Rapid communication
Weight loss and improvement of obesity-related illness in 500 U.S. patients following laparoscopic adjustable gastric banding procedure
Hadar Spivak, M.D. a, *
Mary F. Hewitt, M.D. a
Amir Onn, M.D. a
Elizabeth E. Half, M.D. a
a Park Plaza Hospital Professional Bldg., 1200 Binz, Ste. 1470, Houston, TX 77004, USA
| * Corresponding author: Tel.: +1-713-520-8900; fax: +1-713-520-8905. |
| E-mail address: hspivak@houston.rr.com |
Manuscript received April 9, 2004 , revised manuscript received June 23, 2004
PII S0002-9610(04)00481-7
Abstract Background Obesity and its related illness is a primary health concern today.
Methods Five hundred morbidly obese patients (mean age 42 years; mean preoperative weight 123 kg) underwent laparoscopic adjustable gastric banding surgery in a private U.S. hospital setting within a comprehensive multidisciplinary bariatric program. Patients were followed up to 36 months. Comorbidity status was assessed for 163 patients who completed ≥18 months’ follow-up by comparing medications (type and dosage) prescribed for each comorbid condition before surgery and at follow-up.
Results At 36 months after surgery, mean body mass index (BMI) had decreased from 45.2 to 34.9 kg/m2 and mean percent excess weight loss (%EWL) was 47%. Complications were as follows: gastric pouch dilatation (6.8%), slippage (2.8%), and stoma obstruction (0.6%). There was no mortality. Resolution or improvement of comorbidities were as follows: gastroesophageal reflux disease (GERD) (87%; usually immediately postsurgery), asthma (81.8%), diabetes (66%), dyslipidemia (65.5%), hypertension (48%), and sleep apnea (33%).
Conclusions Gastric banding provides good weight loss and significant reduction in comorbidities with few and minor complications.
| Keywords |
| | Obesity | |
| | Gastric banding | |
| | GERD | |
| | Hypertension | |
| | Diabetes | |
| | Dyslipidemia | |
Obesity has grown to epidemic proportions in western societies and is associated with considerable increases in morbidity and mortality [1], [2], [3]. Excess weight is linked to an increased risk of cardiovascular disease, hypertension, diabetes, sleep apnea, and asthma, as well as gastroesophageal reflux [1], [3]. According to the U.S. Surgeon General, hypertension is twice as common in adults who are obese as in those who are at a healthy weight, and more than 80% of people with diabetes are overweight or obese [1]. Weight loss has been shown to improve these comorbid conditions [1].
For the severely obese, nonsurgical methods (including diet, exercise, and behavioral modification) are usually ineffective, and rarely result in sustained weight loss [4], [5]. Surgery is the only treatment that has been proven to consistently achieve long-term reduction of excess weight in patients with severe clinical obesity [4], [6].
The most commonly performed bariatric operation outside of the United States is a restrictive procedure involving a laparoscopically placed adjustable gastric band (LAP-BAND System, INAMED Health, Santa Barbara, CA) [5]. The gastric banding procedure is reversible (if medically indicated), does not permanently alter the normal anatomy, and is adjustable, allowing for fine-tuning of the outlet diameter so that it can be modified to the individual patient [7]. Since the June 2001 Food and Drug Administration (FDA) approval of the LAP-BAND (the only adjustable gastric band approved for use in the United States), experience in this country has grown. The present report describes our series of 500 consecutive US patients, making this one of the largest and longest followed series in the United States to date. (Hadar Spivak, MD, first author on this paper, has previously reported his experience with this gastric band in Israel, and, after relocating to the United States in 1999, has subsequently reported his early experience with 271 US patients.)
MATERIALS AND METHODS
Between November 2000 and September 2003, 500 patients (432 women) underwent gastric banding placement by a single surgeon at our facilities in the Houston, TX, area. Follow-up was extended until February 2004. Ninety percent of patients were available for 2- and 3-year follow-up. The mean age of patients was 42 years (range 18 to 63 years). The mean preoperative body weight was 123 kg (range 93 to 192 kg) and the mean body mass index (BMI) was 45.2 kg/m2 (range 35 to 61).
