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Laparoscopic Sleeve Gastrectomy Recent Literature Review Surgeon Date.

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Presentation on theme: "Laparoscopic Sleeve Gastrectomy Recent Literature Review Surgeon Date."— Presentation transcript:

1 Laparoscopic Sleeve Gastrectomy Recent Literature Review Surgeon Date

2 | January 28, 2010 | 2 | Agenda Introduction Review of Bariatric Surgery Weight Loss for Sleeve Gastrectomy Comparative Studies Case Studies Complications for Sleeve Gastrectomy Obesity Related Disease Outcomes for Sleeve Gastrectomy Comparative Studies Case Studies Implementation of Sleeve Gastrectomy as a Covered Procedure

3 | January 28, 2010 | 3 | John Doe, M.D., F.A.C.S. Titles Disclosures Consulting Research Stock

4 | January 28, 2010 | 4 | Sleeve Gastrectomy Bariatric procedure originally as part of Biliopancreatic Diversion and Duodenal Switch (BPDDS) Remove part of stomach, creating a sleeve from antrum to esophagus. A bougie or nasogastric tube is used to size the sleeve Utilizes same instrumentation as other bariatric procedures Surgeon Training Programs Fellowships Resident Training CME courses Clinical Immersion

5 | January 28, 2010 | 5 | Bariatric Surgery Adjustable Gastric Banding (AGB) Sleeve Gastrectomy (SG) Roux-en-Y Gastric Bypass (RNYGB) Biliopancreatic Diversion/Duoden al Switch (BPDDS) Mechanism of Action Restrictive Malabsorptive Hormonal Malabsorptive Hormonal Restrictive Benefits Low Complications Good Weight Loss Continuous GI Tract Reduces Hunger Better Weight Loss Early Effect on Diabetes Best Weight Loss % of Cases In %5%45%5% ASMBS, Rational for Bariatric Surgery,

6 | January 28, 2010 | 6 | Two Year Weight Loss and Mortality Adapted from Buchwald H, et al, Bariatric surgery, a systematic review and meta-analysis, JAMA. 2004;292: and Maggard M, et al, Meta-Analysis: Surgical Treatment of Obesity, Ann Intern Med. 2005;142: Roux-en-Y Switch 10% 50% 100% Two Year Excess Weight Loss 30 Day Mortality (log scale %) Banding

7 | January 28, 2010 | 7 | Two Year Weight Loss and Mortality Roux-en-Y Switch 10% 50% 100% Two Year Excess Weight Loss Gastrectomy Adapted from Buchwald H, et al, Bariatric surgery, a systematic review and meta-analysis, JAMA. 2004;292: and Maggard M, et al, Meta-Analysis: Surgical Treatment of Obesity, Ann Intern Med. 2005;142: and Brethauer et al Systematic review of sleeve gastrectomy as staging and primary bariatric procedure SOARD 2009;5. 30 Day Mortality (log scale %) Banding

8 | January 28, 2010 | 8 | Safety of Bariatric Surgery Mortality Rate LABS 1 DeMaria 2 Buchwald % 0.50% 1.00% 1.50% 2.00% Rate (%) HCUP 4 1) LABS Reporting Group N Engl J Med 2009;361: ) DeMaria et al Ann Surg Oct;246(4): ) Buchwald et al JAMA. 2004;292: ) AHRQ, Healthcare Cost and Utilization Project (HCUP), accessed 01/13/10, 2007 data DRG 288http://hcupnet.ahrq.gov/

9 | January 28, 2010 | 9 | Safety of Surgery Mortality Rate Lap Cholecystectomy % 0.50% 1.00% 1.50% 2.00% Rate (%) Appendectomy 6 GI Obstruction 7 CABG w/ cath 9 Drug Eluding Stent 10 Carotid Stent 11 Hernia 5 LABS 1 DeMaria 2 Buchwald 3 HCUP 4 1) LABS Reporting Group N Engl J Med 2009;361: ) DeMaria et al Ann Surg Oct;246(4): ) Buchwald et al JAMA. 2004;292: ) AHRQ, Healthcare Cost and Utilization Project (HCUP), accessed 01/13/10, 2007 data DRG 288http://hcupnet.ahrq.gov/ 5) Ibid 2007 data DRG’s 161 and162 6) Ibid 2007 data DRG’s 166 and167 7) Ibid 2007 data DRG’s 180 and181 8) Ibid 2007 data DRG’s 493 and 494 9) Ibid 2007 data DRG’s 547 and ) Ibid 2007 data DRG’s 557 and ) Ibid 2007 data DRG 577

