About the Author 2

Why I Wrote This Book for You 6

Chapter 1: Weight-Loss Surgery 101: An Overview 9

Open Versus Laparoscopic 9

Types of Procedures 11

Malabsorbtive 12

Restrictive 12

Combination 13

Surgical Procedures; Inpatient and Outpatient 13

Are You a Candidate for a Weight-Loss Procedure? 15

Considering Your Options in Weight-Loss Surgery 16

The Laparoscopic Adjustable Gastric Band (LAGB) 17

The Basics on Bands 19

Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) 20

Laparoscopic Sleeve Gastrectomy (LSG) 24

Eating Behaviors 27

Very High Body Mass Index 29

For Adolescent Patients 30

Older Patients 32

Making Comparisons 34

The Numbers Game 36

Advantages of Keeping Your Decision Private 42

Advantages of Being Open About Your Decision 43

Discreet but Honest 44

Chapter 4: Insurance 45

Weight-Loss Surgery Without Insurance 46

Medicare and Medicaid 48

Medical Tourism 50

A Final Word 53

Appendix A: For More Information 55

About the Author

Kent C. Sasse, M.D., M.P.H., F.A.C.S.

Dr. Sasse is a nationally renowned authority on surgical weight-loss procedures and a leader in the rapidly evolving field of bariatric surgery. He founded the program for Adolescents and Weight-Loss Surgery at Western Bariatric Institute and wrote the research protocol for surgical weight loss in teenagers. The distinguished recipient of several awards, including membership in the prestigious Alpha Omega Alpha Society for top medical graduates in the country, Dr. Sasse is founder and medical director of both iMetabolic (International Metabolic Institute) and Western Bariatric Institute (a nationally recognized ASBS Center of Excellence).

Dr. Sasse is the recipient of a bachelor’s degree in biochemistry from the University of California, San Diego, where he graduated cum laude. He went on to receive two master’s degrees, including one in public health stemming from research related to biostatistics and bioethics, from the University of California, Berkeley. Dr. Sasse completed residency training in surgery, focusing on gastrointestinal surgery and physiology, at the University of California, San Francisco, as well as fellowship training at the Lahey Clinic in Boston, Massachusetts, before establishing his practice in northern Nevada.

Dedicated to the highest levels of scientific research and individualized, state-of-the-art treatment of patients, Dr. Sasse brings a wealth of experience and expertise to the rapidly evolving field of weight-loss surgery. He has written and continues to pursue several IRB-approved research protocols regarding weight loss and weight-loss surgery, and he lectures frequently on topics related to obesity and weight reduction at the University of Nevada School of Medicine. Through his nationally recognized programs, Dr. Sasse and his outstanding faculty provide patients the highest levels of compassionate medicine, scientific evidence and personalized care in the field of weight reduction.

Please visit www.sasseguide.com for more information on Dr. Sasse and his programs and facilities.

Western Bariatric Institute

Dr. Sasse and his colleagues have built upon modern, minimally invasive surgical techniques in applying advanced cutting-edge technology in surgical weight-loss solutions for patients in the West. Together with his colleagues John Ganser, M.D., and Robert Watson, M.D., Dr. Sasse founded Western Bariatric Institute, a nationally recognized surgical weight-loss center and American Society of Metabolic and Bariatric Surgery Center of Excellence. Dr. Sasse serves as medical director and dedicates himself to compassionate, individualized care of every patient. He has written and pursues several Institutional Review Board-approved research protocols regarding weight loss and weight-loss surgery, including those related to teens and adolescents.

International Metabolic Institute (iMetabolic)

Dr. Sasse founded International Metabolic Institute, a center offering sound medically-supervised (nonsurgical) solutions for weight loss that involve dietary modifications, behavior-changing techniques, prescription weight-loss medications, fitness training, psychological counseling and inspirational life coaching. As medical director of iMetabolic, Dr. Sasse oversees its outstanding medical faculty in developing the highest quality medically supervised weight-loss programs. Visit www.iMetabolic.com for more information.

Together these centers provide state-of-the-art weight-loss solutions for people suffering from excess body weight.

