Surgery for Obesity and Related Diseases ] (2014) 00–00
Editorial comment
Revisional metabolic/bariatric surgery: a moral obligation Today in United States healthcare, there is a covert assault on performing revisional surgery in individuals who have failed to lose weight or maintain weight loss after their primary metabolic/bariatric operations. Aligned against revisional surgery are certain payors, insurance providers, hospital and practice administrators, and some of our own metabolic/bariatric surgical colleagues. The arguments offered by this segment of the provider community are that the results of revisional surgery are not predictable in terms of hospitalization and follow-up care, that revisional surgery may have an increased complication rate compared with primary surgery and may be less successful than primary surgery, and above all, that revisional surgery may be financially disadvantageous. This negative response to revisional bariatric surgery is manifest at national, state, and local levels. There is a lack of conceptional support from the National Institutes of Health and a lack of critical financial support from the Affordable Care Act. On the state level, 28 states do not mandate or approve metabolic/bariatric procedures. Locally, the policies of some hospitals and departments of surgery, even in academic institutions, seek to eliminate or minimize revisional bariatric surgery. Yet, there are no papers in the medical literature that justify and support this perspective of denial. There are, however, numerous, evidence-based publications in support of revisional surgery for patients in whom the primary metabolic/bariatric surgery procedure has failed. A recent position paper on revisions by 13 experienced metabolic/bariatric surgeons concludes with the statement, “Morbid obesity is a chronic disease and acceptable long-term management after a primary bariatric procedure should include the surgical options of conversion, correction, or other adjuvant therapy to achieve an acceptable treatment effect in cases of weight recidivism, inadequate weight loss, inadequate co-morbidity reduction, or complications from the primary procedure” [1]. If we exclude the hundreds of papers that have been written concerning revisions after laparoscopic adjustable gastric band surgery, the sentiments of Brethauer et al. are voiced in a myriad of publications, of which a small sampling would include papers by Shimizu et al. [2], Hallowell et al.
[3], Himpens et al. [4], Keshishian et al. [5], Rawlins et al. [6], Srikanth et al. [7], Khoursheed et al. [8], Steffen et al. [9], Morales et al. [10], Gonzalez et al. [11], Schouten et al. [12], Gagne et al. [13], Suter et al. [14], Schouten et al. [15], Cordera et al. [16], Patel et al. [17], Westling et al. [18], Vasas et al. [19], Greenbaum et al. [20], Menon et al. [21], Jain-Spangler et al. [22], Parikh et al. [23], Vassallo et al. [24], and Chousleb et al. [25]. The co-authors of these papers include well-known authorities in metabolic/bariatric surgery, such as Schauer, Cadiere, Rosenthal, Greve, Horber, de la Torre, Sarr, and Pomp. At the 2014 annual Digestive Disease Week meeting in Chicago, Illinois, May 2–6, 2014, Dr. Ranjan Sudan, on behalf of a task force of the American Society for Metabolic and Bariatric Surgery (ASMBS), presented a paper reviewing 451,485 bariatric surgery operations, of which 6.3% were reoperations, demonstrating that the adverse events rates for primary and revisional surgery are essentially identical. In addition, the resolution of co-morbidities after reoperations is essentially identical to the resolution rate after primary bariatric surgery. At the recent meeting of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) in Montreal, Canada, August 27–30, 2014, nearly one third of the papers presented concerned revisional surgery. Not one of them advocated the abolishment or strict limitation of revisional surgery. On the contrary, a general sentiment was expressed by Dr. Michel Gagner, the President of the 2014 Congress, that in the future simple procedures will constitute most of primary surgery, with the expectation that a conversion to more definitive secondary operations will be performed as needed in a substantial number of patients. My own support of revisional metabolic/bariatric surgery is based on 5 fundamental principles: 1. We have fought overwhelming prejudice for over 50 years to have obesity regarded as a disease by our fellow physicians and by the public. At last, this outcome has come to pass and is reflected in the position statements of the American Medical Association [26] and the American Association of Clinical Endocrinologists [27], and implied in the World Health Organization statement on
