Weight loss Surgery at St. Weight loss Surgery at St. Agnes HospitalAgnes Hospital

Andrew M. Averbach, M.D., FACSAndrew M. Averbach, M.D., FACS

Director of Bariatric and Minimally Director of Bariatric and Minimally Invasive SurgeryInvasive Surgery

Spectrum of the Spectrum of the obesityobesity

Terms Used to Describe Various Levels of Body FatTerms Used to Describe Various Levels of Body Fat

Normal Weight (BMI 18.5 to 24.9)

Overweight(BMI 25 to 29.9)

Obese(BMI 30 to 34.9)

Severely Obese(BMI 35 to 39.9 )

Morbidly Obese(BMI 40 or more)

Obesity Classification Obesity Classification Disease Stage by BMIDisease Stage by BMI

BMIBMI Class/StageClass/Stage DefinitionDefinition Risk of DM II, Risk of DM II, HTN, CAD, HTN, CAD, Sleep apnea, Sleep apnea, premature premature deathdeath

30-34.930-34.9 II ObeseObese IncreasedIncreased

35-39.935-39.9 IIII Severely Severely obeseobese

HighHigh

40—49.940—49.9 IIIIII Morbidly Morbidly obeseobese

Extremely Extremely highhigh

50-59.950-59.9 IVIV Mega obeseMega obese Extremely Extremely highhigh

>60>60 IVIV Mega-mega Mega-mega obeseobese

Extremely Extremely highhigh

Health Risks Health Risks

• Obese people have higher risk for:Obese people have higher risk for:• Diabetes Type II (adult onset)Diabetes Type II (adult onset)• Severe arthritisSevere arthritis• High blood pressure (not controlled with medications)High blood pressure (not controlled with medications)• Sleep apnea (disordered breathing during sleep)Sleep apnea (disordered breathing during sleep)• Obesity related heart muscle weaknessObesity related heart muscle weakness• High cholesterol (not controlled with diet and High cholesterol (not controlled with diet and

medications)medications)• Fatty liver that can lead to cirrhosisFatty liver that can lead to cirrhosis

Source: The Surgeon General’s Call to Action to Prevent Overweight and Obesity.

Related Diseases (Co-morbid Related Diseases (Co-morbid conditions):conditions):

Health Risks Health Risks (cont.)(cont.)

Related Diseases and Health ProblemsRelated Diseases and Health Problems• Obese people are at higher risk for:Obese people are at higher risk for:

• Certain types of cancer (breast, uterine, colon)Certain types of cancer (breast, uterine, colon)

• Digestive disorders (e.g. gastro-esophageal reflux Digestive disorders (e.g. gastro-esophageal reflux disease, or GERD, gall bladder problems)disease, or GERD, gall bladder problems)

• Breathing difficulties (e.g. shortness of breath, Breathing difficulties (e.g. shortness of breath, asthma).asthma).

• Psychological problems such as depression.Psychological problems such as depression.

• Problems with fertility and pregnancy.Problems with fertility and pregnancy.

• Stress Incontinence.Stress Incontinence.

Source: The Surgeon General’s Call to Action to Prevent Overweight and Obesity.

Types of Surgery to Types of Surgery to Treat ObesityTreat Obesity

• Types of weight-loss surgeriesTypes of weight-loss surgeries• MalabsorptiveMalabsorptive procedures procedures

shorten the digestive tract (shorten the digestive tract (Duodenal switch, Duodenal switch, Biliopancreatic diversionBiliopancreatic diversion))

• RestrictiveRestrictive procedures procedures reduce how much the stomach can hold reduce how much the stomach can hold

((Lap Band, Laparoscopic Sleeve GastectomyLap Band, Laparoscopic Sleeve Gastectomy))• CombinedCombined procedures procedures

shorten the digestive tract and reduce how much shorten the digestive tract and reduce how much the stomach can hold (the stomach can hold (Laparoscopic Gastric Laparoscopic Gastric bypassbypass))

Surgical procedures to Surgical procedures to Treat Morbid Obesity Treat Morbid Obesity

Gastric Bypass(GBP)

LAP-BANDSystem

Sleeve Gastrectomy

Expected Outcomes Expected Outcomes from the Surgeryfrom the Surgery

• Improvement or resolution of:Improvement or resolution of:• Diabetes (type 2): 80% Diabetes (type 2): 80%

• High blood pressure: 80% High blood pressure: 80%

• Asthma: marked improvementAsthma: marked improvement

• GERD (gastro-esophageal reflux disease): 95% GERD (gastro-esophageal reflux disease): 95%

• Sleep apnea: close to 100% Sleep apnea: close to 100%

• High cholesterol: 80% improvement/resolutionHigh cholesterol: 80% improvement/resolution

• InfertilityInfertility

• Depression. Depression.

