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Laparoscopic Sleeve Gastrectomy Recent Literature Review

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1 Laparoscopic Sleeve Gastrectomy Recent Literature Review
Surgeon Date 1

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 Implementation of Sleeve Gastrectomy as a Covered Procedure There is a new CPT code for Sleeve Gastrectomy CMS issued an NCD providing coverage for Bariatric Surgery in early 2006 70 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 (53) Sleeve Gastrectomy offers unique advantages compared to other bariatric procedures | January 28, |

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

4 Sleeve Gastrectomy 1 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 2 3 4 | January 28, |

5 Bariatric Surgery Adjustable Gastric Banding (AGB) Sleeve Gastrectomy
(SG) Roux-en-Y Gastric Bypass (RNYGB) Biliopancreatic Diversion/Duodenal Switch (BPDDS) Mechanism of Action Restrictive Malabsorptive Hormonal Benefits Low Complications Good Weight Loss Continuous GI Tract Reduces Hunger Better Weight Loss Early Effect on Diabetes Best Weight Loss % of Cases In 2008 40% 5% 45% ASMBS, Rational for Bariatric Surgery, | January 28, |

6 Two Year Weight Loss and Mortality
100% Switch Roux-en-Y Two Year Excess Weight Loss 50% Banding 10% 0.01 0.1 1 10 30 Day Mortality (log scale %) 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: | January 28, |

7 Two Year Weight Loss and Mortality
100% Switch Roux-en-Y Two Year Excess Weight Loss Gastrectomy 50% Banding 10% 0.01 0.1 1 10 30 Day Mortality (log scale %) 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 . | January 28, |

8 Safety of Bariatric Surgery
Mortality Rate 2.00% 1.50% Rate (%) 1.00% 0.50% 0.00% LABS – Longitudinal Assesment of Bariatric Surgery NIH grant DeMaria – Mortality score for bariatric surgery Buchwald – Meta – Analysis Mortality rate is for all bariatric proceudures LABS1 HCUP4 DeMaria2 Buchwald3 1) LABS Reporting Group N Engl J Med 2009;361:445-54 2) DeMaria et al Ann Surg Oct;246(4):578-82 3) Buchwald et al JAMA. 2004;292: 4) AHRQ, Healthcare Cost and Utilization Project (HCUP), accessed 01/13/10, 2007 data DRG 288 | January 28, |

9 Safety of Surgery Mortality Rate 2.00% 1.50% Rate (%) 1.00% 0.50%
0.00% LABS1 HCUP4 Hernia5 DeMaria2 Buchwald3 Lap Cholecystectomy8 GI Obstruction7 CABG w/ cath9 Carotid Stent11 Appendectomy6 Drug Eluding Stent10 1) LABS Reporting Group N Engl J Med 2009;361:445-54 2) DeMaria et al Ann Surg Oct;246(4):578-82 3) Buchwald et al JAMA. 2004;292: 4) AHRQ, Healthcare Cost and Utilization Project (HCUP), accessed 01/13/10, 2007 data DRG 288 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 558 11) Ibid 2007 data DRG 577 | January 28, |

10 Lost Work Days, Claims, per 100 FTE's Days and Number of Claims
Cost of Obesity Lost Work Days, Claims, per 100 FTE's 200 $70,000 180 $60,000 160 $50,000 140 120 $40,000 Claims Days and Number of Claims Lost Workdays 100 Medical Claims Cost $30,000 Indemnity Claims Cost 80 60 $20,000 40 $10,000 20 $- <18.5 (Obesity (Obesity >40 (Obesity class (Underweight) (Recommended (Overweight) class I) class II) III) weight) Obesity Class Ostbye T et al. Obesity and workers' compensation: results from the Duke Health and Safety Surveillance System .Arch Intern Med Apr 23;167(8): | January 28, |

11 Annual Per Capita Cost of Obesity
Percapita Healthcare Spend (2008 Dollars) by BMI $6,000 $5,341 Women $5,000 $4,648 $4,380 $4,000 $3,601 $3,273 $3,382 $3,248 Per Capita Spend ($) $2,798 $3,000 $2,616 $2,099 Men $1,837 $1,861 $2,000 $1,000 $- <18.5 (Under-weight) (Recom-mended weight) (Obesity class I) (Obesity class II) >40 (Obesity class III) (Over-weight) 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. 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): | January 28, |

12 Return on Intervention
Months to Recoup Intervention Costs 70 Surgical costs recovered in 13 to 60 months ROI driven by Cost of surgery Comorbidities prior to surgery Weight Loss 60 50 Finklestein1 40 Crémieux2 Time (months) 30 Sampalis3 20 Gallagher4 10 Laparoscopic Bariatric Surgery Open Bariatric Surgery Bariatric Surgery 1) Finkelstein and Brown Am J Manag Care. 2005; 11: 2) Cremieux et al. Am J Manag Care 2008; 14: 3) Sampalis et al Obes Surg 2004; 14: 4) Gallagher et al Obes Surg 2003; 13: Type of Surgery | January 28, |

