1. What Is Obesity?
A life-long, progressive, life-threatening, costly, genetically-related, multi-factorial disease of excess fat storage with multiple co-morbidities
ASBS

2. 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

3. Obesity and Mortality Risk
2.5
2.0
Mortality Ratio
1.5
1.0
Very Low
Very High
Moderate
Low
Moderate
High 20 25 30 35 40
BMI
Gray DS. Med Clin North Am. 1989;73(1):1–13.

4. 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

5. Medical Co-Morbidities Resolved after Bariatric Surgery
Sources: Bariatric Surgery: A Summary of the Literature, 1990 to 2001
Wittgrove AC,Clark GW. Laparoscopic Gastric bypass roux-n-y-500 patients. Obes Surg And others.

6. Non-Medical Co-Morbidities
Physical
Economic
Psychological
Social

7. 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

8. 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 with significant co-morbidity
documented dietary attempts ineffective

9. 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

10. 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 follow-up
ASBS

11. 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

12. 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
The operation produced significant and durable weight loss with an average maximum weight loss of 70% of excess weight at about 2 years after surgery. At 5 years the loss was 58%, 10 years it was 55% and after 14 years it was 49%.
More striking is the control of diabetes. Pre-op 27% had NIDDM and 27% had impaired glucose tolerance. Within 10 days of surgery most patients had no further evidence of diabetes. Long term 91% were restored to euglycemic.
Pre-op 58% had hypertension. Post-op this was reduced to 14%. Additionally these patients noted marked improvement in cardiorespiratory function, arthritis problems and improvement in fertility.
*Results achieved in most but not all cases. Degree of improvements vary by individual

13. Laparoscopic Adjustable Gastric Banding
Restrictive
Good results in Europe and Australia
Inamed Lap Band™ FDA approved 6/01
40-55% EBW Loss

14. How does the Band work? Surgery Factors: Restriction of meal size
Decreased appetite
Patient Factors:
Decreased calorie intake
Increased calorie expenditure

15. 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

16. 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

17. Results of Bariatric Surgery
Weight loss
Reduction or improvement in co-morbidities
Increased longevity
Improved Quality of Life
health
social
personal
work

18. Lifetime supplements are necessary to prevent…
Iron Deficiency Anemia
Folate Deficiency
Vitamin B-12 Deficiency
Daily long term intake of chewable or liquid vitamins is essential. 600 mg per day of Vit B-12 is recommended. Vit B-12 may also be given once monthly by injection. Fe supplements are also recommended and both of these are given together in the form of Trinsicon which contains liver stomach concentrate with intrinsic factor, Vit B-12, Fe, Vit C, Folic acid and other factors of Vit B complex.

19. 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

20. How are good results achieved?
Follow ASBS recommendations
Surgeon and Hospital commitment
Dedicated bariatric team
Comprehensive care
Lifelong follow up
Database management

21. Weight Loss Program Team
Surgeon
Nurse Practicioner
Bariatric Coordinator
Registered Dietician
Clinical psychologist
Exercise Specialist
Office support staff
While we have come a long way here at Holy Cross in the past months, we have much work left to be done. Our team is not yet complete and we have several more phases of the program that we will institute in the next year.
I look forward to working closely with those of you involved in the treatment of these challenging patients. As for the rest of you, I hope this program has served to give you some insight as to the challenges that these patients face on a daily basis just to get by. Thank you.

22. Will My Insurance Pay 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?

23. 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.)

24. 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

25. What Makes Sacramento Bariatric 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!

26. 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