Bariatric SurgeryBariatric SurgeryLong-term outcomesLong-term outcomes

Bariatric Volumes in Bariatric Volumes in MarylandMaryland

DRG 288 & ICD-9 Procedure code DRG 288 & ICD-9 Procedure code definitiondefinition

   FY02FY02 FY03FY03 FY04FY04 FY05FY05 FY06FY06 Total Cases Market ShareTotal Cases Market Share

HOSPITALHOSPITALSvc Svc AreaArea TotalTotal

Svc Svc AreaArea TotalTotal

Svc Svc AreaArea TotalTotal

Svc Svc AreaArea TotalTotal

Svc Svc AreaArea TotalTotal FY02FY02 FY03FY03 FY04FY04 FY05FY05 FY06FY06

ST. AGNES ST. AGNES 1313 2424 7575 135135 153153 311311 174174 368368 229229 469469 6%6% 13%13% 20%20% 20%20% 26%26%

BAYVIEWBAYVIEW 66 5353 2222 148148 4040 281281 3636 306306 3939 304304 15%15% 14%14% 18%18% 17%17% 14%14%

GBMCGBMC 00 00 00 00 00 3131 1818 158158 3333 188188 0.0%0.0% 0.0%0.0% 2.0%2.0% 8.9%8.9% 13%13%

SINAISINAI 1212 8383 1414 7676 2121 6060 5656 188188 5151 184184 23.9%23.9% 7.6%7.6% 3.9%3.9% 10.6%10.6% 12%12%

HOLY CROSSHOLY CROSS 00 3333 88 160160 00 6262 22 102102 33 149149 9.5%9.5% 16.0%16.0% 4.0%4.0% 5.7%5.7% 7.8%7.8%

UMMSUMMS 44 1414 77 2727 99 2222 44 2222 2828 130130 4.0%4.0% 2.7%2.7% 1.4%1.4% 1.2%1.2% 6.8%6.8%

SHADY GROVESHADY GROVE 00 00 00 66 22 107107 22 145145 11 105105 0.0%0.0% 0.6%0.6% 7.0%7.0% 8.2%8.2% 5.5%5.5%

PENINSULA REGIONALPENINSULA REGIONAL 00 00 22 5454 00 9898 11 9696 00 102102 0.0%0.0% 5.4%5.4% 6.4%6.4% 5.4%5.4% 5.3%5.3%

WASHINGTON WASHINGTON ADVENTISTADVENTIST 00 00 00 1010 44 127127 22 117117 00 9191

0.0%0.0% 1.0%1.0% 8.3%8.3% 6.6%6.6%

4.7%4.7%

HARFORD MEMORIALHARFORD MEMORIAL 00 00 00 00 00 00 33 6060 11 5858 0.0%0.0% 0.0%0.0% 0.0%0.0% 3.4%3.4% 3.0%3.0%

SAINT JOSEPHSAINT JOSEPH 11 33 1010 4545 2222 110110 1818 9999 1414 5757 0.9%0.9% 4.5%4.5% 7.2%7.2% 5.6%5.6% 3.0%3.0%

FRANKLIN SQUAREFRANKLIN SQUARE 1313 6969 3535 146146 1212 7272 1111 6060 88 4747 19.8%19.8% 14.6%14.6% 4.7%4.7% 3.4%3.4% 2.4%2.4%

UNION MEMORIALUNION MEMORIAL 33 1313 1616 5151 99 1818 55 2828 66 3737 3.7%3.7% 5.1%5.1% 1.2%1.2% 1.6%1.6% 1.9%1.9%

SUBURBANSUBURBAN 00 00 00 00 77 8989 00 2222 00 00 0.0%0.0% 0.0%0.0% 5.8%5.8% 1.2%1.2% 0.0%0.0%

GOOD SAMARITANGOOD SAMARITAN 1414 5050 2424 115115 3030 140140 00 00 00 00 14.4%14.4% 11.5%11.5% 9.1%9.1% 0.0%0.0% 0.0%0.0%

