Gastric bypass surgery

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Gastric bypass procedures (GBP) are any of a group of similar operations used to treat morbid obesity—the severe accumulation of excess weight as fatty tissue—and the health problems (comorbidities) it causes. Bariatric surgery is the term encompassing all of the surgical treatments for morbid obesity, not just gastric bypasses, which make up only one class of such operations.

A gastric bypass first divides the stomach into a small upper pouch and a much larger, lower "remnant" pouch and then re-arranges the small intestine to allow both pouches to stay connected to it. Surgeons have developed several different ways to reconnect the intestine, thus leading to several different GBP names. Any GBP leads to a marked reduction in the functional volume of the stomach, accompanied by an altered physiological and psychological response to food. The resulting weight loss, typically dramatic, markedly reduces comorbidities. The long-term mortality rate of gastric bypass patients has been shown to be reduced by up to 40%^[1][2]; however, complications are common and surgery-related death occurs within one month in 2% of patients.^[3]

Contents 1 Surgical indications 2 Surgical techniques 2.1 Essential features 2.2 Variations of the gastric bypass 2.2.1 Gastric bypass, Roux en-Y (proximal) 2.2.2 Gastric bypass, Roux en-Y (distal) 2.2.3 Loop Gastric bypass ("Mini-gastric bypass") 3 Physiology of the gastric bypass 4 Complications 4.1 Mortality and complication rates 4.2 Complications of abdominal surgery 4.2.1 Infection 4.2.2 Hemorrhage 4.2.3 Hernia 4.2.4 Bowel obstruction 4.2.5 Venous thromboembolism 4.3 Complications of gastric bypass 4.3.1 Anastomotic leakage 4.3.2 Anastomotic stricture 4.3.3 Anastomotic ulcer 4.3.4 Dumping syndrome 4.4 Nutritional deficiencies 4.4.1 Nutritional effects 4.4.1.1 Protein nutrition 4.4.1.2 Calorie nutrition 4.4.1.3 Vitamins 4.4.1.4 Minerals 5 Results and health benefits of gastric bypass 6 Living with gastric bypass 7 Surgeon Accredidation 8 See also 9 Cited references 10 General references 11 External links

Surgical indications

Gastric bypass is indicated for the surgical treatment of morbid obesity, a diagnosis which is made when the patient is seriously obese, has been unable to achieve satisfactory and sustained weight loss by dietary efforts, and is suffering from co-morbid conditions which are either life-threatening or a serious impairment to the quality of life.

In the past, serious obesity was interpreted to mean weighing at least 100 pounds (45 kg) more than the "ideal body weight", an actuarially determined body weight at which one was estimated to be likely to live the longest, as determined by the life insurance industry. This criterion failed for persons of short stature.

In 1991, the National Institutes of Health sponsored a consensus panel whose recommendations have set the current standard for consideration of surgical treatment, the body mass index (BMI). The BMI is defined as the body weight (in kilograms), divided by the square of the height (in meters). The result is expressed as a number usually between 20 and 70, in units of kilograms per square meter.

The Consensus Panel of the National Institutes of Health (NIH) recommended the following criteria for consideration of bariatric surgery, including gastric bypass procedures:

1. People who have a body mass index (BMI) of 40 or higher. Or,
2. People with a BMI of 35 or higher with one or more related comorbid conditions.

The Consensus Panel also emphasized the necessity of multidisciplinary care of the bariatric surgical patient, by a team of physicians and therapists, to manage associated co-morbidities, nutrition, physical activity, behavior and psychological needs. The surgical procedure is best regarded as a tool which enables the patient to alter lifestyle and eating habits, and to achieve effective and permanent management of their obesity and eating behavior.

Since 1991, major developments in the field of bariatric surgery, particularly laparoscopy, have outdated some of the conclusions of the NIH panel. In 2004, a Consensus Conference was sponsored by the American Society for Bariatric Surgery (ASBS), which updated the evidence and the conclusions of the NIH panel. This Conference, composed of physicians and scientists of many disciplines, both surgical and non-surgical, reached several conclusions, amongst which were:

• Bariatric surgery is the most effective treatment for morbid obesity
• Gastric bypass is one of four types of operations for morbid obesity.
• Laparoscopic surgery is equally effective and as safe as open surgery.
• Patients should undergo comprehensive pre-operative evaluation, and have multi-disciplinary support, for optimum outcome.

