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  • Intestinal bypass: (anastomosing the jejunum to the ileum -bypassing most of the intestine) Relatively low-risk surgically (biliopancreatic diversion)
  • Note times and days in hospital are averages. The four weeks = length of time before returning to work.
  • Self sabotage: easier to cheat; flush down foods; non-compliant --  don’t come in for adjustments.
  • MVI- must be chewable (could be Children’s Complete) Ca + D important. 1200-1500mg Ca/d Post-menstrual women and men require less iron and need to be monitored d/t altered absorption and diet. Self-monitoring of urine output, stool output
  • Fluid goals: non-caloric, non-carbonated, non-caffeinated liquids. At Stage 3, pt should see RD. Allowed proteins vs.. not recommended. Stage 4: more normalized eating
  • Fluid goals: non-caloric, non-carbonated, non-caffeinated liquids. At Stage 3, pt should see RD. Allowed proteins vs.. not recommended. Stage 4: more normalized eating
  • Stage 3: all foods must be moist or pureed. C/w non-caloric….like stage 1, 2.
  • Stage 3: all foods must be moist or pureed. C/w non-caloric….like stage 1, 2.
  • No Exercise 6-8wks – risk of hernia
  • Kristin’s dumb question: Is this the theory that Roux-en-Y should accomplish? Do we want the person to adapt to listen to their body (which will tell them when they’re hungry through hormones, etc)?
  • Grehlin speeds up appetite…only hormone to do this.
  • Thought grehlin to be factor of why r-en-y so successful. Grehlin theory disproved d/t evidence in small bowel…still searching for reason why per hormones.
  • Fix reference.
  • What’s seroma?
  • Most common complications? Wound infection?
  • Supplement of MVI with Iron is adequate. Cases reported for all four deficiencies in post-gbp pt’s….thiamine not as well-documented
  • EDNOS: Eating disorder not otherwise specified
  • usually associated with the technique employed, upon the diagnosis of changes in eating behavior
  • Again, What are factors in weight loss? Why do people lose weight?
  • Look up Gila monster.
  • University of Cincinnati Medical Center
  • Theory: possibly pt’s have extra food left over and spouses eat it.
  • Especially dm, htn, hyperlipidemia

Transcript

  • 1. An Overview of Bariatric Surgery Kristin Dermody Angela Illing May 23, 2005
  • 2. THE OBESITY EPIDEMIC
  • 3. A Quick Background of Obesity
    • Derived from the Latin word obesus – “to devour”
    • Definition: having a very high amount of body fat in relation to lean body mass
    • Classifications using Body Mass Index (BMI)
  • 4. BMI Categories
    • A BMI of : Classifies one as :
      • <18.5 Underweight
      • 18.5-24.9 Normal weight
      • 25-29.9 Overweight
      • 30-34.9 Obesity Class I
      • 35-39.9 Obesity Class II
      • 40-49.9 Obesity Class III
      • 50 and above Super Obesity
  • 5. Obesity is a BIG problem…
    • 1.7 billion worldwide are overweight or obese
    • The US has a higher percentage of overweight and obese people than any country in the world
    • And the numbers are growing…
  • 6. US Incidence of Obesity
    • Approximately 2/3 of the United States population is overweight.
    • Of those, almost 50% are obese.
    • In total, approximately 5% of the US population is morbidly obese
    • Alarmingly, the BMI subgroups growing the most quickly are 35 or higher and 40 or higher.
  • 7. Massachusetts: Not-so-’Phat’ Facts
    • 55% of Mass adults  overweight or obese*
    • Of these obese adults**
      • 18% non-Hispanic white
      • 30% non-Hispanic black
      • 22% Hispanic
    • 24% of Mass high school students  overweight or at risk of becoming overweight
      • Obesity rate among Mass adults by 81% from 1990 to 2000*
    *CDC BRFSS, 2002; **CDC YRBSS, 2003
  • 8. History of Obesity 1985
  • 9.  
  • 10. Potential Consequences of Obesity
    • Obesity is associated with a rise in many comorbid conditions, including:
      • Type 2 Diabetes
      • Hyperlipidemia
      • Hypertension
      • Obstructive Sleep Apnea
      • Heart Disease
      • Stroke
      • Asthma
      • Back and lower extremity weight-
      • bearing degenerative problems
      • Cancer
      • Depression
      • AND MORE!