All OtherAll Other 11 66 22 2828 00 44 00 33 00 00 1.7%1.7% 2.8%2.8% 0.3%0.3% 0.2%0.2% 0.0%0.0%

Grand TotalGrand Total 6767 348348 215215 1,0011,001 309309 1,5321,532 332332 1,7741,774 413413 1,9211,921100.0100.0

%%100.0100.0

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ASBS/SRC COE requirementsASBS/SRC COE requirements• Surgeons: ABS certified, bariatric training, >50 cases/year, Surgeons: ABS certified, bariatric training, >50 cases/year,

>125 cases in the past, postop.management>125 cases in the past, postop.management• Hospital with >125 cases/year; bariatric surgery Hospital with >125 cases/year; bariatric surgery

credentialing and in-service education programcredentialing and in-service education program• Hospital with integrated multidisciplinary program (OR, Hospital with integrated multidisciplinary program (OR,

specialized nurses, dietician, psychologist, consultants, specialized nurses, dietician, psychologist, consultants, critical care, radiology and etc.)critical care, radiology and etc.)

• Patients education and informed consent (indications, Patients education and informed consent (indications, surgery, alternative Tx, outcomes, risks, follow-up and etc)surgery, alternative Tx, outcomes, risks, follow-up and etc)

• Bariatric team: Med.Director, coordinator,specialists, nursesBariatric team: Med.Director, coordinator,specialists, nurses• Bariatric on call coverageBariatric on call coverage• Clinical pathways, standardized orders, proceduresClinical pathways, standardized orders, procedures• Support groups, outcome/long-term follow-up and databaseSupport groups, outcome/long-term follow-up and database

Gastric bypass resultsGastric bypass resultsVariableVariable Average for Average for

Centers of Centers of Excellence Excellence

(US average)(US average)

St. Agnes St. Agnes ProgramProgram

Personal Personal resultsresults

Number of Number of patientspatients

55 000 55 000 (140 (140 000)000)

15001500 750750

MortalityMortality 0.3% 0.3% (2%)(2%) 0.25%0.25% 0%0%

MorbidityMorbidity 10% 10% (30%)(30%) 8.5%8.5% 8%8%

Re-Re-operationsoperations

2.5% 2.5% (5%)(5%) 2%2% 1.3%1.3%

Re-admissionRe-admission 4.5% 4.5% (10%)(10%) 4.5%4.5% 4.4%4.4%

Bowel Bowel obstructionobstruction

2.5% 2.5% (4%)(4%) 0.95%0.95% 0.85%0.85%

Marginal Marginal ulcerulcer

5 % 5 % (5-(5-7%)7%)

0.99%0.99% 0.73%0.73%

EBWL % 1 EBWL % 1 yearyear

65% (NA)65% (NA) 67.6%67.6% 70%70%

Laparoscopic vs. Open Gastric Laparoscopic vs. Open Gastric BypassBypass

2004-2006 2004-2006OutcomesOutcomes Lap.Gastric bypassLap.Gastric bypass

N= 16,357N= 16,357Open Gastric Open Gastric Bypass N=6,055Bypass N=6,055

Odds ratio Odds ratio (95%CI)(95%CI)

Mean LOS (d) +SDMean LOS (d) +SD 2.7+2.02.7+2.0 4.0+4.74.0+4.7 P<0.05P<0.05

MORBIDITYMORBIDITY 7.4%7.4% 13.0%13.0% 2.12.1

PulmonaryPulmonary 0.7%0.7% 2.2%2.2% 3.053.05

PneumoniaPneumonia 0.6%0.6% 1.2%1.2% 2.272.27

DVT/PEDVT/PE 0.3%0.3% 0.7%0.7% 3.063.06

LeakLeak 1.4%1.4% 3.1%3.1% 2.242.24

HemorrhageHemorrhage 1.7%1.7% 1.9%1.9% 1.331.33

Wound infectionWound infection 0.5%0.5% 2.3%2.3% 5.075.07

30-day readmission30-day readmission 2.6%2.6% 4.7%4.7% 2.032.03

MORTALITYMORTALITY 0.1%0.1% 0.3%0.3% 3.443.44

Mean cost+SDMean cost+SD $13,743+6,873$13,743+6,873 $14,585+15,813$14,585+15,813 P<0.05P<0.05

Nguyen et al., J Am Coll Surg.2007; 205:248-255

Laparoscopic Gastric Laparoscopic Gastric Bypass Bypass

AdvantagesAdvantages• Rapid initial Rapid initial

weight lossweight loss• Higher total Higher total

average weight average weight loss .loss .

