laparoscopic sleeve gastrectomy recent literature review surgeon date

Laparoscopic Sleeve

Gastrectomy

Recent Literature Review

SurgeonDate

| January 28, 2010 |2 |

Agenda

• Introduction

• Review of Bariatric Surgery

• Weight Loss for Sleeve Gastrectomy

• Comparative Studies

• Case Studies

• Complications for Sleeve Gastrectomy

• Obesity Related Disease Outcomes for Sleeve Gastrectomy

• Comparative Studies

• Case Studies

• Implementation of Sleeve Gastrectomy as a Covered Procedure

| January 28, 2010 |3 |

John Doe, M.D., F.A.C.S.

• Titles

Disclosures• Consulting • Research • Stock

| January 28, 2010 |4 |

Sleeve GastrectomyBariatric procedure originally as part of

Biliopancreatic Diversion and Duodenal Switch (BPDDS)

Remove part of stomach, creating a sleeve from antrum to esophagus.

A bougie or nasogastric tube is used to size the sleeve

Utilizes same instrumentation as other bariatric procedures

Surgeon Training Programs

Fellowships

Resident Training

CME courses

Clinical Immersion

4

1

2

3

| January 28, 2010 |5 |

Bariatric Surgery

Adjustable Gastric Banding

(AGB)

Sleeve Gastrectomy

(SG)

Roux-en-Y Gastric Bypass

(RNYGB)

Biliopancreatic Diversion/Duoden

al Switch(BPDDS)

Mechanism of Action

• Restrictive • Restrictive• Restrictive• Malabsorptive• Hormonal

• Malabsorptive• Hormonal• Restrictive

Benefits

• Low Complications

• Good Weight Loss

• Continuous GI Tract

• Reduces Hunger

• Better Weight Loss

• Early Effect on Diabetes

• Best Weight Loss

% of CasesIn 2008

40% 5% 45% 5%

ASMBS, Rational for Bariatric Surgery, http://www.asbs.org/Newsite07/patients/resources/asbs_rationale.htm

| January 28, 2010 |6 |

Two Year Weight Loss and Mortality

Adapted from Buchwald H, et al, Bariatric surgery, a systematic review and meta-analysis, JAMA. 2004;292:1724-1737 and Maggard M, et al, Meta-Analysis: Surgical Treatment of Obesity, Ann Intern Med. 2005;142:547-559 .

Roux-en-Y

Switch

10%

50%

100%T

wo

Yea

r E

xces

s W

eig

ht

Lo

ssT

wo

Yea

r E

xces

s W

eig

ht

Lo

ss

30 Day Mortality (log scale %)

0.01 0.1 1 10

Banding

| January 28, 2010 |7 |

Two Year Weight Loss and Mortality

Roux-en-Y

Switch

10%

50%

100%T

wo

Yea

r E

xces

s W

eig

ht

Lo

ssT

wo

Yea

r E

xces

s W

eig

ht

Lo

ss

0.01 0.1 1 10

Gastrectomy

Adapted from Buchwald H, et al, Bariatric surgery, a systematic review and meta-analysis, JAMA. 2004;292:1724-1737 and Maggard M, et al, Meta-Analysis: Surgical Treatment of Obesity, Ann Intern Med. 2005;142:547-559 and Brethauer et al Systematic review of sleeve gastrectomy as staging and primary bariatric procedure SOARD 2009;5 .

30 Day Mortality (log scale %)

Banding

| January 28, 2010 |8 |

Safety of Bariatric SurgeryMortality Rate

LAB

S1

DeM

aria

2B

uchw

ald

3

0.00%

0.50%

1.00%

1.50%

2.00%

Rat

e (%

)

HC

UP

4

1) LABS Reporting Group N Engl J Med 2009;361:445-542) DeMaria et al Ann Surg. 2007 Oct;246(4):578-823) Buchwald et al JAMA. 2004;292:1724-17374) AHRQ, Healthcare Cost and Utilization Project (HCUP), http://hcupnet.ahrq.gov/ accessed 01/13/10, 2007 data DRG 288

| January 28, 2010 |9 |

Safety of SurgeryMortality Rate

Lap

Cho

lecy

stec

tom

y80.00%

0.50%

1.00%

1.50%

2.00%

Rat

e (%

)