10 | January 28, 2010 | 10 | Cost of Obesity Ostbye T et al. Obesity and workers' compensation: results from the Duke Health and Safety Surveillance System.Arch Intern Med Apr 23;167(8): Lost Work Days, Claims, per 100 FTE's <18.5 (Underweight) (Recommended weight) (Overweight) (Obesity class I) (Obesity class II) >40 (Obesity class III) Obesity Class Days and Number of Claims $- $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 Claims Lost Workdays Medical Claims Cost Indemnity Claims Cost

11 | January 28, 2010 | 11 | Annual Per Capita Cost of Obesity Wee et al. Health care expenditures associated with overweight and obesity among US adults: importance of age and race. Am J Public Health Jan;95(1): <18.5 (Under- weight) (Recom- mended weight) (Over- weight) (Obesity class I) (Obesity class II) >40 (Obesity class III) BMI (Obesity Class) Adjusted annual expenditures according to body mass index (BMI [kg/m2]), for a typical White man or woman, aged 35 to 44 years, who is a high school (but not a college) graduate, has private insurance coverage, and resides in a metropolitan setting in the South. Percapita Healthcare Spend (2008 Dollars) by BMI $3,273 $3,248 $3,601 $4,380 $4,648 $5,341 $1,837 $1,861 $2,099 $2,616 $2,798 $3,382 $- $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 Per Capita Spend ($) Women Men

12 | January 28, 2010 | 12 | Return on Intervention Surgical costs recovered in 13 to 60 months ROI driven by Cost of surgery Comorbidities prior to surgery Weight Loss Months to Recoup Intervention Costs Laparoscopic Bariatric Surgery Open Bariatric Surgery Bariatric Surgery Type of Surgery Time (months) Crémieux 2 Gallagher 4 Finklestein 1 Sampalis 3 1) Finkelstein and Brown Am J Manag Care. 2005; 11: ) Cremieux et al. Am J Manag Care 2008; 14: ) Sampalis et al Obes Surg 2004; 14: ) Gallagher et al Obes Surg 2003; 13:

13 | January 28, 2010 | 13 | Why Coverage for Sleeve Gastrectomy Category 1 CPT Code Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy) effective January 1, 2010 Estimated 10,000 procedures in peer reviewed articles have been published since 2006 on Sleeve Gastrectomy that show similar results to other covered Bariatric Procedures for –Weight loss, as measured by excess BMI loss (39) –Comorbidity resolution (19) –Complication rates (16)

14 | January 28, 2010 | 14 | Comparative Weight Loss Evidence Published since 2006 Sleeve Gastrectomy compared to other bariatric procedure(s) Greater than 12 Month Follow-up BMI reported pre-op and at follow-up Excess BMI Loss calculated 1 Where EBMLI = Excess BMI Loss BMI 0 = Pre-operative BMI BMI t = BMI at time of follow-up 1 Deitel et al Reporting Weight Loss 2007, editorial Obes Surg 2007;17: papers meet the above criteria

15 | January 28, 2010 | 15 | Comparative Weight Loss Evidence YearAuthor N Total (SG) Duration (months) ControlStudy 2006Himpens 80 (40) 24LAGB Single Center Prospective Randomized 2008Karamanakos 32 (16) 12RYGBP Single Center Prospective Randomized 2008Vidal 91 (39) 12RYGBPSingle Center Case Matched 2009Strain 121 (30) 21 LAGB, RYGBP, SWITCH Single Center Prospective Cohort Study 2007Lee 846 (216) 36 LAGB, RYGBP, SWITCH Single Center Prospective Cohort Study 2009Wong 94 (30) 24 LAGB, RYGBP Single Center Prospective Cohort Study

16 | January 28, 2010 | 16 | Himpens et al. Prospective Randomized Study Between Laparoscopic Gastric Banding and Laparoscopic Isolated Sleeve Gastrectomy: Results after 1 and 3 Years Time (Mo) EBMIL 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% EWL (BMI(25)) Sleeve Gastrectomy Adjustable Gastric Band Single Center Randomized Trial (40/40) More loss of hunger in Sleeve Gastrectomy group Himpens et al. A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. Obes Surg 2006;16:1450–6.

