Endocrine and Nutritional Management of the Post-Bariatric Surgery Patient:An Endocrine Society Clinical Practice Guideline

T h e E n d o c r i n e S o c i e t y ’ s

CliniCal Guidelines

Authors: david Heber, Frank l. Greenway, lee M. Kaplan, edward livingston, Javier salvador, andChristopherstill

Co-Sponsoring Associations: american Gastroenterological association institute, and european society ofendocrinology

Affiliations: davidGeffenschoolofMedicineatuniversityofCalifornia(d.H.),losangeles,California90095;PenningtonBiomedicalResearchCenter(F.l.G.),louisianastateuniversitysystem,BatonRouge,louisiana;Massachusetts General Hospital (l.M.K.), Boston, Massachusetts; university of Texas southwestern MedicalCenter(e.l.),dallas,Texas;universityClinicofnavarra(J.s.),Pamplona,spain;andGeisingerMedicalCenter(C.s.),danville,Pennsylvania

Disclaimer: ClinicalPracticeGuidelinesaredevelopedtobeofassistancetoendocrinologistsandotherhealthcareprofessionalsbyprovidingguidanceand recommendations forparticularareasofpractice.TheGuidelinesshouldnotbeconsideredinclusiveofallproperapproachesormethods,orexclusiveofothers.TheGuidelinescannotguaranteeanyspecificoutcome,nordotheyestablishastandardofcare.TheGuidelinesarenotintendedtodictatethetreatmentofaparticularpatient.Treatmentdecisionsmustbemadebasedontheindependentjudg-mentofhealthcareprovidersandeachpatient’sindividualcircumstances.

Theendocrinesocietymakesnowarranty,expressorimplied,regardingtheGuidelinesandspecificallyexcludesanywarrantiesofmerchantabilityandfitnessforaparticularuseorpurpose.Thesocietyshallnotbeliablefordirect,indirect,special,incidental,orconsequentialdamagesrelatedtotheuseoftheinformationcontainedherein.

FirstpublishedinJournal of Clinical Endocrinology & Metabolism,november2010,95(11):4823–4843.

©Theendocrinesociety,2010

Endocrine and Nutritional Management of the Post-Bariatric Surgery Patient:An Endocrine Society Clinical Practice Guideline

T h e E n d o c r i n e S o c i e t y ’ s

CliniCal Guidelines

Table of Contents

abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

summaryofRecommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Methodsofdevelopmentofevidence-BasedRecommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

PreventionandTreatmentofWR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

PostoperativenutritionalManagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

ManagementofdiabetesMellitusandlipids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

BoneHealthandGout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

GastroenterologicalandeatingBehaviorConsiderations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

OrderForm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

Reprintinformation,Questions&Correspondences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . insideBackCover

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Abstract

Objective: We sought to provide guidelines for thenutritional and endocrine management of adultsafter bariatric surgery, including those with diabetesmellitus .Thefocusisontheimmediatepostoperativeperiodandlong-termmanagementtopreventcompli-cations, weight regain, and progression of obesity-associated comorbidities . The treatment of specificdisordersisonlysummarized .

Participants: The Task Force was composed of achair,fiveadditionalexperts,amethodologist,andamedical writer . it received no corporate funding orremuneration .

Consensus Process: Consensuswasguidedbysystem-aticreviewsofevidenceanddiscussions .Theguide-lineswerereviewedandapprovedsequentiallybyTheendocrine society’s Clinical Guidelines subcom-mitteeandClinicalaffairsCoreCommittee,membersresponding to a web posting, and The endocrinesocietyCouncil .ateachstage,theTaskForceincor-poratedchangesinresponsetowrittencomments .

Evidence: Thisevidence-basedguidelinewasdevel-opedusingtheGradingofRecommendations,assess-ment, development, and evaluation (GRade)systemtodescribe the strengthof recommendationsandthequalityofevidence .

Conclusions:Bariatric surgery isnot a guaranteeofsuccessfulweightlossandmaintenance .increasingly,patients regain weight, especially those undergoingrestrictive surgeries such as laparoscopic bandingratherthanmalabsorptivesurgeriessuchasRoux-en-Ybypass .activenutritionalpatienteducationandclin-ical management to prevent and detect nutritionaldeficienciesarerecommendedforallpatientsunder-going bariatric surgery . Management of potentialnutritional deficiencies is particularly important forpatients undergoing malabsorptive procedures, andstrategiesshouldbeemployedtocompensateforfoodintoleranceinpatientswhohavehadamalabsorptiveproceduretoreducetherisk forclinically importantnutritionaldeficiencies .Toenhancethetransitiontolifeafterbariatricsurgeryandtopreventweightregainand nutritional complications, all patients shouldreceivecarefromamultidisciplinaryteamincludinganexperiencedprimarycarephysician,endocrinolo-gist,orgastroenterologistandconsiderenrollingpost-operativelyinacomprehensiveprogramfornutritionand lifestyle management . Future research shouldaddress the effectiveness of intensive postoperativenutritionalandendocrinecareinreducingmorbidityandmortalityfromobesity-associatedchronicdiseases .

J Clin Endocrinol Metab, November 2010, 95 (11):4823–4843

Abbreviations:AGB, Adjustable gastric banding; BPD, biliopancreatic diversion; 1,25-D, 1,25-dihydroxyvitamin D; 25-D, 25-hydroxyvitamin D; DS, duodenal switch; GBS, gastric bypass surgery; GLP-1, glucagon-like peptide-1; GS, gastric sleeve; HbA1c, glycated hemoglobin; LAGB, laparoscopic AGB; LDL, low-density lipoprotein; NAFLD, nonalcoholic fatty liver disease; RYGB, Roux-en-Y gastric bypass; T2DM, type 2 diabetes mellitus; WR, weight regain.

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SuMMAry Of rECOMMENdATiONS

1.0. Prevention and treatment of weight regain (Wr)

1.1. We recommend that a technically proficientsurgical team, preferably accredited by a nationalcertifying organization and an integrated medicalsupportteamabletoprovidedietaryinstructionandbehavior modification be available postoperativelyandduringlong-termfollow-up(1| ) .

1.2. WerecommendthattreatmentofWRpostoper-ativelyshouldincludeamultidisciplinaryapproachtomedical weight loss, including diet instruction,increased activity, behavior modification, and phar-macologicaltherapy(1| ) .

1.3. We suggest, in cases of severe or unremittingpostoperative weight gain, the determination ofwhetherthesurgicalmanipulationofthegastrointes-tinaltractremainsanatomicallyintact[e.g. absenceofgastrogastric fistula after Roux-en-Y gastric bypass(RYGB), integrity of band after a restrictive proce-dure] . if not intact, a multidisciplinary team shouldconsider all options, including patient education,behavior modification, additional weight loss thera-pies, or referral for revisionary surgery as clinicallyindicated(2| ) .

2.0. Postoperative nutritional management

2.1. We recommend that nutritional managementshould include: an average of 60–120 g of proteindailyinallpatientstomaintainleanbodymassduringweight lossand for the long term .This is especiallyimportantinthosetreatedwithmalabsorptiveproce-dures topreventproteinmalnutritionand itseffects(1| ) .

2.2. We recommend that long-term vitamin andmineralsupplementationbeconsideredinallpatientsundergoingbariatricsurgery,withthosewhohavehadmalabsorptiveprocedures requiringpotentiallymoreextensivereplacementtherapytopreventnutritionaldeficiencies(1| ) .

2.3. Werecommendperiodicclinicalandbiochemicalmonitoring (see Table 2) for micro- and macronutri-tionaldeficienciesafterbariatricsurgery(1| ) .

3.0. Management of diabetes mellitus and lipids

3.1. We recommend that postoperative glycemiccontrol should consist of achieving glycated hemo-globin (Hba1c) of 7% or less, with fasting bloodglucose no greater than 110 mg/dl and postprandialglucosenogreaterthan180mg/dl(1| ) .

3.2. Wesuggest thatphysicians andfloornursesbefamiliarwithglycemictargetsandinsulinprotocols,aswellastheuseofdextrose-freeivfluidsandlow-sugarliquidsupplements(2| ) .

3.3. Werecommendthatobesepatientswithtype1diabetes receive scheduled insulin therapy duringtheirhospitalstay,asrequired(1| ) .

3.4. Werecommendthatlipidabnormalitiesshouldbe treated according to the national CholesteroleducationProgram(nCeP)guidelines[adultTreat-ment Panel iii (aTP iii)] and that existing lipid-lowering therapy for low-density lipoprotein (ldl)-cholesterolandtriglyceridevaluesshouldbecontinuedafter surgery if levels remain above desired goals(1| ) .

4.0. Bone health and gout

4.1. Werecommendthatpatientswhohaveunder-gone malabsorptive [i.e. RYGB, gastric sleeve (Gs),biliopancreatic diversion (BPd)] obesity surgicalprocedures should have vitamin d, calcium, phos-phorus,PTH,andalkalinephosphataselevelsfollowedevery6monthsandhaveadual-energyx-rayabsorp-tiometryforbonedensityperformedyearlyuntilstable(1| ) .

4.2. Werecommendvitamindandcalciumsupple-mentation postoperatively for malabsorptive obesitysurgicalproceduresandthatthedosesareadjustedbya qualified medical professional based on serummarkersandmeasuresofbonedensity(1| ) .

4.3. Wesuggestthatpatientswithfrequentattacksofgout shouldhaveprophylactic therapy to lessen thechance of acute gout postoperatively as they loseweight(2| ) .

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5.0. Gastroenterologicalandeatingbehaviorconsiderations

5.1. We recommend that bariatric surgery patients should sip fluids in the immediate postoperative period when fully awake after surgery and that they can only be discharged if satisfactorily tolerating oral fluids (1| ).

5.2.Particularly after procedures with a gastric restric-tive component, we recommend that gradual progres-sion of food consistency over weeks to months be used to allow patients to adjust to a restrictive meal plan and to minimize vomiting, which can damage surgical anastamoses or lead to gastroesophageal reflux after restrictive procedures (1| ).

5.3. We suggest continuous reinforcement of new nutritional habits that discourage the intake of simple carbohydrate-dense foods and beverages, to minimize the frequency of bothersome gastrointestinal symp-toms due to dumping, including abdominal pain and cramping, nausea, diarrhea, lightheadedness, flushing, tachycardia, and syncope (2| ).

5.4.We suggest that patients, who present with post-prandial symptoms of hypoglycemia, particularly neuroglycopenic symptoms, should undergo further evaluation for the possibility of insulin-mediated hypoglycemia (2| ).

MethodofdevelopMentofevidence-BasedRecoMMendations

The Clinical Guidelines Subcommittee of The Endo-crine Society deemed endocrine and nutritional management of the post-bariatric surgery patient a priority area in need of practice guidelines and appointed a Task Force to formulate evidence-based recommendations. The Task Force followed the approach recommended by the Grading of Recom-mendations, Assessment, Development, and Evalua-tion group, an international group with expertise in development and implementation of evidence-based guidelines. The Task Force used the best available

research evidence that members identified to inform the recommendations and consistent language and graphical descriptions of both the strength of a recom-mendation and the quality of evidence. To indicate the strength of the recommendation, strong recom-mendations use the phrase “we recommend” and the number 1, and weak recommendations use the phrase “we suggest” and the number 2. Cross-filled circles represent the quality of the evidence, such that

denotes very low quality evidence; , low quality; , moderate quality; and , high quality. The Task Force has confidence that patients who receive care according to the strong recommendations will derive, on average, more good than harm. Weak recommendations require more careful consideration of the patient’s circumstances, values, and preferences to determine the best course of action.

Linked to each recommendation is a description of the evidence, the values that panelists considered in making the recommendation (when making these explicit was necessary), and remarks, a section in which panel-ists offer technical suggestions for testing conditions, dosing, and monitoring. These technical comments reflect the best available evidence applied to a typical patient. Often, this evidence comes from the unsys-tematic observations of the panelists and should, therefore, be considered suggestions.

intRoduction

The incidence of severe obesity has increased more rapidly than the incidence of non-severe obesity. Between 1999 and 2004, obesity increased by 24% in the United States, whereas the incidence of severe obesity is rising even more rapidly (1). Bariatric surgery has gained wide acceptance as a treatment for severe obesity, especially when complicated by type 2 diabetes mellitus (T2DM). An estimated 200,000 operations were performed in 2009 alone at a cost of about $5 billion. After surgery, patients are cared for by their primary care physicians, endocrinologists, or gastroenterologists. Frequently, these patients present

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alsoaidinthepreventionofWRbykeepingpatientsfocusedonlifestyleissuesoverthelongterm,butthishasnotbeendemonstratedinclinicaltrials .inaddi-tion, the facility where the surgeon practices musthaveexperiencewithbariatricpatientsanda famil-iaritywithroutinepostoperativecare .

Physicians referring patients to bariatric surgeryshould request specific experience and performancedatafromthebariatricsurgeonorprogramregardingthe procedure being considered . Various resourcesareavailabletolocateasuitablebariatricsurgeononthe internet or by contacting the surgical ReviewCorporation, american society for Metabolic andBariatricsurgery,americanCollegeofsurgeons,orthe Obesity society . These resources should be astartingpointforfindingsurgeonstoworkinacollab-orativefashionwithendocrinologists,gastroenterolo-gists, and primary care physicians interested in thepostoperativecareofpatientsafterbariatricsurgery .

1.0. PrEvENTiON ANd TrEATMENT Of Wr

Recommendations

1.1. We recommend that a technically proficientsurgical team, preferably accredited by a nationalcertifying organization, and an integrated medicalsupportteamabletoprovidedietaryinstructionandbehavior modification be available postoperativelyandduringlong-termfollow-up(1| ) .

withassociatedcomorbidities,includingT2dM,poly-cystic ovarian disease, metabolic bone disease, lipidabnormalities, fatty liver, degenerative jointdisease,hypertension, gastroesophageal reflux disease, andobstructivesleepapnea .

Bariatric surgery is not a guarantee of success, andpatients require postoperative care . To reduce thelikelihoodofweightregain(WR)andtoensurethatcomorbid conditions are adequately managed, allpatients should receive careful medical follow-uppostoperatively .Toguidepatientsthroughthetransi-tiontolifeafterbariatricsurgery,amultidisciplinaryteamthatincludesanexperiencedprimarycarephysi-cian, endocrinologist, or gastroenterologist shouldprovidecare, andpatients shouldconsider enrollingpostoperativelyinacomprehensiveprogramfornutri-tionandlifestylemanagement .suchsupportcaneasethe transition to life after bariatric surgery andmayhelppreventWR .

Commonoperations includevariousbandingproce-dures,whichrestricttheamountoffoodenteringthestomach, theRYGB, theduodenal switch(ds)/Gs,ortheBPd(Fig .1) .Themodificationsofgastrointes-tinal function after these surgeries are least withbanding,greaterwithRYGB,andgreatestwithBPdords/Gs .asthephysiologicalalterationsofgastro-intestinal function increase, there is an impressionthatlessmedical,dietary,andbehavioralinterventionisneededtoinduceweightloss .Purerestrictiveopera-tions such as adjustable gastric banding are morecommonlyassociatedwithWRandweightlossfailurethan techniques with a malabsorptive componentsuchasRYGB .However,theuseofroutinealgorithmsinpostoperativecareisessentialtoreducetheriskofWRandpostoperativecomplications .