App

ende

ctom

y6

GI O

bstru

ctio

n7

CA

BG

w/ c

ath

9

Dru

g E

ludi

ng S

tent

10C

arot

id S

tent

11

Her

nia5

LAB

S1

DeM

aria

2B

uchw

ald

3

HC

UP

4

1) LABS Reporting Group N Engl J Med 2009;361:445-542) DeMaria et al Ann Surg. 2007 Oct;246(4):578-823) Buchwald et al JAMA. 2004;292:1724-17374) AHRQ, Healthcare Cost and Utilization Project (HCUP), http://hcupnet.ahrq.gov/ accessed 01/13/10, 2007 data DRG 2885) Ibid 2007 data DRG’s 161 and162 6) Ibid 2007 data DRG’s 166 and1677) Ibid 2007 data DRG’s 180 and181 8) Ibid 2007 data DRG’s 493 and 4949) Ibid 2007 data DRG’s 547 and 548 10) Ibid 2007 data DRG’s 557 and 55811) Ibid 2007 data DRG 577

| January 28, 2010 |10 |

Cost of Obesity

Ostbye T et al. Obesity and workers' compensation: results from the Duke Health and Safety Surveillance System .Arch Intern Med. 2007 Apr 23;167(8):766-73.

Lost Work Days, Claims, per 100 FTE's

0

20

40

60

80

100

120

140

160

180

200

<18.5(Underweight)

18.5-24.9(Recommended

weight)

25-29.9(Overweight)

30-34.9 (Obesityclass I)

35-39.9 (Obesityclass II)

>40 (Obesity classIII)

Obesity Class

Day

s an

d N

um

ber

of

Cla

ims

$-

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

Claims

Lost WorkdaysMedical Claims Cost

Indemnity Claims Cost

| January 28, 2010 |11 |

Annual Per Capita Cost of Obesity

Wee et al. Health care expenditures associated with overweight and obesity among US adults: importance of age and race. Am J Public Health. 2005 Jan;95(1):159-65.

<18.5 (Under-weight)

18.5-24.9 (Recom-mended weight)

25-29.9 (Over-

weight)

30-34.9 (Obesity class I)

35-39.9 (Obesity class II)

>40 (Obesity class III)

BMI(Obesity Class)

Adjusted annual expenditures according to body mass index (BMI [kg/m2]), for a typical White man or woman, aged 35 to44 years, who is a high school (but not a college) graduate, has private insurance coverage, and resides in a metropolitan setting in the South.

Percapita Healthcare Spend (2008 Dollars) by BMI

$3,273 $3,248$3,601

$4,380$4,648

$5,341

$1,837 $1,861$2,099

$2,616$2,798

$3,382

$-

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000P

er

Ca

pit

a S

pe

nd

($

)

Women

Men

| January 28, 2010 |12 |

Return on Intervention

Surgical costs recovered in 13 to 60 months

ROI driven by • Cost of surgery• Comorbidities prior

to surgery• Weight Loss

Months to Recoup Intervention Costs

0

10

20

30

40

50

60

70

Laparoscopic Bariatric Surgery

Open Bariatric Surgery

Bariatric Surgery

Type of Surgery

Tim

e (m

on

ths)

Crémieux2

Gallagher4

Finklestein1

Sampalis3

1) Finkelstein and Brown Am J Manag Care. 2005; 11: 641-646.2) Cremieux et al. Am J Manag Care 2008; 14: 589-5963) Sampalis et al Obes Surg 2004; 14: 939-9474) Gallagher et al Obes Surg 2003; 13: 245-248.

| January 28, 2010 |13 |

Why Coverage for Sleeve Gastrectomy

• Category 1 CPT Code 43775 Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy) effective January 1, 2010

• Estimated 10,000 procedures in 2008• 70 peer reviewed articles have been published since

2006 on Sleeve Gastrectomy that show similar results to other covered Bariatric Procedures for