17 | January 28, 2010 | 17 | Vidal et al. 1 and Karamanakos et al. 2 EBMIL 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Time (Mo) EWL (BMI(25)) Sleeve Gastrectomy 2 Roux en Y Gastric Bypass 2 Vidal – Single center case matched comparison Vidal - Similar weight loss and diabetes resolution Karamanakos- Single center randomized study Karamanakos – Better weight loss and reduced ghrelin levels with SG 1) Vidal et al. Type 2 diabetes mellitus and the metabolic syndrome following sleeve gastrectomy in severely obese subjects. Obes Surg 2008;18:1077– 82. 2) Karamanakos et al. Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin and peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a prospective, double blind study. Ann Surg 2008;247:401–7. Sleeve Gastrectomy 1 Roux en Y Gastric Bypass 1

18 | January 28, 2010 | 18 | Lee et al. Vertical gastrectomy for morbid obesity in 216 patients: report of two-year results EBMIL 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Time (Mo) EWL (BMI(25)) Sleeve Gastrectomy Adjustable Gastric Band Single Center Cohort Study (846 patients) All laparoscopic procedures SG patients had higher pre-op BMI but similar EBMIL to Roux en Y and BPPDS patients Lee et al. Vertical gastrectomy for morbid obesity in 216 patients: report of two-year results. Surg Endosc 2007;21:1810–6. Roux en Y Gastric Bypass Biliopancreatic Diversion and Duodenal Switch

19 | January 28, 2010 | 19 | Strain et al. Comparison of weight loss and body composition changes with four surgical procedures EBMIL 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Time (Mo) EWL (BMI(25)) Sleeve Gastrectomy Roux en Y Gastric Bypass Adjustable Gastric Band Biliopancreatic Diversion and Duodenal Switch Single Center Cohort Study (121 patients) All laparoscopic procedures Sleeve Gastrectomy and Biliopancreatic Diversion (BPDDS) patients had higher pre-op BMI’s 1) Strain et al. Comparison of weight loss and body composition changes with four surgical procedures. Surg Obes Relat Dis Sep-Oct;5(5): Epub 2009 Apr 14. 2) Strain et al.Comparison of effects of gastric bypass and biliopancreatic diversion with duodenal switch on weight loss and body composition 1-2 years after surgery.Surg Obes Relat Dis Jan-Feb;3(1):31-6. Epub 2006 Nov

20 | January 28, 2010 | 20 | Wong et al. Laparoscopic bariatric surgery: a five-year review Time (Mo) EBMIL 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% EWL (BMI(25)) Sleeve Gastrectomy Adjustable Gastric Band Roux en Y Gastric Bypass Single Center Cohort Study (94 patients) All laparoscopic procedures Roux en Y patients had higher pre-op BMI’s Wong et al. Laparoscopic bariatric surgery: a five-year review. Hong Kong Med J Apr;15(2):100-9.

21 | January 28, 2010 | 21 | Case Study Weight Loss Evidence Published since Dec 2005 Greater than 10 Patients BMI reported pre-op and at follow-up Excess BMI Loss calculated 1 Where EBMLI = Excess BMI Loss BMI 0 = Pre-operative BMI BMI t = BMI at time of follow-up 1 Deitel et al Reporting Weight Loss 2007, editorial Obes Surg 2007;17: papers meet the above criteria

22 | January 28, 2010 | 22 | Case Study Weight Loss Evidence Pre-Op Follow Up Time t (months) Total Number of Patients at Time t Total Number of Studies Average BMI at Time, BMI t (kg/m 2 )

23 | January 28, 2010 | 23 | Case Study Weight Loss Evidence 0% 20% 30% 40% 50% 60% 70% 80% 90% 100% Time (Mo) BMI EWL (%) Excess BMI Loss 95% Confidence interval 10% Weighted Analysis of longitudinal Excess BMI Loss from 39 papers on previous slide

24 | January 28, 2010 | 24 | Sleeve Gastrectomy Weight Loss Compared to Roux en Y Bypass and Adjustable Gastric Banding Excess BMI Loss 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Time (Mo) BMI EWL (%) Adjustable Gastric Band 2 Roux en Y Gastric Bypass 2 Roux en Y Gastric Bypass 1 Adjustable Gastric Band 1 1)Christou et al. Five-year outcomes of laparoscopic adjustable gastric banding and laparoscopic Roux-en-Y gastric bypass in a comprehensive bariatric surgery program in Canada, Can J Surg, Vol. 52, No. 6, December 2009 E )Angrisani et al. Laparoscopic adjustable gastric banding versus Roux-en-Y gastric bypass: 5-year results of a prospective randomized trial, Surg Obes Rel Dis 2007;3: Sleeve Gastrectomy

