Bariatric endoscopy


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Bariatric endoscopy

  1. 1. 67C.C. Thompson (ed.), Bariatric Endoscopy, DOI 10.1007/978-1-4419-1710-2_6,© Springer Science+Business Media New York 2013IntroductionThe most important thing to understand in thepostoperative management of the bariatric patientis the progression of milestones. Bariatric surgeryis a controlled abnormality, so it is to be expectedthat patients will experience eating differently.However, it is essential that patients be monitoredto ensure an adequate intake of calories, a mini-mum being approximately 500–800 cal a day [1].It is also critical that they receive adequate pro-tein and adequate micronutrients. Careful physi-cal exam remains the cornerstone of diagnosis ofpostoperative difficulties. Many of these patientsare young and thus have a functional reserve; as aresult, when a disaster strikes, they may initiallycompensate well enough to mask many of thesymptoms. Providers must have a low thresholdfor augmenting their patient’s nutrition, even ifparenteral nutrition must be started. The overallgoal in the short term should not be massiveweight loss but a controlled amount of weightloss preserving lean muscle mass.To maximize success and limit potential prob-lems, it is essential that all members of the health-care team be familiar with the postoperativeissues. The purpose of this chapter will be tohighlight key issues in postoperative managementof the various procedures and touch briefly onwhat complications should be considered duringthis period.Bariatric surgery may be categorized intoprocedures that involve only the stomach vs.procedures that manipulate both stomach andintestine. The former includes laparoscopicadjustable gastric banding and sleeve gastrec-tomy as well as the emerging plication of thegreater curvature. The second category includesgastric bypass and the duodenal switch.Postoperative care is similar within these cate-gories, with some notable exceptions, and thiswill provide the structure for this chapter. Theessential caveat in the postoperative care of allbariatric patients is the need to maintain ade-quate nutrition. It is a misnomer to believe thatobese patients have a greater degree of reservebecause of their size. The definition of obesity isexcess adiposity; it does not mean they haveexcess lean muscle mass or micronutrients andobese patients at baseline will often be deficientin one or both of these. The amount of weightloss after bariatric surgery that is optimal or evenadequate has not yet been defined or universallyaccepted [2]. There are patients that lose asignificant amount of weight in the first monthfollowing surgery; but much of this is usuallywater due to improvement in the underlyinginsulin resistance and the related diurese. Thecritical thing is to provide adequate support,assess clinical progression, and be vigilant forpotential complications.M.S. Roslin, M.D., F.A.C.S(*) • D. McPhee, M.D.• S. Kulkarni, M.D.Department of General and Minimally Invasive Surgery,Lenox Hill Hospital, 186 E 76th Street, 1st Floor,New York, NY 10021, USAe-mail: mroslin@lenoxhill.net6Basic Postoperative Managementof the Bariatric PatientMitchell S. Roslin, Diana McPhee, and Sujit Kulkarni
  2. 2. 68 M.S. Roslin et al.Gastric-Only OperationsLaparoscopic Adjustable GastricBandingLaparoscopic adjustable gastric banding consistsof placing a silicone-based ring around the topportion of the stomach (Fig. 6.1). On the innerside of the silicone ring is a balloon, which isconnected by a catheter to a port placed subcuta-neously in the abdominal wall. Accessing theport with a needle allows fluid to be added to theballoon, providing a greater level of restriction.Advocates of the laparoscopic adjustable gastricbanding systems highlight the low initial surgicalcomplication rate and the initial successful weightloss experienced by patients, with many patientslosing up to 60% of excess weight [3]. However,there is a risk of band erosion and a high rate ofreoperation.The band functions as a restrictor or high-pressure zone that is placed distally to the GEjunction. When the procedure is successful, thepatient will be satisfied by eating a small portionof food that will stay above the restrictor forseveral hours and then pass through the diges-tive circuit allowing the patient to be satisfiedwith less food and achieve weight loss. In ourexperience with laparoscopic adjustable gastricbanding, the patients that successfully loseweight with the band are satisfied with smallerportions after inflation of the band; however,other patients remain unsatiated despite therestriction and resort to maladaptive eating pat-terns. Many caregivers ascribe such treatmentfailures to noncompliance; however, somepatients may fail this therapy because of lack ofhunger suppression. To