– Weight loss, as measured by excess BMI loss (39)– Comorbidity resolution (19)– Complication rates (16)

| January 28, 2010 |14 |

Comparative Weight Loss Evidence

• Published since 2006• Sleeve Gastrectomy compared to other bariatric

procedure(s)• Greater than 12 Month Follow-up• BMI reported pre-op and at follow-up• Excess BMI Loss calculated1

250

0

BMI

BMIBMIEBMIL t

WhereEBMLI = Excess BMI Loss

BMI0 = Pre-operative BMI

BMIt = BMI at time of follow-up

1 Deitel et al Reporting Weight Loss 2007, editorial Obes Surg 2007;17:565-568

6 papers meet the above criteria

| January 28, 2010 |15 |

Comparative Weight Loss Evidence

Year AuthorN

Total (SG)

Duration (months)

Control Study

2006 Himpens80

(40)24 LAGB

Single Center Prospective Randomized

2008 Karamanakos32

(16)12 RYGBP

Single Center Prospective Randomized

2008 Vidal91

(39)12 RYGBP Single Center Case Matched

2009 Strain121 (30)

21LAGB,

RYGBP,SWITCH

Single Center Prospective Cohort Study

2007 Lee846

(216)36

LAGB, RYGBP,SWITCH


2009 Wong94

(30)24

LAGB, RYGBP


| January 28, 2010 |16 |

Himpens et al. Prospective Randomized Study BetweenLaparoscopic Gastric Banding and Laparoscopic Isolated

Sleeve Gastrectomy: Results after 1 and 3 Years

Time (Mo)

EBMIL

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 10 20 30 40 50 60

EW

L (

BM

I(25

)) Sleeve Gastrectomy

Adjustable Gastric Band

• Single Center Randomized Trial (40/40)

• More loss of hunger in Sleeve Gastrectomy group

Himpens et al. A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. Obes Surg 2006;16:1450–6.

| January 28, 2010 |17 |

Vidal et al.1 and Karamanakos et al.2

EBMIL

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 10 20 30 40 50 60Time (Mo)

EW

L (

BM

I(25

))

Sleeve Gastrectomy2

Roux en Y Gastric Bypass2

• Vidal – Single center case matched comparison

• Vidal - Similar weight loss and diabetes resolution

• Karamanakos- Single center randomized study

• Karamanakos – Better weight loss and reduced ghrelin levels with SG

1) Vidal et al. Type 2 diabetes mellitus and the metabolic syndrome following sleeve gastrectomy in severely obese subjects. Obes Surg 2008;18:1077– 82.2) Karamanakos et al. Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin and peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a prospective, double blind study. Ann Surg 2008;247:401–7.

Sleeve Gastrectomy1


| January 28, 2010 |18 |

Lee et al. Vertical gastrectomy for morbid obesity in 216 patients: report of two-year results

EBMIL

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 10 20 30 40 50 60Time (Mo)

EW

L (

BM

I(25

))

Sleeve Gastrectomy


• Single Center Cohort Study (846 patients)

• All laparoscopic procedures

• SG patients had higher pre-op BMI but similar EBMIL to Roux en Y and BPPDS patients

Lee et al. Vertical gastrectomy for morbid obesity in 216 patients: report of two-year results. Surg Endosc 2007;21:1810–6.

Roux en Y Gastric Bypass

Biliopancreatic Diversion and Duodenal Switch

| January 28, 2010 |19 |

Strain et al. Comparison of weight loss and body composition changes with four surgical procedures

EBMIL

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 10 20 30 40 50 60Time (Mo)

EW

L (

BM

I(25

))Sleeve Gastrectomy



Biliopancreatic Diversion and Duodenal Switch



• Sleeve Gastrectomy and Biliopancreatic Diversion (BPDDS) patients had higher pre-op BMI’s

1) Strain et al. Comparison of weight loss and body composition changes with four surgical procedures. Surg Obes Relat Dis. 2009 Sep-Oct;5(5):582-7. Epub 2009 Apr 14.2) Strain et al.Comparison of effects of gastric bypass and biliopancreatic diversion with duodenal switch on weight loss

and body composition 1-2 years after surgery.Surg Obes Relat Dis. 2007 Jan-Feb;3(1):31-6. Epub 2006 Nov 20.