Obesity Prevention Foundation

In 2006, Dr. Sasse founded the Obesity Prevention Foundation, a nonprofit organization dedicated to the prevention of obesity and excessive weight gain among adolescents. Through his work treating thousands of individuals suffering the health consequences of excessive weight and obesity, Dr. Sasse has seen that the real path to resolving this health crisis in the future will come from prevention. He has brought experts from many fields to work together to prevent excessive weight gain and obesity among children and teens. Visit www.ObesityPreventionFoundation.org to learn more.

Why I Wrote This Book for You

I wrote this book to provide you with the latest, cutting-edge information to help you decide which weight-loss surgical procedure might be right for you. Bariatric surgery is a rapidly evolving medical field that offers the best hope for long-term sustained weight loss that has ever come along. New studies appear on a regular basis, shining new light on surgical weight-loss procedures and success stories from those procedures.

If you're struggling with a weight problem and have begun to consider weight-loss surgery, you may have questions about the differences between the surgical procedures. If you don’t understand the differences, it's difficult to make the best choice. In addition, some surgeons or centers only focus on one particular type of procedure even if it may not be best suited for every single patient. Many surgeons, weight-loss programs and primary care physicians have their own personal experiences with specific procedures and their own biases for and against those procedures.

I wrote this book to provide you with as much unbiased information as possible, from an experienced bariatric surgeon and director of a weight-loss program who is not wedded to any one procedure. This up-to-date information is designed to enable you to choose the best operation for you and achieve the best possible weight-loss results from the procedure you choose.

Every individual has different medical, psychological and dietary conditions that may affect the outcome of weight-loss surgery. In most cases there's going to be more than one surgical option that would work for you and result in the kind of weight-loss success you're looking for. In order to decide which option to take, you need to research what's available to you and learn as much as you can about each surgical procedure and its distinctive features. This book is designed to help you understand the types of laparoscopic weight-loss procedures available, so that when you sit down with a bariatric surgeon, you've got information at your disposal, you'll be less confused by all the new information being given to you and you can make a sound, informed choice. If you can find an informational seminar on weight-loss procedures in your area, offered by an outstanding weight-loss center, I urge you to attend. You can also research online with one of the specialty societies for weight-loss surgery: the American College of Surgeons (www.facs.org) or the American Society for Metabolic and Bariatric Surgery (www.asbs.org). When it comes to making a decision about having an operation, I believe you can never have too much information.

When you find a surgeon you think you want to work with, make an appointment to talk through your thoughts, concerns and choices. The more information you have at the time you meet with your prospective surgeon, the better questions you'll be able to ask and the more information you'll be able to gather to make your decisions.

Keep in mind as you look for a bariatric surgeon to work with, the best surgical weight-loss programs involve a comprehensive approach to successful weight loss. The procedure you choose to undergo doesn't work by itself; you need to learn new skills and use the operation as a tool as you work to achieve better health through long-term weight loss. For this comprehensive approach, weight-loss programs employ specialists in mental health and nutrition who evaluate and coach each patient before and after surgery. In my practice, Western Bariatric Institute, we've found these meetings with professionals experienced in coaching individuals through successful lifelong weight loss are invaluable opportunities for patients. I urge you to take advantage of them.

Chapter 1: Weight-Loss Surgery 101: An Overview

I wrote this book to help you decide if weight-loss surgery is a solution for you, and if so, which procedure? The first question I imagine most people have when looking at the field of bariatric surgery is: What is weight-loss surgery?

Weight-loss surgery is a surgical procedure designed to restrict the amount of food a person can either consume or absorb, based on the nature of that particular procedure. By restricting what a person can consume or absorb, caloric intake is reduced and weight loss is achieved.

There are different types of surgical weight-loss procedures, including inpatient (requiring hospital admission) and outpatient (performed in an outpatient surgical facility with release from recovery within 23 hours.) There are also different types of weight-loss procedures when looking at the complexity and intrusiveness of the procedure. There are open operations with a standard incision, and there are laparoscopic procedures, performed with small keyhole-type incisions and a camera. Nearly all of the weight-loss procedures being in the U.S. are now being done with laparoscopy due to its lower risk of complications, pain, and recovery time.