http://dx.doi.org/10.1016/j.soard.2014.09.006 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
2
H. Buchwald / Surgery for Obesity and Related Diseases ] (2014) 00–00
obesity [28]. Failing to perform or severely limiting revisional metabolic/bariatric surgery, is a backward step renouncing this hard-earned recognition and our own underlying commitments as metabolic/bariatric surgeons. 2. Nowhere else in the spectrum of medicine is a patient denied remedial or revisional care. An individual refractory to a cardiogenic drug is offered an alternative agent. A patient with an anastomotic recurrence of a carcinoma of the colon after a subtotal colectomy, without major or limited metastatic disease, is offered a repeat excision. Furthermore, the salvage rate after revisional metabolic/ bariatric surgery far exceeds that of the uncontested revisional surgery performed for cancers, heart disease, orthopedic reconstructions, and other disease entities. 3. Once metabolic/bariatric care is initiated, it is the physician’s, especially the involved metabolic/bariatric surgeon’s, responsibility to maintain that care without being motivated by financial considerations. At the same time, I do not advocate that every surgeon performing metabolic/bariatric surgery should do revisional operations. Revisional surgery demands a dedicated, skilled, and experienced metabolic/bariatric surgeon, a hospital facility and personnel capable and willing to care for the difficult postoperative patient, and a supportive administration dedicated to patient care first and foremost. In addition to teaching hospitals, these criteria may be met by certain private practice hospitals and clinics. 4. A major academic teaching institution performing primary metabolic/bariatric surgery should be obligated to provide revisional metabolic/bariatric surgery. In my opinion, it should be mandatory for a major academic teaching institution offering a metabolic/bariatric fellowship to be a resource for revisional surgery. In addition, such an institution is ethically responsible for conducting clinical outcomes trials of revisional procedures to evaluate the relative benefits of these procedures. 5. Any teaching program certified as a Center of Excellence by the ASMBS/American College of Surgeons, or other similar national body, cannot abrogate its responsibility to perform and support metabolic/bariatric revisional surgery. I, therefore, believe that denying or severely limiting revisional metabolic/bariatric surgery is a denial of the precepts of our discipline and an abandonment of the underprivileged population who has placed its trust and future in our hands. Revisional metabolic/bariatric surgery is a moral obligation. Henry Buchwald, M.D., Ph.D. Past-President, American Society for Metabolic and Bariatric Surgery Past-President, International Federation for the Surgery of Obesity and Metabolic Disorders
Professor of Surgery and Biomedical Engineering, University of Minnesota, Minneapolis Minnesota References [1] Brethauer SA, Kothari S, Sudan R, et al. Systematic review on reoperative bariatric surgery, American Society for Metabolic and Bariatric Surgery Revision Task Force. Surg Obes Relat Dis. Epub 2014 Feb 22. [2] Shimizu H, Annaberdyev S, Motamarry I, Kroh M, Schauer PR, Brethauer SA. Revisional bariatric surgery for unsuccessful weight loss and complications. Obes Surg 2013;23:1766–73. [3] Hallowell PT, Stellato TA, Yao DA, Robinson A, Schuster MM, Graf KN. Should bariatric revisional surgery be avoided secondary to increased morbidity and mortality? Am J Surg 2009;197:391–6. [4] Himpens J, Coromina L, Verbrugghe A, Cadiere GB. Outcomes of revisional procedures for insufficient weight loss or weight regain after Roux-en-Y gastric bypass. Obes Surg 2012;22:1746–54. [5] Keshishian A, Zahriya K, Hartoonian T, Ayagian C. Duodenal switch is a safe operation for patients who have failed other bariatric operations. Obes Surg 2004;14:1187–92. [6] Rawlins ML, Teel D, Hedgcorth K, Maguire JP. Revision of Rouxen-Y gastric bypass to distal bypass for failed weight loss. Surg Obes Relat Dis 2011;7:45–9. [7] Srikanth MS, Oh KH, Fox SR. Revision to malabsorptive Roux-en-Y gastric bypass (MRNYGBP) provides long-term (10 years) durable weight loss in patients with failed anatomically intact gastric restrictive operations: long-term effectiveness of a malabsorptive Roux-en-Y gastric bypass in salvaging patients with poor weight loss or complications following gastroplasty and adjustable gastric bands. Obes Surg 2011;21:825–31. [8] Khoursheed M, Al-Bader I, Mouzannar A, et al. Sleeve gastrectomy or gastric bypass as revisional bariatric procedures: retrospective evaluation of outcomes. Surg Endosc 2013;27:4277–83. [9] Steffen R, Potoczna N, Bieri N, Horber FF. Successful multiintervention treatment of severe obesity: a 7-year prospective study with 96% follow-up. Obes Surg 2009;19:3–12. [10] Morales MP, Wheeler AA, Ramaswamy A, Scott JS, de la Torre RA. Laparoscopic revisional surgery after Roux-en-Y gastric bypass and sleeve gastrectomy. Surg Obes Relat Dis 2010;6:485–90. [11] Gonzalez R, Gallagher SF, Haines K, Murr MM. Operative technique for converting a failed vertical banded gastroplasty to Roux-en-Y gastric bypass. J Am Coll Surg 2005;201:366–74. [12] Schouten R, Wiryasaputra DC, van Dielen FM, van Gemert WG, Greve JW. Influence of reoperations on long-term quality of life after restrictive procedures: a prospective study. Obes Surg 2011;21:871–9. [13] Gagne DJ, Dovec E, Urbandt JE. Laparoscopic revision of vertical banded gastroplasty to Roux-en-Y gastric bypass: outcomes of 105 patients. Surg Obes Relat Dis 2011;7:493–9. [14] Suter M, Ralea S, Millo P, Alle JL. Laparoscopic Roux-en-Y gastric bypass after failed vertical banded gastroplasty: a multicenter experience with 203 patients. Obes Surg 2012;22:1554–61. [15] Schouten R, van Dielen FM, van Gemert WG, Greve JW. Conversion of vertical banded gastroplasty to Roux-en-Y gastric bypass results in restoration of the positive effect on weight loss and co-morbidities: evaluation of 101 patients. Obes Surg 2007;17:622–30. [16] Cordera F, Mai JL, Thompson GB, Sarr MG. Unsatisfactory weight loss after vertical banded gastroplasty: is conversion to Roux-en-Y gastric bypass successful? Surgery 2004;136:731–7. [17] Patel S, Szomstein S, Rosenthal RJ. Reasons and outcomes of reoperative bariatric surgery for failed and complicated procedures (excluding adjustable gastric banding). Obes Surg 2011;21:1209–19.
Editorial / Surgery for Obesity and Related Diseases ] (2014) 00–00 [18] Westling A, Ohrvall M, Gustavsson S. Roux-en-Y gastric bypass after previous unsuccessful gastric restrictive surgery. J Gastrointest Surg 2002;6:206–11. [19] Vasas P, Dillemans B, Van Cauwenberge S, De Visschere M, Vercauteren C. Short-and long-term outcomes of vertical banded gastroplasty converted to Roux-en-Y gastric bypass. Obes Surg 2013;23:241–8. [20] Greenbaum DF, Wasser SH, Riley T, Juengert T, Hubler J, Angel K. Duodenal switch with omentopexy and feeding jejunostomy—a safe and effective revisional operation for failed previous weight loss surgery. Surg Obes Relat Dis 2011;7:213–8. [21] Menon T, Quaddus S, Cohen L. Revision of failed vertical banded gastroplasty to non-resectional Scopinaro biliopancreatic diversion: early experience. Obes Surg 2006;16:1420–4. [22] Jain-Spangler K, Portenier D, Torquati A, Sudan R. Conversion of vertical banded gastroplasty to stand-alone sleeve gastrectomy or biliopancreatic diversion with duodenal switch. J Gastrointest Surg 2013;17:805–8.
3
[23] Parikh M, Pomp A, Gagner M. Laparoscopic conversion of failed gastric bypass to duodenal switch: technical considerations and preliminary outcomes. Surg Obes Relat Dis 2007;3:611–8. [24] Vassallo C, Andreoli M, La Manna A, Turpini C. 60 reoperations on 890 patients after gastric restrictive surgery. Obes Surg 2001;11:752–6. [25] Chousleb E, Patel S, Szomstein S, Rosenthal R. Reasons and operative outcomes after reversal of gastric bypass and jejunoileal bypass. Obes Surg 2012;22:1611–6. [26] American Medical Association. Report 4 of the Council on Scientific Affairs (A-05). Recommendations for Physician and Community Collaboration on the Management of Obesity (Resolution 420, A-13), 2013. Available from: http://media.npr.org/documents/2013/ jun/ama-resolution-obesity.pdf. [27] Mechanick JI, Garber AJ, Handelsman Y, Garvey WT. American Association of Clinical Endocrinologists’ position statement on obesity and obesity medicine. Endocr Pract 2012;18(5):642–8. [28] World Health Organization. Health topics: Obesity [cited 2014 Sept 3]. Available from: http://www.who.int/topics/obesity/en/.