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 2008 70 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) | January 28, |

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 calculated1 Where EBMLI = Excess BMI Loss BMI0 = Pre-operative BMI BMIt = BMI at time of follow-up 6 papers meet the above criteria 1 Deitel et al Reporting Weight Loss 2007, editorial Obes Surg 2007;17: | January 28, | 14 14

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

16 Himpens et al. Prospective Randomized Study Between Laparoscopic Gastric Banding and Laparoscopic Isolated Sleeve Gastrectomy: Results after 1 and 3 Years EBMIL 100% 90% Single Center Randomized Trial (40/40) More loss of hunger in Sleeve Gastrectomy group 80% 70% Sleeve Gastrectomy 60% EWL (BMI(25)) 50% Adjustable Gastric Band 40% 30% 20% 10% 0% 10 20 30 40 50 60 Time (Mo) 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. | January 28, |

17 Vidal et al.1 and Karamanakos et al.2
EBMIL 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 100% 90% Sleeve Gastrectomy2 80% Roux en Y Gastric Bypass2 70% Roux en Y Gastric Bypass1 60% Sleeve Gastrectomy1 EWL (BMI(25)) 50% 40% 30% 20% 10% 0% 10 20 30 40 50 60 Time (Mo) 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. | January 28, |

18 Adjustable Gastric Band
Lee et al. Vertical gastrectomy for morbid obesity in 216 patients: report of two-year results EBMIL Biliopancreatic Diversion and Duodenal Switch 100% Sleeve Gastrectomy 90% 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 Roux en Y Gastric Bypass 80% 70% Adjustable Gastric Band 60% EWL (BMI(25)) 50% 40% 30% 20% 10% 0% 10 20 30 40 50 60 Time (Mo) Lee et al. Vertical gastrectomy for morbid obesity in 216 patients: report of two-year results. Surg Endosc 2007;21:1810–6. | January 28, |

19 Strain et al. Comparison of weight loss and body composition changes with four surgical procedures
EBMIL Single Center Cohort Study (121 patients) All laparoscopic procedures Sleeve Gastrectomy and Biliopancreatic Diversion (BPDDS) patients had higher pre-op BMI’s 100% 90% Biliopancreatic Diversion and Duodenal Switch 1 2 80% 2 1 Roux en Y Gastric Bypass 70% 60% EWL (BMI(25)) 1 Sleeve Gastrectomy 50% 1 Adjustable Gastric Band 40% 30% 20% 10% 0% 10 20 30 40 50 60 Time (Mo) 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, |

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

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 calculated1 Where EBMLI = Excess BMI Loss BMI0 = Pre-operative BMI BMIt = BMI at time of follow-up 39 papers meet the above criteria 1 Deitel et al Reporting Weight Loss 2007, editorial Obes Surg 2007;17: | January 28, | 21 21

22 Case Study Weight Loss Evidence
Pre-Op Follow Up Time t (months) 6 12 18 24 36 Total Number of Patients at Time t 2660 96 1770 245 451 98 Total Number of Studies 39 4 21 5 Average BMI at Time, BMIt (kg/m2) 47.9 33.3 33.9 35.3 33.7 30.9 | January 28, | 22 22

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

24 Sleeve Gastrectomy Weight Loss Compared to Roux en Y Bypass and Adjustable Gastric Banding
Excess BMI Loss 100% 90% Roux en Y Gastric Bypass1 80% Roux en Y Gastric Bypass2 70% Adjustable Gastric Band1 60% Sleeve Gastrectomy BMI EWL (%) 50% Adjustable Gastric Band2 40% 30% 20% 10% 0% 10 20 30 40 50 60 Time (Mo) 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 2)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: | January 28, |

25 Safety of Bariatric Surgery and Gastrectomy
Mortality Rate 2.00% 1.50% Rate (%) Bariatric Surgery Sleeve Gastrectomy 1.00% 0.50% 0.00% LABS1 HCUP4 DeMaria2 Buchwald3 Brethauer5 Case Review Sanchez-Santos6 1) LABS Reporting Group N Engl J Med 2009;361:445-54 2) DeMaria et al Ann Surg Oct;246(4):578-82 3) Buchwald et al JAMA. 2004;292: 4)AHRQ, Healthcare Cost and Utilization Project (HCUP), 2007 data DRG 288 5) Brethouer et all Surg Obes Rel Diseas 2009;5: 6) Sanchez-Santos et al Obes Surg, | January 28, |

26 Aggregate Perioperative Complications
2005 to present N greater than 100 patients 16 Studies Case Review (N= 2936) Spanish Registry1 (n=504) Comp Total Frequency Mortality 8 0.27% 2 0.36% Staple Line 69 2.4% 11 2.0% Wound Site 18 0.6% 1 0.2% Bleeding 21 0.7% 6 1.1% Other 14 0.5% 5 0.9% Stricture 13 0.4% Respiratory 0.3% Thrombosis 7 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 | January 28, |

