1. 67C.C. Thompson (ed.), Bariatric Endoscopy, DOI 10.1007/978-1-4419-1710-2_6,
© Springer Science+Business Media New York 2013
Introduction
The most important thing to understand in the
postoperative management of the bariatric patient
is the progression of milestones. Bariatric surgery
is a controlled abnormality, so it is to be expected
that patients will experience eating differently.
However, it is essential that patients be monitored
to 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 of
postoperative difficulties. Many of these patients
are young and thus have a functional reserve; as a
result, when a disaster strikes, they may initially
compensate well enough to mask many of the
symptoms. Providers must have a low threshold
for augmenting their patient’s nutrition, even if
parenteral nutrition must be started. The overall
goal in the short term should not be massive
weight loss but a controlled amount of weight
loss 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 postoperative
issues. The purpose of this chapter will be to
highlight key issues in postoperative management
of the various procedures and touch briefly on
what complications should be considered during
this period.
Bariatric surgery may be categorized into
procedures that involve only the stomach vs.
procedures that manipulate both stomach and
intestine. The former includes laparoscopic
adjustable gastric banding and sleeve gastrec-
tomy as well as the emerging plication of the
greater curvature. The second category includes
gastric bypass and the duodenal switch.
Postoperative care is similar within these cate-
gories, with some notable exceptions, and this
will provide the structure for this chapter. The
essential caveat in the postoperative care of all
bariatric patients is the need to maintain ade-
quate nutrition. It is a misnomer to believe that
obese patients have a greater degree of reserve
because of their size. The definition of obesity is
excess adiposity; it does not mean they have
excess lean muscle mass or micronutrients and
obese patients at baseline will often be deficient
in one or both of these. The amount of weight
loss after bariatric surgery that is optimal or even
adequate has not yet been defined or universally
accepted [2]. There are patients that lose a
significant amount of weight in the first month
following surgery; but much of this is usually
water due to improvement in the underlying
insulin resistance and the related diurese. The
critical thing is to provide adequate support,
assess clinical progression, and be vigilant for
potential 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, USA
e-mail: mroslin@lenoxhill.net
6Basic Postoperative Management
of the Bariatric Patient
Mitchell S. Roslin, Diana McPhee, and Sujit Kulkarni

2. 68 M.S. Roslin et al.
Gastric-Only Operations
Laparoscopic Adjustable Gastric
Banding
Laparoscopic adjustable gastric banding consists
of placing a silicone-based ring around the top
portion of the stomach (Fig. 6.1). On the inner
side of the silicone ring is a balloon, which is
connected by a catheter to a port placed subcuta-
neously in the abdominal wall. Accessing the
port with a needle allows fluid to be added to the
balloon, providing a greater level of restriction.
Advocates of the laparoscopic adjustable gastric
banding systems highlight the low initial surgical
complication rate and the initial successful weight
loss experienced by patients, with many patients
losing up to 60% of excess weight [3]. However,
there is a risk of band erosion and a high rate of
reoperation.
The band functions as a restrictor or high-
pressure zone that is placed distally to the GE
junction. When the procedure is successful, the
patient will be satisfied by eating a small portion
of food that will stay above the restrictor for
several hours and then pass through the diges-
tive circuit allowing the patient to be satisfied
with less food and achieve weight loss. In our
experience with laparoscopic adjustable gastric
banding, the patients that successfully lose
weight with the band are satisfied with smaller
portions after inflation of the band; however,
other patients remain unsatiated despite the
restriction and resort to maladaptive eating pat-
terns. Many caregivers ascribe such treatment
failures to noncompliance; however, some
patients may fail this therapy because of lack of
hunger suppression. To date, research has shown
no reduction in the hormone ghrelin, considered
the primary hormone involved in hunger, with
gastric banding [4].