date, research has shownno reduction in the hormone ghrelin, consideredthe primary hormone involved in hunger, withgastric banding [4].During the early postoperative period afterthe band is placed, it is usually not filled. Despitethis, many patients still experience early satietyin the immediate postoperative period. This isprobably due to the inhibition of receptiverelaxation following eating. Patients are told toadhere to a liquid or mush diet for their first 3weeks following surgery. This diet allows theband to scar into place, reducing the risk ofmovement, slippage, or gastric prolapse. Rarely,an acute slippage can be found. The hallmark ofan acute slippage is inability to tolerate liquidsand an abdominal film demonstrating change inposition from the 1 to 7 o’clock position nor-mally seen following laparoscopic adjustablebanding to a 3–9 o’clock or horizontal position;rarely, the band may rotate up to 180° [5]. Inover 1,000 adjustable bandings, we have onlyseen one case of acute slippage. Following theclear liquid phase of diet, patients are advancedto solid food. We recommend that adjustableband patients obtain a food scale and weightheir food, with the ideal portion size being 4 ozof solid food. If patients are not satiated with4 oz of food after progressing to a diet of regu-lar consistency, we will begin adding fluid to theband. Generally, we fill the bands on a gradualbasis seeing the patients on at least a monthlybasis until they achieve restriction. Once a rea-sonable amount of fluid is placed into the band,an upper GI series is performed to make surethat the anatomy correlates with the patient’ssymptoms. Alternatively, the balloon can befilled under fluoroscopy.Numerous filling schedules have been pro-posed; most of these aim to modify the amountof fluid in the band until the patients experiencesatiety with small food portions. In our experi-ence, the symptoms experienced by the patientdo not reliably correlate with the degree of fillingnor necessarily indicate pathology related to theband. When patients have heart burn, regurgita-tion, or inability to tolerate oral intake, abdomi-nal films will often show that the band is too tightand there is some dilation of the esophagus or theconcentric pouch. However, the absence of hun-ger suppression and a satisfaction with a smallamount of food are not reliable indicators thatthe band requires more fluid. It is thereforeessential in the postoperative management ofband patients to correlate X-ray imaging orfluoroscopic imaging with the patient’s symp-toms and not rely only on history to determineadequate titration of the band.
  3. 3. 696 Basic Postoperative Management of the Bariatric PatientWhile the advantage of laparoscopic adjustablegastric banding is reduction in serious complica-tions immediately following the surgery, there isan increased risk of requiring revisional proce-dures. The revisional surgical rate for laparo-scopic adjustable gastric banding has beenestimated approximately 5% per year [3].Complications necessitating revision includeissues with the port, poor tolerance of oral intake,esophageal dilatation, gastric prolapse, concen-tric dilatation, or inadequate weight loss.One of the most common issues that patientswill present for endoscopy or will be seen byan endoscopist following LAP-BAND surgerywill be symptoms of reflux or regurgitation. Inthe initial postoperative period, there is actu-ally a reduction in GERD-type symptoms inpatients that receive laparoscopic adjustablegastric banding. This is due to the fact that thehiatus is probably repaired in many patientsduring the surgery. The band itself can functionas a prosthesis preventing regurgitation; fur-thermore, with weight loss, abdominal pres-sure is reduced, lowering reflux. GERD-typesymptoms are very common in patients withobesity because of the increased abdominalpressure of the abdomen, and this actuallyleads to reflux symptom, similar to what is seenin pregnancy. Thus, the reappearance of refluxsymptoms after they have been alleviated byweight loss usually indicates the presence ofacid producing cells above the band. Manyphysicians prescribe proton pump inhibitors,and we think that this is fine to reduce thesymptoms of esophagitis. However, the pri-mary treatment for GERD symptoms followinglaparoscopic adjustable gastric banding shouldbe relaxing of the band and making sure thatthere is no evidence of gastric prolapse orslippage [3].Fig. 6.1 Laparoscopic adjustable gastric banding