• Higher rate of co-Higher rate of co-morbidity morbidity resolutionresolution

• Over 40 years of Over 40 years of surgical surgical experience in USAexperience in USA

DisadvantagesDisadvantages• Bigger operation and Bigger operation and

somewhat slower somewhat slower recovery.recovery.

• Major surgery to Major surgery to reversereverse

• Possibility of Possibility of nutritional problems nutritional problems such as Iron deficiency such as Iron deficiency anemia and vitamin B anemia and vitamin B 12 deficiency12 deficiency

• 2-5% chances of ulcers 2-5% chances of ulcers at the junction of the at the junction of the stomach and the small stomach and the small bowelbowel

The LAP-BAND SystemThe LAP-BAND System

AdvantagesAdvantages• Lowest mortality rateLowest mortality rate• No stomach stapling or No stomach stapling or

cutting, or intestinal re-cutting, or intestinal re-routingrouting

• AdjustableAdjustable• Smaller operation , Smaller operation ,

easily reversibleeasily reversible• Lowest operative Lowest operative

complication ratecomplication rate• Low malnutrition riskLow malnutrition risk

DisadvantagesDisadvantages• Slower weight loss.Slower weight loss.• Regular follow-up critical for Regular follow-up critical for

optimal resultsoptimal results• Requires more commitment Requires more commitment

from the patient.from the patient.• Slippage or erosion and injury Slippage or erosion and injury

to the esophagus or stomach to the esophagus or stomach as possible complications.as possible complications.

• Possibility of mechanical Possibility of mechanical problems with device, problems with device, infectioninfection

Band intolerance, poor weight Band intolerance, poor weight loss may result in Band loss may result in Band removal in about 5% of removal in about 5% of patientspatients

Laparoscopic Sleeve Laparoscopic Sleeve Gastrectomy is an alternative Gastrectomy is an alternative

to:to:• Roux-en-Y gastric bypass Roux-en-Y gastric bypass Because:Because:• Lower risk of deficienciesLower risk of deficiencies• No risk of marginal ulcerNo risk of marginal ulcer• No or minimal “dumping”No or minimal “dumping”• No risk of intestinal obstructionNo risk of intestinal obstruction• Easily converted to bypass for Easily converted to bypass for

inadequate weight lossinadequate weight loss• Contraindications to bypass Contraindications to bypass

(chr.anemia, Crohn’s disease (chr.anemia, Crohn’s disease etc.)etc.)

• Comparable long-term weight Comparable long-term weight loss to Gastric bypassloss to Gastric bypass

• Very effective as 1-st stage prior Very effective as 1-st stage prior to Gastric bypass in BMI>60 to Gastric bypass in BMI>60

• Lap BandLap BandBecause:Because:• No risk of system No risk of system

malfunctioning malfunctioning (slippage, erosion, (slippage, erosion, infection and etc.)infection and etc.)

• No need for adjustmentNo need for adjustment• No foreign body/plasticNo foreign body/plastic• Contraindications to Lap Contraindications to Lap

Band (connective tissue Band (connective tissue disorders, allergy)disorders, allergy)

• Need to take NSAIDs for Need to take NSAIDs for arthritis or heart diseasearthritis or heart disease

• Sleeve gastrectomy Sleeve gastrectomy showed superior weight showed superior weight loss at 3 yearsloss at 3 years

Laparoscopic Sleeve Laparoscopic Sleeve GastrectomyGastrectomy

Disadvantages:Disadvantages:• Potential for inadequate weight loss/ weight regain due to Potential for inadequate weight loss/ weight regain due to

sleeve dilatationsleeve dilatation• People with BMI>60 may need 2-nd stage surgery (Gastric People with BMI>60 may need 2-nd stage surgery (Gastric