During the early postoperative period after
the band is placed, it is usually not filled. Despite
this, many patients still experience early satiety
in the immediate postoperative period. This is
probably due to the inhibition of receptive
relaxation following eating. Patients are told to
adhere to a liquid or mush diet for their first 3
weeks following surgery. This diet allows the
band to scar into place, reducing the risk of
movement, slippage, or gastric prolapse. Rarely,
an acute slippage can be found. The hallmark of
an acute slippage is inability to tolerate liquids
and an abdominal film demonstrating change in
position from the 1 to 7 o’clock position nor-
mally seen following laparoscopic adjustable
banding to a 3–9 o’clock or horizontal position;
rarely, the band may rotate up to 180° [5]. In
over 1,000 adjustable bandings, we have only
seen one case of acute slippage. Following the
clear liquid phase of diet, patients are advanced
to solid food. We recommend that adjustable
band patients obtain a food scale and weigh
their food, with the ideal portion size being 4 oz
of solid food. If patients are not satiated with
4 oz of food after progressing to a diet of regu-
lar consistency, we will begin adding fluid to the
band. Generally, we fill the bands on a gradual
basis seeing the patients on at least a monthly
basis until they achieve restriction. Once a rea-
sonable amount of fluid is placed into the band,
an upper GI series is performed to make sure
that the anatomy correlates with the patient’s
symptoms. Alternatively, the balloon can be
filled under fluoroscopy.
Numerous filling schedules have been pro-
posed; most of these aim to modify the amount
of fluid in the band until the patients experience
satiety with small food portions. In our experi-
ence, the symptoms experienced by the patient
do not reliably correlate with the degree of filling
nor necessarily indicate pathology related to the
band. When patients have heart burn, regurgita-
tion, or inability to tolerate oral intake, abdomi-
nal films will often show that the band is too tight
and there is some dilation of the esophagus or the
concentric pouch. However, the absence of hun-
ger suppression and a satisfaction with a small
amount of food are not reliable indicators that
the band requires more fluid. It is therefore
essential in the postoperative management of
band patients to correlate X-ray imaging or
fluoroscopic imaging with the patient’s symp-
toms and not rely only on history to determine
adequate titration of the band.

3. 696 Basic Postoperative Management of the Bariatric Patient
While the advantage of laparoscopic adjustable
gastric banding is reduction in serious complica-
tions immediately following the surgery, there is
an increased risk of requiring revisional proce-
dures. The revisional surgical rate for laparo-
scopic adjustable gastric banding has been
estimated approximately 5% per year [3].
Complications necessitating revision include
issues 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 patients
will present for endoscopy or will be seen by
an endoscopist following LAP-BAND surgery
will be symptoms of reflux or regurgitation. In
the initial postoperative period, there is actu-
ally a reduction in GERD-type symptoms in
patients that receive laparoscopic adjustable
gastric banding. This is due to the fact that the
hiatus is probably repaired in many patients
during the surgery. The band itself can function
as a prosthesis preventing regurgitation; fur-
thermore, with weight loss, abdominal pres-
sure is reduced, lowering reflux. GERD-type
symptoms are very common in patients with
obesity because of the increased abdominal
pressure of the abdomen, and this actually
leads to reflux symptom, similar to what is seen
in pregnancy. Thus, the reappearance of reflux
symptoms after they have been alleviated by
weight loss usually indicates the presence of
acid producing cells above the band. Many
physicians prescribe proton pump inhibitors,
and we think that this is fine to reduce the
symptoms of esophagitis. However, the pri-
mary treatment for GERD symptoms following
laparoscopic adjustable gastric banding should
be relaxing of the band and making sure that
there is no evidence of gastric prolapse or
slippage [3].
Fig. 6.1 Laparoscopic adjustable gastric banding

4. 70 M.S. Roslin et al.