2

21

1

1

1

| January 28, 2010 |20 |

Wong et al. Laparoscopic bariatric surgery: a five-year review

Time (Mo)

EBMIL

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 10 20 30 40 50 60

EW

L (

BM

I(25

))Sleeve Gastrectomy





• Roux en Y patients had higher pre-op BMI’s

Wong et al. Laparoscopic bariatric surgery: a five-year review. Hong Kong Med J. 2009 Apr;15(2):100-9.

| January 28, 2010 |21 |

Case Study Weight Loss Evidence

• Published since Dec 2005• Greater than 10 Patients• BMI reported pre-op and at follow-up• Excess BMI Loss calculated1

250

0

BMI

BMIBMIEBMIL t

WhereEBMLI = Excess BMI Loss

BMI0 = Pre-operative BMI

BMIt = BMI at time of follow-up

1 Deitel et al Reporting Weight Loss 2007, editorial Obes Surg 2007;17:565-568

39 papers meet the above criteria

| January 28, 2010 |22 |


Pre-Op

Follow Up Time t (months)

6 12 18 24 36

Total Number of Patients at

Time t2660 96 1770 245 451 98

Total Number of Studies

39 4 21 5 5 4

Average BMI at Time, BMIt

(kg/m2)47.9 33.3 33.9 35.3 33.7 30.9

| January 28, 2010 |23 |


0%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 10 20 30 40 50 60Time (Mo)

BM

I E

WL

(%

)Excess BMI Loss

95% Confidence interval

10%

Weighted Analysis of longitudinal Excess BMI Loss from 39 papers on previous slide

| January 28, 2010 |24 |

Sleeve Gastrectomy Weight Loss Compared to Roux en Y Bypass and Adjustable Gastric Banding

Excess BMI Loss

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 10 20 30 40 50 60Time (Mo)

BM

I E

WL

(%

)

Adjustable Gastric Band2



Adjustable Gastric Band1

1)Christou et al. Five-year outcomes of laparoscopic adjustable gastric banding and laparoscopic Roux-en-Ygastric bypass in a comprehensive bariatric surgery program in Canada, Can J Surg, Vol. 52, No. 6, December 2009 E249-2582)Angrisani et al. Laparoscopic adjustable gastric banding versus Roux-en-Y gastric bypass: 5-year results of a prospective randomized trial, Surg Obes Rel Dis 2007;3:127-133

Sleeve Gastrectomy

| January 28, 2010 |25 |

Safety of Bariatric Surgery and GastrectomyMortality Rate

0.00%

0.50%

1.00%

1.50%

2.00%

Rat

e (%

)

Bre

thau

er5

San

chez

-San

tos

6

Cas

e R

evie

w

Bariatric Surgery Sleeve Gastrectomy

1) LABS Reporting Group N Engl J Med 2009;361:445-542) DeMaria et al Ann Surg. 2007 Oct;246(4):578-823) Buchwald et al JAMA. 2004;292:1724-17374)AHRQ, Healthcare Cost and Utilization Project (HCUP), 2007 data DRG 288 http://hcupnet.ahrq.gov/5) Brethouer et all Surg Obes Rel Diseas 2009;5:469-4756) Sanchez-Santos et al Obes Surg, 2009 19 459-467

LAB

S1

DeM

aria

2B

uchw

ald

3

HC

UP

4

| January 28, 2010 |26 |

Aggregate Perioperative Complications

Case Review(N= 2936)

Spanish Registry1 (n=504)