Postoperative management of the bariatric surgerypatient begins by having the proper team in placebefore the operation is performed . To enhance thelikelihoodoflong-termsuccess,thebariatricsurgeonshouldbepartofacomprehensiveteamthatprovidespre-and postoperative care . Patient support groupshavetheadditionaladvantageofmaintainingcontactbetween the patients and their primary care physi-cians, endocrinologists, or gastroenterologists whoprovidecare formedicalneeds .support groupsmay

FIG. 1. Diagram of surgical options. [Adapted with permis-sion from W. J. Pories: J Clin Endocrinol Metab 93:S89–S96, 2008 (248). © The Endocrine Society.]

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with the preoperative period (3, 10) . some studieshave suggested an influence of genetic factors (11,12) .althoughithasbeensuggestedthatgastrointes-tinal hormones such as ghrelin, glucagon-likepeptide-1 (GlP-1), and peptide YY 3-36 may beinvolvedinpostoperativeweighthomeostasis(13–15)due to observed decreases in ghrelin concentrationsandincreases inGlP-1andpeptideYYafterRYGBandBPd,other studies donot confirma clear rela-tionship between these changes, appetite/satietyscores, and weight reduction (16) . a reduction inleptinandinsulinserumconcentrationsmayalsoplaya role(17) .Weight loss isalwaysaccompaniedbyareduction in resting energy expenditure, but thisdecreaseisproportionaltothelossofleanbodymass,and therefore, there is no evidence of adaptivedecreasesinrestingmetabolicrateduetosurgerythatcould explain WR (17, 18) . Mechanical problemssuchasband slippageorpouchand stomaldilation,especially in restrictive operations such as verticalbanded gastroplasty, gastric banding, sleeve gastrec-tomy, and RYGB could potentially impair gastricneuralsignalsdrivingsatietysensationstothecentralnervous system, favoring increased food intake andWR . no conclusive evidence that WR is due tosurgical factors has been found (19, 20) . adaptiveintestinal mechanisms leading to changes in theabsorptivecapacityofthesmallbowelcanalsoinflu-enceWR(21,22) .ingeneral,purerestrictiveopera-tions are more commonly associated with WR andweight loss failure than other techniques with amalabsorptivecomponent(4,23,24) .arecentmeta-analysis of 14 studies (25) found that excess bodyweight loss at 1 yr was 76% after RYGB comparedwith 50% after laparoscopic adjustable banding and

1.2. WerecommendthattreatmentofWRpostoper-ativelyshouldincludeamultidisciplinaryapproachtomedical weight loss, including diet instruction,increased activity, behavior modification, and phar-macologicaltherapy(1| ) .

1.3. Wesuggestincasesofsevereorunremittingpost-operativeweightgain thedeterminationofwhetherthesurgicalmanipulationofthegastrointestinaltractremains anatomically intact (e.g. absence of gastro-gastricfistulaafterRYGBandintegrityofbandaftera restrictive procedure) . if not intact, a multidisci-plinary team should consider all options, includingpatienteducation,behaviormodification,additionalweightlosstherapies,orreferralforrevisionarysurgeryasclinicallyindicated(2| ) .

1.1.–1.3. Evidence

WRisnotuncommoninpatientsundergoingbariatricsurgery, and it canbe expected that 20–25%of thelostweightwillberegainedoveraperiodof10yr .TheimpactofthisWRoncomorbidconditionsisdepen-denton individual risk factors .Thevastmajorityoflong-term studies after either pure restrictive ormixed techniques show WR (2–5), which in somecasesmay leadtoapercentageofexcessweight losslowerthan50%(5–7) .althoughWRprevalencehasbeenreportedin7–50%ofcases(7,8),thisclassifica-tionasWRisbasedonanarbitraryamountofWR(50%ofthelostweight) .Ontheotherhand,lossofpatientstofollow-upatlatestagesmayunderestimatethetrueprevalenceofWR .significantWRisaccom-paniedbyreversalorreductionofsurgicallyimprovedobesity comorbidities, including common medicalconditionsandpsychosocialfunctioning,whichmayleadtoadecreaseinqualityoflife(3,9) .

Causes of WR

WR is most commonly related to noncompliancewithdietaryandlifestyleinstructions,althoughdiffer-ences in physiological responses and occasionallysurgical failure can be the cause (Table 1) . Foodrecords show that calorie intake is reduced afterbariatricsurgery,butincreasesat1–2yraftersurgerycoincide with WR (3) . in general, patients reportgreaterphysicalactivityoverthelongtermcompared

TABLE 1. Causes and prevention of Wr

Causes

Noncompliance with dietary and lifestyle recommendations

Physiological factors (variations in response to surgery)

Surgical failure

Prevention

Optimizing patient selection criteria

realistic preoperative expectations

Consideration of benefits of bypass vs. restrictive procedures

Adherence to scheduled visits

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Assumed values and preferences

Ourrecommendationplacesahighvalueonpotentialbenefits derived from maintenance of weight reduc-tion to control obesity-associated comorbidities andto improve psychological function, general health,andqualityoflife .

2.0. POSTOPErATivE NuTriTiONAl MANAGEMENT

Recommendations

2.1. We recommend that nutritional managementshouldincludeanaverageof60–120gofproteindailyin all patients to maintain lean body mass duringweight lossand for the long term .This is especiallyimportantinthosetreatedwithmalabsorptiveproce-dures topreventproteinmalnutritionand itseffects(1| ) .

2.2. We recommend that long-term vitamin andmineralsupplementationbeconsideredinallpatientsundergoingbariatricsurgery,withthosewhohavehadmalabsorptiveprocedures requiringpotentiallymoreextensivereplacementtherapytopreventnutritionaldeficiencies(1| ) .

2.3. Werecommendperiodicclinicalandbiochem-icalmonitoring(Table2)formicro-andmacronutri-tionaldeficienciesafterbariatricsurgery(1| ) .

2.1.–2.3. Evidence

Protein intake

Protein malnutrition, defined by hypoalbuminemia(albumin<3 .5mg/dl),remainsthemostseveremacro-nutrientcomplicationassociatedwithmalabsorptivesurgicalprocedures .somestudieshavereporteditin13%ofsuperobesepatients2yrafteradistalRYGBwith Rouxlimb at least 150 cm, less than 5% ofpatientswithaRouxlimblessthan150cm(38,39),and 3–18% of patients after BPd (40–45) . Other

that long-term reoperation rates were lower afterRYGB(16vs.24%) .Psychologicalfactorsandeatingdisorders can also promote WR, especially whendevelopedinthepostsurgicalperiod(26) .althoughindividualsdifferintheirresponsetosurgery,postsur-gery adherence to scheduled visits and compliance,morethanpersonalitydisorders,wasfoundtopredictoutcome of bariatric restrictive surgery in severelyobesepatients(27) .

Prevention and treatment of WR

PreventionofWRisessentialtomaintainthebenefitsofbariatricsurgeryona long-termbasis .Keyfactorsarepreoperative realisticexpectations, adherence toscheduled visits (27), compliance with nutritionalrecommendations, maintenance of regular physicalactivity of at least 150 min/wk (28), and periodicassessmenttopreventortreateatingorotherpsychi-atric disorders (27, 29) . in general, bariatric surgeryhas a favorable impact on psychological condition(30,31),althoughsomeimprovementsmaydisappearovertime .Fromthenutritionalpointofview,alowglycemicload,moderatelyhighproteincontentdiet,combinedwithaphysicalactivityprogramhasbeenshowntoeffectivelytreatWRintheshortterm(32) .Promotingadherencetodietandlifestylerecommen-dations by collecting food records and monitoringbodyweight carefully is alsouseful .Participation insupportgroupscouldalsobehelpfulinthepreventionandtreatmentofWR(33,34) .

Because patients with a mechanically intact malab-sorptiveoperationwhohaveexperiencedWRarenotlikely to achieve sustained weight loss after pouchrevision, revisional surgery is inadvisable for them(35) .WhenWRissevereandunremitting,consider-ation shouldbegivento revisionalbariatric surgery,and this should be discussed with a surgeon experi-encedinrevisionalsurgery . insomecases,RYGBords(36,37)canbeindicatedafterfailureofapreviousrestrictive operation . nevertheless, application ofconventionalstrategiesandtheriskofseriouspostop-erative complications must be carefully evaluatedbeforemakingthisdecision(36) .

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proteinneedsareconstantacrossallenergy intakes .soatlowenergyintake,proteinneedstobeahigherpercentageoftotalcalories,andathighenergyintake,proteincanbereducedasapercentageoftotalcalo-ries .ingeneral,dietaryproteinshouldbeestablishedfirst in any diet in proportion to body weight, andthencarbohydratesandfatsshouldbeaddedasdeter-minedbyenergyneeds .Proteinisanimportantpartofgoodnutritionateverymeal .Vitaminsandmineralscanfulfillnutrientneedsonaonce-per-daybasis,butfor protein, the body has no ability to store a dailysupply . To maintain healthy muscles and bones foradults,atleast30gofproteinshouldbeconsumedatmorethanonemeal .Breakfastisanimportantmealfordietaryproteinbecausethebodyisinacatabolicstateafteranovernightfast .amealwithatleast30gprotein is required to initiate repletion of bodyproteins .Proteinatbreakfastisalsocriticalforregula-tion of appetite and daily food intake . The recom-mended dietary allowance represents the minimumdailyintakeforactivehealthyadults .Formostadults,replacing some dietary carbohydrates with proteinwillhelptomaintainbodycompositionandmobility,

studieshavefoundonlya0–6%incidenceofproteindeficiency after RYGB up to 43 months postopera-tively(46–48) .Proteinmalnutritioncausesanannualhospitalizationrateof1%peryearaftermalabsorptiveproceduresandleadstosignificantmorbidity(42,49) .

When it occurs, protein malnutrition is generallyobserved at 3–6 months after surgery and is largelyattributedtothedevelopmentoffoodintolerancetoprotein-rich foods (50) . Protein-deficient meals arecommon after RYGB . Purely restrictive procedures[adjustablegastricbanding(aGB)andsleevegastrec-tomy], for example, can induce digestive symptoms,foodintolerance,ormaladaptiveeatingbehaviorsduetopre-orpostsurgicaleatingdisorders(51) .Preven-tion of protein malnutrition requires regular assess-ment of protein intake and counseling regardingingestion of protein from protein-rich foods andmodularproteinsupplements .Proteinneedsforadultsrelate tobodyweight .dietaryproteinneed is oftenpresented as a percentage of energy intakes . Thedietary reference intakes represent the acceptableprotein range as 10–35% of total energy . However,

Table 2. Schedule for clinical and biochemical monitoring

Pre- operative 1 month 3 months 6 months 12 months 18 months 24 months Annually

Complete blood count X X X X X X X X

LFTs X X X X X X X X

Glucose X X X X X X X X

Creatinine X X X X X X X X

Electrolytes X X X X X X X X

Iron/ferritin X Xa Xa Xa Xa Xa

Vitamin B12 X Xa Xa Xa Xa Xa

Folate X Xa Xa Xa Xa Xa

Calcium X Xa Xa Xa Xa Xa

Intact PTH X Xa Xa Xa Xa Xa

25-D X Xa Xa Xa Xa Xa

Albumin/prealbumin X Xa Xa Xa Xa Xa

Vitamin A X Optional Optional

Zinc X Optional Optional Optional Optional

Bone mineral density and body composition X Xa Xa Xa

Vitamin B1 Optional Optional Optional Optional Optional Optional

Data indicate the suggested schedule for laboratory monitoring after bariatric surgery. LFT, Liver function tests.

a Examinations should only be performed after RYGB, BPD, or BPD/DS. All of them are considered as suggested for patients submitted to restrictive surgery where frank deficiencies are less common.

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at increased risk (e.g. existingosteoporosis andheavymenstruation)(42,57,63,64) .Bestpracticeguidelinespublished recently recommend a daily multivitaminandcalciumsupplementationwithaddedvitamindforallweight-losssurgerypatients(65) .

Vitamin d in doses required to optimize vitamin dstatus should be carefully considered . suboptimalvitamindlevelsarenowrecognizedtobeacommoncondition in the general population and should bescreenedforbeforesurgerybymeasuring25-hydroxyvi-tamin d (25-d) levels . Recommended doses ofelemental calcium after bariatric surgery range from1200–2000 mg daily, and these usually containvitamin d as well (41, 48, 57, 66) . Calcium andvitamindcanalsobegivenasseparatesupplements .Calciumcarbonatepreparationsareeasilyavailableinchewableformsandarebettertoleratedshortlyaftersurgery .However,patientsmustbeinstructedtotakecalciumcarbonatepreparationswithmealstoenhanceintestinal absorption . Calcium citrate preparationsarepreferredbecausethissaltisbetterabsorbedintheabsenceofgastricacidproduction(67–69) .

The multivitamin-mineral preparations should havetherecommendeddailyrequirementsforvitaminsandminerals . initially, one to two tablets of a chewablepreparationareadvisedbecausetheyarebettertoler-ated after malabsorptive procedures . However,nonchewable preparations or products with fortifiedamountsoffolicacidandiron,suchasprenatalvita-mins,canbeused .

Vitamin B12 deficiencies can occur after bariatricsurgery procedures that bypass the lower stomach .impairment of vitamin B12 absorption after RYGBresultsfromdecreaseddigestionoftheprotein-boundcobalamins and impaired formation of intrinsicfactor-vitaminB12complexesrequiredforabsorption(57,70–72) .accordingtoonestudy,30%ofRYGBpatients receiving only a multivitamin supplementwill have a B12 deficiency after 1 yr (73) . in otherstudies,theincidenceofvitaminB12deficiencyafterRYGB is 33–40% at postoperative yr 1 (74) and8–37%byyr2–4(48,60,75,76) .inastudyofverticalbanded gastroplasty patients (n=26), there were noinstances of vitamin B12 deficiency at 1 yr (77) .anemias as a result of vitaminB12deficiencyhave

improve blood lipids and lipoproteins, and help tocontrolfoodintake(52–55) .

Modularproteinsupplementscanbesortedintofourcategories: 1) protein concentrates derived from acompleteproteinsuchasmilk,soy,oreggs;2)proteinconcentratesderivedfromcollagen,eitheraloneorincombinationwithacompleteprotein;3)dosesofoneormoredispensable(nonessential)aminoacids;and4)hybridsofthecompleteorcollagen-basedproteinsand amino acid dose . Modular protein supplementsaregenerallyprovidedeitherasasubstrateforproteinsynthesisor as a sourceofoneormoreaminoacidsthatmaybeconditionally indispensable (condition-allyessential)(50) .

Hospitalizationwithinitiationofparenteralnutritionsupportmayberequired(38)incasesofsevereproteindeficiency,buttherearenocurrentlyacceptedguide-lines or clinical studies guiding nutritional therapyafter weight loss surgery . nutritional support withparenteralnutritionforatleast3–4wkmayrarelyberequired after RYGB when enteral nutrition is notsuccessful (56) .Cautionmustbe exercisedwith theinitiation of solutions containing high amounts(>100–200 g/d) of dextrose in the setting of severemalnutritiontoavoidrefeedingsyndrome .symptomsofrefeedingsyndromeincludeswellingwithsignsofvolumeoverloadassociatedwithhypokalemia,hypo-phosphatemia,andhypomagnesemia .Thisconstella-tion of clinical features results from theinsulin-mediated influxofelectrolytes intocellsandrenal salt and water retention (57) . if a patientrequiresprolongedparenteralnutrition,thensurgicalrevisionandlengtheningofthecommonchanneltodecrease malabsorption is warranted (41), althoughthiswillincreasethelikelihoodofWR .