Editorial comment
Revisional metabolic/bariatric surgery: a moral obligation Today in United States healthcare, there is a covert assault on performing revisional surgery in individuals who have failed to lose weight or maintain weight loss after their primary metabolic/bariatric operations. Aligned against revisional surgery are certain payors, insurance providers, hospital and practice administrators, and some of our own metabolic/bariatric surgical colleagues. The arguments offered by this segment of the provider community are that the results of revisional surgery are not predictable in terms of hospitalization and follow-up care, that revisional surgery may have an increased complication rate compared with primary surgery and may be less successful than primary surgery, and above all, that revisional surgery may be financially disadvantageous. This negative response to revisional bariatric surgery is manifest at national, state, and local levels. There is a lack of conceptional support from the National Institutes of Health and a lack of critical financial support from the Affordable Care Act. On the state level, 28 states do not mandate or approve metabolic/bariatric procedures. Locally, the policies of some hospitals and departments of surgery, even in academic institutions, seek to eliminate or minimize revisional bariatric surgery. Yet, there are no papers in the medical literature that justify and support this perspective of denial. There are, however, numerous, evidence-based publications in support of revisional surgery for patients in whom the primary metabolic/bariatric surgery procedure has failed. A recent position paper on revisions by 13 experienced metabolic/bariatric surgeons concludes with the statement, “Morbid obesity is a chronic disease and acceptable long-term management after a primary bariatric procedure should include the surgical options of conversion, correction, or other adjuvant therapy to achieve an acceptable treatment effect in cases of weight recidivism, inadequate weight loss, inadequate co-morbidity reduction, or complications from the primary procedure” [1]. If we exclude the hundreds of papers that have been written concerning revisions after laparoscopic adjustable gastric band surgery, the sentiments of Brethauer et al. are voiced in a myriad of publications, of which a small sampling would include papers by Shimizu et al. [2], Hallowell et al.
[3], Himpens et al. [4], Keshishian et al. [5], Rawlins et al. [6], Srikanth et al. [7], Khoursheed et al. [8], Steffen et al. [9], Morales et al. [10], Gonzalez et al. [11], Schouten et al. [12], Gagne et al. [13], Suter et al. [14], Schouten et al. [15], Cordera et al. [16], Patel et al. [17], Westling et al. [18], Vasas et al. [19], Greenbaum et al. [20], Menon et al. [21], Jain-Spangler et al. [22], Parikh et al. [23], Vassallo et al. [24], and Chousleb et al. [25]. The co-authors of these papers include well-known authorities in metabolic/bariatric surgery, such as Schauer, Cadiere, Rosenthal, Greve, Horber, de la Torre, Sarr, and Pomp. At the 2014 annual Digestive Disease Week meeting in Chicago, Illinois, May 2–6, 2014, Dr. Ranjan Sudan, on behalf of a task force of the American Society for Metabolic and Bariatric Surgery (ASMBS), presented a paper reviewing 451,485 bariatric surgery operations, of which 6.3% were reoperations, demonstrating that the adverse events rates for primary and revisional surgery are essentially identical. In addition, the resolution of co-morbidities after reoperations is essentially identical to the resolution rate after primary bariatric surgery. At the recent meeting of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) in Montreal, Canada, August 27–30, 2014, nearly one third of the papers presented concerned revisional surgery. Not one of them advocated the abolishment or strict limitation of revisional surgery. On the contrary, a general sentiment was expressed by Dr. Michel Gagner, the President of the 2014 Congress, that in the future simple procedures will constitute most of primary surgery, with the expectation that a conversion to more definitive secondary operations will be performed as needed in a substantial number of patients. My own support of revisional metabolic/bariatric surgery is based on 5 fundamental principles: 1. We have fought overwhelming prejudice for over 50 years to have obesity regarded as a disease by our fellow physicians and by the public. At last, this outcome has come to pass and is reflected in the position statements of the American Medical Association [26] and the American Association of Clinical Endocrinologists [27], and implied in the World Health Organization statement on