  4. 4. 70 M.S. Roslin et al.In the postoperative management of bandpatients, it is essential to understand the physiol-ogy of bands. The band creates a potential high-pressure zone with the pressure increasing withfills. The esophagus therefore must create higherpressure during peristalsis to have food pass thelower esophageal sphincter and then through theband. The silicon is inelastic and will not stretch;this can create a problem if the band is overfilledor if the patient eats more than prescribed por-tions. Patients who attempt to eat more than theprescribed portions can cause emesis. Long term,the patient’s pouch or even their esophagus candilate, causing regurgitation and reflux symp-toms. Another possibility is the pressure causesthe band to move causing a prolapse or chronictype of slippage. It is therefore essential to edu-cate patients to monitor the amount of food thatthey take by weighing their food. In addition, thepresence of new onset GERD, regurgitation, oran increase in the ability to be able to toleratefood as well as a decrease in the ability to toleratefood should prompt radiological imaging. Thepreferential exam is an upper GI series. Use ofendoscopy is required to determine the degree ofesophagitis. Only an endoscopist with consider-able experience can ascertain the position of theband.Vertical Sleeve GastrectomyThe vertical sleeve gastrectomy is an increasingpopular option for bariatric surgery. This opera-tion involves resection of the greater curvature ofthe stomach using staples that cut and divide(Fig. 6.2). There are differing opinions regardingwhere to begin the transaction, with most sur-geons starting between 3 and 5 cm towards thegreater curvature [6]. It is performed over a bou-gie, the size of which ranges from size 32 Frenchup to a size 60. It is essential to leave adequatearea round the angularis/incisura, and the purposeof the operation is to resect the majority of thefundus and greater curvature of the stomach, tab-ularizing the stomach to look similar to a banana.The advantage of this operation is that a smallamount of food will provide stretch and a feelingof satiety. In addition to removing the most elasticpart of the stomach, resecting the fundus mayalso beneficially alter the neurendocrine functionof the stomach by removing cells that producepolypeptides such as ghrelin that are importantin hunger and satiety [7].The key to the postoperative management ofvertical sleeve gastrectomy is understanding thata gastric sleeve is a high-pressured system, incontrast to a gastric bypass. This is due to thepreservation of the pyloric valve as well as thelong staple line and the tubular structure of thesleeve. As a result, the high-pressured systemneeds to be taken into account when and if thereare any complications. Postoperative dietaryinstructions for patients undergoing verticalsleeve gastrectomy include staying on a liquefiedor mush diet for the first several weeks followingsurgery.A dreaded complication following verticalsleeve gastrectomy is a leak of the staple line.These leaks commonly happen by the GE junc-tion. There are many different theories as towhy this takes place, but the most prevailingtheory is that this is the area of greatest pressureof the high staple line [8]. Others suggest thatthis is the area of lowest blood flow [6]. We alsomake sure to leave adequate area for the angu-laris/incisura as this is a common site of stenosis.We believe it is essential that the staple line bestraight and not veer out towards the spleencreating a narrowing distally and a wide funduson top. We believe such a preparation predis-poses patients to potential leaks as well as thedevelopment of reflux symptoms in the future.If a leak does occur, the endoscopist will beactively involved in the postoperative manage-ment of the patient.Should a leak occur, the first goal of therapyis to control sepsis. This requires percutaneousdrainage or operative intervention. However,there are many potential roles for endoscopyin helping control the leak. Stents have beenused with varying degrees of success for themanagement of postoperative sleeve leaks [9].Frequently, they require insertion of more thanone covered stent potentially putting a stentwithin a stent. The primary goal of placing a
  5. 5. 716 Basic Postoperative Management of the Bariatric Patientstent is to alleviate any distal high-pressure zoneand allow enteric contents to drain distally.Another potential benefit of placing a stent is tocover the area of the leak allowing the patient tohave oral intake. It is also feasible to use Botoxas well in the pylorus, thereby facilitating drain-age and allowing the stomach to heal.Another postoperative difficulty seen inpatients after vertical sleeve gastrectomy is symp-toms of gastric reflux. The causes of this are mul-tifactorial, but ultimately the removal of thefundus decreases the ability of the stomach toaccommodate a large bolus of food [10]. Themajority of patients that experience reflux willfind relief from their symptoms if they are strictlycompliant with the guidelines for portion sizes.In patients that have intractable reflux, it is impor-tant to obtain imaging studies to make sure