Vitamin and mineral supplementation

The anatomic changes imposed by malabsorptivesurgeryincreasetheriskforvariousvitaminandmineraldeficiencies, which can occur commonly within thefirstyearaftersurgery(42,43,48,58–62) .afterRYGB,screeningand supplementationofdeficiencieswithamultivitamin-mineral, iron, vitamin B12, or calciumwith vitamin d is routinely conducted, and prophy-lacticsupplementationshouldbeconsideredinpatients

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consumedinthepresenceofcalciumsupplementsorwithdairyproducts .Calciumatdosesof300–600mghas a direct dose-related inhibiting effect on ironabsorption .Thishasbeenseenwithcalciumcarbonate,calciumcitrate,andcalciumphosphate .The risk forirondeficiency increasesover time,with some seriesreporting that more than half of subjects had lowferritinlevels4yraftertheRYGB,BPd,orBPd/ds(48) . iron deficiency after RYGB is influenced bymultiplefactorsandcanpersistto7yrpostoperatively(93) . iron deficiency has been reported to occur inup to 50% of patients after RYGB, most frequentlyinwomenwithmenorrhagia(63,64) .Thus,empiricironsupplementationis recommended(84,85) . inarandomized, controlled trial, iron supplementation(65mgelementalironbymouthtwicedaily)preventedthedevelopmentofirondeficiency,althoughitdidnotalways prevent the development of anemia (85),suggestingthatinsomesubjectsafterRYGB,anemiamaybe related to factors other than irondeficiency .supplementationwithlowerdoses(80mg/d)doesnotuniversally prevent iron deficiency (48) . Vitamin Cincreases iron absorption and should be includedempirically with iron supplementation (65, 84) .Becauseoral ironsupplementation isassociatedwithpoor absorption and adverse gastrointestinal effects,and im injections are painful, intermittent iv ironinfusion may be required during treatment . irondextran, ferric gluconate, or ferric sucrose may beadministered iv . supplementation should followcurrentlyacceptedguidelinestonormalizehemoglobin(85), and continued surveillanceofhemoglobin andironstudiesisrecommended .

steatorrheainducedbymalabsorptivesurgicalproce-durescanleadtodeficienciesinfat-solublevitamins,whichtypicallypresentasaneczematousrash(38,42,49) .Vitaminadeficiencyafterbariatricsurgeryresultsfrompoornutritionalintake,maldigestion,malabsorp-tion,andimpairedhepaticreleaseofvitamina .intwoseries, the incidence of vitamin a deficiency was61–69% 2–4 yr after BPd, with or without ds (40,94) .inathirdseries,theincidencewasaslowas5%by4yr(62) .althoughdataare scarce,mildvitaminadeficiencycanalsooccurafterdistalRYGBproceduresandiseasilycorrectedwithoralsupplementation(62) .Oral supplementation of vitamin a, 5,000–10,000

beenreportedtooccurinmorethan30%ofpatients1–9yrafterRYGB(42,78) .

TheinitiationofvitaminB12supplementationwithin6 months postoperatively is recommended by mostsurgical groups in the absence of controlled studies .OralcrystallinevitaminB12atadoseofatleast350mg/d has been shown to maintain normal plasmavitaminB12 levels(78–80) .Optimaldosingoforal,sublingual, or intranasal forms of B12 supplementa-tionhasnotbeenwellstudied .However,inastudyofpostoperativeRYGBpatientsbyClementset al.(81),1000mgvitaminB12imevery3monthsorintranasalB12, 1000 mg every week, resulted in a lower inci-dence of vitamin B12 deficiency (3 .6% at 1 yr and2 .3%at2yr)comparedwiththefrequencyof12–37%describedbyBrolinandleung(62) .inmanyinstitu-tions, intranasal administration of vitamin B12 hasbeen supplanted by sublingual administration ofvitaminB12 .Onestudydemonstratedthatoralandsublingual administration of 500 mg vitamin B12was equally efficacious in correcting vitamin B12deficiency(82) .

Regardless of the preparation, multivitamin supple-ments providing 400 mg/d folate can effectivelyprevent the development of folate deficiency afterRYGB(48,56,83) .Thissuggests thatthe intakeoffolicacidfromthedietandroutinemultivitaminsisgenerallysufficienttopreventfolicaciddeficiency .

iron deficiency is common after Roux-en Y bypass,especiallyforwomenwithmenorrhagiaduetoexces-sivemenstrualbloodloss .Forthisreason,prophylacticironsupplementationisrequiredtoreducetheriskofirondeficiencyanemia(84–86) .decreasedliberationand absorption of heme from foods are caused frombypassoftheacidenvironmentinthelowerstomachandtheabsorptivesurfacesoftheduodenumandupperjejunum(87–89) .Moreover,mealsaftermalabsorptiveproceduresarefrequentlylowinmeats,whichresultsindecreasedhemeintake .irondeficiencymayalsobeexacerbatedas a resultof anutrient-nutrient inhibi-toryabsorptiveinteractionbetweenironandcalcium,anothermineralthatshouldbegivenroutinelyduringthe postoperative period . Most studies (90, 91), butnot all studies (92), show that nonheme-and heme-iron absorption is inhibited up to 50–60% when

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Regularmonitoringandscreeningoflaboratoryvaluesand nutritional intake before and after bariatricsurgery are key to ensuring adequacy of nutrition .Therefore, they are recommended after bariatricsurgeries,evenifpatientstoleratetheirdietwellwithnovomitingordiarrhea, todetect subclinicalnutri-tionaldeficienciesandpreventdevelopmentoffrankdeficiencies(113–116) .Malabsorptiveprocedurescanbeassociatedwithmicronutrientandmacronutrientdeficienciesandrequirelifelongsupplementationandmonitoring of laboratory data by a team familiarwith possible deficiencies (113, 114) . Fat-solublevitaminlevels,especiallyvitamina,shouldbemoni-tored annually after malabsorptive procedures (48,60) .Restrictiveprocedures,oftenoverlooked,suchaslaGB,alsorequirecertainattentiontosupplementa-tionandlaboratorydatasecondarytodecreasedintakeor poor tolerance of certain foods or food groups .Baseline data should be obtained before bariatricsurgery to permit correction of deficiencies and toprovidecomparisonvalues .

selectionandtimingofpreoperativelaboratorytestsisbased on each patient’s specific clinical indicationsbecauseobesityaloneisnotariskfactorforpostopera-tivecomplications(117) .evaluationbytheanesthesi-ologistcanreveal importantpreoperativerisk factorsincluding metabolic syndrome, respiratory diseasesincluding asthma, andperipheral vascular or throm-botic predisposition . The use of a designated anes-thesiateamfamiliarwithbariatricoperationscanhelpmaximize perioperative management and minimizecomplications .Thereisinsufficientevidencetorecom-mendorderingroutinepreoperativetests(118),butinviewofthehighriskfordevelopmentofmicronutrientdeficienciesaftermalabsorptiveprocedures,preopera-tive evaluation of iron status (Fe, total iron bindingcapacity, ferritin, and/or serum transferrin receptor),vitaminB12,25-d,andPTHisrecommended(Table3) .Preoperativemicronutrientdeficiencieshavebeendescribed in bariatric surgery patients, e.g. 14–43 .9%irondeficiency,5–29%B12deficiency,and40–68 .1%vitaminddeficiency(119,120) .Treatmentforclini-cally significant deficiencies, e.g. iron deficiencyanemia,shouldbeinitiatedpreoperatively .

iu/d, is recommended until the vitamin a levelnormalizes .VitaminKdeficiencycanalsobecommonwithBPdandBPd/ds .inaresearchsetting,vitaminKlevelshavebeenmeasured,andlevelswerelowin50–60%ofpatientswhounderwentBPdorBPd/ds(68,95) .inthatstudy,noclinicalsymptomssuchaseasybruising,increasedbleeding,clottingalterations,or metabolic bone disease because of the role ofvitaminKinosteocalcinformationwereobserved .intheclinicalsetting,vitaminKshouldbesupplementedorally or im when inR values rise above 1 .4 as themeasurement of vitamin K levels and effects onvitaminK-inducedproteinsareresearchprocedures .

Thiamine deficiency can occur as a result of bypassofthejejunum,wherethiamineisprimarilyabsorbed,or as a result of impaired nutritional intake fromrecurrent emesis(96,97) . acute neurological deficitsasaresultofthiaminedeficiencyhavebeenreportedas soon as 1–3 months after surgery (98–107) . earlyrecognition is paramount to initiate appropriatesupplementationandtoavoidpotentialcomplicationsresulting from the administration of dextrose-containingsolutions(108) .althoughnotoftenevalu-ated, thiamine status is best assessed by determiningerythrocyte transketolase activity . Parenteral supple-mentationwiththiamine(100mg/d)shouldbeiniti-atedinthepatientwithactiveneurologicalsymptoms(109,110) .aftera7-to14-dcourse,anoralprepara-tion(10mg/d)canbeuseduntilneurological symp-tomsresolve(56,111,112) .severethiaminedeficiencymostcommonlyoccursinpatientswhodevelopsevere,intractablevomitingafterbariatricsurgery,usuallyduetoamechanicalproblemsuchasstomalstenosisafterRYGBexcessivebandtightnessorslippageafterlapa-roscopicaGB(laGB) .itisimportantthatpersistentvomiting be resolved aggressively to prevent thisdevastatingcomplication .

Biochemical and clinical monitoring

The extent of metabolic and nutritional evaluationcompletedafterbariatricsurgeryshouldbeguidedbythe surgical procedure performed . Purely gastricrestrictiveproceduresarenotassociatedwithaltera-tionsinintestinalcontinuityanddonotalternormaldigestivephysiology .asaresult,selectivenutritionaldeficienciesareuncommon .

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3.4. Werecommendthatlipidabnormalitiesshouldbe treated according to the nCeP guidelines (aTPiii) and that existing lipid-lowering therapy forldl-cholesterol and triglyceride values should becontinuedaftersurgeryiflevelsremainabovedesiredgoals(1| ) .

3.1.–3.4. Evidence

Type 2 diabetes mellitus

T2dM is commonly associated with severe obesitybutcanimprovetothepointthatlittleornomedica-tion isnecessary inpatientsafterRYGB(121–123) .Fasting plasma glucose concentrations have beenreportedtoreturntonormalbeforehospitaldismissaland before significant weight loss (124–137) . afterRYGBorBPd/ds/Gs,insulin-treatedpatientsexpe-rienceasignificantdecreaseininsulinrequirements;the majority of patients can discontinue insulintherapy by 6 wk after surgery (136, 138), and somemay even be able to discontinue insulin beforehospital discharge . The long-term effects of these

3.0. MANAGEMENT Of diABETES MElliTuS ANd liPidS

Recommendations

3.1. We recommend that postoperative glycemiccontrol shouldconsistofachievingglycatedHba1cof 7% or less with fasting blood glucose no greaterthan 110 mg/dl and postprandial glucose no greaterthan180mg/dl(1| ) .

3.2. Wesuggest thatphysicians andfloornursesbefamiliarwithglycemictargetsandinsulinprotocolsaswellastheuseofdextrose-freeivfluidsandlow-sugarliquidsupplements(2| ) .

3.3. Werecommendthatobesepatientswithtype1diabetes receive scheduled insulin therapy duringtheirhospitalstay,asrequired(1| ) .

TABLE 3. diagnosis and treatment of nutritional deficiencies

deficiency

Symptoms and signs

Confirmation

Treatment first phase

Treatment second phase

Protein malnutrition Weakness, decreased muscle mass, brittle hair, generalized edema

Serum albumin and prealbumin levels, serum creatinine

Protein supplements Enteral or parenteral nutrition; reversal of surgical procedure

Calcium/vitamin D Hypocalcemia, tetany, tingling, cramping, metabolic bone disease

Total and ionized calcium levels, intact PTH, 25-D, urinary N-telopeptide, bone densitometry

Calcium citrate, 1,200–2,000 mg, oral vitamin D, 50,000 IU/d

Calcitriol oral vitamin D 1,000 IU/d

Vitamin B12 Pernicious anemia, tingling in fingers and toes, depression, dementia

Blood cell count, vitamin B12 levels

Oral crystalline B12, 350 mg/d

1,000 –2,000 mg/2–3 months im

Folic acid Macrocytic anemia, palpitations, fatigue, neural tube defects

Cell blood count, folic acid levels, homocysteine

Oral folate, 400 mg/d (included in multivitamin)

Oral folate, 1,000 mg/d

Iron Decreased work ability, palpitations, fatigue, koilonychia, pica, brittle hair, anemia

Blood cell count, serum iron, iron binding capacity, ferritin

Ferrous sulfate 300 mg 2–3 times/d, taken with vitamin C

Parenteral iron administration

Vitamin A Xerophthalmia, loss of nocturnal vision, decreased immunity

Vitamin A levels Oral vitamin A, 5,000–10,000 IU/d

Oral vitamin A, 50,000 IU/d

Details are shown for the diagnosis and treatment for specific nutritional deficiencies.

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Postoperative glycemic control

achievement of postoperative glycemic control(Hba1c≤7%;bloodglucose≤110mg/dlfastingand≤ 180 mg/dl postprandial) represents a realistic goal(148,149) .PreoperativeglycemiccontrolrepresentedbyanHba1c less than7%hasbeenassociatedwithdecreasedperioperativeinfectiouscomplications(150) .Patientswithpoorcontrolonoralmedicationsorwhorequirehighdosesofinsulinpreoperativelymayrequireinsulinforseveraldaysaftersurgerytomaintainbloodglucoseconcentrationsinadesirablerange .

Patientsrequiringinsulinbeforesurgeryshouldhavetheir blood glucose concentrations monitored regu-larly and insulin administered as needed to controlhyperglycemia . in the intensive care unit, glycemiccontrol can be maintained with a nurse-driven,dynamicintensiveinsulintherapyprotocoltargetinga blood glucose level of 140–180 mg/dl (151) . innon-intensive care unit patients, target glycemiccontrolisaccomplishedwithscinsulin:basalinsulin-ization insulin treatment with intermediate-actingnPHinsulin,long-actinginsulinglargine,orinsulindetemir;boluspreprandial insulinizationwith rapid-acting insulinaspart,glulisine,or lispro;andcorrec-tion insulin every 3–6 h, also with rapid-actinginsulin(152) .

Physicians and floor nurses should be familiar withglycemictargetsandinsulinprotocolsaswellaswiththeuseofdextrose-freeivfluidsandlow-sugarliquidsupplements .Parametersforstartingivinsulinshouldfollowestablishedclinicalprotocols .Patients shouldbeinstructedonregularmonitoringofmeteredbloodglucose concentrations to guide adjustments inglucose-loweringtherapy . inthepatientwithpersis-tent hyperglycemia, continued surveillance andpreventive care as recommended by the americandiabetes association are advised . sulfonylureadrugs should generallybe avoided in the immediatepostoperative period when insulin sensitivity mayimproveandincreasetheriskofhypoglycemia .Theseagentsshouldbereintroducedlateronlyifclinicallyindicated . The long-term management of patientswhoachieveremissionoftheirT2dMaftersurgeryisnot established, but routine follow-up should becontinued .

bypassoperationsappeartoincludebothweightloss-dependentand-independenteffects(139) .

By contrast, gastric restrictive operations such asbandingappear to improveT2dMasa resultof theweightlossitself .Therefore,theeffectswilllikelybereversedifthereisWR(140) .

