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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

ASBS

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
slide3

Obesity and Mortality Risk

2.5

2.0

MortalityRatio

1.5

1.0

VeryLow

VeryHigh

Moderate

Low

Moderate

High

0

20

25

30

35

40

BMI

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

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

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

ASBS

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