thereis not a corkscrew or an obstruction of the sleeve.A late presentation of reflux symptoms is often asign of dilation of the upper fundus.After approximately 1 month of a mush diet,diets are advanced to include solid food. Patientsshould be reminded that the sleeve will stretchand will double in size over the next severalyears. The best way to avoid stretching of thesleeve is to eat small portions that are regulatedand weighed rather than eat to the capacity of thesleeve with each meal.Micronutrient deficiencies seem to be lesscommon in patients after sleeve gastrectomywhen compared with gastric bypass. All patientswho have a sleeve gastrectomy will need to begiven vitamin B12 supplementation and a multi-vitamin [11].Gastric PlicationSuture plication of the greater curvature of thestomach is an emerging operation. This is doneto imbricate the greater curvature of the stomachFig. 6.2 Sleeve gastrectomy
  6. 6. 72 M.S. Roslin et al.(Fig. 6.3). The exact advantages of this operationcompared to sleeve gastrectomy have not yetbeen defined, but the operation is theoreticallyreversible and there is some thought that the riskof leakage would be lower. The actual feasibilityof reversing this procedure has not been demon-strated. Serosa-to-serosa application will createdense adhesions making separation difficult.Early reports of results from the Cleveland Clinicas well as from abroad in Brazil and Iran havedocumented excess weight loss of approximately50% at 1 year from surgery; 3-year data isbecoming available [12]. At the present time,this is an experimental procedure and the degreeand type of complications are unknown.Furthermore, while numerous techniques havebeen proposed, as of yet there is no consensus onthe most expedient approach. Early complica-tions include nausea as well as pain from theedema and venous congestion from the imbri-cated greater plication. Long-term complicationshave not been ascertained. In addition, it is notclear how difficult it will be to perform revisionaloperations.Similar to other gastric-only operations, theinitial postoperative diet should include at leasta 3-week course of a liquid diet. In addition,supplementation with a multivitamin is suggested.Other medications should be crushed in theearly postoperative period of time. In addition,the impact of the anatomy on sustained-releaseddrugs has not yet been determined. In operationsthat require a gastrectomy such as the sleevegastrectomy, we suggest that sustained-releasedand long-acting medications are changed totheir short-acting versions that have more pre-dictable absorption.Gastric Intestinal OperationsGastric BypassGastric bypass is the most common staplingoperation performed in the United States.Advocates highlight 70% of excess weight lossachieved at 1 year with excellent relief fromcomorbidities [13]. Gastric bypass has beenchampioned as the gold standard operation bymany bariatric surgeons. The operation involvescreating a small pouch that excludes the fundusbased on the lesser curvature of the stomach withgastrojejunostomy with bypass of various lengthsof intestine (Fig. 6.4).Fig. 6.3 (a) Single plication of gastric greater curva-ture—original technique. (b) Double plication of gastricgreater curvature—modified technique (with kind permis-sion from Springer Science+Business. Skrekas G, et al.Media: obesity surgery, laparoscopic gastric greater cur-vature plication: results and complications in a series of135 patients 2011;21:1658, Figure 1)
  7. 7. 736 Basic Postoperative Management of the Bariatric PatientThe early postoperative dietary instructionsinclude a liquefied diet for several weeks.Nutritional guidelines include supplementing thediet with a multivitamin, calcium, vitamin B12,and iron [14]. In addition, supplementation withthe fat-soluble vitamins such as A, D, E, and Kbecause of the intestinal bypass operation isimportant.Compared with vertical sleeve gastrectomy,gastric bypass and the gastric jejunostomy createa lower pressure system [15]. Gastric bypass pro-vides excellent relief of GERD-type symptomsby diverting both the biliary flow as well as theacid-producing cells. Early complications fromgastric bypass include anastomotic leak, wherestenting may again be advocated to control thesource of sepsis. Because this is a low-pressuresystem, anastomotic leaks in bypass patientsseem to be easier to control compared with leaksfrom a vertical sleeve gastrectomy.Other early complications that may come toendoscopic evaluation include stricture of thegastrojejunostomy and marginal ulceration [16].Since the long-term efficacy of the operationinvolves maintaining the restrictive anastomo-sis, we currently do not suggest early dilatationfor any patients that can adequately handle clearliquid fluids. The indication for endoscopy anddilation is the inability to be able to drink2 quarts of clear liquid or warm tea. The diagno-sis of a marginal ulcer of the gastrojejunostomyneeds to be entertained in any gastric bypasspatient with new onset of nausea and vomiting,whether in the early or late postoperative period.Fig. 6.4 Roux-en-Y gastric bypass
