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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?.

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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


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

Obesity and Mortality Risk



















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

obesity related co morbidities
Type II Diabetes



Cardiac Disease


Respiratory Disease

Sleep apnea

Obesity hypoventilation syndrome

Degenerative arthritis


Pseudotumor cerebri


Nephrotic syndrome



Infectious complications

Stress incontinence

Venous stasis ulcers


Obesity Related Co-Morbidities
medical co morbidities resolved after bariatric surgery
Medical Co-Morbidities Resolved after Bariatric Surgery

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

non medical co morbidities
Non-Medical Co-Morbidities
  • 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 conference 1991
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 35-40 with significant co-morbidity
    • documented dietary attempts ineffective
who is a surgical candidate
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
roux en y gastric bypass
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


how does the roux en y work
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
results of gastric bypass
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

*Results achieved in most but not all cases. Degree of improvements vary by individual

laparoscopic adjustable gastric banding
Laparoscopic Adjustable Gastric Banding
  • Restrictive
  • Good results in Europe and Australia
  • Inamed Lap Band™ FDA approved 6/01
  • 40-55% EBW Loss
how does the band work
How does the Band work?

Surgery Factors:

  • Restriction of meal size
  • Decreased appetite

Patient Factors:

  • Decreased calorie intake
  • Increased calorie expenditure
advantages of laparoscopy
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

hospital course
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

results of bariatric surgery
Results of Bariatric Surgery
  • Weight loss
  • Reduction or improvement in co-morbidities
  • Increased longevity
  • Improved Quality of Life
    • health
    • social
    • personal
    • work
lifetime supplements are necessary to prevent
Lifetime supplements are necessary to prevent…
  • Iron Deficiency Anemia
  • Folate Deficiency
  • Vitamin B-12 Deficiency
complications of gastric bypass
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

how are good results achieved
How are good results achieved?
  • Follow ASBS recommendations
  • Surgeon and Hospital commitment
  • Dedicated bariatric team
  • Comprehensive care
  • Lifelong follow up
  • Database management
weight loss program team
Weight Loss Program Team
  • Surgeon
  • Nurse Practicioner
  • Bariatric Coordinator
  • Registered Dietician
  • Clinical psychologist
  • Exercise Specialist
  • Office support staff
will my insurance pay for this procedure
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?
what happens if my insurance company denies my request
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.)
how long does it take to pre authorize my surgery
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
what makes sacramento bariatric different
What Makes SacramentoBariatric 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

* Patients must commit to lifelong changes in diet

and behavior

* Think seriously about options

* We are here to help