http://dx.doi.org/10.1016/j.soard.2014.09.006 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
2
H. Buchwald / Surgery for Obesity and Related Diseases ] (2014) 00–00
obesity [28]. Failing to perform or severely limiting revisional metabolic/bariatric surgery, is a backward step renouncing this hard-earned recognition and our own underlying commitments as metabolic/bariatric surgeons. 2. Nowhere else in the spectrum of medicine is a patient denied remedial or revisional care. An individual refractory to a cardiogenic drug is offered an alternative agent. A patient with an anastomotic recurrence of a carcinoma of the colon after a subtotal colectomy, without major or limited metastatic disease, is offered a repeat excision. Furthermore, the salvage rate after revisional metabolic/ bariatric surgery far exceeds that of the uncontested revisional surgery performed for cancers, heart disease, orthopedic reconstructions, and other disease entities. 3. Once metabolic/bariatric care is initiated, it is the physician’s, especially the involved metabolic/bariatric surgeon’s, responsibility to maintain that care without being motivated by financial considerations. At the same time, I do not advocate that every surgeon performing metabolic/bariatric surgery should do revisional operations. Revisional surgery demands a dedicated, skilled, and experienced metabolic/bariatric surgeon, a hospital facility and personnel capable and willing to care for the difficult postoperative patient, and a supportive administration dedicated to patient care first and foremost. In addition to teaching hospitals, these criteria may be met by certain private practice hospitals and clinics. 4. A major academic teaching institution performing primary metabolic/bariatric surgery should be obligated to provide revisional metabolic/bariatric surgery. In my opinion, it should be mandatory for a major academic teaching institution offering a metabolic/bariatric fellowship to be a resource for revisional surgery. In addition, such an institution is ethically responsible for conducting clinical outcomes trials of revisional procedures to evaluate the relative benefits of these procedures. 5. Any teaching program certified as a Center of Excellence by the ASMBS/American College of Surgeons, or other similar national body, cannot abrogate its responsibility to perform and support metabolic/bariatric revisional surgery. I, therefore, believe that denying or severely limiting revisional metabolic/bariatric surgery is a denial of the precepts of our discipline and an abandonment of the underprivileged population who has placed its trust and future in our hands. Revisional metabolic/bariatric surgery is a moral obligation. Henry Buchwald, M.D., Ph.D. Past-President, American Society for Metabolic and Bariatric Surgery Past-President, International Federation for the Surgery of Obesity and Metabolic Disorders
Professor of Surgery and Biomedical Engineering, University of Minnesota, Minneapolis Minnesota References [1] Brethauer SA, Kothari S, Sudan R, et al. Systematic review on reoperative bariatric surgery, American Society for Metabolic and Bariatric Surgery Revision Task Force. Surg Obes Relat Dis. Epub 2014 Feb 22. [2] Shimizu H, Annaberdyev S, Motamarry I, Kroh M, Schauer PR, Brethauer SA. Revisional bariatric surgery for unsuccessful weight loss and complications. Obes Surg 2013;23:1766–73. [3] Hallowell PT, Stellato TA, Yao DA, Robinson A, Schuster MM, Graf KN. Should bariatric revisional surgery be avoided secondary to increased morbidity and mortality? Am J Surg 2009;197:391–6. [4] Himpens J, Coromina L, Verbrugghe A, Cadiere GB. Outcomes of revisional procedures for insufficient weight loss or weight regain after Roux-en-Y gastric bypass. Obes Surg 2012;22:1746–54. [5] Keshishian A, Zahriya K, Hartoonian T, Ayagian C. Duodenal switch is a safe operation for patients who have failed other bariatric operations. Obes Surg 2004;14:1187–92. [6] Rawlins ML, Teel D, Hedgcorth K, Maguire JP. Revision of Rouxen-Y gastric bypass to distal bypass for failed weight loss. Surg Obes Relat Dis 2011;7:45–9. [7] Srikanth MS, Oh KH, Fox SR. Revision to malabsorptive Roux-en-Y gastric bypass (MRNYGBP) provides