ThelongerT2dMhasbeenpresent,thelesslikelyitis to respond to surgically inducedweight loss (124,126), most likely due to destruction of pancreaticbeta-cells .Whetherweightlossand/orbypasssurgeryitselfwillalsoslowthecellularandmoleculareventsleadingtobeta-celldestructioninthelongtermhasnotbeenestablished .

improvementsinhyperglycemiaareobservedalmostimmediately after RYGB, in part due to increasedreleaseofGlP-1(141–143)andpossiblyotherincre-tins .RubinoandGagner(144)observedthatRYGBandBPdachieveddurableprimarybeneficialeffectson glycemic control in 80–100% of patients withT2dM,independentofeffectsonbodyweight .Theseconclusions were supported by rat studies in whichgastrojejunalbypasscontrolledT2dMindependentofweightloss(145) .inasubsequentstudyof10obesepatients undergoing RYGB, a potential mechanismwas elucidated (136) . Bypass of the proximal smallbowel was associated with a statistically significantincrease in GlP-1 and hyperinsulinemia . Moreover,early presentation of undigested food to the distalsmallbowelwasassociatedwithatrendtowardgreaterlevels of GlP-1 and restoration of normal glucose-stimulatedinsulinsecretion(136) .Theseand/orotherintestinal factors may also restore meal-inducedsuppression of ghrelin release from the stomach,resultingindecreasedfoodintake(146) .Oneexpla-nationfortheimmediateeffectsofRYGBandintes-tinalbypassonglucosemetabolismisthatsecretionofincretins,includingglucose-dependentinsulinotropicpolypeptideandGlP-1,recoversrapidlyaftersurgery .Bypassoftheduodenumwithoutgastricbypassorilealinterpositionhasbeen foundto improvediabetes inboth animal models and patients (136, 143, 147) .althoughthesechanges inglucosehomeostasismayplayaphysiologicalrole,moreresearchisneededtodeterminetheircontributiontoglucosecontrolunderreal-worldconditionsofrapidweightlossafterRYGB .

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takentoruleoutesophagealorgastricvaricesand/orneed for transplantation (158), and liver transplantpatients may undergo successful bariatric surgery(167) .naFldisbeingincreasinglyrecognizedasanimportant cause of liver-related morbidity andmortality(168)andmaybethemostcommoncauseof cryptogenic cirrhosis in the obese patient (169) .abnormaltransaminasesshouldbefollowedatappro-priateintervalsuntiltheyfallintothenormalrangeorstabilize .

Lipid disorders

Triglyceride and ldl-cholesterol decrease andhigh-density lipoprotein-cholesterol increases afterlaGB,RYGB,BPd,orBPd/dssurgery(170–183) .However, conventional lipid measurements of totalandldl-cholesterolmaynotbereflectiveofdyslip-idemicrisksand/orinsulinresistanceinobesepeople,as suggestedby a cross-sectional studyof572obesepatients (184) . The improvement in dyslipidemiaappears tobe relatednotonly to thepercentageofexcessweight loss(170)butalso to thedecrease ininsulinresistance(170) .Giventheimprovementincardiovascularmortalityafterbariatricsurgery,thesechangeshavelikelyledtoadecreasedriskofcardio-vascular disease . Recent studies show decreasedcardiovascularandmyocardialinfarctionmortalityinbariatricsurgerypatients(185) .Previouslyunrecog-nized lipidabnormalitiesmaybe identifiedandcanstrengthen the case for medical necessity for theseprocedures . lipid abnormalities should be treatedaccording to the nCeP guidelines (186) . lipid-loweringtherapyforldl-cholesterolandtriglyceridevalues that remainabovedesiredgoalsafter surgeryshould be continued . BPd and BPd/ds procedureshavebeenassociatedwithlowertriglycerideandldlvalues(128) .duetothedramaticreductionsinlipidlevels, the doses of lipid-lowering drugs should beperiodicallyreevaluated .

Postoperative pregnancies

Womenwithahistoryofoligomenorrheaandandro-genicity due to polycystic ovarian syndrome maybecome fertile during the postoperative period andshouldbecounseledthatunexpectedpregnanciescanoccur unless contraceptive methods are employed .Themanagementofpregnancyrequiresmeetingthenutritionalneedsofapregnantmotherwithattentiontomicronutrients andprotein .Wegenerally recom-mend that patients take precautions to avoid preg-nancyfor12to18monthsaftersurgery .Ratesofmanyadverse maternal and neonatal outcomes may belower inwomenwhobecomepregnantafterhavinghadbariatricsurgerycomparedwithratesinpregnantwomen who are obese; however, further data areneededfromrigorouslydesignedstudies(153) .

Fatty liver disease and nonalcoholic fatty liver disease (NAFLD)

Manyobesepatientswillhave abnormal liver func-tion tests with asymptomatic increases in serumalanine aminotransferase and aspartate aminotrans-ferase .Thesechangesaremostcommonlyassociatedwith fatty liver disease or naFld . at the time ofsurgery,84%ofseverelyobesesubjectshavesteatosisonliverbiopsyspecimens(154),whereas20and8%have inflammationandfibrosis, respectively .Weightloss after laGB, RYGB, BPd, or BPd/ds leads toregression of steatosis and inflammation, includingdecreasedbridgingfibrosis in somecases (155–164) .Theclinicalchallengeistodeterminewhichpatientsrequire additional evaluation, because fatty liverdiseaseisadiagnosisofexclusion .Gallstones,chronichepatitisBorC,alcoholuse,andpotentialsideeffectsofmedications(suchasacetaminophen,nonsteroidalinflammatoryagents,andclopidogrel)areamongtheless common causes of liver disease . Patients withmarked increases in liver function tests (generallyconsidered at two to three times the upper limit ofnormal)shouldbeconsideredforadditionaltestingbyhepatobiliary ultrasonography or computed tomog-raphy, and a hepatitis screen if this was not donebeforesurgery(165) .Patientswithmild-to-moderatecirrhosis may benefit from bariatric surgery withacceptable complication risks (166) . if cirrhosis issuspected, preoperative endoscopy should be under-

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2yrand25–48%by4yr;17–52%ofpatientsdevelopavitaminddeficiencyby2yrand50–63%by4yr(40, 69, 74, 94, 200, 201) . increased awarenessregarding the prevalence of metabolic bone diseaseaftermalabsorptiveprocedureshasledtotherecom-mendationthatcalciumsupplementationberoutinelyprovided(41,56,202,203) .

Vitaminddeficiencyandbonemineralizationdefectsresultfromdecreasedsunlightexposure,maldigestion,impairedmixingofpancreaticandbiliarysecretions,anddecreasedvitamindabsorptionintheproximalsmall bowel (42, 63, 204–207) . Vitamin d supple-mentationcanbeprovidedwithergocalciferol,50,000iuone to three timesperweek, although in severecasesofvitamindmalabsorption,dosingashighas50,000iuonetothreetimesadaymaybenecessary .

indicators of bone loss in malabsorptive procedurescan be detected in serum measures at 6 months .supplementation with vitamin d and calcium canimproveparametersofbonehealth,butlargeamountsmaybeneededinsomeindividuals .

at present, there are no conclusive data regardingthe association of altered calcium and vitamin dhomeostasis with laGB surgery . in two reports,laGBwasnotassociatedwithsignificant reductionin bone mineral density (208, 209) . Calcium defi-ciencyandmetabolicbonediseasecanoccurinRYGBpatients(55,62,206,210,211) .Theonsetofmeta-bolic bone disease is insidious and results from adecreaseintheintakeofcalcium-richfoods,bypassoftheduodenumandproximaljejunumwherecalciumis preferentially absorbed, and malabsorption ofvitamind(56,63,207,212) .

ariseinserumintactPTHindicatesnegativecalciumbalanceand/oravitaminddeficiency .elevationsofbone-specific alkaline phosphatase and osteocalcinlevels,which indicate increasedosteoblasticactivityandboneformation,areoftentheinitialabnormali-ties found (63, 207) . The appropriate use of boneturnover markers has been proposed as a usefulscreeningtoolformetabolicbonediseaseafterRYGBbecauseserumcalciumandphosphatelevelsareoftennormal, but this has not been established (56, 207,212,213) .

4.0. BONE hEAlTh ANd GOuT

Recommendations

4.1. Werecommendthatpatientswhohaveunder-gonemalabsorptive(i.e.RYGB,Gs,andBPd)obesitysurgicalproceduresshouldhavevitamind,calcium,phosphorus, PTH, and alkaline phosphatase levelsfollowedevery6monthsandhaveadual-energyx-rayabsorptiometry for bone density performed yearlyuntilstable(1| ) .

4.2. Werecommendvitamindandcalciumsupple-mentation postoperatively for malabsorptive obesitysurgicalproceduresandthatthedosesbeadjustedbyaqualifiedmedicalprofessionalbasedonserummarkersandmeasuresofbonedensity(1| ) .

4.3. Wesuggestthatpatientswithfrequentattacksofgout shouldhaveprophylactic therapy to lessen thechance of acute gout postoperatively as they loseweight(2| ) .

4.1.–4.3. Evidence

Obesity is associated with greater bone density, butweight loss by diet or other means decreases bonedensity .Bone loss is accompaniedby an increase inbone turnover, but only malabsorptive procedurescauseadisproportionatelossofbonecomparedwithweightlossthroughdietarycalorierestriction .

The Roux-en-Y procedure is the leading bariatricoperation performed in the united states . in thissurgery, the primary sites for calcium absorption arebypassed . Patients become calcium-and vitamind-deficient, and the body then up-regulates PTH,causing increased production of vitamin d andincreased calcium resorption from bone . Gastricbanding uses a restrictive band and has not beenshowntoproducethesamebonelossastheRoux-en-Yprocedure,norhastherebeenevidenceofsecondaryhyperparathyroidism(187–199) .

Overall, after a malabsorptive bariatric procedure,10–25%ofpatientsdevelopacalciumdeficiencyby

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25-dlevelsnormalize .Primarytreatmentiswithergo-calciferol,butinindividualswithpersistentlyelevatedPTH levelsorbone loss, calcitriol (1,25-d) therapyhas been used in this setting . However, appropriateusehasnot been established . intravenous (0 .25–0 .5mg/d) or oral (0 .25–1 .0 mg daily or twice daily)calcitrioltherapyhasbeenusedinsituationscharac-terized by symptomatic hypocalcemia and severevitamindmalabsorption .Manyobesepatientshavesuboptimallevelsofvitamind,anditisimportanttonormalizevitamind levelspreoperativelywhen theprocedurecontemplatedislikelytoresultinvitamindmalabsorption .However,inasymptomaticpatientsinwhom25-dlevelsfailtoreachoptimallevels(25-d30ng/ml),functionallynormalize1,25-dlevels,andsuppresselevatedPTHlevels, theuseofcalcitriol isunproven .adequatecalciumandvitamindsupple-mentationhasbeenachievedwhen levels for serumcalcium,bone-specificalkalinephosphataseorosteo-calcin,25-d,and24-hurinarycalciumexcretionratesarenormal .PTHlevelsmaypersistabovethenormalrange,evenwithfunctionallyrepletevitamindlevels(25-d > 30 ng/ml) . Monitoring of vitamin d andPTH levels should be accompanied by monitoringofcalcium .ifelevatedcalciumlevelsarefound,thenPTH levels should be measured to detect primaryhyperparathyroidism . in most bariatric surgerypatients,therewillbesecondaryhyperparathyroidismsecondary to negative calcium balance as indicatedratherthanprimaryhyperparathyroidism .

Obesepatientswithabodymass indexgreater than40kg/m2areatgreaterriskforosteoarthritis,progres-sion of arthritis, and gout, which can improve withweight loss (224) . after bariatric surgery, hip andknee pain may improve, and exercise capacity mayincrease(225–228) .Moreover,serumuricacidlevelsdecrease (81) . Gout may be precipitated duringweight loss after intestinal bypass (211), just assurgery itself is a risk factor for acute gout attacks .Therefore, patients with frequent attacks of goutshould have prophylactic therapy started well inadvanceofsurgerytolessenthechanceofacutegoutimmediatelyaftersurgery .

after gastric restrictive procedures, urinary C-telo-peptide levels, indicative of increased bone resorp-tion, are elevated (213) . in the event of prolongedimmobilizationafterlaGBorRYGB,increasedboneresorption, especially in association with criticalillness,mightbeassociatedwithhypercalciuriaand,ifrenal calciumexcretion is impaired, frankhypercal-cemia(214) .Rapidandextremeweightlossisassoci-atedwithboneloss(215–217),eveninthepresenceofnormalvitamindandPTHlevels(213) .

decreased weight-bearing after surgery may alsocontribute to bone loss and can be estimated withn-orCtelopeptidelevels(213) .afteramalabsorptivebariatric procedure, patients might have continuedsecondary hyperparathyroidism, low 25-d levels,increased1,25-dihydroxyvitamind(1,25-d)levels,and hypocalciuria (67, 207, 210, 211, 213, 218) .left uncorrected, secondary hyperparathyroidismwillpromotebonelossandincreasestheriskforosteo-peniaandosteoporosis(210) .Thepresenceofhypo-calcemia in the setting of vitamin d deficiencyexacerbatesmineralizationdefectsandacceleratesthedevelopment of osteomalacia (219) . in an observa-tionalstudybydinizMdeet al.(220),29%ofpatientsdeveloped secondary hyperparathyroidism and 0 .9%hypocalcemiabeyondRYGBpostoperativemonth3 .Paradaet al.(221)reportedthat53%ofpatientshadsecondaryhyperparathyroidismafterRYGB .Youssefet al. (222) foundagreaterdegreeof secondaryhyper-parathyroidismandvitaminddeficiencywithlongerRouxlimblengthafterRYGB .

Riedtet al.(223)foundthatwomenwhohavehadaRYGB experienced decreased estradiol-and vitamind-dependentintestinalcalciumabsorption .Thiswasassociated with increased n-telopeptide (marker ofbone resorption), increased osteocalcin (marker ofbone formation), or an uncoupling effect on boneremodeling (223) . Compston et al. (60) found anincreased incidence of metabolic bone disease withstandard BPd and a 50-cm common channel, butwithout reduced serum 25-d levels . after bariatricsurgery,themostcommoncauseofsecondaryhyper-parathyroidism with normal vitamin d levels iscalcium deficiency . a common regimen consists ofweekly parenteral ergocalciferol, 100,000 iu, until

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5.0. GASTrOENTErOlOGiCAl ANd EATiNG BEhAviOr CONSidErATiONS

Recommendations

5.1. We recommend that bariatric surgery patientsshould sip fluids in the immediate postoperativeperiodwhen fully awakeafter surgeryand that theycanonlybedischargedifsatisfactorilytoleratingoralfluids(1| ) .

5.2. Particularlyafterprocedureswithagastricrestric-tivecomponent,werecommendthatgradualprogres-sionoffoodconsistencyoverweekstomonthsbeusedtoallowpatientstoadjusttoarestrictivemealplanandtominimizevomiting,whichcandamagesurgicalanastamoses or lead to gastroesophageal reflux afterrestrictiveprocedures(1| ) .

5.3. We suggest continuous reinforcement of newnutritionalhabitsthatdiscouragetheintakeofsimplecarbohydrate-densefoodsandbeveragestominimizethe frequency of bothersome gastrointestinal symp-tomsduetodumping,includingabdominalpainandcramping,nausea,diarrhea,lightheadedness,flushing,tachycardia,andsyncope(2| ) .

5.4. Wesuggestthatpatientswhopresentwithpost-prandial symptoms of hypoglycemia, particularlyneuroglycopenic symptoms, should undergo furtherevaluation for the possibility of insulin-mediatedhypoglycemia(2| ) .