In the postoperative management of band
patients, it is essential to understand the physiol-
ogy of bands. The band creates a potential high-
pressure zone with the pressure increasing with
fills. The esophagus therefore must create higher
pressure during peristalsis to have food pass the
lower esophageal sphincter and then through the
band. The silicon is inelastic and will not stretch;
this can create a problem if the band is overfilled
or if the patient eats more than prescribed por-
tions. Patients who attempt to eat more than the
prescribed portions can cause emesis. Long term,
the patient’s pouch or even their esophagus can
dilate, causing regurgitation and reflux symp-
toms. Another possibility is the pressure causes
the band to move causing a prolapse or chronic
type of slippage. It is therefore essential to edu-
cate patients to monitor the amount of food that
they take by weighing their food. In addition, the
presence of new onset GERD, regurgitation, or
an increase in the ability to be able to tolerate
food as well as a decrease in the ability to tolerate
food should prompt radiological imaging. The
preferential exam is an upper GI series. Use of
endoscopy is required to determine the degree of
esophagitis. Only an endoscopist with consider-
able experience can ascertain the position of the
band.
Vertical Sleeve Gastrectomy
The vertical sleeve gastrectomy is an increasing
popular option for bariatric surgery. This opera-
tion involves resection of the greater curvature of
the stomach using staples that cut and divide
(Fig. 6.2). There are differing opinions regarding
where to begin the transaction, with most sur-
geons starting between 3 and 5 cm towards the
greater curvature [6]. It is performed over a bou-
gie, the size of which ranges from size 32 French
up to a size 60. It is essential to leave adequate
area round the angularis/incisura, and the purpose
of the operation is to resect the majority of the
fundus and greater curvature of the stomach, tab-
ularizing the stomach to look similar to a banana.
The advantage of this operation is that a small
amount of food will provide stretch and a feeling
of satiety. In addition to removing the most elastic
part of the stomach, resecting the fundus may
also beneficially alter the neurendocrine function
of the stomach by removing cells that produce
polypeptides such as ghrelin that are important
in hunger and satiety [7].
The key to the postoperative management of
vertical sleeve gastrectomy is understanding that
a gastric sleeve is a high-pressured system, in
contrast to a gastric bypass. This is due to the
preservation of the pyloric valve as well as the
long staple line and the tubular structure of the
sleeve. As a result, the high-pressured system
needs to be taken into account when and if there
are any complications. Postoperative dietary
instructions for patients undergoing vertical
sleeve gastrectomy include staying on a liquefied
or mush diet for the first several weeks following
surgery.
A dreaded complication following vertical
sleeve gastrectomy is a leak of the staple line.
These leaks commonly happen by the GE junc-
tion. There are many different theories as to
why this takes place, but the most prevailing
theory is that this is the area of greatest pressure
of the high staple line [8]. Others suggest that
this is the area of lowest blood flow [6]. We also
make 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 be
straight and not veer out towards the spleen
creating a narrowing distally and a wide fundus
on top. We believe such a preparation predis-
poses patients to potential leaks as well as the
development of reflux symptoms in the future.
If a leak does occur, the endoscopist will be
actively involved in the postoperative manage-
ment of the patient.
Should a leak occur, the first goal of therapy
is to control sepsis. This requires percutaneous
drainage or operative intervention. However,
there are many potential roles for endoscopy
in helping control the leak. Stents have been
used with varying degrees of success for the
management of postoperative sleeve leaks [9].
Frequently, they require insertion of more than
one covered stent potentially putting a stent
within a stent. The primary goal of placing a

5. 716 Basic Postoperative Management of the Bariatric Patient
stent is to alleviate any distal high-pressure zone
and allow enteric contents to drain distally.
Another potential benefit of placing a stent is to
cover the area of the leak allowing the patient to
have oral intake. It is also feasible to use Botox
as well in the pylorus, thereby facilitating drain-
age and allowing the stomach to heal.
Another postoperative difficulty seen in
patients after vertical sleeve gastrectomy is symp-
toms of gastric reflux. The causes of this are mul-
tifactorial, but ultimately the removal of the
fundus decreases the ability of the stomach to
accommodate a large bolus of food [10]. The
majority of patients that experience reflux will
find relief from their symptoms if they are strictly
compliant with the guidelines for portion sizes.