Comp Total Frequency Total Frequency

Mortality 8 0.27% 2 0.36%

Staple Line 69 2.4% 11 2.0%

Wound Site 18 0.6% 1 0.2%

Bleeding 21 0.7% 6 1.1%

Other 14 0.5% 5 0.9%

Stricture 13 0.4% 1 0.2%

Respiratory 8 0.3% 1 0.2%

Thrombosis 7 0.2% 1 0.2%

2005 to presentN greater than 100 patients16 Studies

1 Sanchez-Santos et al. Short- and Mid-term Outcomes of Sleeve Gastrectomy for Morbid Obesity: The Experience of the Spanish National Registry, Obes Surg 2009;19 :1203–1210

| January 28, 2010 |27 |

Aggregate Perioperative Complications2006 to presentN greater than 100 patients16 Studies

Comp Case RNY1 BPDDS1 AGB1 SG2

Staple Line 2.4% 2.2% 1.8% 2.7%

Bleeding 0.7% 2.0% 0.2% 0.3% 1.0%

Reoperation 1.6% 4.2% 7.7% 1.8%

1) Maggard M, et al, Meta-Analysis: Surgical Treatment of Obesity, Ann Intern Med. 2005;142:547-559 2) Brethauer et al Systematic review of sleeve gastrectomy as staging and primary bariatric procedure SOARD

2009;5 .

| January 28, 2010 |28 |

Reinsurance for Private Pay Patients

Personal Communication, BLIS Inc, Copyright © 2010 BLIS Inc. Used with permission.

| January 28, 2010 |29 |

Comparative Studies – Obesity Related Comorbidity Outcomes

Year AuthorN

Total (SG)

Duration (months)

Control Outcomes

2006 Himpens 80 (40) 24 LAGBAppetite suppression greater in SG group

2008 Karamanakos 32 (16) 12 RYGBP

For both groups, glucose and triglycerides significantly decreasedAppetite suppression greater in SG group

2008 Vidal 91 (39) 12 RYGBP84.6% T2DM resolution rates for both groups

2009 Strain 121 (30) 21LAGB, RYGBP,

SWITCHOutcomes not reported

2007 Lee846

(216)36

LAGB, RYGBP,SWITCH

Outcomes not reported

2009 Wong 94 (30) 24 LAGB, RYGBPSurgery improved hypertension, diabetes and dislipidemia

| January 28, 2010 |30 |

Case Study Obesity Related Comorbidity Outcomes• Published since 2006• Greater than 10 Patients• BMI reported pre-op and at follow-up

Number of patients in Subgroup

# of Studies Showing results

% Resolved or Improved

Total 1754 19

Type 2 Diabetes 397 18 95%

Hypertension 428 14 88%

Hyperlipidemia 189 11 73%

Sleep Apnea 234 10 91%

Degenerative joint disease/ joint pain

210 6 70%

| January 28, 2010 |31 |

2010 HEDIS Measurements that are affected by Gastrectomy

• Adult BMI Assessment • Comprehensive Diabetes Care -HbA1c

control (<7.0%) and Poor Control (>9%) • Relative Resource Use for People With

Diabetes• Relative Resource Use for People With

Uncomplicated Hypertension

National Committee for Quality Assurance (NCQA), Healthcare Effectiveness Data and Information Set (HEDIS) 2010 Measures, http://www.ncqa.org/Portals/0/HEDISQM/HEDIS2010/2010_Measures.pdf

| January 28, 2010 |32 |

Bariatric Surgery Procedures

30 Day Mortality


0.001 0.01 0.1 1 10

Banding

Roux-en-Y

Switch

10%

50%

100%

Exc

ess

Wei

gh

t L

oss

Exc

ess

Wei

gh

t L

oss

Gastrectomy

| January 28, 2010 |33 |


30 Day Mortality


0.001 0.01 0.1 1 10

Banding

Roux-en-Y

Switch

10%

50%

100%D

iab

etes

Res

olu

tio

n R

ate

Dia

bet

es R

eso

luti

on

Rat

e

Exc

ess

Wei

gh

t L

oss

Exc

ess

Wei

gh

t L

oss

Gastrectomy

| January 28, 2010 |34 |


30 Day Mortality


0.001 0.01 0.1 1 10

Banding

Roux-en-Y

Switch

10%

50%

100%D

iab

etes

Res

olu

tio

n R

ate

Dia

bet

es R

eso

luti

on

Rat

e

Gastrectomy

| January 28, 2010 |35 |

Society Support

Societies that endorse Sleeve Gastrectomy• American Society for Metabolic and Bariatric