POSTSURGICAL MANAGEMENT
Postoperative follow-up was provided by the surgeon, with the support of members of the hospital Family Practice residency program, a nurse coordinator, a psychologist, and a nutritionist. On the day of discharge, patients were instructed to follow a clear to full liquid diet for the first 48 hours, followed by a diet of pureed foods, protein shakes, and nutritional supplements for the first month. Small amounts of solid food were introduced starting in the second month, as tolerated. Patients returned to the office between the seventh and tenth day after surgery for a wound check, review of dietary instructions, and referral to available support groups. They were then scheduled to return between 1 and 3 months later; subsequently, patients were instructed to return as needed (typically a few times per year). During these office visits, we assessed weight loss, amount of restriction, satiety, feeling of hunger, and compliance. Our evaluation of the patient’s progress led us to take one or more approaches: band adjustment, behavioral modification (with referral to psychologist or support group), and/or further nutritional guidance.
In order to take advantage of the adjustability feature of the device, between 2 and 5 office-based adjustments to the band were performed during the first year after surgery and, generally, 1 or 2 adjustments per year were needed subsequently. Additional visits were required for evaluation and management of complications, if and when they occurred. Esophagrams were performed both immediately after surgery and at 1 year. Also, any time a complication was suspected, an additional esophagogram was performed.
After surgery, patients continued follow-up with their primary care physician or a professional consultant (such as a cardiologist or pulmonologist) who managed their obesity-related illnesses and adjusted their medication as necessary. The surgical team had no input as to the medical management of these patients’ comorbid conditions, including the type and dosage of medications. Data regarding comorbidities were collected during office visits and through telephone questionnaires. For the purpose of this comorbidity assessment, patients (n = 163) who had completed at least 18 months of follow-up were included. This time period was considered sufficient for patients to lose the bulk of their weight and for their primary care physician or specialist to adjust their medications as necessary. A total of 136 comorbid conditions were recorded preoperatively in this cohort of 163 patients (some patients had more than 1 comorbidity and some had none).
Obesity-related illness status was assessed by comparing medications prescribed for each comorbidity before surgery and during follow-up. Based on the type and dosage of medications, a Resolved, Improved, or Not Improved comorbidity scale was created. Assessing improvement of comorbid illnesses based on this type of medication score has been used previously [8]. Prior to surgery, all patients (N = 500) underwent a thorough laboratory workup including metabolic profile and complete blood count with indices. During the period of follow-up, 54 of the 163 patients had a repeat laboratory evaluation. Data regarding comorbidities were assessed by comparing the lower exact confidence boundary against a null hypothesis of 10% improvement.
RESULTS
Mean operative time was 42 minutes (range 23 to 86 minutes), including the time required for additional procedures, such as cholecystectomy or repair of hiatal hernia. Mean hospital stay was 1 day (range 4 hours to 7 days). The majority of patients received 2 to 5 band adjustments (generally an in-office procedure) during the first year after surgery. Almost all patients required their first band adjustment within the first 3 months after surgery.
WEIGHT LOSS
Mean BMI decreased from a baseline of 45.2 (35-68) kg/m2 to 39.0 (n = 290), 36.9 (n = 143), 35.1 (n = 81), and 34.9 (n = 29) kg/m2 at 6, 12, 24, and 36 months after surgery, respectively (Fig. 1). Of note, patients could have registered at different months postoperatively. Mean excess weight loss (%EWL) was 39% at 12 months, 45% at 24 months, and 47% at 36 months (Fig. 2).
Fig. 1 Reduction in BMI over time after laparoscopic adjustable gastric banding surgery.
Fig. 2 %EWL over time after laparoscopic adjustable gastric banding surgery.
IMPROVEMENT OF OBESITY-RELATED ILLNESS
Prior to surgery, 48 patients were diagnosed with gastroesophageal reflux disease (GERD). Of these, 42 (87.5%) relied on proton pump inhibitors and 6 (12.5%) were on H2 blockers. Typically, GERD resolved immediately after surgery and, as a routine, all patients with GERD were taken off their medications. However, while at a mean follow-up of 20 months (range 18 to 36), 35 had complete resolution of GERD and 7 improved, 6 patients continued to experience GERD symptoms and were placed back on medications. Significant improvement in other obesity-related illnesses was also seen (Table 1).