In patients that have intractable reflux, it is impor-
tant to obtain imaging studies to make sure there
is not a corkscrew or an obstruction of the sleeve.
A late presentation of reflux symptoms is often a
sign of dilation of the upper fundus.
After approximately 1 month of a mush diet,
diets are advanced to include solid food. Patients
should be reminded that the sleeve will stretch
and will double in size over the next several
years. The best way to avoid stretching of the
sleeve is to eat small portions that are regulated
and weighed rather than eat to the capacity of the
sleeve with each meal.
Micronutrient deficiencies seem to be less
common in patients after sleeve gastrectomy
when compared with gastric bypass. All patients
who have a sleeve gastrectomy will need to be
given vitamin B12 supplementation and a multi-
vitamin [11].
Gastric Plication
Suture plication of the greater curvature of the
stomach is an emerging operation. This is done
to imbricate the greater curvature of the stomach
Fig. 6.2 Sleeve gastrectomy

6. 72 M.S. Roslin et al.
(Fig. 6.3). The exact advantages of this operation
compared to sleeve gastrectomy have not yet
been defined, but the operation is theoretically
reversible and there is some thought that the risk
of leakage would be lower. The actual feasibility
of reversing this procedure has not been demon-
strated. Serosa-to-serosa application will create
dense adhesions making separation difficult.
Early reports of results from the Cleveland Clinic
as well as from abroad in Brazil and Iran have
documented excess weight loss of approximately
50% at 1 year from surgery; 3-year data is
becoming available [12]. At the present time,
this is an experimental procedure and the degree
and type of complications are unknown.
Furthermore, while numerous techniques have
been proposed, as of yet there is no consensus on
the most expedient approach. Early complica-
tions include nausea as well as pain from the
edema and venous congestion from the imbri-
cated greater plication. Long-term complications
have not been ascertained. In addition, it is not
clear how difficult it will be to perform revisional
operations.
Similar to other gastric-only operations, the
initial postoperative diet should include at least
a 3-week course of a liquid diet. In addition,
supplementation with a multivitamin is suggested.
Other medications should be crushed in the
early postoperative period of time. In addition,
the impact of the anatomy on sustained-released
drugs has not yet been determined. In operations
that require a gastrectomy such as the sleeve
gastrectomy, we suggest that sustained-released
and long-acting medications are changed to
their short-acting versions that have more pre-
dictable absorption.
Gastric Intestinal Operations
Gastric Bypass
Gastric bypass is the most common stapling
operation performed in the United States.
Advocates highlight 70% of excess weight loss
achieved at 1 year with excellent relief from
comorbidities [13]. Gastric bypass has been
championed as the gold standard operation by
many bariatric surgeons. The operation involves
creating a small pouch that excludes the fundus
based on the lesser curvature of the stomach with
gastrojejunostomy with bypass of various lengths
of intestine (Fig. 6.4).
Fig. 6.3 (a) Single plication of gastric greater curva-
ture—original technique. (b) Double plication of gastric
greater 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 of
135 patients 2011;21:1658, Figure 1)

7. 736 Basic Postoperative Management of the Bariatric Patient
The early postoperative dietary instructions
include a liquefied diet for several weeks.
Nutritional guidelines include supplementing the
diet with a multivitamin, calcium, vitamin B12,
and iron [14]. In addition, supplementation with
the fat-soluble vitamins such as A, D, E, and K
because of the intestinal bypass operation is
important.
Compared with vertical sleeve gastrectomy,
gastric bypass and the gastric jejunostomy create
a lower pressure system [15]. Gastric bypass pro-
vides excellent relief of GERD-type symptoms
by diverting both the biliary flow as well as the
acid-producing cells. Early complications from
gastric bypass include anastomotic leak, where
stenting may again be advocated to control the
source of sepsis. Because this is a low-pressure
system, anastomotic leaks in bypass patients
seem to be easier to control compared with leaks
from a vertical sleeve gastrectomy.
