1. Is weight- loss surgery the answer for you?
Dr. Terry Scarborough & Dr. Sherman Yu
Is weight- loss surgery the answer for you?

2. What are you going to learn today?
What is obesity?
Your daily challenges
What is obesity costing you?
What are your surgical options?
Summary
What are your next steps?
Texas Laparoscopic Consultants, LLP April 2009

3. Welcome to TLC Surgery
We are an entire practice dedicated to helping you succeed with weight loss surgery and living a longer, happier, healthier life!
A multi-disciplinary Bariatric focused practice
Lead by 2 fellowship trained, board certified Surgeons
Nutritionists
Psychologist
Insurance Specialists
Texas Laparoscopic Consultants, LLP April 2009

4. How obesity can affect you
More tell-tale image / no sleeveless

5. Many factors influence obesity
Continue to speak to the patient not being alone in this challenge
Texas Laparoscopic Consultants, LLP April 2009

6. Obesity is…
…a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems.
It is also…
multi-factorial (many different factors can cause obesity)
life-long
progressive
potentially life-threatening
costly
Texas Laparoscopic Consultants, LLP April 2009

7. How do we measure obesity?
According to the National Institute of Health – Body Mass Index (BMI) is a measure of body fat based on height and weight that applies to both adult men and women
BMI Indicators
Healthy Range – 24.9
Overweight 25.0 – 29.9
Obese 30.0 – 34.9
Severe Obesity 35.0 – 39.9
Morbid Obesity 40.0 – 49.9
Super-Morbid Obesity > 50
An opportunity to speak to the formula BMI= Weight(kg) / Height (m)2. Great chance to get the participants involved - create an example using the BMI wheel that has been distributed.
NHLBI 2000 (NIH), Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity in Adults
Texas Laparoscopic Consultants, LLP April 2009

8. Many serious illnesses are associated with obesity
Type-2 Diabetes1,3
Hypertension1,3
Hyperlipidemia1,3
Respiratory disease1,3
Sleep apnea1,2,3
Depression3
Menstrual irregularity2
Amenorrhea2
Dysmenorrhea2
Urinary stress incontinence3
Asthma/pulmonary disorder2,3
Cancer1,3
Gastroesophageal reflux disease (GERD)2,3
Degenerative joint disease (DJD)3
Heart disease 2
Gallstones1,2,3
Fatty liver disease2,3
Coronary artery disease1,3
Stroke1
Osteoarthritis1,2
Infertility2
NHLBI 2000 (NIH), Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity in Adults
NIDDK 2006 (NIH), Understanding Adult Obesity.
Schneider BE & Mun EC. Diabetes Care. 2005; 28:475-80
Texas Laparoscopic Consultants, LLP April 2009

9. You’re not alone More than 65% of adults are overweight or obese.1
32% of children are overweight.1
4.8% of adults are morbidly obese.1
Total medical cost for obesity in 2003 was $75 billion.2
325,000 obesity-related deaths occur annually.3
Wang, Y & Beydoun, MA. Epidemiol Rev. 2007; 29: 6-28.
“Quick Facts: Economic and Health Burden of Chronic Disease,” CDC, updated 2007
Nordmann AJ et al., Arch Intern Med. 2006; 166:
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10. Daily Challenges

11. You face obstacles and prejudices every day
Speak to being able to do the simple things.
Texas Laparoscopic Consultants, LLP April 2009

12. High BMI can affect life expectancy
In younger & middle aged women & men, increased BMI may increase the risk of dying prematurely1
Teens entering adulthood with BMI >40 die 8-13 years earlier than the general population2
RELATIVE RISK OF ALL CAUSE MORTALITY
<18.5
>35.0
WOMEN MEN
BMI
Freedman DM et al. Int J of Obesity. 2006; 30:
Fontaine KR et al. JAMA. 2003; 289:
Texas Laparoscopic Consultants, LLP April 2009

13. How much can obesity really cost?

14. What are the costs for you?
Conventional treatments
Type of Diet Completing One Year Weight Loss
at One Year1
Atkins® /40 (53%) kg (5 lbs.)
Zone /40 (65%) kg (7 lbs.)
Weight Watchers ® /40 (65%) kg (7 lbs.)
Ornish /40 (50%) kg (7 lbs.)
Day-to-day living
Clothing, food
1. Dansinger, et al. JAMA 2005;293(1). Atkins is a registered trademark of Atkins Nutritionals, Inc. Weight Watchers is a registered trademark of Weight Watchers International, Inc.
Texas Laparoscopic Consultants, LLP April 2009