Surgical techniques

The gastric bypass, in its various forms, accounts for a large majority of the bariatric surgical procedures performed. It is estimated that 200,000 such operations were performed in the United States in 2008 ^[4]. An increasing number of these operations are now performed by limited access techniques, termed "laparoscopy".

Laparoscopic surgery is performed using several small incisions, or ports, one of which conveys a surgical telescope connected to a video camera, and others permit access of specialized operating instruments. The surgeon actually views his operation on a video screen. The method is also called limited access surgery, reflecting both the limitation on handling and feeling tissues, and also the limited resolution and two-dimensionality of the video image. With experience, a skilled laparoscopic surgeon can perform most procedures as expeditiously as with an open incision — with the option of using an incision should the need arise.

The Laparoscopic Gastric Bypass, Roux-en-Y, first performed in 1993, is regarded as one of the most difficult procedures to perform by limited access techniques, but use of this method has greatly popularized the operation, with benefits which include shortened hospital stay, reduced discomfort, shorter recovery time, less scarring, and minimal risk of incisional hernia.

Essential features

The gastric bypass procedure consists in essence of:

• Creation of a small, (15–30 mL/1–2 tbsp) thumb-sized pouch from the upper stomach, accompanied by bypass of the remaining stomach (about 400 mL and variable). This restricts the volume of food which can be eaten. The stomach may simply be partitioned (typically by the use of surgical staples), or it may be totally divided into two parts (also with staplers). Total division is usually advocated, to reduce the possibility that the two parts of the stomach will heal back together ("fistulize"), negating the operation.
• Re-construction of the GI tract to enable drainage of both segments of the stomach. The technique of this reconstruction produces several variants of the operation, which differ in the lengths of small bowel used, the degree to which food absorption is affected, and the likelihood of adverse nutritional effects.

Variations of the gastric bypass

Gastric bypass, Roux en-Y (proximal)

This variant is the most commonly employed gastric bypass technique, and is by far the most commonly performed bariatric procedure in the United States. It is the operation which is least likely to result in nutritional difficulties. The small bowel is divided about 45 cm (18 in) below the lower stomach outlet, and is re-arranged into a Y-configuration, to enable outflow of food from the small upper stomach pouch, via a "Roux limb". In the proximal version, the Y-intersection is formed near the upper (proximal) end of the small bowel. The Roux limb is constructed with a length of 80 to 150 cm (30 to 60 inches), preserving most of the small bowel for absorption of nutrients. The patient experiences very rapid onset of a sense of stomach-fullness, followed by a feeling of growing satiety, or "indifference" to food, shortly after the start of a meal.

Gastric bypass, Roux en-Y (distal)

The normal small bowel is 600 to 1000 cm (20 to 33 feet) in length. As the Y-connection is moved farther down the Gastrointestinal tract, the amount of bowel capable of fully absorbing nutrients is progressively reduced, in pursuit of greater effectiveness of the operation. The Y-connection is formed much closer to the lower (distal) end of the small bowel, usually 100 to 150 cm (40 to 60 inches) from the lower end of the bowel, causing reduced absorption (mal-absorption) of food, primarily of fats and starches, but also of various minerals, and the fat-soluble vitamins. The unabsorbed fats and starches pass into the large intestine, where bacterial actions may act on them to produce irritants and malodorous gases. These increasing nutritional effects are traded for a relatively modest increase in total weight loss.

Loop Gastric bypass ("Mini-gastric bypass")

The first use of the gastric bypass, in 1967, used a loop of small bowel for re-construction, rather than a Y-construction as is prevalent today. Although simpler to create, this approach allowed bile and pancreatic enzymes from the small bowel to enter the esophagus, sometimes causing severe inflammation and ulceration of either the stomach or the lower esophagus. If a leak into the abdomen occurs, this corrosive fluid can cause severe consequences. Numerous studies show the loop reconstruction (Billroth II gastrojejunostomy) works more safely when placed low on the stomach, but can be a disaster when placed adjacent to the esophagus. Thus even today thousands of "loops" are used for general surgical procedures such as ulcer surgery, stomach cancer and injury to the stomach, but bariatric surgeons abandoned use of the construction in the 1970s, when it was recognized that its risk is not justified for weight management.

The Mini-Gastric Bypass, which uses the loop reconstruction, has been suggested as an alternative to the Roux en-Y procedure, due to the simplicity of its construction, which reduced the challenge of laparoscopic surgery.