Bypass) to achieve normal weightBypass) to achieve normal weight• Sweet eaters, grazers, binge eaters have suboptimal resultsSweet eaters, grazers, binge eaters have suboptimal results• Potential complications with long staple linePotential complications with long staple line• Not reversibleNot reversible• May worsen reflux disease (heartburn)May worsen reflux disease (heartburn)• Not covered by any insuranceNot covered by any insurance• Will have to take vitamins, B12, calcium, possibly antacidsWill have to take vitamins, B12, calcium, possibly antacids• Mortality 0-0.5%, complications 2.5%, leaks 1%Mortality 0-0.5%, complications 2.5%, leaks 1%

Gastric Band Adjustment Gastric Band Adjustment and Follow-upand Follow-up

• Follow-up for life with bariatric surgeonFollow-up for life with bariatric surgeon• Follow-up at 2 and 6 weeks after surgeryFollow-up at 2 and 6 weeks after surgery• First adjustment after 6 weeksFirst adjustment after 6 weeks• First adjustment in the office if possible or using X-rayFirst adjustment in the office if possible or using X-ray• Subsequent adjustments done as needed Subsequent adjustments done as needed • Patient-driven adjustment policy: Patient-driven adjustment policy:

Despite your best effort (healthy eating and regular Despite your best effort (healthy eating and regular exercise) - no weight loss for 2-3 weeks in a rowexercise) - no weight loss for 2-3 weeks in a row

• Follow-up visit every 3 months during 1-2 yearFollow-up visit every 3 months during 1-2 year• Annual Band adjustment under X-ray to look for optimal Annual Band adjustment under X-ray to look for optimal

restriction and to detect early potential problems with restriction and to detect early potential problems with the bandthe band

St.Agnes Hospital St.Agnes Hospital outcomes with Lap Bandoutcomes with Lap Band

• 550 cases550 cases• Mortality 0%Mortality 0%• Morbidity 3.2%Morbidity 3.2%• Re-operations 1.2% (stomach Re-operations 1.2% (stomach

laceration - 3; acute band laceration - 3; acute band obstruction,port infection; band obstruction,port infection; band intolerance)intolerance)

• Re-admission within 1 month Re-admission within 1 month 2% (dehydration; atelectases; 2% (dehydration; atelectases; wound infection).wound infection).

• Average LOS – 1 day (range 0-5)Average LOS – 1 day (range 0-5)• Band slippage – 0.57%, no band Band slippage – 0.57%, no band

erosions erosions • Band removal/gastric bypass – Band removal/gastric bypass –

1.2%1.2%

• 275 cases275 cases• Mortality 0%Mortality 0%• Morbidity 2.3%Morbidity 2.3%• Re-operations 1% (stomach Re-operations 1% (stomach

laceration)laceration)• Re-admission 1.5%Re-admission 1.5%• Average LOS 1 dayAverage LOS 1 day• No slips, erosions, infection No slips, erosions, infection

or band removal to dateor band removal to date

Total for our program My personal results

Weight loss after gastric Weight loss after gastric bypass vs. Lap bandbypass vs. Lap band

Jan et al., J.GI Surgery, 2007

% Excess Body Weight Loss by % Excess Body Weight Loss by ProcedureProcedure

St. Agnes HospitalSt. Agnes Hospital

18.4612.76

35.88

20.33

52.89

26.35

67.6

33.36

68.99

35.94

0

20

40

60

80

100

1 mon 3 mon 6 mon 1 year 2 year

% Excess Body Weight Lost by Procedure 4/2005 - 12/2007

Bypass Lapband

% Weight Excess Body Loss by initial BMI% Weight Excess Body Loss by initial BMISt.Agnes HospitalSt.Agnes Hospital