5.1.–5.4. Evidence

Vomiting and surgical complications

Chronicvomiting,generallydescribedbythepatientasspittinguporthefoodgetsstuck,canoccur .Onethird to two thirds of patients report postoperativevomiting (229–231) . Vomiting is thought to occurmost commonly during the first few postoperativemonths (232), when the patients are adapting to asmallgastricpouch .Thisvomitingisnotbelievedtobeapurgingbehavioras seenwithbulimianervosa .

instead,patientsmayvomitinresponsetointolerablefoods or in an effort to clear food that has becomelodgedintheupperdigestivetract .Frequentvomitingmaysuggest:1)obstruction,necessitatingevaluationwith a gastrointestinal contrast study, before anyendoscopic procedure in laGB patients; 2) reflux,inflammation, stoma erosion/ulceration, or stenosis,necessitating endoscopy; or 3) gastric dysmotility,necessitating a radionuclide gastric-emptying study .Regurgitation that occurs after a laGB can bemanaged with appropriate band adjustments andnutritionaladvice .

Continuous reinforcementofnewnutritionalhabitswill help minimize the frequency of bothersomegastrointestinalsymptoms .Guidanceremainsimpor-tant to optimize nutritional intake in patients whohavehadamal-absorptiveprocedurebecauseof therisk for clinically important nutritional deficiencies(233) .Forsurgerieswithagastricrestrictivecompo-nent, regular visits with the clinical team provideguidanceasthemealplanisprogressed .Thelimitedvolume capacity of the gastric pouch (30–60 ml)resultsinmarkedrestrictionsintheamountandrateat which food can be eaten . during the first fewmonths after surgery, episodesof regurgitation, typi-callywithoutnauseaortruevomiting,arecommoniffoodisconsumedin largevolumesortooquicklyorifitisnotchewedthoroughly .

RYGB has been associated with staple line failure(234,235)andastomalulcerationrateofupto16%(234, 236) . staple line disruption and gastrogastricfistulas can also occur after gastric transection andincrease the risk of marginal ulceration (234, 237) .Morerecentstaplingtechniquesonlyrarelyresultinstaplelinefailure,althoughthereisnoclearguidanceregardingtheoptimalstaplingmethod .

latesurgicalcomplicationsincludeanastomoticstric-ture, staple line dehiscence, pouch dilation, internalhernia with intestinal obstruction (complete orpartial),anastomoticleaks,andincisionalhernias(41,238) .aninternalherniaafterRYGB,BPd,orBPd/ds is a potentially fatal complication secondary tobowel infarction and peritonitis . The symptoms arethoseofasmallbowelobstructionwithcrampingpain,usuallyperiumbilical .Therearethreelocationsforan

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late dumping can be due to reactive hypoglycemiaandcanoftenbemanagedwithnutritionalmanipula-tion or be treated prophylactically by having thepatienteatasmallsnack .

Postprandial hypoglycemia

Post-RYGB patients who present with postprandialsymptoms of hypoglycemia, particularly neuroglyco-penic symptoms, should undergo further evaluationforthepossibilityof insulin-mediatedhypoglycemia .in a study conducted in one institution, only nineadultpatientswithoutahistoryofgastricbypasshadsurgicallyconfirmednesidioblastosisduringthesameperiod in which six patients were evaluated andtreated for theconditionafter gastricbypass surgery(GBs) (245) . The study described six patients withsevere, intractablepostprandial symptomsassociatedwith endogenous hyperinsulinemic hypoglycemia .This complication, believed to be secondary to theRYGB anatomy in some patients, has necessitatedpartialpancreatectomyforreliefofthesymptomsandhypoglycemia . in these patients, histological exami-nationdemonstratedpancreaticisletcellhyperplasia .This complication may present from 2 to 9 yr afterRYGB .inarecentstudyof14patientswithhyperin-sulinemic hypoglycemia, the glucose and insulinresponses to mixed meals were measured (246) . asubsequent studyof sixRYGBpatientswithpostop-erativehypoglycemiacomparedwithleanandobesecontrols without hypoglycemia failed to find anincrease inbeta-cellmass (247)andconcluded thatpost-GBshypoglycemiaisnotduetoanincreaseinbeta-cellmassor formation .Rather, they concludedthatpostprandialhypoglycemiaafterGBsisduetoacombinationof gastricdumpingand inappropriatelyincreasedinsulinsecretion,eitherasafailuretoadap-tively decrease insulin secretion after GBs or as anacquiredphenomenon(247) .

internal hernia: at the jejunojejunostomy, throughthemesocolon,orbetweentheRouxlimbmesentery,mesocolon, and the retroperitoneum (Petersenhernia) .diagnosismaybeobtainedwithagastrografinuppergastrointestinalorabdominalcomputedtomog-raphy;however,aswithaleak,thesestudiesareoftenmisleading(41) .inmanyinstances,thebestcourseofmanagementisanexploratorylaparotomyorlaparos-copyforrecurrentcrampingabdominalpain .

Dumping syndrome

abdominal pain and cramping, nausea, diarrhea,lightheadedness, flushing, tachycardia, and syncope,indicative of dumping, are reported frequently andservetodiscouragethe intakeofenergy-dense foodsand beverages (203, 239, 240) . Gastric dumpingoccursinitiallyin70–76%ofpatientswhohavehadaRYGB(61,124,241) .However,thefrequencyofclin-ically troublesome complaints is unknown . somereports suggest that thedumping syndromemaynotoccur in all patients or may occur only transientlyduring the first postoperative year (242) . For somepatients,dumpingmaybeconsideredtobeadesiredsideeffectbecause itdiscourages ingestionofcalori-callydenseliquidsthatcouldmitigateweightloss .itusedtobethoughtthatdumpingsymptomsweretheresult of the hyperosmolarity of intestinal contents,whichresultedinaninfluxoffluidintotheintestinallumen with subsequent intestinal distention, fluidsequestrationintheintestinallumen,decreasedintra-vascularvolume,andhypotension .Morerecentdatasuggestthatfoodbypassingthestomachandenteringthesmallintestineleadstothereleaseofgutpeptidesthat are responsible for dumping symptoms becausetheycanoftenbeblockedwithscoctreotide,asoma-tostatinanalog(243) .

dumping symptoms tend to become less prominentwith time (240) and canusually be controlledwithcertainnutritionalchanges,suchas:1)eatingsmall,frequentmeals;2)avoidingingestionofliquidswithin30minofasolid-foodmeal;3)avoidingsimplesugarsandincreasingintakeoffiberandcomplexcarbohy-drates;and4)increasingproteinintake(244) .ifthesemeasuresareunsuccessful,thenoctreotide,50mgsc30minbeforemealsmay reduce symptoms in somepatients(244) .

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Suggested directions for future researchdueto thenatureof thephysician-patient relation-ship in individualizing bariatric surgical approaches,researchthatcomparesdifferenttypesofsurgeryinarandomized, prospective, controlled design study ischallenging .However,itwouldbepossibletodesignapostoperativestudythatassignssubjectsrandomlytostandard intervention or intensive intervention toexamineeffectsonWR,morbidity,andmortality .Bystratifyingthestudytoexamine laparoscopicadjust-ablebandingandRYGB,itwouldbepossibletotailorthe interventions to the needs of the two types ofoperationsasrestrictiveandmalabsorptive .itisalsopossible that this type of research could be appliedsuccessfully to more aggressive malabsorptive proce-duresaslongastheappropriatesafetystandardswereincorporated .

Finally, treatment of diabetes and metabolic diseasethrough surgical intervention requires greater study .Thescientificrationalefortheapproachissound,butquestions remain pertaining to long-term outcomeand the possible occurrence of nesidioblastosis aftergastricbypass .Theseissuesandtheimpactonoverallmortalityindiabetesdeservemuchmoreattentioninfutureclinicalresearch .

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1 . Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM2006Prevalenceofoverweightandobesityintheunitedstates,1999–2004 .JaMa295:1549–1555

2 . Sjöström L, Narbro K, Sjöström CD, Karason K, Larsson B, Wedel H, Lystig T, Sullivan M, Bouchard C, Carlsson B, Bengtsson C, Dahlgren S, Gummesson A, Jacobson P, Karlsson J, Lindroos AK, Lönroth H, Näslund I, Olbers T, Stenlöf K, Torgerson J, Agren G, Carlsson LM; Swedish Obese Subjects Study2007effectsofbariatricsurgeryonmortalityinswedishobesesubjects .nenglJMed357:741–752

3 . Sjöström L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, Carlsson B, Dahlgren S, Larsson B, Narbro K, Sjöström CD, Sullivan M, Wedel H; Swedish Obese Subjects Study Scientific Group2004lifestyle,diabetes,andcardio-vascularriskfactors10yearsafterbariatricsurgery .nenglJMed351:2683–2693

4 . Maggard MA, Shugarman LR, Suttorp M, Maglione M, Sugerman HJ, Sugarman HJ, Livingston EH, Nguyen NT, Li Z, Mojica WA, Hilton L, Rhodes S, Morton SC, Shekelle PG 2005 Meta-analysis: surgical treatment of obesity . anninternMed142:547–559

5 . Pajecki D, Dalcanalle L, Souza de Oliveira CP, Zilberstein B, Halpern A, Garrido Jr AB, Cecconello I2007Follow-upofRoux-en-Ygastricbypasspatientsat5ormoreyearspost-operatively .Obessurg17:601–607

6 . Larrad-Jiménez A, Díaz-Guerra CS, de Cuadros Borrajo P, Lesmes IB, Esteban BM2007short-,mid-andlong-termresultsoflarradbiliopancreaticdiversion .Obessurg17:202–210

7 . Capella JF, Capella RF 1996Theweightreductionoperationofchoice:verticalbandedgastroplastyorgastricbypass?amJsurg171:74–79

8 . Magro DO, Geloneze B, Delfini R, Pareja BC, Callejas F, Pareja JC2008long-termweightregainaftergastricbypass:a5-yearpro¬spectivestudy .Obessurg18:648–651

9 . Karlsson J, Taft C, Rydén A, Sjöström L, Sullivan M2007Ten-yeartrendsinhealth-relatedqualityoflifeaftersurgicaland conventional treatment for severe obesity: the sOsinterventionstudy .intJObes(lond)31:1248–1261

10 . Silver HJ, Torquati A, Jensen GL, Richards WO 2006Weight, dietary and physical activity behaviors two yearsaftergastricbypass .Obessurg16:859–864

11 . Parikh M, Lo H, Chang C, Collings D, Fielding G, Ren C 2006Comparisonofoutcomesafter laparoscopicadjustablegastricbandinginafrican-americansandwhites .surgObesRelatdis2:607–610;discussion610–612

12 . Xu Y, Ramos EJ, Middleton F, Romanova I, Quinn R, Chen C, Das U, Inui A, Meguid MM2004GeneexpressionprofilespostRoux-en-Ygastricbypass .surgery136:246–252

references13 . Cummings DE, Weigle DS, Frayo RS, Breen PA, Ma MK,

Dellinger EP, Purnell JQ 2002 Plasma ghrelin levels afterdiet-inducedweight lossor gastricbypass surgery .nengl JMed346:1623–1630

14 . Fröhbeck G, Rotellar F, Hernández-Lizoain JL, Gil MJ, Gómez-Ambrosi J, Salvador J, Cienfuegos JA 2004Fastingplasmaghrelinconcentrations6monthsaftergastricbypassarenotdeterminedbyweightlossorchangesininsulinemia .Obessurg14:1208–1215

15 . le Roux CW, Welbourn R, Werling M, Osborne A, Kokkinos A, Laurenius A, Lönroth H, Fändriks L, Ghatei MA, Bloom SR, Olbers T2007Guthormonesasmediatorsof appetite and weight loss after Roux-en-Y gastric bypass .annsurg246:780–785

16 . Christou NV, Look D, McLean AP 2005Pre-andpost-pran-dial plasma ghrelin levels do not correlate with satiety orfailure to achieve a successful outcome after Roux-en-Ygastricbypass .Obessurg15:1017–1023

17 . Coupaye M, Bouillot JL, Coussieu C, Guy-Grand B, Basdevant A, Oppert JM2005One-yearchangesinenergyexpenditure and serum leptin following adjustable gastricbandinginobesewomen .Obessurg15:827–833

18 . Carey DG, Pliego GJ, Raymond RL2006Bodycompositionandmetabolicchangesfollowingbariatricsurgery:effectsonfatmass, leanmassandbasalmetabolicrate: sixmonthstoone-yearfollow-up .Obessurg16:1602–1608

19 . Madan AK, Tichansky DS, Phillips JC2007doespouchsizematter?Obessurg17:317–320

20 . Nishie A, Brown B, Barloon T, Kuehn D, Samuel I2007Comparisonofsizeofproximalgastricpouchandshort-termweightlossfollowingroutineuppergastrointestinalcontraststudyafterlaparoscopicRoux-en-Ygastricbypass .Obessurg17:1183–1188

21 . O’Brien PE, McPhail T, Chaston TB, Dixon JB 2006systematicreviewofmedium-termweightlossafterbariatricoperations .Obessurg16:1032–1040

22 . Borg CM, le Roux CW, Ghatei MA, Bloom SR, Patel AG 2007Biliopancreaticdiversioninratsisassociatedwithintes-tinalhypertrophyandwithincreasedGlP-1,GlP-2andPYYlevels .Obessurg17:1193–1198

23 . te Riele WW, Vogten JM, Boerma D, Wiezer MJ, van Rams-horst B2008Comparisonofweightlossandmorbidityaftergastricbypassandgastricbanding:asinglecentereuropeanexperience .Obessurg18:11–16

24 . Prachand VN, Davee RT, Alverdy JC 2006duodenalswitchprovides superiorweight loss in the super-obese(BMi≥50kg/m2)comparedwithgastricbypass .annsurg244:611–619

25 . Tice JA, Karliner L, Walsh J, Petersen AJ, Feldman MD2008 Gastric banding or bypass? a systematic reviewcomparingthetwomostpopularbariatricprocedures .amJMed121:885–893

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22

26 . Burgmer R, Grigutsch K, Zipfel S, Wolf AM, de Zwaan M, Husemann B, Albus C, Senf W, Herpertz S2005Theinflu-enceofeatingbehaviorandeatingpathologyonweightlossaftergastricrestrictionoperations .Obessurg15:684–691

27 . Pontiroli AE, Fossati A, Vedani P, Fiorilli M, Folli F, Pagan-elli M, Marchi M, Maffei C2007Post-surgeryadherencetoscheduledvisitsandcompliance,morethanpersonalitydisor-ders, predict outcome of bariatric restrictive surgery inmorbidlyobesepatients .Obessurg17:1492–1497

28 . Evans RK, Bond DS, Wolfe LG, Meador JG, Herrick JE, Kellum JM, Maher JW2007Participationin150min/wkofmoderateorhigherintensityphysicalactivityyieldsgreaterweightlossaftergastricbypasssurgery .surgObesRelatdis3:526–530

29 . van Hout GC, Verschure SK, van Heck GL 2005 Psycho-socialpredictorsof success followingbariatric surgery .Obessurg15:552–560

30 . Mamplekou E, Komesidou V, Bissias Ch, Papakonstan-tinou A, Melissas J2005Psychologicalconditionandqualityoflifeinpatientswithmorbidobesitybeforeandaftersurgicalweightloss .Obessurg15:1177–1184

31 . van Hout GC, Fortuin FA, Pelle AJ, van Heck GL 2008Psychosocial functioning, personality, and body imagefollowingverticalbandedgastroplasty .Obessurg18:115–120