Physiology of the gastric bypass

The gastric bypass reduces the size of the stomach by well over 90%. A normal stomach can stretch, sometimes to over 1000 ml, while the pouch of the gastric bypass may be 15 ml in size. The Gastric Bypass pouch is usually formed from the part of the stomach which is least susceptible to stretching. That, and its small original size, prevents any significant long-term change in pouch volume. What does change, over time, is the size of the connection between stomach and bowel, and the ability of the small bowel to hold a greater volume of food. Over time, the functional capacity of the pouch increases; by that time, weight loss has occurred, and the increased capacity serves to allow maintenance of a lower body weight.

When the patient ingests just a small amount of food, the first response is a stretching of the wall of the stomach pouch, stimulating nerves which tell the brain that the stomach is full. The patient feels a sensation of fullness, as if they had just eaten a large meal — but with just a thumbful of food. Most people do not stop eating simply in response to a feeling of fullness, but the patient rapidly learns that subsequent bites must be eaten very slowly and carefully, to avoid increasing discomfort, or even vomiting.

Food is first churned in the stomach before passing into the small bowel. When the lumen of the small bowel comes into contact with nutrients a number of hormones are released including cholecystikin (CCK) from the duodenum and PYY and GLP-1 from the ileum. These hormones inhibit further food intake and have thus been dubbed satiety factors. Ghrelin, is a hormone that is released in the stomach that stimulates hunger and food intake. Changes in circulating hormone levels after gastric bypass have been hypothesized to produce reductions in food intake and body weight in obese patients. However, these findings remain controversial, and the exact mechanisms by which gastric bypass surgery reduces food intake and body weight have yet to be elucidated.

To gain the maximum benefit from this physiology, it is important that the patient eat only at mealtimes, 2 to 3 small meals daily, and avoid snacks and grazing between meals, which can effectively "bypass the bypass". This requires a change in eating behavior, and alteration of long-acquired habits for finding food. In almost every case where weight gain occurs late after surgery, capacity for a meal has not greatly increased. The cause of regaining weight is eating between meals, usually high-caloric snack foods. There is no known operation which can completely counteract the adverse effects of destructive eating behavior.

Complications

Any major surgery involves the potential for complications — adverse events which increase risk, hospital stay, and mortality. Some complications are common to all abdominal operations, while some are specific to bariatric surgery. A person who chooses to undergo bariatric surgery should know about these risks.

Mortality and complication rates

In experienced hands, the overall complication rate of this type of surgery ranges from 7% for laparoscopic procedures to 14.5% for operations through open incisions, during the 30 days following surgery. Mortality for this study was 0% in 401 laparoscopic cases, and 0.6% in 955 open procedures. Similar mortality rates – 30-day mortality of 0.11%, and 90-day mortality of 0.3% – have been recorded in the U.S. Centers of Excellence program, the results from 33,117 operations at 106 centers.

Mortality is affected by complications, which in turn are affected by pre-existing risk factors such as degree of obesity, heart disease, obstructive sleep apnea, diabetes mellitus, and history of prior pulmonary embolism. It is also affected by the experience of the operating surgeon: the "learning curve" for laparoscopic bariatric surgery is estimated to be about 100 cases. Unfortunately, the way a surgeon becomes experienced in dealing with problems is by encountering those problems over time.

Complications of abdominal surgery

Infection

Infection of the incisions or of the inside of the abdomen (peritonitis, abscess) may occur, due to release of bacteria from the bowel during the operation. Nosocomial infection, such as pneumonia, bladder or kidney infections, and sepsis (bloodborne infection) are also possible. Effective short-term use of antibiotics, diligent respiratory therapy, and encouragement of activity within a few hours after surgery, can reduce the risks of infections.

Hemorrhage

Many blood vessels must be cut in order to divide the stomach and to move the bowel. Any of these may later begin bleeding, either into the abdomen (intra-abdominal hemorrhage), or into the bowel itself (gastrointestinal hemorrhage). Transfusions may be needed, and re-operation is sometimes necessary. Use of blood thinners, to prevent venous thromboembolic disease, may actually increase the risk of hemorrhage slightly.

Hernia

A hernia is an abnormal opening, either within the abdomen, or through the abdominal wall muscles. An internal hernia may result from surgery, and re-arrangement of the bowel, and is mainly significant as a cause of bowel obstruction. An incisional hernia occurs when a surgical incision does not heal well; the muscles of the abdomen separate and allow protrusion of a sac-like membrane, which may contain bowel or other abdominal contents, and which can be painful and unsightly. The risk of abdominal wall hernia is markedly decreased in laparoscopic surgery.