14.19.1

26.6

14.8

40.9

21.6

53.2

22.9

66.1

25.4

0

20

40

60

80

100

1 mon 3 mon 6 mon 1 year 2 year

Initial BMI Above 60, % EBWL 4/05 - 12/07

Bypass Lapband

19.6912.79

39.21

20.05

57.03

26.87

72.27

34.11

71.65

35.07

0

20

40

60

80

100

1 mon 3 mon 6 mon 1 year 2 year

Initial BMI 40 - 49.9, % EBWL 4/05 - 12/07

Bypass Lapband

16.911.1

31.7

17.7

46.8

21.2

61.5

29.1

64.1

32.8

0

20

40

60

80

100

1 mon 3 mon 6 mon 1 year 2 year

Initial BMI 50 - 59.9, % EBWL 4/05 - 12/07

Bypass Lapband

23.97

14.51

50.97

24.31

73.83

30.56

86.01

38

78

44.8

0

20

40

60

80

100

1 mon 3 mon 6 mon 1 year 2 year

Initial BMI Below 40, % EBWL 4/05 - 12/07

Bypass Lapband

Weight Loss Results by SurgeonWeight Loss Results by Surgeon

18.313

35.6

20.9

52.3

27.8

66.9

35

66.1

33.8

0

20

40

60

80

100

1 mon 3 mon 6 mon 1 year 2 year

% Excess Body Weight Lost by Procedure, Singh - 4/2005 - 12/2007

Bypass Lapband

18.712.4

36.1

19.3

53.5

24

68.6

30.4

72.8

40.6

0

20

40

60

80

100

1 mon 3 mon 6 mon 1 year 2 year

% Excess Body Weight Lost by Procedure, Averbach - 4/2005 - 12/2007

Bypass Lapband

Lap Band: Best results Lap Band: Best results seenseen

• BMI 35-49BMI 35-49• No serious co-morbiditiesNo serious co-morbidities• Good exercise tolerance; no Good exercise tolerance; no

disabling arthritisdisabling arthritis• Have a greater commitment to Have a greater commitment to

exercise and good dietary choices exercise and good dietary choices then with other proceduresthen with other procedures

Lap Band vs. Diet in BMI 30-35%Lap Band vs. Diet in BMI 30-35%

Laparoscopic Sleeve Laparoscopic Sleeve GastrectomyGastrectomy

BMI decrease at 2 yearsBMI decrease at 2 years

0

10

20

30

40

50

Band Bypass Sleeve

0 mo

12 mo

24 mo

Band or Bypass? Band or Bypass? How patients How patients

choose?choose?• Lap Band (%)Lap Band (%)

• Low risk of surgery (85)Low risk of surgery (85)• Quicker recovery (80)Quicker recovery (80)• ““I felt it was better for I felt it was better for

me.”me.”• 6% less patients decide 6% less patients decide

to have Lap Band after to have Lap Band after seminar and surgeons seminar and surgeons consultconsult

• 50% choose Lap Band50% choose Lap Band

• Lap Gastric BypassLap Gastric Bypass

• More overall weight loss More overall weight loss (92)(92)

• Quicker weight loss (79)Quicker weight loss (79)• ““I felt it was better for I felt it was better for

me.”me.”• 6% more switch to 6% more switch to

bypass after seminar and bypass after seminar and surgeon consultsurgeon consult

• 50% choose Gastric 50% choose Gastric bypassbypass

What procedure to choose? What procedure to choose? We will decide together.We will decide together.

Laparoscopic Gastric BypassLaparoscopic Gastric Bypass

• Your choiceYour choice• Procedure of choice for any BMIProcedure of choice for any BMI• Multiple co-morbidities requiring quick resolutionMultiple co-morbidities requiring quick resolution• BMI >50BMI >50

Laparoscopic Gastric Banding (Lap Band)Laparoscopic Gastric Banding (Lap Band)

• Your choice.Your choice.• BMI 35-49BMI 35-49• No/few co-morbidities, no disabling arthritis, women who plan to No/few co-morbidities, no disabling arthritis, women who plan to

have children within a yearhave children within a year

Laparoscopic Sleeve GastrectomyLaparoscopic Sleeve Gastrectomy• Procedure of choice for any BMIProcedure of choice for any BMI• BMI>50 and you do not want gastric bypassBMI>50 and you do not want gastric bypass• Your choiceYour choice

Who qualifies for the Who qualifies for the Bariatric Surgery?Bariatric Surgery?

• NIH criteriaNIH criteria1.1. Weight: BMI more than 40 or 35 with two serious Weight: BMI more than 40 or 35 with two serious

illnesses.illnesses.2.2. Free from untreated mental illnesses such as Bulimia Free from untreated mental illnesses such as Bulimia

and Schizophrenia, Bipolar disorder or Severe and Schizophrenia, Bipolar disorder or Severe depression, Mental retardation, Anorexia.depression, Mental retardation, Anorexia.