  8. 8. 74 M.S. Roslin et al.Any patient that presents with intolerance oforal intake should undergo prompt imagingstudies to rule out any evidence of leak, perito-nitis, and sepsis. Once that is ruled out, it is safeto endoscope these patients shortly after surgerylooking for the presence of a marginal ulcer orpotential stricture. Practitioners should bear inmind that morbidly obese patients often havedecreased nutritional reserves despite theirexcess weight. Providers should therefore havea low threshold for starting TPN in patients whodo not tolerate oral intake following gastricbypass surgery.Long-term health concerns in patients aftergastric bypass include a variety of micronutri-ent deficiencies. Patients commonly havedecreased absorption of iron and calcium. Thefirst portion of the duodenum is very importantin the absorption of divalent cations. It isimportant in supplementation to instructpatients not to take their iron and calcium at thesame time. Furthermore, gastric bypass patientswho eat foods with a high glycemic index areprone to developing hypoglycemia. Theore-tically, the dumping syndrome experienced bybypass patients after eating carbohydrate-richmeals should deter them from eating inappro-priate amounts of carbohydrates. Some patientshowever become caught in a vicious cycle ofcraving carbohydrates and then binging, result-ing in further hypoglycemia. It is therefore ourpractice to encourage these patients to eat smallmeals frequently that are low on the glycemicindex.One of the most serious complications fol-lowing gastric bypass is internal hernia. If rec-ognized and repaired promptly, patients recoverquickly and can often be sent home one day fol-lowing surgery. Unfortunately, a missed internalhernia can result in a midgut volvulus and ashort bowel syndrome. Providers must thereforeremain vigilant for this complication in thepostoperative period. Any gastric bypass patientthat has new onset pain, especially with obstruc-tive-type symptoms, should immediatelyundergo CT scan. If radiological studies cannotrule out this complication, urgent laparoscopy isindicated.Sleeve Gastrectomy with DuodenalSwitchThe duodenal switch operation involves thecreation of sleeve gastrectomy followed by anintestinal bypass (Fig. 6.5). Classically, the diam-eter of the sleeve gastrectomy created for thisprocedure was larger than the sleeve gastrectomyperformed without a bypass procedure. Our grouphas suggested doing a smaller sleeve gastrectomyas well as a non-malabsorptive intestinal bypasswith limb lengths preserving a minimum of125 cm common channel and 150 cm alimentarylimb. With this type of operation, our group hasachieved excellent results with most patients hav-ing bowel movements one to three times a day.This is likely to be better tolerated than patientswho undergo a standard duodenal switch opera-tion, which can cause significant malabsorptivesymptoms with patients typically moving theirbowels more than six times daily.When compared to the other bariatric proce-dures, duodenal switch operations have the great-est amount of weight loss, greatest improvementin comorbidities with the exception of reflux, andthe lowest amount of recidivism. However, theyhave the highest risk for micronutrient deficiency.There are case reports of postoperative bariatricpatients with adequate caloric intake who havenonetheless had severe micronutrient deficienciesresulting in thiamine deficiency or Korsakoffsyndrome as early as 1–2 months following sur-gery; these patients are at risk for irreversibleneurologic changes. As a result, it is importantthat any patient who has a biliopancreatic diver-sion such as a duodenal switch to be on severalmultivitamins a day as well as supplemental vita-mins A, D, E, K, and B12, iron, and calcium.Patients require blood work at least one to twotimes per year. It is much easier to supplementthan it is to replete patients that have developeddocumented clinically significant deficiencies.These points are essential for any bariatric patientthat has intestinal manipulation.It is important in the postoperative manage-ment for these patients to monitor their musclemass and make sure they do not have any sign ofhypoproteinemia or weakness [1]. The earliest