Table 1 . Reduction of obesity-related illnesses following LAP-BAND surgery in 163 patients with ≥18 months of follow-up | Comorbidity | No. of patients | Resolved | Improved | Not improved | P |
| | n (%) | n (%) | n (%) | |
| GERD* | 48 | 35 (72.9) | 7 (14.6) | 6 (12.5) | <0.05 |
| Hypertension | 40 | 17 (42.5) | 2 (5) | 21 (52.5) | <0.05 |
| Dyslipidemia | 16 | 10 (63.5) | 0 | 6 (37.5) | <0.05 |
| Diabetes | 12 | 4 (33) | 4 (33) | 4 (33) | <0.05 |
| Asthma | 11 | 9 (81.8) | 0 | 2 (18.2) | <0.05 |
| Sleep apnea | 9 | 3 (33) | 0 | 6 (67) | NS |
|
| NS = not significant. |
* Improvement in GERD was seen immediately after surgery.
|
Within the group of 54 patients who had the repeat metabolic panel after surgery, no signs of anemia were found, and no significant changes were observed in the patients’ calcium or albumin levels (Table 2). Significant reduction was seen in triglycerides, from a mean of 158.2 mg/dL to a mean of 119.9 mg/dL (P = 0.0015), although total cholesterol did not decrease. Greater losses in weight were associated with greater reductions in triglycerides (r = 0.39, P = 0.0094).
Table 2 . Laboratory values before and after LAP-BAND surgery in 163 patients with ≥18 months of follow-up | Laboratory test | No. of patients | Mean preoperative result | Mean follow-up result | P |
| Hemoglobin (g/dL) | 52 | 13.4 | 13.3 | NS |
| MCV (fL) | 53 | 87.1 | 88.7 | <0.05 |
| Calcium (mg/dL) | 54 | 9.43 | 9.31 | NS |
| Albumin (g/dL) | 49 | 4.01 | 4.02 | NS |
| Total cholesterol (mg/dL) | 41 | 197 | 203 | NS |
| HDL (mg/dL) | 41 | 46 | 52 | <0.05 |
| LDL (mg/dL) | 36 | 119 | 128 | NS |
| Triglycerides (mg/dL) | 42 | 158.2 | 119.9 | <0.05 |
|
| MCV = mean corpuscular volume; HDL = high-density lipoprotein fraction; LDL = low-density lipoprotein fraction; NS = not significant. |
COMPLICATIONS
Gastric pouch dilatation, the most prevalent complication in this series, occurred in 34 patients (6.8%), and produced symptoms of GERD, substernal chest pain, and progressive dysphagia. Fortunately, this is an easily (and nonsurgically) reversible condition that we treat by removing the fluid from the band-via the access port-and allowing it to remain deflated for 2 to 3 weeks. We observed in some patients a degree of distal esophageal dilatation in association with the pouch dilatation. The esophageal dilatations, however, were also found to be reversible and none has been permanent in this group of patients (Fig. 3).
Fig. 3 Complete resolution of gastric pouch dilatation with short-term band deflation. (A) Gastric and distal esophageal dilatation in a 38-year-old man 11 months after gastric band placement (2.2 mL fill). The patient’s symptoms consisted of progressive dysphasia and reflux. (B) Normalization of anatomy 2 weeks after band deflation, which resulted in complete resolution of symptoms. Subsequently, the patient has undergone further fills and maintains a %EWL of 40%.
Infrequently, the symptoms of gastric pouch dilatation fail to resolve with deflation of the band and we must consider the likelihood that the condition is actually gastric slippage, a more serious complication. In this study, 14 patients (2.8%) experienced gastric slippage. All were admitted for hydration and laparoscopic surgery [9] soon after diagnosis. Among this group, only 1 band required removal (pregnant patient in second trimester), 1 band was exchanged for another band, and 12 bands were successfully repositioned. All patients were discharged on the day of surgery or the day following. Immediate postoperative stoma obstruction (outlet stenosis), was found in 3 patients (0.6%), who required laparoscopic reoperation to thin the area where the band was placed. Two other patients had a transient obstruction not requiring surgery, which involved extended hospitalization (for ∼7 days) until the edema subsided and the patient slowly regained the ability to swallow.
One (0.2%) band erosion occurred, for which the patient underwent elective removal of the band and conversion to gastric bypass. There were 25 (5%) access port problems requiring exploration with or without laparoscopy. Most port problems occurred in the first 50 patients due to the original placement of the access port in the upper left quadrant where the access port-tube connection was sharply angled and wear-and-tear was excessive. We placed the access port in a better location in later operations in this series [10], after which the complication became rare (approximating 1%). Recently, the manufacturer has modified the access port, making its tubing longer to minimize this problem.