Surgery• Society of American Gastrointestinal and

Endoscopic Surgery• American College of Surgeons

| January 28, 2010 |36 |

Blue Distinction Centers for Bariatric Surgery Offering Sleeve Gastrectomy

Hospital Surgeon (* Author)

University of Alabama Hospital E.E. Frezza*, M.D

UC Irvine Medical Center N. Nguyen*, M.D

Yale-New Haven Hospital R. Bell*, M.D

Cleveland Clinic Hospital, FL R. Rosenthal*, M.D

University of Chicago Medical Center Chicago V. Prachand*, M.D

North Shore University HealthSystem (Evanston) C. Frantzides, MD

Clarian North Medical Center S. Mattar*, M.D

Johns Hopkins Bayview Medical M. Schweitzer, M.D

Massachusetts General Hospital J Pratt, M.D

University of Minnesota Medical Center S. Ikramuddin, MD

Atlantic City Medical Center A Onopchenko, MD

Lenox Hill Hospital M. Roslin, MD

Cleveland Clinic Hospital, OH P. Schauer*, MD

Blue Distinction Centers for Bariatric Surgery, http://www.bcbs.com/innovations/bluedistinction/blue-distinction-bariatric/bluedistinctionbariatric.pdf

| January 28, 2010 |37 |

Sleeve Gastrectomy Patient Characteristics

• BMI greater than 40 kg/m2

• BMI greater than 35 kg/m2 with significant obesity related comorbidities

• Participate multidisciplinary Center of Excellence program• Model medical profile

– NSAID use– Prior surgery– Large ventral hernia– Revisions– Need to reduce comorbidities prior to planned operation– Earlier intervention

| January 28, 2010 |38 |

Professional Education

• Surgeon Training– CME– Fellowships– Residency– Clinical Immersion

• Staff Training– Patient Education– Perioperative Management– Follow-up

• Patient Pathways

| January 28, 2010 |39 |

Sleeve Gastrectomy Advantages

• No anastomoses• Continuity of gastrointestinal tract

– Functional pylorus– Does not bypass duodenum

• Reduces hunger• No implanted device• Follow up visits to adjust device not needed

| January 28, 2010 |40 |

Conclusions

• Weight loss drives obesity related comorbidity resolution• Sleeve Gastrectomy has better weight loss than Adjustable

Gastric Banding • Sleeve Gastrectomy has fewer complications than Roux en Y

Gastric Bypass or Biliopancreatic Diversion and Duodenal Switch

• Mid term data to 3 years tracks with other covered bariatric procedures

• Sleeve Gastrectomy is as effective as other covered procedures

• Sleeve Gastrectomy should be covered as a medically necessary treatment for Morbid Obesity and Related Diseases

| January 28, 2010 |41 |

Questions

| January 28, 2010 |42 |

ReferencesSlide # In order of appearance Reference

6, 7, 8, 25, 32, 33, 34

Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292:1724-37.

Buchwald Abstract Buchwald PDF

6, 7, 32, 33, 34

Maggard MA, Shugarman LR, Suttorp M et al, Meta-Analysis: Surgical Treatment of Obesity, Ann Intern Med. 2005;142:547-559

Maggard AbstractMaggard PDF

7, 25, 32, 33, 34

Brethauer SA, Hammel JP, Schauer PR. Systematic review of sleeve gastrectomy as staging and primary bariatric procedure. Surg Obes Relat Dis 2009;5:469-75.

Brethauer Abstract

8, 9, 25 Longitudinal Assessment of Bariatric Surgery (LABS) Consortium et al, Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med. 2009 Jul 30;361(5):445-54.

LABS AbstractLABS PDF

8, 9, 25 DeMaria EJ, Murr M, Byrne TK, et al Validation of the obesity surgery mortality risk score in a multicenter study proves it stratifies mortality risk in patients undergoing gastric bypass for morbid obesity.Ann Surg. 2007 Oct;246(4):578-82; discussion 583-4.