Other early complications that may come to
endoscopic evaluation include stricture of the
gastrojejunostomy and marginal ulceration [16].
Since the long-term efficacy of the operation
involves maintaining the restrictive anastomo-
sis, we currently do not suggest early dilatation
for any patients that can adequately handle clear
liquid fluids. The indication for endoscopy and
dilation is the inability to be able to drink
2 quarts of clear liquid or warm tea. The diagno-
sis of a marginal ulcer of the gastrojejunostomy
needs to be entertained in any gastric bypass
patient with new onset of nausea and vomiting,
whether in the early or late postoperative period.
Fig. 6.4 Roux-en-Y gastric bypass

8. 74 M.S. Roslin et al.
Any patient that presents with intolerance of
oral intake should undergo prompt imaging
studies to rule out any evidence of leak, perito-
nitis, and sepsis. Once that is ruled out, it is safe
to endoscope these patients shortly after surgery
looking for the presence of a marginal ulcer or
potential stricture. Practitioners should bear in
mind that morbidly obese patients often have
decreased nutritional reserves despite their
excess weight. Providers should therefore have
a low threshold for starting TPN in patients who
do not tolerate oral intake following gastric
bypass surgery.
Long-term health concerns in patients after
gastric bypass include a variety of micronutri-
ent deficiencies. Patients commonly have
decreased absorption of iron and calcium. The
first portion of the duodenum is very important
in the absorption of divalent cations. It is
important in supplementation to instruct
patients not to take their iron and calcium at the
same time. Furthermore, gastric bypass patients
who eat foods with a high glycemic index are
prone to developing hypoglycemia. Theore-
tically, the dumping syndrome experienced by
bypass patients after eating carbohydrate-rich
meals should deter them from eating inappro-
priate amounts of carbohydrates. Some patients
however become caught in a vicious cycle of
craving carbohydrates and then binging, result-
ing in further hypoglycemia. It is therefore our
practice to encourage these patients to eat small
meals frequently that are low on the glycemic
index.
One of the most serious complications fol-
lowing gastric bypass is internal hernia. If rec-
ognized and repaired promptly, patients recover
quickly and can often be sent home one day fol-
lowing surgery. Unfortunately, a missed internal
hernia can result in a midgut volvulus and a
short bowel syndrome. Providers must therefore
remain vigilant for this complication in the
postoperative period. Any gastric bypass patient
that has new onset pain, especially with obstruc-
tive-type symptoms, should immediately
undergo CT scan. If radiological studies cannot
rule out this complication, urgent laparoscopy is
indicated.
Sleeve Gastrectomy with Duodenal
Switch
The duodenal switch operation involves the
creation of sleeve gastrectomy followed by an
intestinal bypass (Fig. 6.5). Classically, the diam-
eter of the sleeve gastrectomy created for this
procedure was larger than the sleeve gastrectomy
performed without a bypass procedure. Our group
has suggested doing a smaller sleeve gastrectomy
as well as a non-malabsorptive intestinal bypass
with limb lengths preserving a minimum of
125 cm common channel and 150 cm alimentary
limb. With this type of operation, our group has
achieved excellent results with most patients hav-
ing bowel movements one to three times a day.
This is likely to be better tolerated than patients
who undergo a standard duodenal switch opera-
tion, which can cause significant malabsorptive
symptoms with patients typically moving their
bowels 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 improvement
in comorbidities with the exception of reflux, and
the lowest amount of recidivism. However, they
have the highest risk for micronutrient deficiency.
There are case reports of postoperative bariatric
patients with adequate caloric intake who have
nonetheless had severe micronutrient deficiencies
resulting in thiamine deficiency or Korsakoff
syndrome as early as 1–2 months following sur-
gery; these patients are at risk for irreversible
neurologic changes. As a result, it is important
that any patient who has a biliopancreatic diver-
sion such as a duodenal switch to be on several
multivitamins 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 two
times per year. It is much easier to supplement
than it is to replete patients that have developed
documented clinically significant deficiencies.