Bowel obstruction

Abdominal surgery always results in some scarring of the bowel, called adhesions. A hernia, either internal or through the abdominal wall, may also result. When bowel becomes trapped by adhesions or a hernia, it may become kinked and obstructed, sometimes many years after the original procedure. Usually an operation is necessary to correct this problem.

Venous thromboembolism

Any injury, such as a surgical operation, causes the body to increase the coagulation of the blood. Simultaneously, activity may be reduced. There is an increased probability of formation of clots in the veins of the legs, or sometimes the pelvis, particularly in the morbidly obese patient. A clot which breaks free and floats to the lungs is called a pulmonary embolus, a very dangerous occurrence. Commonly, blood thinners are administered before surgery, to reduce the probability of this type of complication.

Complications of gastric bypass

Anastomotic leakage

An anastomosis is a surgical connection between the stomach and bowel, or between two parts of the bowel. The surgeon attempts to create a water-tight connection by connecting the two organs with either staples or sutures, either of which actually makes a hole in the bowel wall. The surgeon will rely on the healing power of the body, and its ability to create a seal like a self-sealing tire, to succeed with the surgery. If that seal fails to form, for any reason, fluid from within the gastrointestinal tract can leak into the sterile abdominal cavity and give rise to infection and abscess formation. Leakage of an anastomosis can occur in about 2% of gastric bypass procedures, usually at the stomach-bowel connection. Sometimes leakage can be treated with antibiotics, and sometimes it will require immediate re-operation. It is usually safer to re-operate if an infection cannot be definitely controlled immediately.

Anastomotic stricture

As the anastomosis heals, it forms scar tissue, which naturally tends to shrink ("contract") over time, making the opening smaller. This is called a "stricture". Usually, the passage of food through an anastomosis will keep it stretched open, but if the inflammation and healing process outpaces the stretching process, scarring may make the opening so small that even liquids can no longer pass through it. The solution is a procedure called gastroendoscopy, and stretching of the connection by inflating a balloon inside it. Sometimes this manipulation may have to be performed more than once to achieve lasting correction.

Anastomotic ulcer

Ulceration of the anastomosis occurs in 1-16% of patients^[5]. Possible causes of such ulcers are:

• Restricted blood supply to the anastomosis (compare to the blood supply available to the original stomach)
• Anastomosis tension
• Gastric acid
• Helicobacter pylori
• Smoking
• Use of Non-steroidal anti-inflammatory drugs

This condition can be treated as follows:

• Use of Proton pump inhibitors, e.g., Nexium
• Use of a Cytoprotectant and acid Buffering agent, e.g., Sucralfate
• Temporary restriction of the consumption of solid foods

Dumping syndrome

Normally, the pyloric valve at the lower end of the stomach regulates the release of food into the bowel. When the Gastric Bypass patient eats a sugary food, the sugar passes rapidly into the bowel, where it gives rise to a physiological reaction called dumping syndrome. An affected person feels his heart beating rapidly and forcefully, breaks into a cold sweat, gets a feeling of butterflies in the stomach, and has a "sky is falling" type of anxiety. He/she usually has to lie down, and is very uncomfortable for about 30 to 45 minutes. Diarrhea may then follow.

Nutritional deficiencies

• Hyperparathyroidism, due to inadequate absorption of calcium, may occur for GBP patients. Calcium is primarily absorbed in the duodenum, which is bypassed by the surgery. Most patients can achieve adequate calcium absorption by supplementation with Vitamin D and Calcium Citrate (carbonate may not be absorbed - it requires an acidic stomach, which is bypassed).
• Iron frequently is seriously deficient, particularly in menstruating females, and must be supplemented. Again, it is normally absorbed in the duodenum. Ferrous sulfate can cause considerable GI distress in normal doses; alternatives include ferrous fumarate, or a chelated form of iron. Occasionally, a female patient develops severe anemia, even with supplements, and must be treated with parenteral iron.
• Vitamin B₁₂ requires intrinsic factor from the gastric mucosa to be absorbed. In patients with a small gastric pouch, it may not be absorbed, even if supplemented orally, and deficiencies can result in pernicious anemia and neuropathies. Sublingual B₁₂ appears to be adequately absorbed.
• Thiamine deficiency (also known as beriberi) will, rarely, occur as the result of its absorption site in the jejunum being bypassed. This deficiency can also result from inadequate nutritional supplements being taken post operatively.
• Protein malnutrition is a real risk. Some patients suffer troublesome vomiting after surgery, until their GI tract adjusts to the changes, and cannot eat adequate amounts even with 6 meals a day. Many patients require protein supplementation during the early phases of rapid weight loss, to prevent excessive loss of muscle mass.
• Vitamin A deficiencies generally occur as a result of the deficiencies that involve the fat-soluble vitamins. This often comes after intestinal bypass procedures such as jejunoileal bypass (no longer performed) or biliopancreatic diversion/duodenal switch procedures. In these procedures, fat absorption is markedly impaired. There is also the possibility of a vitamin A deficiency with use of Xenical or Alli weight loss medications.