Open Versus Laparoscopic

Originally, surgical weight-loss procedures were open operations, meaning the surgeon made an incision from the patient's sternum to below the navel and had to cut through abdominal muscle. The procedures often took several hours to accomplish and several weeks to recover from, including hospitalization of 7 days to two weeks.

There are still some procedures that are performed with open operations, but they're few and far between. Most of the time, weight-loss surgery today means minimally invasive laparoscopic surgery. Minimally invasive means the surgery is performed with the least possible trauma to the body, the least pain and tissue damage. Rather than a large incision, surgeons use laparoscopic procedures, which allow them to guide cameras, surgical equipment and weight-loss devices through keyhole incisions (very small incisions measuring 5 to 15 millimeters that create less trauma for the body.) This technique means markedly less postoperative pain and short recovery times. Frequently, patients who undergo laparoscopic weight-loss surgery only have to take off a little time from work: from a few days to two or three weeks downtime after going home from the surgical facility.

Open techniques are more invasive, meaning there's more impact on the body from large incisions and it takes longer to recover from the operation. Medical science has made major strides forward in creating minimally invasive weight-loss surgical procedures that can be performed in outpatient facilities using laparoscopic techniques.

While there are still a few surgeons who might recommend open surgery, most no longer do. Numerous studies confirm laparoscopic surgery to be less invasive and safer than open procedures, resulting in fewer wound problems, hernias and respiratory complications. The training required to safely perform advanced laparoscopic surgery is intensive and long, so seek out a highly skilled and experienced laparoscopic expert.

Though most surgeons do go forward with laparoscopic procedures today, there are a few cases in which scar tissue, adhesions or prior surgery can make open surgery necessary. I wouldn't advise anyone to undergo open abdominal weight-loss surgery, except in these cases. In a few cases, a surgeon may need to convert from laparoscopic to an open technique during the procedure due to complications. But for the vast majority of weight-loss procedures, laparoscopy, in skilled hands, offers many advantages in terms of safety, comfort and recovery time.

Types of Procedures

There are essentially three ways surgical weight-loss procedures work and three types of operations.

The procedures work by

• Creating malabsorption of nutrients;

• Limiting space for food intake; and

• Creating a feeling of satiety.

The types of procedures are

• Malabsorptive; those that cause malabsorption.

• Restrictive: those that restrict stomach capacity

• Combination: one procedure is intermediate and does both.

Malabsorbtive

With malabsorptive procedures, not all of the calories a person eats are absorbed. Instead, they pass straight through the body and don’t contribute to weight-gain. Essentially, with these types of procedures, some of the intestine is bypassed so food can pass through without being absorbed into the bloodstream. In the 1970s, a procedure called jejuno-ileal bypass (JIB) became popular and resulted in profound weight loss. Unfortunately, it also created some troubling nutritional deficiencies with serious adverse health effects. Today, a few centers still offer a purely malabsorptive procedure known as the bilio-pancreatic diversion (BPD) which causes fewer, but still significant side effects along the lines of anemia, protein deficiency and vitamin deficiencies. The Roux-en-Y gastric bypass, the most popular weight-loss procedure in the U.S., also contains an element of malabsorbtion that we will discuss further, but it causes far fewer nutritional side effects than the BPD while producing similar profound weight loss.

Restrictive

Restrictive (limited-capacity) procedures work by limiting capacity, creating a restriction in the stomach and limiting the amount of space available to fill with food. In the early days of surgical weight-loss procedures, limited-capacity procedures involved stapling the stomach to reduce space (called stomach stapling, gastroplasty, vertical banded gastroplasty or gastric partitioning), but today these techniques usually refer to laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB), where a portion of the stomach is made smaller by creating a pouch with a limited capacity to hold food. Because of the limited capacity, someone who has undergone this procedure has less space to fill, fills up faster and eats less, all of which trigger weight loss.

Combination

The Roux-en-Y gastric bypass contains elements of both restrictive and malabsorptive procedures. The surgeon creates a small stomach pouch; a portion of the small intestine and the remaining stomach is bypassed. Therefore, a person feels full faster and eats less, but also experiences some reduction in the absorption of nutrients.