32 . Faria SL, de Oliveira Kelly E, Lins RD, Faria OP 2010nutritional management of weight regain after bariatricsurgery .Obessurg20:135–139

33 . Orth WS, Madan AK, Taddeucci RJ, Coday M, Tichansky DS 2008 support group meeting attendance is associatedwithbetterweightloss .Obessurg18:391–394

34 . Elakkary E, Elhorr A, Aziz F, Gazayerli MM, Silva YJ2006dosupportgroupsplayaroleinweightlossafterlaparoscopicadjustablegastricbanding?Obessurg16:331–334

35 . Schwartz RW, Strodel WE, Simpson WS, Griffen Jr WO 1988Gastricbypassrevision:lessonslearnedfrom920cases .surgery104:806–812

36 . Iannelli A, Amato D, Addeo P, Buratti MS, Damhan M, Ben Amor I, Sejor E, Facchiano E, Gugenheim J2008lapa-roscopicconversionofverticalbandedgastroplasty (MasonMaclean)intoRoux-en-Ygastricbypass .Obessurg18:43–46

37 . Keshishian A, Zahriya K, Hartoonian T, Ayagian C 2004duodenal switch is a safe operation for patients who havefailedotherbariatricoperations .Obessurg14:1187–1192

38 . Brolin RE 2002Bariatric surgery and long-termcontrolofmorbidobesity .JaMa288:2793–2796

39 . Faintuch J, Matsuda M, Cruz MELF, Silva MM, Teivelis MP, Garrido Jr AB, Gama-Rodrigues JJ 2004 severeprotein-caloriemalnutritionafterbariatricprocedures .Obessurg14:175–181

40 . Dolan K, Hatzifotis M, Newbury L, Fielding G 2004a comparison of laparoscopic adjustable gastric bandingand biliopancreatic diversion in superobesity . Obes surg14:165–169

41 . Byrne TK 2001 Complications of surgery for obesity . surgClinnortham81:1181–1193,vii–viii

42 . Stocker DJ2003Managementofthebariatricsurgerypatient .endocrinolMetabClinnortham32:437–457

43 . Marceau S, Biron S, Lagace M, Hould FS, Potvin M, Bourque RA, Marceau P 1995 Biliopancreatic diversion,withdistalgastrectomy,250cmand50cmlimbs:long-termresults .Obessurg5:302–307

44 . Marinari GM, Murelli F, Camerini G, Papadia F, Carlini F, Stabilini C, Adami GF, Scopinaro N 2004a15-yearevalu-ationofbiliopancreaticdiversionaccordingtotheBariatricanalysisReportingOutcomesystem(BaROs) .Obessurg14:325–328

45 . Nanni G, Balduzzi GF, Capoluongo R, Scotti A, Rosso G, Botta C, Demichelis P, Daffara M, Coppo E1997Biliopan-creaticdiversion:clinicalexperience .Obessurg7:26–29

46 . Kalfarentzos F, Dimakopoulos A, Kehagias I, Loukidi A, Mead N1999Verticalbandedgastroplastyversusstandardordistal Roux-en-Y gastric bypass based on specific selectioncriteriainthemorbidlyobese:preliminaryresults .Obessurg9:433–442

47 . Brolin RE, Kenler HA, Gorman JH, Cody RP1992long-limbgastricbypassinthesuperobese .aprospectiverandom-izedstudy .annsurg215:387–395

48 . Skroubis G, Sakellaropoulos G, Pouggouras K, Mead N, Nikiforidis G, Kalfarentzos F 2002 Comparison of nutri-tional deficiencies after Roux-en-Y gastric bypass and afterbiliopancreatic diversion with Roux-en-Y gastric bypass .Obessurg12:551–558

49 . Marceau P, Hould FS, Lebel S, Marceau S, Biron S 2001Malabsorption obesity surgery . surg Clin north am81:1113–1127

50 . Bock MA2003Roux-en-Ygastricbypass:thedietitian’sandpatient’sperspectives .nutrClinPract18:141–144

51 . Ziegler O, Sirveaux MA, Brunaud L, Reibel N, Quilliot D 2009 Medical follow up after bariatric surgery: nutritionalanddrugissues .Generalrecommendationsforthepreventionand treatment of nutritional deficiencies . diabetes Metab35:544–557

52 . Layman DK2003Theroleofleucineinweightlossdietsandglucosehomeostasis .Jnutr133:261s–267s

53 . Volpi E, Sheffield-Moore M, Rasmussen BB, Wolfe RR2001Basalmuscleaminoacidkineticsandproteinsynthesisinhealthyyoungandoldermen .JaMa286:1206–1212

54 . Garlick PJ 2005 The role of leucine in the regulation ofproteinmetabolism .Jnutr135:1553s–1556s

55 . Layman DK, Walker DA2006Proteinimportanceofleucineintreatmentofobesityandthemetabolicsyndrome .Jnutr136:319s–323s

56 . Kushner R2000Managingtheobesepatientafterbariatricsurgery:acasereportofseveremalnutritionandreviewoftheliterature .JPenJParenterenteralnutr24:126–132

Endo

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23

57 . Carrodeguas L, Kaidar-Person O, Szomstein S, Antozzi P, Rosenthal R2005Preoperativethiaminedeficiencyinobesepopulation undergoing laparoscopic bariatric surgery . surgObesRelatdis1:517–522

58 . lagacé M, Marceau P, Marceau S, Hould FS, Potvin M, Bourque RA, Biron S1995Biliopancreaticdiversionwithanewtypeofgastrectomy:somepreviousconclusionsrevisited .Obessurg5:411–418

59 . Brolin RE, Gorman RC, Milgrim LM, Kenler HA 1991Multivitaminprophylaxisinpreventionofpostgastricbypassvitaminandmineraldeficiencies .intJObes15:661–667

60 . Compston JE, Vedi S, Gianetta E, Watson G, Civalleri D, Scopinaro N 1984Bonehistomorphometry andvitamindstatus after biliopancreatic bypass for obesity . Gastroenter-ology87:350–356

61 . Monteforte MJ, Turkelson CM 2000 Bariatric surgery formorbidobesity .Obessurg10:391–401

62 . Brolin RE, Leung M 1999 survey of vitamin and mineralsupplementation after gastric bypass and biliopancreaticdiversionformorbidobesity .Obessurg9:150–154

63 . Crowley LV, Seay J, Mullin G 1984 late effects of gastricbypassforobesity .amJGastroenterol79:850–860

64 . Saltzman E, Anderson W, Apovian CM, Boulton H, Cham-berlain A, Cullum-Dugan D, Cummings S, Hatchigian E, Hodges B, Keroack CR, Pettus M, Thomason P, Veglia L, Young LS2005Criteriaforpatientselectionandmultidisci-plinaryevaluationandtreatmentof theweight loss surgerypatient .ObesRes13:234–243

65 . Shikora SA, Kim JJ, Tarnoff ME2007nutritionandgastro-intestinalcomplicationsofbariatricsurgery .nutrClinPract22:29–40

66 . Levenson DI, Bockman RS1994areviewofcalciumprepa-rations .nutrRev52:221–232

67 . Miller PD2006Guidelinesforthediagnosisofosteoporosis:T-scoresvsfracture .RevendocrMetabdisord7:75–89

68 . Goode LR, Brolin RE, Chowdhury HA, Shapses SA2004Boneandgastricbypasssurgery:effectsofdietarycalciumandvitamind .ObesRes12:40–47

69 . Bloomberg RD, Fleishman A, Nalle JE, Herron DM, Kini S 2005 nutritional deficiencies following bariatric surgery:whathavewelearned?Obessurg15:145–154

70 . Smith CD, Herkes SB, Behrns KE, Fairbanks VF, Kelly KA, Sarr MG1993GastricacidsecretionandvitaminB12absorptionafterverticalRoux-en-Ygastricbypassformorbidobesity .annsurg218:91–96

71 . Behrns KE, Smith CD, Sarr MG1994Prospectiveevalua-tion of gastric acid secretion and cobalamin absorptionfollowinggastricbypassforclinicallysevereobesity .digdissci39:315–320

72 . Provenzale D, Reinhold RB, Golner B, Irwin V, Dallal GE, Papathanasopoulos N, Sahyoun N, Samloff IM, Russell RM 1992 evidence for diminished B12 absorption after gastricbypass: oral supplementation does not prevent low plasmaB12levels .JamCollnutr11:29–35

73 . Halverson JD 1986 Micronutrient deficiencies after gastricbypassformorbidobesity .amsurg52:594–598

74 . Brolin RE, LaMarca LB, Kenler HA, Cody RP 2002Malab-sorptivegastricbypassinpatientswithsuperobesity .JGastro-intestsurg6:195–203;discussion204–205

75 . Marcuard SP, Sinar DR, Swanson MS, Silverman JF, Levine JS 1989 absence of luminal intrinsic factor after gastricbypasssurgeryformorbidobesity .digdissci34:1238–1242

76 . Cooper PL, Brearley LK, Jamieson AC, Ball MJ1999nutri-tionalconsequencesofmodifiedverticalgastroplastyinobesesubjects .intJObesRelatMetabdisord23:382–388

77 . Strauss RS, Bradley LJ, Brolin RE2001Gastricbypasssurgeryinadolescentswithmorbidobesity .JPediatr138:499–504

78 . Rhode BM, Tamin H, Gilfix BM, Sampalis JS, Nohr C, MacLean LD1995TreatmentofvitaminB12deficiencyaftergastricsurgeryforsevereobesity .Obessurg5:154–158

79 . Rhode BM, Arseneau P, Cooper BA, Katz M, Gilfix BM, MacLean LD 1996 Vitamin B-12 deficiency after gastricsurgeryforobesity .amJClinnutr63:103–109

80 . Kuzminski AM, Del Giacco EJ, Allen RH, Stabler SP, Lindenbaum J 1998effective treatmentof cobalamindefi-ciencywithoralcobalamin .Blood92:1191–1198

81 . Clements RH, Katasani VG, Palepu R, Leeth RR, Leath TD, Roy BP, Vickers SM 2006 incidence of vitamin defi-ciencyafterlaparoscopicroux-en-Ygastricbypassinauniver-sity hospital setting . am surg 72:1196–1202; discussion1203–1204

82 . Sharabi A, Cohen E, Sulkes J, Garty M 2003ReplacementtherapyforvitaminB12deficiency:comparisonbetweenthesublingualandoralroute .BrJClinPharmacol56:635–638

83 . Park AM, Storm DW, Fulmer BR, Still CD, Wood GC, Hartle 2nd JE 2009 a prospective study of risk factors fornephrolithiasisafterRoux-en-Ygastricbypasssurgery .Jurol182:2334–2339

84 . Rhode BM, Shustik C, Christou NV, MacLean LD 1999ironabsorptionand therapyaftergastricbypass .Obessurg9:17–21

85 . Brolin RE, Gorman JH, Gorman RC, Petschenik AJ, Bradley LB, Kenler HA, Cody RP1998Prophylactic ironsupplementation afterRoux-en-Y gastric bypass: a prospec-tive,double-blind,randomizedstudy .archsurg133:740–744

86 . Skroubis G, Anesidis S, Kehagias I, Mead N, Vagenas K, Kalfarentzos F 2006 Roux-en-Y gastric bypass versus avariant of biliopancreatic diversion in a non-superobesepopulation: prospective comparison of the efficacy and theincidenceofmetabolicdeficiencies .Obessurg16:488–495

an E

ndo

crin

E so

ciEt

y cl

inic

al P

ract

icE

guid

Elin

E

24

87 . Lechner GW, Callender AK1981subtotalgastricexclusionand gastric partitioning: a randomized prospective compar-isonofonehundredpatients .surgery90:637–644

88 . Herbert V1968absorptionofvitaminB12and folicacid .Gastroenterology54:110–115

89 . Fondu P, Hariga-Muller C, Mozes N, Neve J, Van Steirteghem A, Mandelbaum IM 1978 Protein-energymalnutritionandanemiainKivu .amJClinnutr31:46–56

90 . Hallberg L, Brune M, Erlandsson M, Sandberg AS, Rossander-Hultén L 1991 Calcium: effect of differentamountsonnonhemeandheme-ironabsorptioninhumans .amJClinnutr53:112–119

91 . Cook JD, Dassenko SA, Whittaker P1991Calciumsupple-mentation: effect on iron absorption . am J Clin nutr53:106–111

92 . Reddy MB, Cook JD 1997 effect of calcium intake onnonhemeiron absorption from a complete diet . am J Clinnutr65:1820–1825

93 . Avinoah E, Ovnat A, Charuzi I 1992 nutritional statusseven years after Roux-en-Y gastric bypass surgery . surgery111:137–142

94 . Slater GH, Ren CJ, Siegel N, Williams T, Barr D, Wolfe B, Dolan K, Fielding GA2004serumfatsolublevitamindefi-ciencyandabnormalcalciummetabolismaftermalabsorptivebariatricsurgery .JGastrointestsurg8:48–55

95 . Davies DJ, Baxter JM, Baxter JN2007nutritionaldeficien-ciesafterbariatricsurgery .Obessurg17:1150–1158

96 . Mejia LA1992Roleofvitaminainirondeficiencyanemia .in:FomonsJ,Zlotkins,eds .nutritionalanemias .newYork:RavenPress;93–104

97 . Shuster MH, Vázquez JA2005nutritionalconcernsrelatedto Roux-en-Y gastric bypass: what every clinician needs toknow .CritCarenursQ28:227–260;quiz261–262

98 . Mason EE1998starvationinjuryaftergastricreductionforobesity .WorldJsurg22:1002–1007

99 . MacLean LD, Rhode BM, Shizgal HM 1983 nutritionfollowing gastric operations for morbid obesity . ann surg198:347–355

100 . Feit H, Glasberg M, Ireton C, Rosenberg RN, Thal E1982Peripheral neuropathy and starvation after gastric parti-tioningformorbidobesity .anninternMed96:453–455

101 . Fawcett S, Young GB, Holliday RL1984Wernicke’senceph-alopathyaftergastricpartitioningformorbidobesity .CanJsurg27:169–170

102 . Villar HV, Ranne RD 1984 neurologic deficit followinggastricpartitioning:possibleroleofthiamine .JPenJParenterenteralnutr8:575–578

103 . Somer H, Bergström L, Mustajoki P, Rovamo L 1985Morbid obesity, gastric plication and a severe neurologicaldeficit .actaMedscand217:575–576

104 . Paulson GW, Martin EW, Mojzisik C, Carey LC 1985neurologic complications of gastric partitioning . archneurol42:675–677

105 . Oczkowski WJ, Kertesz A1985Wernicke’sencephalopathyaftergastroplastyformorbidobesity .neurology35:99–101

106 . Abarbanel JM, Berginer VM, Osimani A, Solomon H, Charuzi I1987neurologiccomplicationsaftergastricrestric-tionsurgeryformorbidobesity .neurology37:196–200

107 . Singh S, Kumar A 2007 Wernicke encephalopathy afterobesitysurgery:asystematicreview .neurology68:807–811

108 . Angstadt JD, Bodziner RA2005PeripheralpolyneuropathyfromthiaminedeficiencyfollowinglaparoscopicRoux-en-Ygastricbypass .Obessurg15:890–892

109 . Chaves LC, Faintuch J, Kahwage S, Alencar Fde A2002aclusterofpolyneuropathyandWernicke-Korsakoffsyndromeinabariatricunit .Obessurg12:328–334

