OBES SURG DOI 10.1007/s11695-014-1458-9
OTHER
Revisional Metabolic/Bariatric Surgery: a Moral Obligation Henry Buchwald
# Springer Science+Business Media New York 2014
Abstract Revisional metabolic/bariatric surgery is a moral obligation; for not to perform revisional 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. Keywords Revisional metabolic/bariatric surgery . Bariatric surgery Today, there is a covert assault in the US healthcare 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 payers, insurance providers, hospital and practice administrators, and some of our own metabolic/ bariatric surgical colleagues. The argument offered by this segment of the provider community is 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 to primary surgery and may be less successful than primary surgery, and, above all, that it may be financially disadvantageous. This negative response to revisional bariatric surgery is manifested 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 Dr. Buchwald was Past-President, American Society for Metabolic and Bariatric Surgery; and Past-President, International Federation for the Surgery of Obesity and Metabolic Disorders. H. Buchwald (*) Departments of Surgery and Biomedical Engineering, University of Minnesota, 420 Delaware Street SE, MMC 290, Minneapolis, MN 55455, USA e-mail: [email protected]
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 longterm 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
OBES SURG
Surgery (ASMBS) presented a paper reviewing 451,485 bariatric surgery operations, of which 6.3 % was re-operations, demonstrating that the adverse events rates for primary and revisional surgery are essentially identical. In addition, the resolution of comorbidities after reoperations is also essentially identical to the resolution rate following 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 five fundamental principles: 1. We have fought an overwhelming prejudice for over 50 years to have obesity be 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 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 anastomic recurrence of a carcinoma of the colon after a subtotal colectomy, without major or limited metastatic disease, is offered a re-excision. Further, 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 is 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 outcome trials of revisional procedures in order 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. Conflict of Interest The author has no conflict of interest.
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, 2014, in press, http://dx.doi.org/10.1016/j.soard.2014.02.014 2. Shimizu H, Annaberdyev S, Motamarry I, et al. Revisional bariatric surgery for unsuccessful weight loss and complications. Obes Surg. 2013;23:1766–73. 3. Hallowell PT, Stellato TA, Yao DA, et al. 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, et al. Outcomes of revisional procedures for insufficient weight loss or weight regain after Rouxen-Y gastric bypass. Obes Surg. 2012;22:1746–54. 5. Keshishian A, Zahriya K, Hartoonian T, et al. 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, et al. Revision of Roux-en-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-enY 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.
OBES SURG 9. Steffen R, Potoczna N, Bieri N, et al. Successful multi- intervention 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, et al. 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, et al. 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, et al. 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, et al. 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, et al. 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, et al. 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. 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, et al. Short- and longterm outcomes of vertical banded gastroplasty converted to Roux-enY gastric bypass. Obes Surg. 2013;23:241–8. 20. Greenbaum DF, Wasser SH, Riley T, et al. 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, et al. Conversion of vertical banded gastroplasty to stand-alone sleeve gastrectomy or biliopancreatic diversion with duodenal switch. J Gastrointest Surg. 2013;17:805–8. 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, et al. 60 reoperations on 890 patients after gastric restrictive surgery. Obes Surg. 2001;11:752–6. 25. Chousleb E, Patel S, Szomstein S, et al. 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(No. 5). 28. World Health Organization. Health topics: obesity. Accessed on 9/3/ 14 at http://www.who.int/topics/obesity/en/
OTHER
Revisional Metabolic/Bariatric Surgery: a Moral Obligation Henry Buchwald
# Springer Science+Business Media New York 2014
Abstract Revisional metabolic/bariatric surgery is a moral obligation; for not to perform revisional 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. Keywords Revisional metabolic/bariatric surgery . Bariatric surgery Today, there is a covert assault in the US healthcare 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 payers, insurance providers, hospital and practice administrators, and some of our own metabolic/ bariatric surgical colleagues. The argument offered by this segment of the provider community is 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 to primary surgery and may be less successful than primary surgery, and, above all, that it may be financially disadvantageous. This negative response to revisional bariatric surgery is manifested 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 Dr. Buchwald was Past-President, American Society for Metabolic and Bariatric Surgery; and Past-President, International Federation for the Surgery of Obesity and Metabolic Disorders. H. Buchwald (*) Departments of Surgery and Biomedical Engineering, University of Minnesota, 420 Delaware Street SE, MMC 290, Minneapolis, MN 55455, USA e-mail: [email protected]
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 longterm 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
OBES SURG
Surgery (ASMBS) presented a paper reviewing 451,485 bariatric surgery operations, of which 6.3 % was re-operations, demonstrating that the adverse events rates for primary and revisional surgery are essentially identical. In addition, the resolution of comorbidities after reoperations is also essentially identical to the resolution rate following 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 five fundamental principles: 1. We have fought an overwhelming prejudice for over 50 years to have obesity be 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 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 anastomic recurrence of a carcinoma of the colon after a subtotal colectomy, without major or limited metastatic disease, is offered a re-excision. Further, 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 is 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 outcome trials of revisional procedures in order 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. Conflict of Interest The author has no conflict of interest.
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, 2014, in press, http://dx.doi.org/10.1016/j.soard.2014.02.014 2. Shimizu H, Annaberdyev S, Motamarry I, et al. Revisional bariatric surgery for unsuccessful weight loss and complications. Obes Surg. 2013;23:1766–73. 3. Hallowell PT, Stellato TA, Yao DA, et al. 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, et al. Outcomes of revisional procedures for insufficient weight loss or weight regain after Rouxen-Y gastric bypass. Obes Surg. 2012;22:1746–54. 5. Keshishian A, Zahriya K, Hartoonian T, et al. 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, et al. Revision of Roux-en-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-enY 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.
OBES SURG 9. Steffen R, Potoczna N, Bieri N, et al. Successful multi- intervention 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, et al. 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, et al. 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, et al. 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, et al. 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, et al. 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, et al. 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. 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, et al. Short- and longterm outcomes of vertical banded gastroplasty converted to Roux-enY gastric bypass. Obes Surg. 2013;23:241–8. 20. Greenbaum DF, Wasser SH, Riley T, et al. 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, et al. Conversion of vertical banded gastroplasty to stand-alone sleeve gastrectomy or biliopancreatic diversion with duodenal switch. J Gastrointest Surg. 2013;17:805–8. 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, et al. 60 reoperations on 890 patients after gastric restrictive surgery. Obes Surg. 2001;11:752–6. 25. Chousleb E, Patel S, Szomstein S, et al. 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(No. 5). 28. World Health Organization. Health topics: obesity. Accessed on 9/3/ 14 at http://www.who.int/topics/obesity/en/