  • 11. CVD & Obesity
    • Fact: Obesity contributes to these co-morbid conditions, however…
    • Recent JAMA article by Gregg et al* suggests CVD risk factors across all BMI groups over past 40 years
      • Suggest: Overweight not quite as bad as it once was, considering other factors:
        • Risk r/t awareness, aggressive identification, pharmacological tx of high chol, HTN.
      • Note: Obese persons still have risk factor levels vs..lean persons.
    Gregg EW, et al. Secular Trends in Cardiovascular Disease Risk Factors According to Body Mass Index in US Adults . JAMA, 2005:293:1863-1874
  • 12. Impact of Obesity
    • These comorbid conditions are together responsible for more than 2.5 million deaths per year worldwide*.
    • This is in addition to billions of dollars in healthcare costs and lost productivity.
    *World Health Organization, World Health Report 2002
  • 13. Obesity and Life Expectancy
    • Recent NEJM article* – If current rates of obesity are left unchecked, the current generation of American children will be the first in two centuries to have a shorter life expectancy than their parents .
    • The life-shortening impact of obesity (currently estimated at 1/3 to ¾ year) could rise to 2 to 5 years , or more, as obese children spend more years at risk for comorbid conditions.
    Olshansky SJ, et al. A Potential Decline in Life Expectancy in the United States in the 21 st Century . NEJM, 352(11):1138-1145, 2005
  • 14. Obesity and Life Expectancy
    • The morbidly obese are perhaps the worst off…
      • Compared to a normal-weight person, a 25-year-old morbidly obese man has a 22% reduction in expected remaining lifespan .
      • This is an approximate loss of 12 YEARS!
      • This number will also likely grow if the ever-expanding numbers of currently obese children continue as obese adults…
  • 15. TREATING OBESITY
  • 16. Weight Loss Strategies
    • Diet therapy
    • Increased Physical Activity
    • Pharmacotherapy (e.g., Orlistat, Meridia)
    • Behavioral Therapy
    • Hypnosis
    • Any combination of the above
  • 17. Bariatric Surgery An effective treatment for combating obesity
  • 18. Bariatric Surgery
    • 1991: NIH establishes guidelines for the surgical therapy of morbid obesity
      • Recommends BMI criteria
        • BMI > 40
        • BMI > 35 + significant comorbidities
    • This therapy now referred to as Bariatric Surgery
  • 19. Types of Bariatric Surgery
    • Purely Restrictive
      • Gastric Balloons (not approved for use in USA)
      • Vertical-banded gastroplasty
      • Gastric adjustable banding (BWH)
    • Restrictive > Malabsorptive
      • Short-limb/Roux-en-Y gastric bypass (BWH)
      • Long-limb/distal Roux-en-Y gastric bypass
    • Malabsorptive > Restrictive
      • Biliopancreatic diversion (BPD)
      • BPD with duodenal switch
      • Very long limb Roux-en-Y gastric bypass
    • Purely Malabsorptive
      • Jejunoilieal bypass
      • Jejunocolonic bypass
  • 20. A Brief History of Bariatric Surgery
    • First developed:
      • Pts with short bowel syndrome  weight loss
    • First weight loss surgeries (ca. 1950s)
      • Intestinal bypass
        • Low-risk surgically BUT many patients developed serious and often fatal complications
      • Biliopancreatic diversion
        • Effective BUT with high risk and many complications
  • 21. Evolution of the Roux-en-Y
    • Gastric partitioning (Roux-en-Y GBP)
      • Based on observations of weight loss in pts receiving subtotal gastric resections for other conditions
      • 1967 – First performed
      • Continues to be studied and refined
  • 22. Roux-en-Y
    • Open*
      • 2 hour procedure
      • 3 days in-house
      • 4 weeks – Return to work
      • 60-70% EBW loss @ 2 yrs
      • 0.5-1.0% Risk of Death
      • Dumping Syndrome
    • Laparoscopic*
      • 2-4 hour procedure
      • 3 days in-house
      • 2-3 weeks – Return to work
      • 60-70% EBW loss @ 2yrs
      • 0.5-1.0% Risk of Death
      • Dumping Syndrome
    * Data based on averages.
  • 23. Evolution of Gastric Banding
    • 1970s
      • Alternative to Roux-en-Y in Europe & Scandinavia
    • 1980s
      • Adjustable silicone band developed
    • 1990s
      • Laproscopic techniques for placement developed
  • 24. Gastric Banding
    • Adjustable Lap Band
      • 1 hr procedure
      • 1 day in-house
      • 1 wk – Return to work
      • 40-45% EBW loss @ 2 yrs
      • <0.1% Risk of Death
      • Self-sabotage easier
  • 25. Who Gets Bariatric Surgery?