110 . Primavera A, Brusa G, Novello P, Schenone A, Gianetta E, Marinari G, Cuneo S, Scopinaro N1993Wernicke-Korsa-koff encephalopathy following biliopancreatic diversion .Obessurg3:175–177

111 . Rindi G, Bordi C, Rappel S, La Rosa S, Stolte M, Solcia E 1996 Gastric carcinoids and neuroendocrine carcinomas:pathogenesis, pathology, and behavior . World J surg20:168–172

112 . Heye N, Terstegge K, Sirtl C, McMonagle U, Schreiber K, Meyer-Gessner M 1994 Wernicke’s encephalopathy: causestoconsider .intensiveCareMed20:282–286

113 . Ernst B, Thurnheer M, Schmid SM, Schultes B 2009evidenceforthenecessitytosystematicallyassessmicronu-trientstatuspriortobariatricsurgery .Obessurg19:66–73

114 . Shah M, Simha V, Garg A2006Review:long-termimpactofbariatricsurgeryonbodyweight,comorbidities,andnutri-tionalstatus .JClinendocrinolMetab91:4223–4231

115 . Xanthakos SA, Inge TH 2006nutritional consequencesofbariatricsurgery .CurrOpinClinnutrMetabCare9:489–496

116 . Alvarez-Leite JI 2004 nutrient deficiencies secondary tobariatricsurgery .CurrOpinClinnutrMetabCare7:569–575

117 . Dindo D, Muller MK, Weber M, Clavien PA2003Obesityingeneralelectivesurgery .lancet361:2032–2035

118 . American Society of Anesthesiologists Task Force on Preanesthesia Evaluation 2002 a report by the americansociety of anesthesiologists task force on preanesthesiaevaluation . Practice advisory for preanesthesia evaluation .anesthesiology96:485–496

119 . Flancbaum L, Belsley S, Drake V, Colarusso T, Tayler E2006Preoperativenutritional statusof patientsundergoingRoux-en-Ygastricbypass formorbidobesity . JGastrointestsurg10:1033–1037

120 . Madan AK, Orth WS, Tichansky DS, Ternovits CA 2006Vitamin and trace mineral levels after laparoscopic gastricbypass .Obessurg16:603–606

Endo

crinE an

d nu

trition

al Man

agEMEn

t of th

E Post-Bariatric su

rgEry PatiEnt

25

121 . Silecchia G, Greco F, Bacci V, Boru C, Pecchia A, Casella G, Rizzello M, Basso N 2005 Results after laparoscopic gastricbandinginpatientsover55yearsofage .Obessurg15:351–356

122 . Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, Schoelles K2004Bariatricsurgery:asystematicreviewandmeta-analysis .JaMa292:1724–1737

123 . Torquati A, Lutfi R, Abumrad N, Richards WO 2005 isRoux-en-Y gastric bypass surgery the most effective treat-mentfortype2diabetesmellitusinmorbidlyobesepatients?JGastrointestsurg9:1112–1118

124 . Pories WJ, Swanson MS, MacDonald KG, Long SB, Morris PG, Brown BM, Barakat HA, deRamon RA, Israel G, Dolezal JM1995Whowouldhavethoughtit?anoperationproves to be the most effective therapy for adult-onsetdiabetes mellitus . ann surg 222: 339–350; discussion350–352

125 . Hickey MS, Pories WJ, MacDonald Jr KG, Cory KA, Dohm GL, Swanson MS, Israel RG, Barakat HA, Considine RV, Caro JF, Houmard JA 1998 a new paradigm for type 2diabetesmellitus: could itbeadiseaseof the foregut?annsurg227:637–643;discussion643–644

126 . Schauer PR, Burguera B, Ikramuddin S, Cottam D, Gourash W, Hamad G, Eid GM, Mattar S, Ramanathan R, Barinas-Mitchel E, Rao RH, Kuller L, Kelley D2003effectoflaparoscopicRoux-en-Ygastricbypassontype2diabetesmellitus .annsurg238:467–484;discussion84–85

127 . Sanderson I, Deitel M 1974 insulin response in patientsreceiving concentrated infusions of glucose and caseinhydrolysate for complete parenteral nutrition . ann surg179:387–394

128 . Deitel M, Sidhu P, Stone E 1991effectofverticalbandedgastroplasty on diabetes in the morbidly obese . Obes surg1:113–114aQ:MM(abstract)

129 . Jensen K, Mason E, Scott D1991Changesinthepostopera-tivehypoglycemicandantihypertensivemedicationrequire-ments in morbidly obese patients after VBG . Obes surg1:113–114(abstract)

130 . Smith SC, Edwards CB, Goodman GN 1996 Changes indiabetic management after Roux-en-Y gastric bypass . Obessurg6:345–348

131 . Mingrone G, DeGaetano A, Greco AV, Capristo E, Bene-detti G, Castagneto M, Gasbarrini G1997Reversibilityofinsulin resistance inobesediabeticpatients: roleof plasmalipids .diabetologia40:599–605

132 . Pories WJ, MacDonald Jr KG, Flickinger EG, Dohm GL, Sinha MK, Barakat HA, May HJ, Khazanie P, Swanson MS, Morgan E 1992 is type ii diabetes mellitus (niddM) asurgicaldisease?annsurg215:633–642;discussion643

133 . Pories WJ, MacDonald KG, Morgan EJ, Sinha MK, Dohm GL, Swanson MS, Barakat HA, Khazanie PG, Leggett-Frazier N, Long SD1992surgicaltreatmentofobesityandits effect on diabetes: 10-y follow-up . am J Clin nutr55(suppl2):582s–585s

134 . Long SD, O’Brien K, MacDonald Jr KG, Leggett-Frazier N, Swanson MS, Pories WJ, Caro JF 1994 Weight loss inseverelyobesesubjectspreventstheprogressionofimpairedglucose tolerance to type ii diabetes . a longitudinal inter-ventionalstudy .diabetesCare17:372–375

135 . Muscelli E, Mingrone G, Camastra S, Manco M, Pereira JA, Pareja JC, Ferrannini E 2005 differential effect of weightlossoninsulinresistanceinsurgicallytreatedobesepatients .amJMed118:51–57

136 . Rubino F, Gagner M, Gentileschi P, Kini S, Fukuyama S, Feng J, Diamond E2004TheearlyeffectoftheRoux-en-Ygastricbypassonhormonesisinvolvedinbodyweightregula-tionandglucosemetabolism .annsurg240:236–242

137 . Wickremesekera K, Miller G, Naotunne TD, Knowles G, Stubbs RS 2005 loss of insulin resistance after Roux-en-Ygastricbypasssurgery:atimecoursestudy .Obessurg15:474–481

138 . Herbst CA, Hughes TA, Gwynne JT, Buckwalter JA1984Gastricbariatricoperationininsulintreatedadults .surgery95:209–214

139 . Laferrére B, Teixeira J, McGinty J, Tran H, Egger JR, Colarusso A, Kovack B, Bawa B, Koshy N, Lee H, Yapp K, Olivan B2008effectofweightlossbygastricbypasssurgeryversus hypocaloric diet on glucose and incretin levels inpatients with type 2 diabetes . J Clin endocrinol Metab93:2479–2485

140 . Dixon JB, O’Brien PE, Playfair J, Chapman L, Schachter LM, Skinner S, Proietto J, Bailey M, Anderson M 2008adjustable gastric banding and conventional therapy fortype 2 diabetes: a randomized controlled trial . JaMa299:316–323

141 . Cummings DE, Overduin J, Foster-Schubert KE 2004Gastric bypass for obesity: mechanisms of weight loss anddiabetesresolution .JClinendocrinolMetab89:2608–2615

142 . Cummings DE, Overduin J, Foster-Schubert KE, Carlson MJ 2007Roleofthebypassedproximalintestineintheanti-diabetic effects of bariatric surgery . surg Obes Relat dis3:109–115

143 . Cohen RV, Schiavon CA, Pinheiro JS, Correa JL, Rubino F 2007 duodenal-jejunal bypass for the treatment of type 2diabetesinpatientswithbodymassindexof22–34kg/m2:areportof2cases .surgObesRelatdis3:195–197

144 . Rubino F, Gagner M 2002 Potential of surgery for curingtype2diabetesmellitus .annsurg236:554–559

145 . Rubino F, Marescaux J 2004 effect of duodenal-jejunalexclusion in a non-obese animal model of type 2 diabetes .annsurg239:1–11

146 . Rubino F, Zizzari P, Tomasetto C, Bluet-Pajot MT, Forgione A, Vix M, Grouselle D, Marescaux J2005Theroleofthesmallbowel intheregulationofcirculatingghrelin levelsandfoodintakeintheobeseZuckerrat .endocrinology146:1745–1751

147 . de Paula AL, Macedo AL, Prudente AS, Queiroz L, Schraibman V, Pinus J 2006 laparoscopic sleeve gastrec-tomywithilealinterposition(“neuroendocrinebrake”):pilotstudyofanewoperation .surgObesRelatdis2:464–467

an E

ndo

crin

E so

ciEt

y cl

inic

al P

ract

icE

guid

Elin

E

26

148 . Vora AC, Saleem TM, Polomano RC, Eddinger VL, Hollen-beak CS, Girdharry DT, Joshi R, Martin D, Gabbay RA2004improvedperioperativeglycemiccontrolbycontinuousinsulininfusionundersupervisionofanendocrinologistdoesnot increase costs in patients with diabetes . endocr Pract10:112–118

149 . Pomposelli JJ, Baxter 3rd JK, Babineau TJ, Pomfret EA, Driscoll DF, Forse RA, Bistrian BR1998earlypostopera-tive glucose control predicts nosocomial infection rate indiabeticpatients .JPenJParenterenteralnutr22:77–81

150 . Dronge AS, Perkal MF, Kancir S, Concato J, Aslan M, Rosenthal RA2006long-termglycemiccontrolandpostop-erativeinfectiouscomplications .archsurg141:375–380

151 . NICE-SUGAR Study Investigators; Finfer S, Chittock DR, Su SY, Blair D, Foster D, Dhingra V, Bellomo R, Cook D, Dodek P, Henderson WR, Hébert PC, Heritier S, Heyland DK, McArthur C, McDonald E, Mitchell I, Myburgh JA, Norton R, Potter J, Robinson BG, Ronco JJ2009intensiveversusconventionalglucosecontrolincriticallyillpatients .nenglJMed360:1283–1297

152 . Datta S, Qaadir A, Villanueva G, Baldwin D 2007Once-daily insulin glargine versus 6-hour sliding scale regularinsulinforcontrolofhyperglycemiaafterabariatricsurgicalprocedure: a randomized clinical trial . endocr Pract13:225–231

153 . Maggard MA, Yermilov I, Li Z, Maglione M, Newberry S, Suttorp M, Hilton L, Santry HP, Morton JM, Livingston EH, Shekelle PG 2008 Pregnancy and fertility followingbariatricsurgery:asystematicreview .JaMa300:2286–2296

154 . Gholam PM, Kotler DP, Flancbaum LJ2002liverpathologyin morbidly obese patients undergoing Roux-en-Y gastricbypasssurgery .Obessurg12:49–51

155 . Mattar SG, Velcu LM, Rabinovitz M, Demetris AJ, Krasin-skas AM, Barinas-Mitchell E, Eid GM, Ramanathan R, Taylor DS, Schauer PR2005surgically-inducedweightlosssignificantly improves nonalcoholic fatty liver disease andthemetabolicsyndrome .annsurg242:610–620

156 . Adams LA, Angulo P2006Treatmentofnon-alcoholicfattyliverdisease .PostgradMedJ82:315–322

157 . Ranløv I, Hardt F1990Regressionofliversteatosisfollowinggastroplasty or gastric bypass for morbid obesity . digestion47:208–214

158 . Silverman EM, Sapala JA, Appelman HD1995Regressionof hepatic steatosis in morbidly obese persons after gastricbypass .amJClinPathol104:23–31

159 . Luyckx FH, Desaive C, Thiry A, Dewe W, Scheen AJ, Gielen JE, Lefe bvre PJ1998liverabnormalitiesinseverelyobesesubjects:effectofdrasticweightlossaftergastroplasty .intJObesRelatMetabdisord22:222–226

160 . Duchini A, Brunson ME2001Roux-en-Ygastricbypassforrecurrent nonalcoholic steatohepatitis in liver transplantrecipientswithmorbidobesity .Transplantation72:156–159

161 . Clark JM, Alkhuraishi AR, Solga SF, Alli P, Diehl AM, Magnuson TH2005Roux-en-Ygastricbypassimprovesliverhistology in patients with non-alcoholic fatty liver disease .ObesRes13:11801186

162 . Barker KB, Palekar NA, Bowers SP, Goldberg JE, Pulcini JP, Harrison SA2006non-alcoholic steatohepatitis: effectof Roux-en-Y gastric bypass surgery . am J Gastroenterol101:368–373

163 . Jaskiewicz K, Raczynska S, Rzepko R, Sledziñski Z 2006nonalcoholic fatty liverdiseasetreatedbygastroplasty .digdissci51:21–26

164 . Mathurin P, Gonzalez F, Kerdraon O, Leteurtre E, Arnals-teen L, Hollebecque A, Louvet A, Dharancy S, Cocq P, Jany T, Boitard J, Deltenre P, Romon M, Pattou F 2006 Theevolutionofseveresteatosisafterbariatricsurgeryisrelatedtoinsulinresistance .Gastroenterology130:1617–1624

165 . Green RM, Flamm S 2002 aGa technical review on theevaluation of liver chemistry tests . Gastroenterology123:1367–1384

166 . Dallal RM, Mattar SG, Lord JL, Watson AR, Cottam DR, Eid GM, Hamad G, Rabinovitz M, Schauer PR 2004Resultsoflaparoscopicgastricbypassinpatientswithcirrhosis .Obessurg14:47–53

167 . Tichansky DS, Madan AK 2005 laparoscopic Roux-en-Ygastricbypassissafeandfeasibleafterorthotopiclivertrans-plantation .Obessurg15:1481–1486

168 . American Gastroenterological Association 2002americanGastroenterologicalassociationmedicalpositionstatement:nonalcoholic fatty liver disease . Gastroenterology 123:1702–1704

169 . Clark JM, Diehl AM2003nonalcoholic fatty liverdiseasean under recognized cause of cryptogenic cirrhosis . JaMa289:30003004

170 . Dixon JB, O’Brien PE 2002 lipid profile in the severelyobese:changeswithweightlossafterlap-bandsurgery .ObesRes10:903–910

171 . Gleysteen JJ, Barboriak JJ 1983improvementinheartdiseaseriskfactorsaftergastricbypass .archsurg118:681–684

172 . Gleysteen JJ 1992 Results of surgery: long term effects onhyperlipidemia .amJClinnutr55(suppl2):591s–593s

173 . Buffington CK, Cowan Jr GS, Smith H 1994 significantchanges in the lipid-lipoprotein status of premenopausalmorbidlyobesefemalesfollowinggastricbypasssurgery .Obessurg4:328–335

174 . Wolf AM, Beisiegel U, Kortner B, Kuhlmann HW 1998doesgastricrestrictionsurgeryreducetherisksofmetabolicdiseases?Obessurg8:9–13

175 . Busetto L, Pisent C, Rinaldi D, Longhin PL, Segato G, De Marchi F, Foletto M, Favretti F, Lise M, Enzi G2000Varia-tioninlipidlevelsinmorbidlyobesepatientsoperatedwiththe lap-Band® adjustable gastric banding system: effects ofdifferentlevelsofweightloss .Obessurg10:569–577