25 | January 28, 2010 | 25 | Safety of Bariatric Surgery and Gastrectomy Mortality Rate 0.00% 0.50% 1.00% 1.50% 2.00% Rate (%) Brethauer 5 Sanchez-Santos 6 Case Review Bariatric Surgery Sleeve Gastrectomy 1) LABS Reporting Group N Engl J Med 2009;361: ) DeMaria et al Ann Surg Oct;246(4): ) Buchwald et al JAMA. 2004;292: )AHRQ, Healthcare Cost and Utilization Project (HCUP), 2007 data DRG ) Brethouer et all Surg Obes Rel Diseas 2009;5: ) Sanchez-Santos et al Obes Surg, LABS 1 DeMaria 2 Buchwald 3 HCUP 4

26 | January 28, 2010 | 26 | Aggregate Perioperative Complications Case Review (N= 2936) Spanish Registry 1 (n=504) CompTotalFrequencyTotalFrequency Mortality 80.27%20.36% Staple Line 692.4%112.0% Wound Site 180.6%10.2% Bleeding 210.7%61.1% Other 140.5%50.9% Stricture 130.4%10.2% Respiratory 80.3%10.2% Thrombosis 70.2% to present N greater than 100 patients 16 Studies 1 Sanchez-Santos et al. Short- and Mid-term Outcomes of Sleeve Gastrectomy for Morbid Obesity: The Experience of the Spanish National Registry, Obes Surg 2009;19 :1203–1210

27 | January 28, 2010 | 27 | Aggregate Perioperative Complications 2006 to present N greater than 100 patients 16 Studies CompCaseRNY 1 BPDDS 1 AGB 1 SG 2 Staple Line2.4%2.2%1.8%2.7% Bleeding0.7%2.0%0.2%0.3%1.0% Reoperation1.6%4.2%7.7%1.8% 1) Maggard M, et al, Meta-Analysis: Surgical Treatment of Obesity, Ann Intern Med. 2005;142: ) Brethauer et al Systematic review of sleeve gastrectomy as staging and primary bariatric procedure SOARD 2009;5.

28 | January 28, 2010 | 28 | Reinsurance for Private Pay Patients Personal Communication, BLIS Inc, Copyright © 2010 BLIS Inc. Used with permission.

29 | January 28, 2010 | 29 | Comparative Studies – Obesity Related Comorbidity Outcomes YearAuthor N Total (SG) Duration (months) ControlOutcomes 2006Himpens80 (40)24LAGB Appetite suppression greater in SG group 2008Karamanakos32 (16)12RYGBP For both groups, glucose and triglycerides significantly decreased Appetite suppression greater in SG group 2008Vidal91 (39)12RYGBP 84.6% T2DM resolution rates for both groups 2009Strain121 (30)21 LAGB, RYGBP, SWITCH Outcomes not reported 2007Lee 846 (216) 36 LAGB, RYGBP, SWITCH Outcomes not reported 2009Wong94 (30)24LAGB, RYGBP Surgery improved hypertension, diabetes and dislipidemia

30 | January 28, 2010 | 30 | Case Study Obesity Related Comorbidity Outcomes Published since 2006 Greater than 10 Patients BMI reported pre-op and at follow-up Number of patients in Subgroup # of Studies Showing results % Resolved or Improved Total Type 2 Diabetes % Hypertension % Hyperlipidemia % Sleep Apnea % Degenerative joint disease/ joint pain %

31 | January 28, 2010 | 31 | 2010 HEDIS Measurements that are affected by Gastrectomy Adult BMI Assessment Comprehensive Diabetes Care -HbA1c control ( 9%) Relative Resource Use for People With Diabetes Relative Resource Use for People With Uncomplicated Hypertension National Committee for Quality Assurance (NCQA), Healthcare Effectiveness Data and Information Set (HEDIS) 2010 Measures,

32 | January 28, 2010 | 32 | Bariatric Surgery Procedures 30 Day Mortality Adapted from Buchwald H, et al, Bariatric surgery, a systematic review and meta-analysis, JAMA. 2004;292: and Maggard M, et al, Meta-Analysis: Surgical Treatment of Obesity, Ann Intern Med. 2005;142: and Brethauer et al Systematic review of sleeve gastrectomy as staging and primary bariatric procedure SOARD 2009; Banding Roux-en-Y Switch 10% 50% 100% Excess Weight Loss Gastrectomy