    • Gender
      • 19% Males
      • 72.6% Females
      • (8% gender not reported)
    • Age
      • Mean age 39 years
      • Range 16-64 years
    • BMI
      • Mean BMI 46.9
      • Range 32.3-68.8
    • Buchwald H, et al. Bariatric Surgery: A Systematic Review and Meta-analysis . JAMA, 14:1724-37, 2004
  • 26. Medical Nutrition Therapy and The Post-op Bariatric Patient
  • 27. Post-Surgical Nutrition
    • Balanced/healthy diet
    • Liquids to pureed to soft to solid*
    • High nutrient density, quality
    • Modified in lactose, fat, sugar
    • Adequate fluid
    • Portion Control
    • Meal Periods/Eating time
    • MVI/MIN
      • Ca (>1200mg/d) + D (10-20mg)
      • Folate (800-1000mcg) +B12
      • Iron (45-100mg elemental – pre-menstrual)
      • Vitamin C (75-100mg)
      • Thiamin
    • Self-monitoring
    • Eating triggers/behaviors
    • Exercise
    * Time line may vary among institutions
  • 28. Post-Op Roux-En-Y Diet
    • Stage One (1 day)
      • Water and clear liquids
      • Non-caloric, non-carbonated, non-caffeinated liquids
      • Fluid goal: 28-32oz/d
    • Stage Two (14 days)
      • High protein, low sugar beverages
      • Fluid goal: 56oz
      • Protein goal: 60-70g/d
      • Chewable MVI + Ca
  • 29. Post-Op Roux-En-Y Diet
    • Stage Three (4 weeks)
      • 5 – 2oz servings diced protein
      • Fluid goal: 56oz
      • Protein goal: 60-70g
      • Chewable MVI + Ca
    • Stage Four (4 months)
      • 3 meals, 2 snacks
      • 850kcal/d
      • Fluid goal: 56oz
      • Protein goal: 60-70g
      • Chewable MVI + Ca
    • Stage Five (ongoing)
      • Regular Meals
      • 1200-1500kcal
      • Fluid & Protein goals: same as above
  • 30. Post-op Lap Band Diet
    • Stage One (1 day)
      • Water & Clear Liquids
      • Non-carbonated, non-caffeinated, non-caloric liquids
      • Fluid goal: 28-32oz/d
    • Stage Two (14 days)
      • 5-8oz servings of High Protein, low sugar Beverage
      • Fluid goal: 56oz
      • Protein goal: 50-60g
      • Chewable MVI + Ca
  • 31. Post-op Lap Band Diet
    • Stage Three (14 days)
      • Pureed Foods, Semi solids
      • 2 small meals, 3 snacks
      • Fluid goal: 56oz
      • Protein goal: 50-60g
      • Chewable MVI + Ca
    • Stage Four (ongoing)
      • Regular meals: 3 meals,2 snacks (1000-1200)
      • Fluid goal: 56oz
      • Protein goal: 50-60g
      • Chewable MVI + Ca
  • 32. Post-Surgical Nutrition & Exercise
    • RD seen frequently
      • 1m  3m  6m  1yr
    • Exercise
      • No heavy lifting or exercise 6-8wks post-op
      • Walking daily OK, encouraged
      • After cleared, strength training important to help skin stretch back
      • Helps with weight loss in the long run
  • 33. When Surgery and Follow-Up Go Well…
  • 34. Efficacy of Bariatric Surgery for Weight Loss
    • Mean percentage excess weight loss:
      • 61.2% - All Patients
      • 47.5% - Gastric Banding
      • 61.6% - Gastric Bypass
      • 68.2% - Gastroplasty
      • 70.1% - BPD or duodenal switch
    • *Buchwald H, et al. Bariatric Surgery: A Systematic Review and Meta-analysis. JAMA, 14:1724-37, 2004
  • 35.
    • Human body regulates nutrient intake over time by secreting hormones
    • Over 40 hormones play a role in regulation of feeding.