Nutritional effects

After surgery, patients feel fullness after ingesting only a small volume of food, followed soon thereafter by a sense of satiety and loss of appetite. Total food intake is markedly reduced. Due to the reduced size of the newly created stomach pouch, and reduced food intake, adequate nutrition demands that the patient follow the surgeon's instructions for food consumption, including the number of meals to be taken daily, adequate protein intake, and the use of vitamin and mineral supplements.

Protein nutrition

Proteins are essential food substances, contained in foods such as meat, fish and poultry, dairy products, soy, nuts, and eggs. With reduced ability to eat a large volume of food, gastric bypass patients must focus on eating their protein requirements first, and with each meal. In some cases, surgeons may recommend use of a liquid protein supplement.

Calorie nutrition

The profound weight loss which occurs after bariatric surgery is due to taking in much less energy (calories) than the body needs to use every day. Fat tissue must be burned, to offset the deficit, and weight loss results. Eventually, as the body becomes smaller, its energy requirements are decreased, while the patient simultaneously finds it possible to eat somewhat more food. When the energy consumed is equal to the calories eaten, weight loss will stop. Proximal GBP typically results in loss of 60 to 80% of excess body weight, and very rarely leads to excessive weight loss. The risk of excessive weight loss is slightly greater with Distal GBP.

Vitamins

Vitamins are normally contained in the foods we eat, as well as any supplements we may choose to take. The amount of food which will be eaten after GBP is severely reduced, and vitamin content is correspondingly reduced. Supplements should therefore be taken, to completely cover minimum daily requirements of all vitamins and minerals. Absorption of most vitamins is not seriously affected after proximal GBP, although vitamin B₁₂ may not be well-absorbed in some persons. Sublingual preparations of B₁₂ will provide adequate absorption. Some studies suggest that GBP patients who took probiotics after surgery were able to absorb and retain higher amounts of B₁₂ than patients who did not take probiotics after surgery. After the distal GBP, fat-soluble vitamins A, D and E may not be well-absorbed, particularly if fat intake is large. Water-dispersed forms of these vitamins may be indicated, on specific physician recommendation.

Minerals

All versions of the GBP bypass the duodenum, which is the primary site of absorption of both iron and calcium. Iron replacement is essential in menstruating females, and supplementation of iron and calcium is preferable in all patients. Ferrous sulfate is poorly tolerated. Alternative forms of iron (fumarate, gluconate, chelates) are less irritating and probably better absorbed. Calcium carbonate preparations should also be avoided; calcium as citrate or gluconate, 1200 mg as calcium, has greater bioavailability independent of acid in the stomach, and will likely be better absorbed.

Results and health benefits of gastric bypass

Weight loss of 65 to 80% of excess body weight (the amount by which actual body weight exceeds actuarial ideal body weight) is typical of most large series of Gastric Bypass operations reported. The medically more significant effects are a dramatic reduction in co-morbid conditions:

• Hyperlipidemia is corrected in over 70% of patients.
• Essential hypertension is relieved in over 70% of patients, and medication requirements are usually reduced in the remainder.
• Obstructive sleep apnea is markedly improved with weight loss and bariatric surgery may be curative for sleep apnea. Snoring also improves in most patients.
• Diabetes mellitus type 2 is reversed in up to 90% of patients^{[citation needed]}, usually leading to a normal blood sugar without medication, sometimes within days of surgery.^{[citation needed]}
• Gastroesophageal reflux disease is relieved from the time of surgery in almost all patients.
• Venous thromboembolic disease signs such as leg swelling are typically much improved.
• Low back pain and joint pain are typically relieved or improved in nearly all patients.