15. Insurance costs go up as BMI goes up
Percentage increase in costs comparing obese to
non-obese (BMI <25)
Body Mass Index (kg/m2)
Services 30 – 34.9 ≥ 35
Physician visits +14% +25%
Pharmacy +60% +78%
Laboratory +24% +85%
All outpatient services +21% +37%
All inpatient services +33% +70%
Overall +25% +44%
Data from a 1993 health survey of members of a large HMO (n = 17,118) Quesenberry et al. Arch Intern Med 1998;158:466
Texas Laparoscopic Consultants, LLP April 2009

16. What are your surgical options?

17. Are you a candidate for weight-loss surgery?
BMI >35 with co-morbidities or >40 without*
Healthy enough to undergo a major operation
Failed attempts at medical weight loss
Absence of drug and alcohol problems
No uncontrolled psychological conditions
Consensus by our multi-disciplinary team
Understands surgery and risks
Must be dedicated to a lifestyle change and lifetime follow-ups
*From the NIH consensus conference in 1991
Texas Laparoscopic Consultants, LLP April 2009

18. Not all weight loss surgeries are the same
Restrictive
Malabsorptive
Combination
Texas Laparoscopic Consultants, LLP April 2009

19. Restrictive Procedures
The size of the stomach is reduced, which limits the amount of food patients can eat.
The smaller stomach pouch fills quickly, helping patients feel satisfied with less food.
Examples of restrictive bariatric procedures:
Gastric banding
Sleeve gastrectomy
Texas Laparoscopic Consultants, LLP April 2009

20. Malabsorptive Procedures
The small intestine is rerouted so that food skips a portion of it.
Some calories and nutrients are not absorbed.
Currently, surgeons rarely perform strictly malabsorptive procedures.
Most procedures that involve malabsorption include restriction and are called combination procedures.
Texas Laparoscopic Consultants, LLP April 2009

21. Combination Procedures
The surgeon creates a small pouch, limiting the amount of food a patient can eat.
A section of the small intestine is rerouted, causing food to bypass a large portion of the small intestine.
Bypassing a portion of the small intestine means the patient’s body absorbs fewer calories.
Examples of combination bariatric procedures:
Gastric bypass
Biliopancreatic diversion with duodenal switch
Texas Laparoscopic Consultants, LLP April 2009

22. Risks of abdominal surgery
Bleeding
Pain
Shoulder pain
Infection
Pneumonia
Complications due to anesthesia & medications
Deep vein thrombosis (Blood clot)
Pulmonary embolism (Blood clot in lung)
Injury to stomach, esophagus, or surrounding organs
Death
Texas Laparoscopic Consultants, LLP April 2009

23. Risks of bariatric surgery
Abdominal hernia
Chest pain
Collapsed lung
Constipation or diarrhea
Dehydration
Enlarged heart
Gallstones, pain from passing a gallstone, inflammation of the gallbladder, or surgery to remove the gallbladder
Gastrointestinal inflammation or swelling
Stoma obstruction
Stretching of the stomach
Surgical procedure repeated
Vomiting and nausea
Texas Laparoscopic Consultants, LLP April 2009

24. Adjustable gastric banding is one type of restrictive procedure
Laparoscopic or Single Incision
Second most frequently performed bariatric procedure in U.S.
Mean excess weight loss at 1 year of 50%
Requires implanted medical device
Lowest rate of complications
Texas Laparoscopic Consultants, LLP April 2009

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26. What are risks and complications of gastric banding?
Migration of implant (band erosion, band slippage, port displacement)
Tubing-related complications (port disconnection, tubing kinking)
Band leak
Port-site infection
Esophageal spasm
Gastroesophageal reflux disease (GERD)
Inflammation of the esophagus or stomach
Note: Your weight, age and medical history play a significant role in determining your specific risks.  Your surgeon can inform you about your specific risks for bariatric surgery.
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27. What can you expect after gastric banding?
Recovery takes time and patience.
The diet is strict.
The capacity of the stomach has changed.
You may experience discomfort and pain as your body heals.
Length of time to return to normal activities can vary from patient to patient.
Your healthcare team will advise you when to return to work and resume prior activities.
Lifestyle changes are necessary to ensure success.
Reference: From REALIZEband.com; life with REALIZE then recovery expectations.
Texas Laparoscopic Consultants, LLP April 2009