Two patients (0.4%) in the first half of our series suffered pulmonary emboli. (While all patients wore sequential compression cuffs, we attribute this low rate to the short surgical procedure [<1 hour], and patient ambulation within hours after surgery.) In patients at high risk for developing pulmonary emboli (i.e., those with BMI >60 kg/m2, severe leg edema, or arthritis of the knee or ankle), we administered low molecular weight heparin prophylaxis during the patients’ hospital stay. Four patients (0.8%) developed pneumonia/atelectasis, 1 associated with postoperative stoma obstruction with aspiration. Three patients with diabetes developed gastric paresis. There were no deaths in the 500-patient series. Seven bands (1.4%) had to be removed due to complications, intolerance, or poor weight loss. Of these, 4 were converted to gastric bypass. A small amount of normal saline (a few tenths of 1 mL) was found to slowly and continuously escape from the bands in the majority of patients. Postoperative complications are summarized in Table 3.
Table 3 . Postoperative complications after laparoscopic adjustable gastric banding surgery for obesity | Complication | No. | % |
| Gastric pouch dilatation | 34 | 6.8% |
| Access port dysfunction | 25 | 5.0% |
| Band slippage | 14 | 2.8% |
| Pneumonia/atelectasis | 4 | 0.8% |
| Stoma obstruction | 3 | 0.6% |
| Gastric paresis | 3 | 0.6% |
| Pulmonary embolism | 2 | 0.4% |
| Trocar site bleeding | 1 | 0.2% |
| Band erosion | 1 | 0.2% |
| Mortality | 0 | 0% |
| Conversion to open procedure | 3 | 0.6% |
COMMENTS
Laparoscopic adjustable gastric banding has been shown in many countries throughout the world to provide good weight loss and significant reduction in obesity-related illness. International experience with the gastric banding system in Europe and Australia shows a reduction in BMI of 9 to 13 kg/m2 from baseline within 2 years of placement, which corresponds to about 50% to 55% %EWL [11], [12], [13], [14], [15], [16]. Weight loss continues even out to 72 months after surgery, and stablizes in reports of up to 7 years’ follow-up [11], [12], [13], [14], [16]. The weight loss with the gastric band has been associated with improvement in, and in some cases, complete resolution of a wide range of comorbid conditions [17], [18], [19], [20], [21], [22], [23].
These good international results, though, have been questioned in the United States, mainly because the data gathered during the FDA-monitored clinical trials in the United States were less favorable. Compared to the international experience, initial U.S. results from the first multicenter clinical trial of the gastric banding system were not as good, with only 36% EWL (overall) and a mean BMI reduction from 47.5 to 38.7 kg/m2 over the 3 years of the formal study. Furthermore, after 7 years, 83 (28%) of the initial 299 patients enrolled had the band removed because of complications such as band slippage/gastric pouch dilatation, esophageal dilatation, and stoma obstruction (incidences combined). These results may have been related to the learning curve of a new technique (only 2 surgeons operated on >50 patients in this trial), low positioning of the band when using the perigastric technique, overly tight band adjustments, and minimal experience with postoperative patient management. It is important to remember that the FDA trial was a pioneering work and done without the benefit of the cumulative knowledge and shared experience that we now have available.
Since then, improvements in the technique, establishment of a smaller pouch, and an enhanced understanding of the importance of the special postsurgical care (including the nuances of adjustments), have allowed our results with the adjustable gastric band, as well as those of other U.S. investigators, to run abreast with the international experience (Table 4). While early weight loss may be more gradual with the gastric band, it has been suggested that weight loss with the gastric band may approach that seen with gastric bypass over the long term [27]. Gastric bypass patients’ weight loss reaches a maximum in the first 12 to 18 months after surgery, but the weight tends to stabilize-or increase-between years 3 and 4 and approximates 49% to 55% %EWL after 10 to 14 years [28]. In a report by the National Institute for Clinical Excellence (a division of the National Health Service in England and Wales) comparing weight reduction and BMI reduction after gastric bypass and after gastric banding, results from the 2 procedures were similar at 5 years after surgery [29]. It has also been shown that weight loss after gastric banding surgery is associated with significant reduction in comorbidities with no signs of malnutrition or malabsorption [14], [16]. With gastric bypass, it has been suggested that anatomic and physiologic changes may result in micronutrient deficiencies [30], [31], [32].