27 Aggregate Perioperative Complications
2006 to present N greater than 100 patients 16 Studies Comp Case RNY1 BPDDS1 AGB1 SG2 Staple Line 2.4% 2.2% 1.8% 2.7% Bleeding 0.7% 2.0% 0.2% 0.3% 1.0% Reoperation 1.6% 4.2% 7.7% 1) Maggard M, et al, Meta-Analysis: Surgical Treatment of Obesity, Ann Intern Med. 2005;142: 2) Brethauer et al Systematic review of sleeve gastrectomy as staging and primary bariatric procedure SOARD 2009;5 . | January 28, |

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

29 Comparative Studies – Obesity Related Comorbidity Outcomes
Year Author N Total (SG) Duration (months) Control Outcomes 2006 Himpens 80 (40) 24 LAGB Appetite suppression greater in SG group 2008 Karamanakos 32 (16) 12 RYGBP For both groups, glucose and triglycerides significantly decreased Vidal 91 (39) 84.6% T2DM resolution rates for both groups 2009 Strain 121 (30) 21 LAGB, RYGBP, SWITCH Outcomes not reported 2007 Lee 846 (216) 36 Wong 94 (30) LAGB, RYGBP Surgery improved hypertension, diabetes and dislipidemia | January 28, |

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 1754 19 Type 2 Diabetes 397 18 95% Hypertension 428 14 88% Hyperlipidemia 189 11 73% Sleep Apnea 234 10 91% Degenerative joint disease/ joint pain 210 6 70% | January 28, | 30 30

31 2010 HEDIS Measurements that are affected by Gastrectomy
Adult BMI Assessment Comprehensive Diabetes Care -HbA1c control (<7.0%) and Poor 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, | January 28, |

32 Bariatric Surgery Procedures
100% Switch Roux-en-Y Gastrectomy Excess Weight Loss 50% Banding 10% 0.001 0.01 0.1 1 10 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;5 . | January 28, |

33 Bariatric Surgery Procedures
100% Switch Roux-en-Y Gastrectomy Excess Weight Loss Diabetes Resolution Rate 50% Banding 10% 0.001 0.01 0.1 1 10 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;5 . | January 28, |

34 Bariatric Surgery Procedures
100% Switch Roux-en-Y Gastrectomy Diabetes Resolution Rate 50% Banding 10% 0.001 0.01 0.1 1 10 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;5 . | January 28, |

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 | January 28, |

36 Blue Distinction Centers for Bariatric Surgery Offering Sleeve Gastrectomy
Hospital Surgeon (* Author) University of Alabama Hospital E.E. Frezza*, M.D UC Irvine Medical Center N. Nguyen*, M.D Yale-New Haven Hospital R. Bell*, M.D Cleveland Clinic Hospital, FL R. Rosenthal*, M.D University of Chicago Medical Center Chicago V. Prachand*, M.D North Shore University HealthSystem (Evanston) C. Frantzides, MD Clarian North Medical Center S. Mattar*, M.D Johns Hopkins Bayview Medical M. Schweitzer, M.D Massachusetts General Hospital J Pratt, M.D University of Minnesota Medical Center S. Ikramuddin, MD Atlantic City Medical Center A Onopchenko, MD Lenox Hill Hospital M. Roslin, MD Cleveland Clinic Hospital, OH P. Schauer*, MD Blue Distinction Centers for Bariatric Surgery, | January 28, |

37 Sleeve Gastrectomy Patient Characteristics
BMI greater than 40 kg/m2 BMI greater than 35 kg/m2 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 | January 28, |

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

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 | January 28, |

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 | January 28, |

41 Questions | January 28, |

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, 25 Longitudinal 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 DeMaria 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 AHRQ, Healthcare Cost and Utilization Project (HCUP), accessed 01/13/10, 2007 data  http://hcupnet.ahrq.gov 10 Ostbye 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 11 Wee 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):159-65  Wee Abstract Wee PDF 12 Finkelstein 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 Abstract Finkelstein PDF | January 28, |

43 References Slide # In order of appearance Reference 12
Cremieux 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 Sampalis 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 Gallagher SF, Banasiak M, Gonzalvo JP, et al. The impact of bariatric surgery on the Veterans Administration healthcare system: a cost analysis. Obes Surg 2003;13:245-8.  Gallagher Abstract 14, 21 Deitel M, Gawdat K, Melissas J. Reporting weight loss Obes Surg 2007;17:565-8. 16 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 17 Vidal 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 Karamanakos 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 Abstract 18 Lee 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 | January 28, |

44 References Slide # In order of appearance Reference 19
Strain GW, Gagner M, Pomp A, et al. Comparison of weight loss and body composition changes with four surgical procedures. Surg Obes Relat Dis 2009;5:582-7.  Strain Abstract 20 Wong SK, Kong AP, Mui WL, et al. Laparoscopic bariatric surgery: a five-year review. Hong Kong Med J 2009;15:100-9. Wong Abstract Wong PDF 24 Christou 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 Angrisani 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 25,26 Sanchez-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 31 National Committee for Quality Assurance (NCQA), Healthcare Effectiveness Data and Information Set (HEDIS) 2010 Measures, PDF | January 28, |


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