28. What can you expect after gastric banding?
Recovery takes time and patience.
Most patients are ready for their first adjustment after eating solid foods for the first week. The exact timing will depend on your progress.
If you are losing 1-2 lbs. per week you may not need an adjustment at that time.
Reference: From REALIZEband.com; life with REALIZE then recovery expectations.
Texas Laparoscopic Consultants, LLP April 2009

29. Vertical sleeve gastrectomy is another restrictive option
Laparoscopic or Single Incision
A very good option between band and bypass.
Mean excess weight loss at 1 year of 59%2
No implanted medical device
No need for adjustments
See adjustable gastric banding
NOT CORRECT PICTURE
ASMBS, Position Statement on Sleeve Gastrectomy as a Bariatric Procedure. June 17, 2007.
Lee CM, et al. Surg Endosc (2007) 21: 1810–1816
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31. What are the risks and complications of a vertical sleeve gastrectomy?
Bleeding or infection
Staple line leak
Abdominal hernia
Pulmonary Embolus
Nausea and vomitting
Note: Your weight, age and medical history play a significant role in determining your specific risks.  Your surgeon can inform you about your specific risks for bariatric surgery.
Texas Laparoscopic Consultants, LLP April 2009 G

32. A combination approach is most common
Roux-en-Y Gastric Bypass
Laparoscopic
Most frequently performed bariatric procedure
Mean excess weight loss at 1 year of 67%1
No implanted medical device
See adjustable gastric banding
Need references
Buchwald, H. et al., JAMA. 2004; 292:
Buchwald H ASBS Consensus Conference Statement, Bariatric surgery for morbid obesity: Health implications for patients, health professionals, and third party payers. SOARD 2005;(1):371-8.
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34. What are the risks and complications of the Roux-en-Y procedure?
Dehiscence (separation of tissue that was stitched or stapled together)
Leaks from staple lines
Ulcers
Internal hernia
Dumping syndrome, an unpleasant side effect that may include vomiting, nausea, weakness, sweating, faintness, and diarrhea
Inability to detect the stomach, duodenum, and parts of the small intestine using X-ray or endoscopy, should problems arise after surgery such as ulcers, bleeding, or malignancy
From NJ presentation
Note: Your weight, age and medical history play a significant role in determining your specific risks.  Your surgeon can inform you about your specific risks for bariatric surgery.
Texas Laparoscopic Consultants, LLP April 2009

35. Duodenal Switch Weight loss: 90% EBW
More risk of protein and vitamin deficiency
Requires maximum compliance with vitamins and protein
Some patients have more frequent stools

36. Gastric Plication Newest procedure No removal of stomach
Not covered by insurance
Results similar to gastric sleeve

37. Summary

38. Choosing the procedure that’s right for you
Considerations
Age
Health Risk (depending on comorbidities)
Amount of weight to lose
Lifestyle
Eating behaviors
Mutual decision between patient and surgeon
Discuss with surgeon during initial consultation
Discuss with family and friends
Texas Laparoscopic Consultants, LLP April 2009

39. Surgery can help you change your life
Improves or resolves obesity-related illnesses
Decreases mortality risk
Reduces healthcare utilization and direct healthcare costs
Remember…surgery is a tool that requires your strong commitment to a lifestyle change and lifetime of follow-up
We could add a slide here showing the resolution of co-morbidities.
* Christou NV, Sampalis JS, Liberman M, et al. Surgery Decreases Long-Term Mortality, Morbidity, and Health Care Use in Morbidly Obese Patients. Annals of Surgery 2004;240(3):
Texas Laparoscopic Consultants, LLP April 2009

40. Resolving your co-morbid conditions
Following bariatric surgery, most patients resolve or improve their co-morbid conditions
Buchwald, et al JAMA Oct 2004.
Texas Laparoscopic Consultants, LLP April 2009

41. What are your next steps?

42. You’ve already taken the first step
Attend seminar (Complete!)
Obtain referral from Primary Care Physician (PCP)
Initial consultation with surgeon
Psychological evaluation
Nutritional evaluation & counseling with one of our dieticians
Verify benefits and obtain insurance authorization
Pre-operative testing
Surgery
Lifelong follow-up appointments and support groups
Texas Laparoscopic Consultants, LLP April 2009

43. When (office hours): Mon-Thurs. 8:00-5:00, Fri. 8:00-4:30
Questions?
1200 Binz Suite # 950
Houston, Tx 77004
When (office hours): Mon-Thurs. 8:00-5:00, Fri. 8:00-4:30
Phone numbers: (713)
Fax number: (281)
Web:
Fill in information pertaining to your practice.
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