long-term (10 years) durable weight loss in patients with failed anatomically intact gastric restrictive operations: long-term effectiveness of a malabsorptive Roux-en-Y gastric bypass in salvaging patients with poor weight loss or complications following gastroplasty and adjustable gastric bands. Obes Surg 2011;21:825–31. [8] Khoursheed M, Al-Bader I, Mouzannar A, et al. Sleeve gastrectomy or gastric bypass as revisional bariatric procedures: retrospective evaluation of outcomes. Surg Endosc 2013;27:4277–83. [9] Steffen R, Potoczna N, Bieri N, Horber FF. Successful multiintervention treatment of severe obesity: a 7-year prospective study with 96% follow-up. Obes Surg 2009;19:3–12. [10] Morales MP, Wheeler AA, Ramaswamy A, Scott JS, de la Torre RA. Laparoscopic revisional surgery after Roux-en-Y gastric bypass and sleeve gastrectomy. Surg Obes Relat Dis 2010;6:485–90. [11] Gonzalez R, Gallagher SF, Haines K, Murr MM. Operative technique for converting a failed vertical banded gastroplasty to Roux-en-Y gastric bypass. J Am Coll Surg 2005;201:366–74. [12] Schouten R, Wiryasaputra DC, van Dielen FM, van Gemert WG, Greve JW. Influence of reoperations on long-term quality of life after restrictive procedures: a prospective study. Obes Surg 2011;21:871–9. [13] Gagne DJ, Dovec E, Urbandt JE. Laparoscopic revision of vertical banded gastroplasty to Roux-en-Y gastric bypass: outcomes of 105 patients. Surg Obes Relat Dis 2011;7:493–9. [14] Suter M, Ralea S, Millo P, Alle JL. Laparoscopic Roux-en-Y gastric bypass after failed vertical banded gastroplasty: a multicenter experience with 203 patients. Obes Surg 2012;22:1554–61. [15] Schouten R, van Dielen FM, van Gemert WG, Greve JW. Conversion of vertical banded gastroplasty to Roux-en-Y gastric bypass results in restoration of the positive effect on weight loss and co-morbidities: evaluation of 101 patients. Obes Surg 2007;17:622–30. [16] Cordera F, Mai JL, Thompson GB, Sarr MG. Unsatisfactory weight loss after vertical banded gastroplasty: is conversion to Roux-en-Y gastric bypass successful? Surgery 2004;136:731–7. [17] Patel S, Szomstein S, Rosenthal RJ. Reasons and outcomes of reoperative bariatric surgery for failed and complicated procedures (excluding adjustable gastric banding). Obes Surg 2011;21:1209–19.
Editorial / Surgery for Obesity and Related Diseases ] (2014) 00–00 [18] Westling A, Ohrvall M, Gustavsson S. Roux-en-Y gastric bypass after previous unsuccessful gastric restrictive surgery. J Gastrointest Surg 2002;6:206–11. [19] Vasas P, Dillemans B, Van Cauwenberge S, De Visschere M, Vercauteren C. Short-and long-term outcomes of vertical banded gastroplasty converted to Roux-en-Y gastric bypass. Obes Surg 2013;23:241–8. [20] Greenbaum DF, Wasser SH, Riley T, Juengert T, Hubler J, Angel K. Duodenal switch with omentopexy and feeding jejunostomy—a safe and effective revisional operation for failed previous weight loss surgery. Surg Obes Relat Dis 2011;7:213–8. [21] Menon T, Quaddus S, Cohen L. Revision of failed vertical banded gastroplasty to non-resectional Scopinaro biliopancreatic diversion: early experience. Obes Surg 2006;16:1420–4. [22] Jain-Spangler K, Portenier D, Torquati A, Sudan R. Conversion of vertical banded gastroplasty to stand-alone sleeve gastrectomy or biliopancreatic diversion with duodenal switch. J Gastrointest Surg 2013;17:805–8.
3
[23] Parikh M, Pomp A, Gagner M. Laparoscopic conversion of failed gastric bypass to duodenal switch: technical considerations and preliminary outcomes. Surg Obes Relat Dis 2007;3:611–8. [24] Vassallo C, Andreoli M, La Manna A, Turpini C. 60 reoperations on 890 patients after gastric restrictive surgery. Obes Surg 2001;11:752–6. [25] Chousleb E, Patel S, Szomstein S, Rosenthal R. Reasons and operative outcomes after reversal of gastric bypass and jejunoileal bypass. Obes Surg 2012;22:1611–6. [26] American Medical Association. Report 4 of the Council on Scientific Affairs (A-05). Recommendations for Physician and Community Collaboration on the Management of Obesity (Resolution 420, A-13), 2013. Available from: http://media.npr.org/documents/2013/ jun/ama-resolution-obesity.pdf. [27] Mechanick JI, Garber AJ, Handelsman Y, Garvey WT. American Association of Clinical Endocrinologists’ position statement on obesity and obesity medicine. Endocr Pract 2012;18(5):642–8. [28] World Health Organization. Health topics: Obesity [cited 2014 Sept 3]. Available from: http://www.who.int/topics/obesity/en/.
