous stasis ulcersHernias

Medical Co-Morbidities Medical Co-Morbidities Resolved after Bariatric Resolved after Bariatric

SurgerySurgery

Type 2 Diabetes 95%

Hypertension 92%

Osteoarthritis 82%

Cardiac Function Improvement

95%

Stress Incontinence 87%

GERD 98%

Cholesterol 97%

Sleep Apnea 75%

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

Non-Medical Co-Non-Medical Co-MorbiditiesMorbidities

Physical Economic Psychological Social

Why Surgery?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 NIH Consensus Conference 1991Conference 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 Who Is a Surgical Candidate?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 Roux-en-Y Gastric BypassBypass

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 How Does the Roux-en-Y Work? Work?

Surgery factors: restriction of meal size “dumping syndrome” some malabsorption decreased appetite

Patient factors: calorie intake calorie expenditure

Results of Gastric Results of Gastric Bypass*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 Laparoscopic Adjustable Gastric BandingGastric Banding

Restrictive Good results in

Europe and Australia Inamed Lap Band™

FDA approved 6/01 40-55% EBW Loss

How does the Band How does the Band work?work?

Surgery Factors: Restriction of meal size Decreased appetite

Patient Factors: Decreased calorie intake Increased calorie expenditure

Advantages of Advantages of LaparoscopyLaparoscopy

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 CourseHospital Course

Laparoscopic Bypass 2-3 days Open Bypass 4-7 days Gastric Band overnight

stay

Swallow study performed day 1-3Liquid diet startedHome when able to tolerate 3-4

oz/hour

Results of Bariatric Results of Bariatric SurgerySurgery

Weight loss Reduction or improvement in co-

morbidities Increased longevity Improved Quality of Life

health social personal work

Lifetime supplements are Lifetime supplements are necessary to prevent…necessary to prevent…

Iron Deficiency Anemia Folate Deficiency Vitamin B-12 Deficiency

Complications of Gastric Complications of Gastric BypassBypass

Early complications: intestinal leakage acute gastric remnant dilatation obstruction cardiopulmonary

MI, PE, pneumonia, atelectasis

Late complications: anastomotic stricture (5–10%) anemia, B12 deficiency, Ca deficiencyChapin 1996

How are good results How are good results achieved?achieved?

Follow ASBS recommendations Surgeon and Hospital

commitment Dedicated bariatric team Comprehensive care Lifelong follow up Database management

Weight Loss Program Weight Loss Program TeamTeam

Surgeon Nurse Practicioner Bariatric Coordinator Registered Dietician Clinical psychologist Exercise Specialist Office support staff

Will My Insurance Pay Will My Insurance Pay for This Procedure?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 What Happens if My Insurance Company Insurance Company Denies My Request?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 How Long Does it Take to Pre-Authorize My to Pre-Authorize My

Surgery?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 What Makes SacramentoSacramento BariatricBariatric

Different?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…Final Words…

* Surgery is only a tool* Surgery is only a tool

* Patients must commit to lifelong * Patients must commit to lifelong changes in dietchanges in diet

and behavior and behavior

* Think seriously about options* Think seriously about options

* We are here to help* We are here to help