Surgical Procedures; Inpatient and Outpatient

Most laparoscopic weight-loss procedures take less than two hours (and often less than one) to perform, and most patients leave the surgical facility or hospital in less than 48 hours. Laparoscopic adjustable gastric banding procedures (LAGB), in particular, can be performed in under an hour (often in 30 to 45 minutes) and requires a stay in the surgery facility of three to six hours. Laparoscopic sleeve gastrectomy (LSG) may be performed with a 24-hour or shorter stay, and laparoscopic Roux-en-Y gastric bypass (LRYGB) can be performed with a one- to two-night stay, or for healthy, motivated patients, it can be performed at some centers as an outpatient procedure with a return home within 23 hours. LAGB and, to a lesser extent, LRYGB and LSG, give rise to the outpatient aspect of minimally invasive outpatient weight-loss surgery – they're procedures that can be performed in outpatient surgery centers which, under most state definitions, perform procedures in which the patient is released within 23 hours or less. Downtime once the patient returns home can be as short as a few days in the case of gastric banding or 14 days for LRYGB.

Outpatient procedures have some advantages, including the fact that the attention and customer service given to surgical patients is often superior, because outpatient surgery is all the staff does. Fewer hospital-acquired bacterial infections occur, and the centers often provide better “creature comforts” for the short time a person spends there. In contrast, hospital staffs have to rise to a variety of occasions and have experience in far more than surgical procedures. In outpatient centers, the staff is geared fully and completely for surgical procedures. If complications do arise during an operation, all outpatient surgical centers are required by law to have emergency transport plans in place to move patients to a hospital and, in many cases, the surgical center is actually located on a major hospital property.

It's generally easier to schedule a procedure in an outpatient facility, and less expensive, because the patient typically only pays for the staff and equipment needed for that specific procedure rather than paying for the wide range of expertise of an entire hospital staff and the facility itself, which almost certainly won't be needed. In health care terms, the “cost structure” of an outpatient surgery facility is more advantageous because the center does not have to subsidize all of the other hospital care that generally would lose money. The net effect is lower costs for outpatient surgery, to both you and your insurance plan if you have one.

Today's minimally invasive outpatient weight-loss procedures are safe and effective ways for people who have tried to lose weight every other way to find success.

Are You a Candidate for a Weight-Loss Procedure?

You're right if you're thinking that weight-loss surgery isn't for someone who just wants to lose a few pounds before an event or even for someone who has been battling the same 10 pounds for a few years. However, if you seriously overweight (Body Mass Index over 30), and if trying to get the weight off with nonsurgical methods has failed, you're a candidate for weight-loss surgery. In 1991, the National Institutes of Health indicated that people with a Body Mass Index of more than 35 with related health conditions created by excess body weight are surgical candidates, as are those with a BMI of more than 40, even if those people don’t have additional identified health complications yet. Many studies show a major advantage in health and longevity from weight-loss surgery when a person has a BMI of 30 or even lower. Therefore, as the procedures have become less invasive, more effective and safer, many centers have reduced their acceptance criteria down to the level of BMI 30.

BMI is calculated from weight and height. While the number is not a measurement of body fat directly, it has been shown to correlate well with the health problems of obesity and therefore is a good indicator. You can calculate your BMI on the chart on my Web site www.SasseGuide.com.

Keep in mind that just because you're a candidate for surgery doesn't mean surgery is right for you or that you can safely undergo a surgical weight-loss procedure right away. There are important preparations to make first. (I highly recommend the audio program Preparing for Weight-Loss Surgery, available at www.AudioDiets.com.)

Some conditions preclude people from being candidates, including being an excessively high risk for surgery or anesthesia. If you cannot undergo the procedure safely, it will need to be postponed. The good news is you can almost undoubtedly change your risk for surgery. The better news? You can do it by losing weight, which will lower your risk for the surgery, improve your health and give you a jumpstart on your new, healthy life at a normal weight.

To learn more about losing weight prior to surgery to reduce your risk, I recommend you visit the following web page that offers the pre-surgery success kit from iMetabolic, with just about everything a person needs to lose significant weight before surgery. (visit www.iMetabolic.com.)It is the same method we have used for years at our surgical center, with great success. The average patient at our center loses over twenty pounds with this method, before ever undergoing surgery.

Considering Your Options in Weight-Loss Surgery

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