These points are essential for any bariatric patient
that has intestinal manipulation.
It is important in the postoperative manage-
ment for these patients to monitor their muscle
mass and make sure they do not have any sign of
hypoproteinemia or weakness [1]. The earliest

9. 756 Basic Postoperative Management of the Bariatric Patient
sign of malnutrition following any bariatric
procedure is a low BUN and low potassium. On
physical exam, the most sensitive sign of protein
malnutrition is difficulty getting from a sitting to
a standing position without using their arms; this
indicates weakness of the gluteus muscles. With
all gastrointestinal operations or any operation
with rapid weight loss, it is essential to reinforce
the importance of getting an adequate amount of
protein; the goal should be 1 g of protein per kg
of body weight.
Early complications after sleeve gastrectomy
with duodenal switch are similar to gastric
bypass, including intolerance of oral intake or
anastomotic leaks. Again, endoscopic stents and
control of sepsis are key in managing these
patients. A good understanding of the anatomy
is absolutely essential. Long-term issues with
duodenal switch include micronutrient and
vitamin deficiencies and risk of intestinal
obstructions similar to gastric bypass. Prompt
recognition of an intestinal obstruction and
possible internal hernia is essential to prevent
catastrophic outcome.
Conclusion
Maintenance of adequate caloric intake, progres-
sion of key milestones, and knowing what com-
plications to consider for each specific procedure
are critical in the postoperative management of
bariatric patients. The most important thing in the
assessment of a patient remains good common
sense and sound judgment in assessing the clini-
cal progression of the patient. A patient who
Fig. 6.5 Sleeve gastrectomy with duodenal switch

10. 76 M.S. Roslin et al.
seems to be struggling should be reevaluated,
including judicious use of imaging such as upper
endoscopy and CT scanning. Occasionally, a
functional cause for their failure to thrive will not
be found. In these particular cases, it is essential
to provide adequate alimentation and allow these
problems to work themselves out. Most impor-
tantly, time is an ally. With good support and
nutrition, these problems will be resolved.
Bariatric surgery is a great tool. It reduces car-
diac risk factors, can cause diabetes to go into
remission, 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 practitioners
involved in the care of bariatric patients under-
stand the various procedures completely as well
as monitor all patients closely in the postopera-
tive period to minimize side effects while con-
tinuing to offer good weight loss results.
References
1. 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. J
Assoc Acad Minor Phys. 2001;12:129–36.
3. Michalik M, Lech P, Bobowicz M, Orlowski M,
Lehmann A. A 5-year experience with laparoscopic
adjustable 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 gastric
band 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 gastric
banding: etiology and treatment. Surg Endosc. 2005;
19:262–7.
6. Mognol P, Chosidow D, Marmuse JP. Laparoscopic
sleeve gastrectomy (LSG): review of a new bariatric
procedure 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 and
hormonal 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 laparoscopic
bariatric procedures: multivariate analysis of factors
related 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 surgery
leaks: 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 importance
of laparoscopic sleeve gastrectomy for the lower
esophageal 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 important
after roux-en-Y gastric bypass? J Gastrointest Surg.
1998;2:436–42.
12. Skrekas G, Antiochos K, Stafyla VK. Laparoscopic
gastric greater curvature plication: results and
complications in a series of 135 patients. Obes Surg.
2011;21(11):1657–63.
13. Brolin RE. Laparoscopic verses open gastric bypass
to treat morbid obesity. Ann Surg. 2004;239(4):
438–40.
14. HatizifotisM,DolanK,NewburyL,etal.Symptomatic
vitamin 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. Am
J Surg. 2004;188:105–10.
16. Capella JF, Capella RF. Gastro-gastric fistulas and
marginal ulcers in gastric bypass procedures for
weight reduction. Obes Surg. 1999;9:22–7.