    Roux-en-Y: Metabolic Sequelae
  • 36. Roux-en-Y: Metabolic Sequelae
    • Two types :
      • Satiety hormones
        • Short-term
        • Help regulate meal size; daily intake
        • Secretion decreases meal size; reduces time to stop
        • Includes (among others) cholecystokinin, amylin, glucagon-like-peptide 1 (GLP-1), enterostatin, and bombesin
      • Adiposity hormones
        • Long-term
        • Related to energy stores
        • Secretion delays onset of beginning of meal
        • Includes insulin, leptin
  • 37. Roux-en-Y: Metabolic Sequelae
    • Also of note is ghrelin, the endogenous ligand for the growth hormone secretagogue receptor
    • Mostly secreted in the fundus of the stomach (part bypassed in RYGB)
    • Contrary to satiety hormones, ghrelin is orexigenic – i.e., increases appetite (fasting increases levels)
  • 38. Roux-en-Y: Metabolic Sequelae
    • Plasma ghrelin normally increases after non-surgical weight loss
      • This supports long-term weight homeostasis
      • Proportional to lean body mass
    • Initial report showed circulating plasma ghrelin greatly decreased in pts s/p RYGB
    • Past theory : exclusion of the fundus of the stomach responsible for lower ghrelin levels (and therefore greater weight loss)
  • 39.
    • Studies since then have shown no change or increase in ghrelin after bypass
    • Additionally, found that post-pyloric nutrient stimulation vs.. stomach distention responsible for changes in ghrelin levels
      • Does not support idea that bypassing stomach fundus responsible for changes, if any, in ghrelin levels
      • Overall, still not well understood
    Roux-en-Y: Metabolic Sequelae Strader AD, et al. Gastrointestinal Hormones and Food Intake. Gastroenterology, 128:175-91, 2005
  • 40. Roux-en-Y: Metabolic Sequelae
    • Further investigation is needed, but thought that one reason certain types (i.e., RYGB) of bariatric surgery are successful at reducing food intake and causing weight loss may be related to enhanced secretion of satiety signals (ghrelin or others).
  • 41. Effect on Comorbid Conditions
    • Diabetes
      • 76.8% - Completely resolved
      • 86.0% - Resolved or improved
    • Hyperlipidemia
      • 70% - Improved
    • HTN
      • 61.7% - Resolved
      • 85.7% - Resolved or improved
    • Obstructive Sleep Apnea
      • 83.6% - Resolved
      • 85.7% - Resolved or improved
    Buchwald H, et al. Bariatric Surgery: A Systematic Review and Meta-analysis. JAMA, 14:1724-37, 2004
  • 42. Metabolic Changes and Diabetes
    • Many metabolic changes contribute to improvement and/or resolution of DM s/p bariatric surgery:
      • Recovery of acute insulin response
      • Decreases of inflammatory indicators (C-reactive protein and interleukin 6)
      • Improvement in insulin sensitivity correlated w/increases in plasma adiponectin
      • Changes in the enteroglucagon response to glucose
      • Reduction in ghrelin levels (s/p RYGB, but not banding)
      • Improvement in beta cell function (s/p banding, but not RYGP)
  • 43. Effect on Quality of Life
    • Studies show overall QOL greatly improved
      • Relief from comorbidities
      • Improved appearance
      • Perception of improved:
        • Well-being
        • Social function
        • Body self-image
        • Self confidence
        • Ability to interact with others
      • Increased time spent in recreational and physical activities
      • Enhanced productivity
      • Increased economic opportunities
        • Often new employment
        • More lucrative employment
  • 44. PROBLEMS AND COMPLICATIONS of Bariatric Surgery
  • 45. Possible Complications of Bariatric Surgery
    • General Complications
      • Pulmonary embolism
      • Incisional hernia
      • Gallstone formation
      • Major wound infection and seroma
      • Abdominal fluid collection
      • Subphrenic abscess
      • Peritonitis
  • 46. Procedure-Specific Complications (RYGB)
    • Anastomotic or staple-line leak
    • Acute gastric distention
    • Staple-line disruption
    • Stomal stenosis
    • Stomal ulceration
    • Small-bowel obstruction
    • Occlusion of Roux limb
  • 47. Intermediate Complications
    • Wound Infection
    • Intra-abdominal bleed
    • Gastric remnant necrosis
    • Ischemic Roux-limb
    • Internal hernia
  • 48. Long-Term GI Complications
    • Nausea
    • Constipation
    • Abdominal pain
    • Marginal ulcers
    • Incisional hernias
    • Vomiting
    • Diarrhea
    • Gallstones
    • Gastritis
    • Intestinal Obstructions
  • 49. Incidence of Complications
    • Operative mortality ( < 30 days):