  9. 9. 756 Basic Postoperative Management of the Bariatric Patientsign of malnutrition following any bariatricprocedure is a low BUN and low potassium. Onphysical exam, the most sensitive sign of proteinmalnutrition is difficulty getting from a sitting toa standing position without using their arms; thisindicates weakness of the gluteus muscles. Withall gastrointestinal operations or any operationwith rapid weight loss, it is essential to reinforcethe importance of getting an adequate amount ofprotein; the goal should be 1 g of protein per kgof body weight.Early complications after sleeve gastrectomywith duodenal switch are similar to gastricbypass, including intolerance of oral intake oranastomotic leaks. Again, endoscopic stents andcontrol of sepsis are key in managing thesepatients. A good understanding of the anatomyis absolutely essential. Long-term issues withduodenal switch include micronutrient andvitamin deficiencies and risk of intestinalobstructions similar to gastric bypass. Promptrecognition of an intestinal obstruction andpossible internal hernia is essential to preventcatastrophic outcome.ConclusionMaintenance of adequate caloric intake, progres-sion of key milestones, and knowing what com-plications to consider for each specific procedureare critical in the postoperative management ofbariatric patients. The most important thing in theassessment of a patient remains good commonsense and sound judgment in assessing the clini-cal progression of the patient. A patient whoFig. 6.5 Sleeve gastrectomy with duodenal switch
  10. 10. 76 M.S. Roslin et al.seems to be struggling should be reevaluated,including judicious use of imaging such as upperendoscopy and CT scanning. Occasionally, afunctional cause for their failure to thrive will notbe found. In these particular cases, it is essentialto provide adequate alimentation and allow theseproblems to work themselves out. Most impor-tantly, time is an ally. With good support andnutrition, these problems will be resolved.Bariatric surgery is a great tool. It reduces car-diac risk factors, can cause diabetes to go intoremission, and gives many people their life back.Unfortunately, there are patients that have suf-fered disastrous complications from these elec-tive procedures. It is essential that all practitionersinvolved in the care of bariatric patients under-stand the various procedures completely as wellas monitor all patients closely in the postopera-tive period to minimize side effects while con-tinuing to offer good weight loss results.References1. Faintuch J, Matsuda M, Cruz ME, et al. Severe pro-tein-calorie malnutrition after bariatric procedures.Obes Surg. 2004;14(2):175–81.2. Sugerman HJ. Bariatric surgery for severe obesity. JAssoc Acad Minor Phys. 2001;12:129–36.3. Michalik M, Lech P, Bobowicz M, Orlowski M,Lehmann A. A 5-year experience with laparoscopicadjustable gastric banding—focus on outcomes, com-plications, and their management. Obes Surg.2011;21(11):1682–6.4. Wang Y, Liu J. Plasma ghrelin modulation in gastricband operation and sleeve gastrectomy. Obes Surg.2009;19(3):357–62.5. Keidar A, Szold A, Carmon E, Blanc A, Abu-Abeid S.Band slippage after laparoscopic adjustable gastricbanding: etiology and treatment. Surg Endosc. 2005;19:262–7.6. Mognol P, Chosidow D, Marmuse JP. Laparoscopicsleeve gastrectomy (LSG): review of a new bariatricprocedure and initial results. Surg Technol Int.2006;15:47–52. Review.7. Peterli R, Steinert RE, Woelnerhanssen B, Peters T,Christoffel-Courtin C, Gass M, et al. Metabolic andhormonal changes after laparoscopic Roux-en-Y gas-tric bypass and sleeve gastrectomy: a randomized,prospective trial. Obes Surg. 2012;22(5):740–8.8. Fernandez Jr AZ, DeMaria EJ, Tichansky DS, et al.Experience with over 3000 open and laparoscopicbariatric procedures: multivariate analysis of factorsrelated to leak and resultant mortality. Surg Endosc.2004;18:193–7.9. Puli SR, Spofford IS, Thompson CC. Use of self-expandable stents in the treatment of bariatric surgeryleaks: a systematic review and meta-analysis.Gastrointest Endosc. 2012;75(2):287–93.10. Petersen WV, Meile T, Küper MA, Zdichavsky M,Königsrainer A, Schneider JH. Functional importanceof laparoscopic sleeve gastrectomy for the loweresophageal sphincter in patients with morbid obesity.Obes Surg. 2012;22(3):360–6.11. Brolin RE, Gorman JH, Gorman RC, et al. Are vita-min B12 and folate deficiency clinically importantafter roux-en-Y gastric bypass? J Gastrointest Surg.1998;2:436–42.12. Skrekas G, Antiochos K, Stafyla VK. Laparoscopicgastric greater curvature plication: results andcomplications in a series of 135 patients. Obes Surg.2011;21(11):1657–63.13. Brolin RE. Laparoscopic verses open gastric bypassto treat morbid obesity. Ann Surg. 2004;239(4):438–40.14. HatizifotisM,DolanK,NewburyL,etal.Symptomaticvitamin A deficiency following biliopancreatic diver-sion. Obes Surg. 2003;13(4):655–7.15. Livingston EH. Procedure, incidence and complica-tion rates of bariatric surgery in the United States. AmJ Surg. 2004;188:105–10.16. Capella JF, Capella RF. Gastro-gastric fistulas andmarginal ulcers in gastric bypass procedures forweight reduction. Obes Surg. 1999;9:22–7.