A recent study in a large comparative series of patients showed an 89% reduction in mortality over the 5 years following surgery, compared to a non-surgically treated group of patients.

Concurrently, most patients are able to enjoy greater participation in family and social activities.

Living with gastric bypass

Gastric bypass surgery has an emotional, as well as a physiological, impact on the individual. Many who have undergone the surgery suffer from depression in the following months.^[6] This is a result of a change in the role food plays in their emotional well-being. Strict limitations on the diet can place great emotional strain on the patient. Energy levels in the period following the surgery will be low. This is due again to the restriction of food intake, but the negative change in emotional state will also have an impact here.^[7] It may take as long as three months for emotional levels to rebound. Muscular weakness in the months following surgery is common. This is caused by a number of factors, including a restriction on protein intake, a resulting loss in muscle mass and decline in energy levels. The weakness may result in balance problems, difficulty climbing stairs or lifting heavy objects, and increased fatigue following simple physical tasks. Many of these issues will pass over time as food intake gradually increases. However, the first months following the surgery can be very difficult, an issue not often mentioned by physicians suggesting the surgery. The benefits and risks of this surgery are well established; however, the psychological effects are not well understood, and potential patients should ensure a strong support system before agreeing to the procedure.

Surgeon Accredidation

The American Society for Metabolic & Bariatric Surgery lists bariatric programs and surgeons in its "Centers of Excellence" network,^[8] while the American College of Surgeons accredits providers through its Bariatric Surgery Center Network.^[9] For listings of surgeons and centers in other countries, the International Federation for the Surgery of Obesity and Metabolic Disorders lists medical associations by country.^[10]

See also

• Adjustable gastric banding surgery
• Duodenal Switch surgery
• Vagotomy - Cutting of the vagus nerve to reduce the feeling of hunger
• StomaphyX - Revisional, natural orifice procedure for patients that have regained weight after gastric bypass

Cited references

General references

• Buchwald, H; Cowan, GSM; Pories, WJ (2007), Surgical Management of Obesity, Saunders Elsevier, ISBN 978-1416000891 
• Buchwald, H (2005), "Bariatric surgery for morbid obesity: health implications for patients, health professionals, and third-party payers", J Am Coll Surg 200 (4): 593–604, doi:10.1016/j.jamcollsurg.2004.10.039, PMID 15804474 
• Christou, N; Sampalis, J; Liberman, M; Look, D; Auger, S; McLean, A; MacLean, L (2004), "Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients", Ann Surg 240 (3): 416–23; discussion 423–4, doi:10.1097/01.sla.0000137343.63376.19, PMID 15319713 
• Wittgrove, AC; Clark, GW (2000), "Laparoscopic Gastric Bypass, Roux en-Y – 500 Patients: Technique and Results with 3-60 Months Follow-up", Obesity Surgery 10: 233–9, doi:10.1381/096089200321643511 
• Fontaine, KR; et al. (2003), "Years of life lost to obesity", JAMA 289: 187–93, doi:10.1001/jama.289.2.187, PMID 12517229 
• Peeters, A; Barendregt, J; Willekens, F; Mackenbach, J; Al-Mamun, A; Bonneux, L (2003), "Obesity in adulthood and its consequences for life expectancy: a life-table analysis", Ann Intern Med 138 (1): 24–32, PMID 12513041, http://www.annals.org/cgi/reprint/138/1/24 
• Hutter, MM; Randall, S; Khuri, SF; Henderson, WG; Abbott, WM; Warshaw, AL (2006), "Laparoscopic Versus Open Gastric Bypass for Morbid Obesity: A Multicenter, Prospective, Risk-Adjusted Analysis From the National Surgical Quality Improvement Program", Annals of Surgery 243 (5): 657–66, doi:10.1097/01.sla.0000216784.05951.0b, PMID 16633001 

External links

• American Society for Metabolic & Bariatric Surgery, an association of healthcare professionals with demonstrated interest and expertise in the surgical management of obesity.
• ASBS Consensus Conference Statement – 2004
• NIH – Gastrointestinal Surgery for Obesity - info site
• NIH Medline Plus – Multiple Links to articles, videos about bariatric surgery
• Original NIH Consensus Panel Statement – 1991 This report contains useful information, but is now 17 years out-of-date, and was written before laparoscopic surgery became available.

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