Table 4 . Reduction in BMI in large series of laparoscopic adjustable gastric banding surgeries | Study | N | Preoperative BMI | 12-Month BMI (n) | 24-Month BMI (n) | 36-Month BMI (n) |
| Angrisani [11] (Italy) | 1863 | 43.7 | 33.7 (n = NA) | 34.8 (n = NA) | 34.1 (n = NA) |
| Favretti [12] (Italy) | 830 | 46.4 | 37.3 (n = 660) | 36.4 (n = 479) | 36.8 (n = 305) |
| Belachew [13] (Belgium) | 763 | 42 | 32 (n = NA) | 30 (n = NA) | |
| O’Brien [16] (Australia) | 709 | 45 | 35 (n = 492) | 33 (n = 336) | 32.5 (n = 273) |
| Vertruyen [7] (Belgium) | 543 | 44 | 33.2 (n = 405) | 31.3 (n = 372) | 30.1 (n = 261) |
| Spivak (U.S.) | 500 | 45.2 | 36.9 (n = 143) | 35.1 (n = 81) | 34.9 (n = 29) |
| Zinzindohoue [14] (France) | 500 | 44.3 | 34.2 (n = 343) | 32.8 (n = 185) | 31.9 (n = 45) |
| Ren [24] (U.S.) | 445 | 52.7 | 39.3 (n = 99) | | |
| Abu-Abeid [25] (Israel) | 391 | 43 | 32 (n = NA) | | |
| Fielding [26] (Australia) | 335 | 47 | 34 (n = 125) | | |
|
| NA = not available. |
In this study, the medication scoring system was used to measure improvement in comorbidities after weight loss with the gastric band. This method was selected because (1) the assessment of patients’ medical conditions is conducted by their primary care physician or other healthcare provider-independent of the surgeon and the surgical team; (2) it is simple; and (3) it has been found to provide an accurate assessment [8]. While most obesity-related illnesses improve with weight loss, the mechanism of improvement in GERD with the gastric band is more complex. It is related, in part, to the weight loss; however, more importantly, the band appears to function as a barrier, preventing the refluxate from entering the esophagus by restricting the gastroesophageal junction and changing the angle of the distal esophagus (as occurs with Nissen fundoplication). We believe that this is the reason GERD resolves immediately after surgery. Over time, however, some patients do experience reflux symptoms, generally as a result of some degree of gastric pouch dilatation.
In conclusion, the laparoscopic adjustable gastric band provides good weight loss and reduces obesity-related illness. Results in the United States now parallel those obtained in the international arena where the band has been available longer. Although the weight loss progress may be less or slower than with more aggressive procedures, the reduction is still clinically meaningful and rarely associated with life-threatening complications.
DISCLOSURE
Hadar Spivak, MD, has served as a consultant to the medical advisory board of INAMED Health and this paper was supported in part by a research grant from INAMED Health.
REFERENCES: [1] The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity. Available at http://www.surgeongeneral.gov/topics/obesity. Accessed 02/20/04. [2] Mokdad A.H., Marks J.S., Stroup D.R., Gerberding J.L., Actual causes of death in the United States, 2000. JAMA (2004) 291 : pp 1238-1245. Abstract [3] Herrera M.F., Lozano-Salazar R.R., Gonzalez-Barranco J., Diseases and problems secondary to massive obesity. Deitel M. Update Surgery for the Morbidly Obese Patient 2000Toronto, Canada: FD-Communications. [4] National Institutes of Health. Gastrointestinal Surgery for Severe Obesity. NIH Consensus Statement Online 1991 Mar 25-27;9(1):1-20. Available at http://consensus.nih.gov/cons/084/084_statement.htm. Accessed 03/17/04. [5] Fisher B.L., Schauer P., Medical and surgical options in the treatment of severe obesity. Am J Surg (2002) 184 : pp 9S-16S. Full Text [6] Dolan K., Creighton L., Hopkins G., Fielding G., Laparoscopic gastric banding in morbidly obese adolescents. Obes Surg (2003) 13 : pp 101-104. Abstract [7] Vertruyen M., Experience with Lap-Band system up to 7 years . Obes Surg (2002) 12 : pp 569-572. Abstract [8] Spivak H., Smith C.D., Phichith A., Asthma and gastroesophageal reflux fundoplication decreases need for systemic corticosteroids . J Gastrointest Surg (1999) 3 : pp 477-482. Abstract [9] Spivak H., Favretti F., Avoiding postoperative