3.3. Documented evidence of weight loss attempts. Documented evidence of weight loss attempts. In Maryland 6 months over the past two years In Maryland 6 months over the past two years (varies by insurance company).(varies by insurance company).

4.4. Understanding by the patient that the surgery is only Understanding by the patient that the surgery is only a tool to lose weight.a tool to lose weight.

5.5. Life style changes, exercise and eating habits Life style changes, exercise and eating habits are of absolute importance.are of absolute importance.

• Age: 18-60 years of ageAge: 18-60 years of age

• Those who have severe uncorrectable heart disease.Those who have severe uncorrectable heart disease.• Heart failure.Heart failure.• Angina and coronary artery disease.Angina and coronary artery disease.

• Severe lung disease (home oxygen).Severe lung disease (home oxygen).• Psychiatric illnessesPsychiatric illnesses

• In whom surgery is not feasible: In whom surgery is not feasible: UNWILLING & UNABLEUNWILLING & UNABLE• Lack of understanding and willingness to learn how Lack of understanding and willingness to learn how

bariatric surgery works for you. bariatric surgery works for you. • Unable or unwilling to make necessary life-style, eating Unable or unwilling to make necessary life-style, eating

habits changeshabits changes• Limited exercise tolerance. Limited exercise tolerance. • Non-compliant with work-up, follow-up and Non-compliant with work-up, follow-up and

recommendationsrecommendations

Who does not qualifies Who does not qualifies for the Bariatric for the Bariatric

Surgery? Surgery?

With ANY Bariatric With ANY Bariatric Procedure Best Outcomes Procedure Best Outcomes

are seen when:are seen when:• HISTORYHISTORY: You seriously tried to loose weight in the past; Surgery is not : You seriously tried to loose weight in the past; Surgery is not

the starting pointthe starting point

• MOTIVATIONMOTIVATION: You leave all the excuses and get the job done.: You leave all the excuses and get the job done.

• INVOLVMENTINVOLVMENT: You are proactively participate in your care; Never say : You are proactively participate in your care; Never say “nobody told me that!” .“nobody told me that!” .

• COMPLIANCECOMPLIANCE: You follow all recommendations, come for regular : You follow all recommendations, come for regular follow-up.follow-up.

• COMMITMENTCOMMITMENT: You exercise regularly and assume good eating habits.: You exercise regularly and assume good eating habits.

• SUPPORTSUPPORT: You have good social/family support or actively seek help : You have good social/family support or actively seek help when needed, attend group support meetings.when needed, attend group support meetings.

When surgery might not When surgery might not work:work:

• You are waiting for weight loss - without exercising and changing You are waiting for weight loss - without exercising and changing eating habits.eating habits.

• You have an excuse why you are not exercising or eating right.You have an excuse why you are not exercising or eating right.

• ““Cheating” with high calorie foods or drinksCheating” with high calorie foods or drinks

• ““Grazing” – continuous eating throughout the dayGrazing” – continuous eating throughout the day

• You rely only on surgery for weight loss. You rely only on surgery for weight loss.

• You think that this is not a You think that this is not a LIFELONG effortLIFELONG effort. . • You show up late or miss your appointment in doctor’s office!You show up late or miss your appointment in doctor’s office!

• You are not coming for regular scheduled follow-up appointmentsYou are not coming for regular scheduled follow-up appointments

Your initial steps:Your initial steps:

1.1. Make sure you meet the NIH criteria.Make sure you meet the NIH criteria.2.2. Check with insurance for coverage.Check with insurance for coverage.3.3. Make sure that we participate with your Make sure that we participate with your

insurance or be willing to cover the expense.insurance or be willing to cover the expense.4.4. See the dietician and psychologist.See the dietician and psychologist.5.5. Fill all the forms and obtain copy of recent Fill all the forms and obtain copy of recent

Physical, consults, studies.Physical, consults, studies.6.6. Make appointment to see Dr.Averbach.Make appointment to see Dr.Averbach.7.7. If you have questions - Call the office.If you have questions - Call the office.

If You are considering If You are considering bariatric surgery and bariatric surgery and

think that:think that:• SafetySafety• ResultsResults• CompassionCompassion• Availability 24/7Availability 24/7• ProfessionalismProfessionalism• DedicationDedication

Are important you can Are important you can call my office call my office tomorrowtomorrow

Thank you!Thank you!

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