      • 0.1% for Purely Restrictive Procedures
      • 0.5% for Gastric Bypass
      • 1.1% for BPD or Duodenal Switch
  • 50. Long-Term Nutrition Complications
    • Malnutrition
    • Vitamin and mineral deficiencies
    • Weight loss failure
    • Dehydration
    • Anemia
    • Dumping Syndrome
    • Hair loss
    • Dry skin
  • 51. Risk of Vitamin and Mineral Deficiencies Post-op
    • Calcium and Vitamin D
      • Reduced absorption d/t bypassed duodenum, proximal jejunum (R-en-Y)
      • Life-long supplements mandatory
    • Iron
      • Absorption decreased d/t decreased contact of food with gastric acid; reduced conversion of iron from ferrous to ferric form (MVI)
    • Vitamin B12
      • Absorption decreased d/t decreased contact with intrinsic factor
      • 60% of patients require long term supplementation of B12
    • Thiamine
      • Connection to Wernicke’s syndrome
      • Cases not well documented
  • 52. Post-Surgical Eating Avoidance Disorder (PSEAD)
    • De novo synthesis of eating disorders post-GBP
      • No history pre-operatively
    • Do not fit criteria for AN, BN, or BED
      • Classify now as EDNOS
    • Characteristics consistent enough to suggest new eating disorder
  • 53. Post-Surgical Eating Avoidance Disorder (PSEAD)
    • Proposed Criteria:
      • Previous h/o morbid obesity followed by bariatric surgery over the last 2 years
      • Higher speed of weight loss than the average
      • Use of purgative strategies or excessive reduction of food intake, related or not related to binge eating episodes
  • 54. Post-Surgical Eating Avoidance Disorder (PSEAD)
    • Proposed Criteria:
      • Reaction of extreme anxiety +/or negative attitude when nutritional correction introduced
      • Intense fear of going back to pre-op wt
      • Does not accept attempts to interrupt the wt loss
      • Denies doing something exaggerated that account for loss
      • Perceives a positive return with wt loss in spite of evidence to the contrary
  • 55. Post-Surgical Eating Avoidance Disorder (PSEAD)
    • Proposed Criteria:
      • Body image dissatisfaction or distortion
      • Follow-up nutritional tests (such as laboratory tests) alterations that are significant and/or not in line with the surgical technique, maintained for more than 2 months after initial interventions
      • Exclude AN and BN, according to DSM IV
      • Exclude Simple Phobias (I.e., Food or Choking Phobia) according to DSM IV
      • Exclude organic causes as the most probable factor for excessive weight loss
    Segal et al. Post-Surgical Refusal to Eat: Anorexia Nervosa, Bulimia Nervosa or a New Eating Disorder? A Case Series . Obes Surg, 14:353-359, 2004
  • 56. Post-Surgical Eating Avoidance Disorder (PSEAD)
    • A proposed ED classification
    • Not yet part of the DSM IV
  • 57. ED: Contraindication for GBP?
    • Pt with h/o of AN or BN likely not a good surgical candidate
      • Pt at high risk for malnutrition after surgery
    • Some with h/o ED receive surgery
    • Important to screen carefully before AND monitor closely post-op to prevent relapse of disorder, malnutrition.
  • 58. Long Term Impact & Future Directions
  • 59. Long-Term Changes: Weight Regain
    • One study of 342 gastric bypass pts showed excellent long-term weight maintenance:
      • % weight loss at:
        • 1 year (89%)
        • 2 years (87%)
        • 5 years (70%)
        • 10 years (75%)
    • However, potential for pouch stretch, self-sabotage, etc. leading to weight regain over time.
    • Surgery relatively new, will have to wait and reanalyze data in a few years.
  • 60. “ Long-term changes in energy expenditure and body composition after massive weight loss induced by gastric bypass surgery” Das SK, et al. Am J Clin Nutr. 2003;78:22-30.
  • 61. Study: EE & Body Composition
    • Objective:
      • To determine changes in energy expenditure and body composition with weight loss after gastric bypass surgery; to identify pre-surgery indicators of weight loss.
  • 62. Study: EE & Body Composition
    • Design & Methods:
      • Included 30 obese men and women
        • Average age 39.0 + 9.6 y
        • Average BMI (kg/m 2 ) 50.1 + 9.3
      • Tested longitudinally under weight-stable conditions before surgery and after weight loss and stabilization (14 + 2 mo)
      • Measured total energy expenditure (TEE), resting energy expenditure (REE), body composition, and fasting leptin
  • 63. Study: EE & Body Composition
    • Results:
      • Weight loss 53.2 + 22.2 kg body weight
      • Significant reduction in REE (-2.4 + 1.0 MJ/d; P < 0.001) and TEE (-3.6 + 2.5 MJ/d; P < 0.001).