complications with the LAP-BAND system. Am J Surg (2002) 184 : pp S31-S37. Full Text [10] Spivak H., Gold D., Guerrero C., Optimization of access-port placement for the Lap-Band system. Obes Surg (2003) 13 : pp 909-912. Abstract [11] Angrisani L., Furbetta F., Doldi S.B., Lap Band adjustable gastric banding systemthe Italian experience with 1863 patients operated on 6 years. Surg Endosc (2003) 17 : pp 409-412. Abstract [12] Favretti F., Cadiere G.B., Segato G., Laparoscopic banding selection and technique in 830 patients. Obes Surg (2002) 12 : pp 385-390. Abstract [13] Belachew M., Belva P.H., Desaive C., Long-term results of laparoscopic adjustable gastric banding for the treatment of morbid obesity. Obes Surg (2002) 12 : pp 564-568. Abstract [14] Zinzindohoue F., Chevallier J.M., Douard R., Laparoscopic gastric banding: a minimally invasive surgical treatment for morbid obesity: prospective study of 500 consecutive patients. Ann Surg (2003) 237 : pp 1-9 . Abstract [15] Allen J.W., Coleman M.G., Fielding G.A., Lessons learned from laparoscopic gastric banding for morbid obesity. Am J Surg (2001) 182 : pp 10-14 . Full Text [16] O’Brien P.E., Dixon J.B., Brown W., The laparoscopic adjustable gastric band (Lap-Band)a prospective study of medium-term effects on weight, health and quality of life. Obes Surg (2002) 12 : pp 652-660. Abstract [17] Alvarez-Cordero R., Ramirez-Wiella G., Aragon-Viruette E., Toledo-Delgado A., Laparoscopic gastric banding initial two year experience. Obes Surg (1998) 8 : pp 360-. Citation [18] Dixon J.B., O’Brien P.E., Health outcomes of severely obese type 2 diabetic subjects 1 year after laparoscopic adjustable gastric banding. Diabetes Care (2002) 25 : pp 358-363. Abstract [19] Dixon J.B., O’Brien P.E., Gastroesophageal reflux in obesity the effect of Lap-Band placement. Obes Surg (1999) 9 : pp 527-531 . Abstract [20] Dixon J.B., Chapman L., O’Brien P., Marked improvement in asthma after LAP-BAND surgery for morbid obesity. Obes Surg (1999) 9 : pp 385-389. Abstract [21] Dixon J.B., Schachter L.M., O’Brien P.E., Sleep disturbance and obesity changes following surgically induced weight loss. Arch Intern Med (2001) 161 : pp 102-106. Abstract [22] Dixon J.B., Dixon M.E., O’Brien P.E., Quality of life after lap-band placement influence of time, weight loss, and comorbidities. Obes Res (2001) 9 : pp 713-721. Abstract [23] Heimbucher J., Fuchs K., Tigges H., Laparoscopic Gastric BandingEffects of Excess Weight Reduction On Obesity Related Morbidity 1999 Linz, Austria: EAES : pp 25-. [24] Ren C.J., Weiner M., Allen J.W., Favorable early results of gastric banding for morbid obesitythe American experience . Surg Endosc (2004) 18 : pp 543-546. Abstract [25] Abu-Abeid S., Szold A., Results and complications of laparoscopic adjustable gastric bandingan early and intermediate experience. Obes Surg (1999) 9 : pp 188-190. Abstract [26] Fielding G.A., Rhodes M., Nathanson L.K., Laparoscopic gastric banding for morbid obesity. Surgical outcome in 335 cases. Surg Endosc (1999) 13 : pp 550-554 . Abstract [27] O’Brien P.E., Dixon J.B., Lap-Bandoutcomes and results. J Laparoendosc Adv Surg Tech (2003) 13 : pp 265-270 . [28] Pories W.J., Swanson M.S., MacDonald K.G., Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus . Ann Surg (1995) 222 : pp 339-352. Abstract [29] Clegg A, Sidhu MK, Colquitt J, et al. Clinical and cost effectiveness of surgery for people with morbid obesity. Available at http://www.nice.org.uk/pdf/AssessmentReport-Surgeryforobesity.pdf. Accessed 03/15/04. [30] Moize V., Geliebter A., Gluck M.E., Obese patients have inadequate protein intake related to protein intolerance up to 1 year following Roux-en-Y gastric bypass . Obes Surg (2003) 13 : pp 23-28. Abstract [31] Avinoah E., Ovnat A., Charuzi I., Nutritional status seven years after Roux-en-Y gastric bypass surgery. Surgery (1992) 111 : pp 137-142. Abstract [32] Brolin R.E., LaMarca L.B., Kenler H.A., Cody R.P., Malabsorptive gastric bypass in patients with superobesity. J Gastrointest Surg (2002) : pp 195-203. 
