What Is Obesity?

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 gt200 of ideal weight, gt100 lb
  overweight, or a Body mass index of ?40

3
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. 198973(1)113.
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
Wittgrove AC,Clark GW. Laparoscopic Gastric
bypass roux-n-y-500 patients. Obes Surg 2000.
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 35-40 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

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

19
Complications of Gastric Bypass

• Early complications
• intestinal leakage
• acute gastric remnant dilatation
• obstruction
• cardiopulmonary
• MI, PE, pneumonia, atelectasis
• Late complications
• anastomotic stricture (510)
• 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

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

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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