      • Changes in REE predicted by changes in fat-free mass and fat mass
      • Average physical activity level (TEE/REE) was 1.61 at both baseline and follow-up ( P = 0.98)
      • Weight loss predicted by baseline fat mass and BMI but not by any energy expenditure variable or leptin.
      • Measured REE at follow-up was not significantly different from predicted REE.
  • 64. Study: EE & Body Composition
    • Conclusions:
      • TEE and REE decreased by 25% on average after massive weight loss and weight stabilization after gastric bypass
      • Decreases in REE largely or completely predicted by decreases in body FFM and fat mass
      • Fasting leptin at baseline found not to be a predictor of energy efficiency/changes, as some previous studies had shown
  • 65. Study: EE & Body Composition
    • Conclusions:
      • Suggested further studies to examine other explanations for variability in weight loss between patients after gastric bypass surgery
        • ? Psychological, behavioral factors
      • Suggested permanent reduction in energy intake critical for long-term weight management
  • 66. Other Future Weight Loss Strategies
    • Gastric stimulation – idea of placing a pacemaker-like device in stomach to control contractions; release of hunger/satiety hormones
    • Hormone therapy - “exendin-4”
      • Hormone produced in Gila monster salivary gland
      • Similar to GLP-1 in humans
        • Reduces gastric emptying
        • Lowers fasting plasma glucose
        • Reduces food intake
      • May prove effective therapy for DM, obesity
  • 67. OTHER CONCERNS
  • 68. Nutrition Support in the Critically Ill GBP Patient
    • Enteral feeding possible, if warranted:
      • Tube surgically placed in excluded stomach (RYGBP)
      • Nasoenteric tube placed endoscopically through pouch
    • If neither option possible (e.g. if pt has anastomotic leak)  TPN.
  • 69. Bariatric Surgery in Special Populations
    • Adolescents
    • Elderly (over 60)
  • 70. Adolescents
    • Few medical centers currently performing bariatric surgery on this population
      • Only extreme cases
    • Highly controversial given incomplete growth period
    • Specialized medical team only
  • 71. Elderly
    • Advanced age common contraindication to surgery
    • Research suggests age may not be as indicative of outcome as once believed
      • Successful GBP cases in 60+*
    St.Peter, Shawn. Impact of Advanced Age on Weight Loss and Health Benefits After Laparoscopic Gastric Bypass. Arch Surg; 140:165-168;2005
  • 72. Spouses of GBP Patients
    • Study by Madan AK, et al (2005) showed gastric bypass patient’s spouses who are obese are more likely to have weight gain while the patients lose weight after surgery
      • Suggest pre-operative counseling for spouses or even consider them for surgery as well
  • 73. Summary
    • Bariatric surgery is a seemingly effective therapy for morbid obesity that is gaining in popularity and prevalence
    • Bariatric surgery provides significant
      • Loss of excess body weight
      • Relief from comorbidities:
        • DM, HTN, hyperlipidemia
      • Improvement in QOL for patients
    • However, these surgeries put pts at risk for
      • Post-op complications & mortality
      • Nutritional deficiencies & GI complications
      • Psychosocial complications
  • 74. References
    • Kim JJ, et al. Surgical Treatment for Extreme Obesity: Evolution of a Rapidly Growing Field. Nutr Clin Prac 18:109-23, 2003
    • Buchwald H, et al. Bariatric Surgery: A Systematic Review and Meta-analysis. JAMA, 14:1724-37, 2004
    • Olshansky SJ, et al. A Potential Decline in Life Expectancy in the United States in the 21 st Century. NEJM, 352(11):1138-1145, 2005
    • Merkle EM, et al. Roux-en-Y Gastric Bypass for Clinically Severe Obesity: Normal Appearance and Spectrum of Complications at Imaging. Radiology, 234(3):674-83, 2005
    • Segal et al. Post-Surgical Refusal to Eat: Anorexia Nervosa, Bulimia Nervosa or a New Eating Disorder? A Case Series. Obes Surg, 14:353-359, 2004
    • Madan AK, et al. Weight changes in spouses of gastric bypass patients. Obes Surg, 15(2):191-4, 2005
  • 75. References
    • Strader AD, et al. Gastrointestinal Hormones and Food Intake. Gastroenterology, 128:175-91, 2005
    • Das SK, et al. Long-term changes in energy expenditure and body composition after massive weight loss induced by gastric bypass surgery. Am J Clin Nutr. 2003;78:22-30.