33 | January 28, 2010 | 33 | Bariatric Surgery Procedures 30 Day Mortality Adapted from Buchwald H, et al, Bariatric surgery, a systematic review and meta-analysis, JAMA. 2004;292: and Maggard M, et al, Meta-Analysis: Surgical Treatment of Obesity, Ann Intern Med. 2005;142: and Brethauer et al Systematic review of sleeve gastrectomy as staging and primary bariatric procedure SOARD 2009; Banding Roux-en-Y Switch 10% 50% 100% Diabetes Resolution Rate Excess Weight Loss Gastrectomy

34 | January 28, 2010 | 34 | Bariatric Surgery Procedures 30 Day Mortality Adapted from Buchwald H, et al, Bariatric surgery, a systematic review and meta-analysis, JAMA. 2004;292: and Maggard M, et al, Meta-Analysis: Surgical Treatment of Obesity, Ann Intern Med. 2005;142: and Brethauer et al Systematic review of sleeve gastrectomy as staging and primary bariatric procedure SOARD 2009; Banding Roux-en-Y Switch 10% 50% 100% Diabetes Resolution Rate Gastrectomy

35 | January 28, 2010 | 35 | Society Support Societies that endorse Sleeve Gastrectomy American Society for Metabolic and Bariatric Surgery Society of American Gastrointestinal and Endoscopic Surgery American College of Surgeons

36 | January 28, 2010 | 36 | Blue Distinction Centers for Bariatric Surgery Offering Sleeve Gastrectomy HospitalSurgeon (* Author) University of Alabama HospitalE.E. Frezza*, M.D UC Irvine Medical CenterN. Nguyen*, M.D Yale-New Haven HospitalR. Bell*, M.D Cleveland Clinic Hospital, FLR. Rosenthal*, M.D University of Chicago Medical Center ChicagoV. Prachand*, M.D North Shore University HealthSystem (Evanston)C. Frantzides, MD Clarian North Medical CenterS. Mattar*, M.D Johns Hopkins Bayview MedicalM. Schweitzer, M.D Massachusetts General HospitalJ Pratt, M.D University of Minnesota Medical CenterS. Ikramuddin, MD Atlantic City Medical CenterA Onopchenko, MD Lenox Hill HospitalM. Roslin, MD Cleveland Clinic Hospital, OHP. Schauer*, MD Blue Distinction Centers for Bariatric Surgery, bariatric/bluedistinctionbariatric.pdf

37 | January 28, 2010 | 37 | Sleeve Gastrectomy Patient Characteristics BMI greater than 40 kg/m 2 BMI greater than 35 kg/m 2 with significant obesity related comorbidities Participate multidisciplinary Center of Excellence program Model medical profile –NSAID use –Prior surgery –Large ventral hernia –Revisions –Need to reduce comorbidities prior to planned operation –Earlier intervention

38 | January 28, 2010 | 38 | Professional Education Surgeon Training –CME –Fellowships –Residency –Clinical Immersion Staff Training –Patient Education –Perioperative Management –Follow-up Patient Pathways

39 | January 28, 2010 | 39 | Sleeve Gastrectomy Advantages No anastomoses Continuity of gastrointestinal tract –Functional pylorus –Does not bypass duodenum Reduces hunger No implanted device Follow up visits to adjust device not needed

40 | January 28, 2010 | 40 | Conclusions Weight loss drives obesity related comorbidity resolution Sleeve Gastrectomy has better weight loss than Adjustable Gastric Banding Sleeve Gastrectomy has fewer complications than Roux en Y Gastric Bypass or Biliopancreatic Diversion and Duodenal Switch Mid term data to 3 years tracks with other covered bariatric procedures Sleeve Gastrectomy is as effective as other covered procedures Sleeve Gastrectomy should be covered as a medically necessary treatment for Morbid Obesity and Related Diseases