DeMaria Abstract

8, 9, 25 AHRQ, Healthcare Cost and Utilization Project (HCUP), http://hcupnet.ahrq.gov/ accessed 01/13/10, 2007 data

http://hcupnet.ahrq.gov

10 Ostbye T, Dement JM, Krause KM. Obesity and workers' compensation: results from the Duke Health and Safety Surveillance System .Arch Intern Med. 2007 Apr 23;167(8):766-73.

Ostbye Abstract Ostbye PDF

11 Wee CC, Phillips RS, Legedza AT, et al. Health care expenditures associated with overweight and obesity among US adults: importance of age and race. Am J Public Health. 2005 Jan;95(1):159-65

Wee Abstract Wee PDF

12 Finkelstein E and Brown DS, A cost-benefit simulation model of coverage for bariatric surgery among full-time employees. Am J Manag Care. 2005; 11: 641-646

Finkelstein Abstract Finkelstein PDF

| January 28, 2010 |43 |

ReferencesSlide # In order of appearance Reference

12 Cremieux PY, Buchwald H, Shikora SA, Ghosh A, Yang HE, Buessing M. A study on the economic impact of bariatric surgery. Am J Manag Care 2008;14:589-96.

Cremieux Abstract Cremieux PDF

12 Sampalis JS, Liberman M, Auger S, Christou NV. The impact of weight reduction surgery on health-care costs in morbidly obese patients. Obes Surg 2004;14:939-47.

Sampalis Abstract

12 Gallagher SF, Banasiak M, Gonzalvo JP, et al. The impact of bariatric surgery on the Veterans Administration healthcare system: a cost analysis. Obes Surg 2003;13:245-8.

Gallagher Abstract

14, 21 Deitel M, Gawdat K, Melissas J. Reporting weight loss 2007. Obes Surg 2007;17:565-8.

16 Himpens J, Dapri G, Cadiere GB. A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. Obes Surg 2006;16:1450-6.

Himpens Abstract

17 Vidal J, Ibarzabal A, Romero F, et al. Type 2 diabetes mellitus and the metabolic syndrome following sleeve gastrectomy in severely obese subjects. Obes Surg 2008;18:1077-82.

Vidal Abstract

17 Karamanakos SN, Vagenas K, Kalfarentzos F, Alexandrides TK. Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin and peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a prospective, double blind study. Ann Surg 2008;247:401-7

Karamanakos Abstract

18 Lee CM, Cirangle PT, Jossart GH. Vertical gastrectomy for morbid obesity in 216 patients: report of two-year results. Surg Endosc 2007;21:1810-6.

Lee Abstract Lee PDF

| January 28, 2010 |44 |

References

Slide # In order of appearance Reference

19 Strain GW, Gagner M, Pomp A, et al. Comparison of weight loss and body composition changes with four surgical procedures. Surg Obes Relat Dis 2009;5:582-7.

Strain Abstract

20 Wong SK, Kong AP, Mui WL, et al. Laparoscopic bariatric surgery: a five-year review. Hong Kong Med J 2009;15:100-9.

Wong AbstractWong PDF

24 Christou N, Efthimiou E.. Five-year outcomes of laparoscopic adjustable gastric banding and laparoscopic Roux-en-Ygastric bypass in a comprehensive bariatric surgery program in Canada, Can J Surg, Vol. 52, No. 6, December 2009 E249-258

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24 Angrisani L, Lorenzo M, Borrelli V. Laparoscopic adjustable gastric banding versus Roux-en-Y gastric bypass: 5-year results of a prospective randomized trial, Surg Obes Rel Dis 2007;3:127-133

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25,26 Sanchez-Santos R, Masdevall C, Baltasar A, et al. Short- and mid-term outcomes of sleeve gastrectomy for morbid obesity: the experience of the Spanish National Registry. Obes Surg 2009;19:1203-10.

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31 National Committee for Quality Assurance (NCQA), Healthcare Effectiveness Data and Information Set (HEDIS) 2010 Measures,

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