41 | January 28, 2010 | 41 | Questions

42 | January 28, 2010 | 42 | References Slide #In order of appearance Reference 6, 7, 8, 25, 32, 33, 34 Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292: Buchwald Abstract Buchwald PDF 6, 7, 32, 33, 34 Maggard MA, Shugarman LR, Suttorp M et al, Meta-Analysis: Surgical Treatment of Obesity, Ann Intern Med. 2005;142: Maggard Abstract Maggard PDF 7, 25, 32, 33, 34 Brethauer SA, Hammel JP, Schauer PR. Systematic review of sleeve gastrectomy as staging and primary bariatric procedure. Surg Obes Relat Dis 2009;5: Brethauer Abstract 8, 9, 25Longitudinal Assessment of Bariatric Surgery (LABS) Consortium et al, Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med Jul 30;361(5): LABS Abstract LABS PDF 8, 9, 25DeMaria EJ, Murr M, Byrne TK, et al Validation of the obesity surgery mortality risk score in a multicenter study proves it stratifies mortality risk in patients undergoing gastric bypass for morbid obesity. Ann Surg Oct;246(4):578-82; discussion DeMaria Abstract 8, 9, 25AHRQ, Healthcare Cost and Utilization Project (HCUP), accessed 01/13/10, 2007 data 10Ostbye T, Dement JM, Krause KM. Obesity and workers' compensation: results from the Duke Health and Safety Surveillance System.Arch Intern Med Apr 23;167(8): Ostbye Abstract Ostbye PDF 11Wee CC, Phillips RS, Legedza AT, et al. Health care expenditures associated with overweight and obesity among US adults: importance of age and race. Am J Public Health Jan;95(1): Wee Abstract Wee PDF 12Finkelstein E and Brown DS, A cost-benefit simulation model of coverage for bariatric surgery among full-time employees. Am J Manag Care. 2005; 11: Finkelstein AbstractFinkelstein Abstract Finkelstein PDF

43 | January 28, 2010 | 43 | References Slide #In order of appearance Reference 12Cremieux PY, Buchwald H, Shikora SA, Ghosh A, Yang HE, Buessing M. A study on the economic impact of bariatric surgery. Am J Manag Care 2008;14: Cremieux Abstract Cremieux PDF 12Sampalis JS, Liberman M, Auger S, Christou NV. The impact of weight reduction surgery on health-care costs in morbidly obese patients. Obes Surg 2004;14: Sampalis Abstract 12Gallagher SF, Banasiak M, Gonzalvo JP, et al. The impact of bariatric surgery on the Veterans Administration healthcare system: a cost analysis. Obes Surg 2003;13: Gallagher Abstract 14, 21Deitel M, Gawdat K, Melissas J. Reporting weight loss Obes Surg 2007;17: Himpens J, Dapri G, Cadiere GB. A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. Obes Surg 2006;16: Himpens Abstract 17Vidal J, Ibarzabal A, Romero F, et al. Type 2 diabetes mellitus and the metabolic syndrome following sleeve gastrectomy in severely obese subjects. Obes Surg 2008;18: Vidal Abstract 17Karamanakos SN, Vagenas K, Kalfarentzos F, Alexandrides TK. Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin and peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a prospective, double blind study. Ann Surg 2008;247:401-7 Karamanakos AbstractKaramanakos Abstract 18Lee CM, Cirangle PT, Jossart GH. Vertical gastrectomy for morbid obesity in 216 patients: report of two-year results. Surg Endosc 2007;21: Lee Abstract Lee PDF

44 | January 28, 2010 | 44 | References Slide #In order of appearance Reference 19Strain GW, Gagner M, Pomp A, et al. Comparison of weight loss and body composition changes with four surgical procedures. Surg Obes Relat Dis 2009;5: Strain Abstract 20Wong SK, Kong AP, Mui WL, et al. Laparoscopic bariatric surgery: a five- year review. Hong Kong Med J 2009;15: Wong Abstract Wong PDF 24Christou N, Efthimiou E.. Five-year outcomes of laparoscopic adjustable gastric banding and laparoscopic Roux-en-Ygastric bypass in a comprehensive bariatric surgery program in Canada, Can J Surg, Vol. 52, No. 6, December 2009 E Christou Abstract Christou PDF 24Angrisani L, Lorenzo M, Borrelli V. Laparoscopic adjustable gastric banding versus Roux-en-Y gastric bypass: 5-year results of a prospective randomized trial, Surg Obes Rel Dis 2007;3: Angrisani Abstract 25,26Sanchez-Santos R, Masdevall C, Baltasar A, et al. Short- and mid-term outcomes of sleeve gastrectomy for morbid obesity: the experience of the Spanish National Registry. Obes Surg 2009;19: Sanchez-Santos Abstract Sanchez-Santos PDF 31National Committee for Quality Assurance (NCQA), Healthcare Effectiveness Data and Information Set (HEDIS) 2010 Measures, PDF


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