Endo

crinE an

d nu

trition

al Man

agEMEn

t of th

E Post-Bariatric su

rgEry PatiEnt

27

176 . Brolin RE, Bradley LJ, Wilson AC, Cody RP2000lipidriskprofileandweightstabilityaftergastricrestrictiveoperationsformorbidobesity .JGastrointestsurg4:464–469

177 . Sjöström CD, Lissner L, Wedel H, Sjöström L1999Reduc-tioninincidenceofdiabetes,hypertensionandlipiddistur-bances after intentional weight loss induced by bariatricsurgery:thesOsinterventionstudy .ObesRes7:477–484

178 . Lubrano C, Cornoldi A, Pili M, Falcone S, Brandetti F, Fabbrini E, Ginanni-Corradini S, Eramo A, Marini M, Migliaccio S, Giancotti V, Badiali M, Falsetto N, Prossoma-riti G, Spera G2004Reductionofriskfactorsforcardiovas-cular diseases in morbid-obese patients followingbiliary-intestinalbypass:3years’follow-up .intJObesRelatMetabdisord28:1600–1606

179 . Palomar R, Fernández-Fresnedo G, Domínguez-Diez A, López-Deogracias M, Olmedo F, Martín de Francisco AL, Sanz de Castro S, Casado Martín F, Gómez-Fleitas M, Arias M, Fernández-Escalante C2005effectsofweight lossafterbiliopancreaticdiversiononmetabolismandcardiovascularprofile .Obessurg15:794–798

180 . Corradini SG, Eramo A, Lubrano C, Spera G, Cornoldi A, Grossi A, Liguori F, Siciliano M, Pisanelli MC, Salen G, Batta AK, Attili AF, Badiali M2005Comparisonofchangesinlipidprofileafterbilio-intestinalbypassandgastricbandinginpatientswithmorbidobesity .Obessurg15:367–377

181 . Zlabek JA, Grimm MS, Larson CJ, Mathiason MA, Lambert PJ, Kothari SN2005Theeffectoflaparoscopicgastricbypasssurgeryondyslipidemiainseverelyobesepatients .surgObesRelatdis1:537–542

182 . Vogel JA, Franklin BA, Zalesin KC, Trivax JE, Krause KR, Chengelis DL, McCullough PA2007Reductioninpredictedcoronaryheartdiseaseaftersubstantialweightreductionafterbariatricsurgery .amJCardiol99:222–226

183 . Williams DB, Hagedorn JC, Lawson EH, Galanko JA, Safadi BY, Curet MJ, Morton JM 2007 Gastric bypassreduces biochemical cardiac risk factors . surg Obes Relatdis3:8–13

184 . Dixon JB, O’Brien P 2001 a disparity between conven-tionallipidandinsulinresistancemarkersatbodymassindexlevelsgreaterthan34kg/m2 .intJObesRelatMetabdisord25:793–797

185 . Adams TD, Gress RE, Smith SC, Halverson RC, Simper SC, Rosamond WD, Lamonte MJ, Stroup AM, Hunt SC2007long-termmortalityfollowinggastricbypasssurgery .nenglJMed357:753–761

186 . National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) 2002 Third Report of the national Cholesterol educationProgram (nCeP) expert Panel on detection, evaluation,andTreatmentofHighBloodCholesterolinadults(adultTreatmentPaneliii)finalreport .Circulation106:3143–3421

187 . Korpershoek HW, Witteman EM, Meinardi JR, Vollaard EJ 2010[severevitaminddeficiencyandhypocalcaemiaafterbariatricsurgery] .nedTijdschrGeneeskd154:a827(dutch)

188 . Vilarrasa N, Gómez JM, Masdevall C, Pujol J, Soler J, Elio I, Gallart L, Vendrell J2009studyoftherelationshipbetweenadiponectin, interleukin-18, ghrelin and bone mineraldensityinmorbidlyobesewomenaftergastricbypass .endo-crinolnutr56:355–360

189 . Nadler EP, Reddy S, Isenalumhe A, Youn HA, Peck V, Ren CJ, Fielding GA 2009 laparoscopic adjustable gastricbanding for morbidly obese adolescents affects android fatloss, resolution of comorbidities, and improved metabolicstatus .JamCollsurg209:638–644

190 . Tsiftsis DD, Mylonas P, Mead N, Kalfarentzos F, Alexan-drides TK 2009 Bone mass decreases in morbidly obesewomenafterlonglimb-biliopancreaticdiversionandmarkedweightlosswithoutsecondaryhyperparathyroidism .aphysi-ologicaladaptationtoweightloss?Obessurg19:1497–1503

191 . Valderas JP, Velasco S, Solari S, Liberona Y, Viviani P, Maiz A, Escalona A, González G2009increaseofboneresorptionandtheparathyroidhormoneinpostmenopausalwomeninthe long-term after Roux-en-Y gastric bypass . Obes surg19:1132–1138

192 . Al-Shoha A, Qiu S, Palnitkar S, Rao DS2009Osteomalaciawithbonemarrowfibrosisduetoseverevitaminddeficiencyafter a gastrointestinal bypass operation for severe obesity .endocrPract15:528–533

193 . Wang A, Powell A 2009 The effects of obesity surgery onbonemetabolism:what orthopedic surgeonsneed toknow .amJOrthop38:77–79

194 . Berarducci A, Haines K, Murr MM2009incidenceofboneloss, falls, and fractures after Roux-en-Y gastric bypass formorbidobesity .applnursRes22:35–41

195 . Stein EM, Strain G, Sinha N, Ortiz D, Pomp A, Dakin G, McMahon DJ, Bockman R, Silverberg SJ2009Vitamindinsufficiencypriortobariatricsurgery:riskfactorsandapilottreatmentstudy .Clinendocrinol(Oxf)71:176–183

196 . Carlin AM, Rao DS, Yager KM, Parikh NJ, Kapke A2009Treatment of vitamin d depletion after Roux-en-Y gastricbypass: a randomized prospective clinical trial . surg ObesRelatdis5:444–449

197 . Fleischer J, Stein EM, Bessler M, Della Badia M, Restuccia N, Olivero-Rivera L, McMahon DJ, Silverberg SJ2008Thedeclineinhipbonedensityaftergastricbypasssurgeryisasso-ciatedwithextentofweight loss . JClinendocrinolMetab93:3735–3740

198 . Duran de Campos C, Dalcanale L, Pajecki D, Garrido Jr AB, Halpern A 2008 Calcium intake and metabolic bonedisease after eight years of Roux-en-Y gastric bypass . Obessurg18:386–390

199 . Schweitzer DH2007Mineralmetabolismandbonediseaseafterbariatricsurgeryandwaystooptimizebonehealth .Obessurg17:1510–1516

200 . Hamoui N, Kim K, Anthone G, Crookes PF 2003 Thesignificance of elevated levels of parathyroid hormone inpatientswithmorbidobesitybeforeandafterbariatricsurgery .archsurg138:891–897

an E

ndo

crin

E so

ciEt

y cl

inic

al P

ract

icE

guid

Elin

E

28

201 . Newbury L, Dolan K, Hatzifotis M, Low N, Fielding G2003Calciumandvitaminddepletionandelevatedparathyroidhormone following biliopancreatic diversion . Obes surg13:893–895

202 . Sugerman HJ 2001 Bariatric surgery for severe obesity . JassocacadMinorPhys12:129–136

203 . Balsiger BM, Kennedy FP, Abu-Lebdeh HS, Collazo-Clavell M, Jensen MD, O’Brien T, Hensrud DD, Dinneen SF, Thompson GB, Que FG, Williams DE, Clark MM, Grant JE, Frick MS, Mueller RA, Mai JL, Sarr MG2000Prospec-tiveevaluationofRoux-enYgastricbypassasprimaryopera-tion for medically complicated obesity . Mayo Clin Proc75:673–680

204 . Favus, MJ1996Primeronthemetabolicbonediseasesanddisorders of mineral metabolism . Philadelphia: lippincott-Raven

205 . Ybarra J, Sánchez-Hernández J, Gich I, De Leiva A, Rius X, Rodríguez-Espinosa J, Pérez A 2005unchangedhypovita-minosis d and secondary hyperparathyroidism in morbidobesityafterbariatricsurgery .Obessurg15:330–335

206 . Sánchez-Hernández J, Ybarra J, Gich I, De Leiva A, Rius X, Rodríguez-EspinosaJ,Pérez A2005effectsofbariatricsurgeryon vitamin d status and secondary hyperparathyroidism:aprospectivestudy .Obessurg15:1389–1395

207 . Ott MT, Fanti P, Malluche HH, Ryo UY, Whaley FS, Strodel WE, Colacchi TA 1992 Biochemical evidence ofmetabolicbonedisease inwomen followingRoux-Ygastricbypassformorbidobesity .Obessurg2:341–348

208 . Strauss BJ, Marks SJ, Growcott JP, Stroud DB, Lo CS, Dixon JB, O’Brien PE 2003 Body composition changesfollowing laparoscopic gastric banding for morbid obesity .actadiabetol40(suppl1):s266–s269

209 . Dixon JB, Strauss BJ, Laurie C, O’Brien PE2007Changesinbodycompositionwithweightloss:obesesubjectsrandom-izedtosurgicalandmedicalprograms .Obesity15:1187–1198

210 . Shaker JL, Norton AJ, Woods MF, Fallon MD, Findling JW 1991 secondary hyperparathyroidism and osteopenia inwomenfollowinggastricexclusionsurgeryforobesity .Osteo-porosint1:177–181

211 . Friedman JE, Dallal RM, Lord JL2008Goutyattacksoccurfrequentlyinpostoperativegastricbypasspatients .surgObesRelatdis4:11–13

212 . Charles P 1992 Calcium absorption and calcium bioavail-ability .JinternMed231:161–168

213 . Pugnale N, Giusti V, Suter M, Zysset E, Héraïef E, Gaillard RC, Burckhardt P 2003 Bone metabolism and risk ofsecondary hyperparathyroidism 12 months after gastricbanding in obese premenopausal women . int J Obes RelatMetabdisord27:110–116

214 . Alborzi F, Leibowitz AB2002immobilizationhypercalcemiain critical illness following bariatric surgery . Obes surg12:871–873

215 . Liel Y, Edwards J, Shary J, Spicer KM, Gordon L, Bell NH 1988Theeffectsofraceandbodyhabitusonbonemineraldensity of the radius, hip, and spine in premenopausalwomen .JClinendocrinolMetab66:1247–1250

216 . Gossain VV, Rao DS, Carella MJ, Divine G, Rovner DR1999 Bone mineral density in obesity; effect of weightloss .JMed30:367–376

217 . Bell NH, Epstein S, Greene A, Shary J, Oexmann MJ, Shaw S1985evidence foralterationof thevitamind-endocrinesysteminobesesubjects .JClininvest76:370–373

218 . De Prisco C, Levine SN2005Metabolicbonediseaseaftergastricbypasssurgeryforobesity .amJMedsci329:57–61

219 . Fitzpatrick LA2002secondarycausesofosteoporosis .MayoClinProc77:453–468

220 . Diniz Mde F, Diniz MT, Sanches SR, Salgado PP, Valadão MM, Arauújo FC, Martins DS, Rocha AL 2004 elevatedserum parathormone after Roux-en-Y gastric bypass . Obessurg14:1222–1226

221 . Parada P, Maruri I, Morales MJ, Otero I, Delgado C, Casal JE, nutritionalcomplicationsafterbariatricsurgery .Programof the8thWorldCongress of the international Federationfor the surgery of Obesity, salamanca, spain, 2003, p 525(abstract33)

222 . Youssef Y, Richards WO, Sekhar N, Kaiser J, Spagnoli A, Abumrad N, Torquati A2007Riskofsecondaryhyperpara-thyroidismafterlaparoscopicgastricbypasssurgeryinobesewomen .surgendosc21:1393–1396

223 . Riedt CS, Brolin RE, Sherrell RM, Field MP, Shapses SA2006 True fractional calcium absorption is decreased afterRoux-en-Ygastricbypasssurgery .Obesity14:1940–1948

224 . Nevitt MC2002Obesityoutcomesindiseasemanagement:clinical outcomes for ostroarthritis . Obes Res 10 (suppl1):33s–37s

225 . Peltonen M, Lindroos AK, Torgerson JS2003Musculoskel-etalpainintheobese:acomparisonwiththegeneralpopula-tionandlong-termchangesafterconventionalandsurgicalobesitytreatment .Pain104:549–557

226 . Hooper MM, Stellato TA, Hallowell PT, Seitz BA, Moskowitz RW 2007 Musculoskeletal findings in obesesubjects before and after weight loss following bariatricsurgery .intJObes(lond)31:114–120

227 . Serés L, Lopez-Ayerbe J, Coll R, Rodriguez O, Vila J, Formiguera X, Alastrue A, Rull M, Valle V2006increasedexercise capacity after surgically induced weight loss inmorbidobesity .Obesity(silverspring)14:273–279

228 . McGoey BV, Deitel M, Saplys RJ, Kliman ME 1990effectofweightlossonmusculoskeletalpaininthemorbidlyobese .JBoneJointsurgBr72:322–323

229 . Mitchell JE, Lancaster KL, Burgard MA, Howell LM, Krahn DD, Crosby RD, Wonderlich SA, Gosnell BA2001long-term follow-up of patients’ status after gastric bypass .Obessurg11:464–468

Endo

crinE an

d nu

trition

al Man

agEMEn

t of th

E Post-Bariatric su

rgEry PatiEnt

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230 . Powers PS, Perez A, Boyd F, Rosemurgy A 1999 eatingpathology before and after bariatric surgery: a prospectivestudy .intJeatdisord25:293–300

231 . Stunkard A, Foster G, Glassman J, Rosato E 1985 Retro-spective exaggeration of symptoms: vomiting after gastricsurgeryforobesity .PsychosomMed47:150–155

232 . Marceau P2000Malabsorptiveprocedure insurgical treat-mentofmorbidobesity .ProblGensurg17:29–39

233 . MacLean LD, Rhode BM, Nohr C, Katz S, McLean AP1997stomalulceraftergastricbypass .JamCollsurg185:1–7

234 . Pories WJ, MacDonald KG 1993Thesurgicaltreatmentofmorbidobesity .CurrOpinGensurg195–205

235 . Lublin M, McCoy M, Waldrep DJ2006Perforatingmarginalulcersafterlaparoscopicgastricbypass .surgendosc20:51–54

236 . MacLean LD, Rhode BM, Nohr CW 2000 late outcomeofgastricbypass .annsurg231:524–528

237 . Brolin RE2000Complicationsofsurgeryforsevereobesity .ProblGensurg17:55–61

238 . Sugerman HJ, Starkey JV, Birkenhauer R1987arandom-izedprospectivetrialofgastricbypassversusverticalbandedgastroplasty for morbid obesity and their effects on sweetsversusnon-sweetseaters .annsurg205:613–624

239 . Collene AL, Hertzler S2003Metabolicoutcomesofgastricbypass .nutrClinPract18:136–140

240 . Mallory GN, Macgregor AM, Rand CS1996Theinfluenceofdumpingonweightlossaftergastricrestrictivesurgeryformorbidobesity .Obessurg6:474–478

241 . Hsu LK, Mulliken B, McDonagh B, Krupa Das S, Rand W, Fairburn CG, Rolls B, McCrory MA, Saltzman E, Shikora S, Dwyer J, Roberts S2002Bingeeatingdisorderinextremeobesity .intJObesRelatMetabdisord26:1398–1403

242 . Didden P, Penning C, Masclee AA2006Octreotidetherapyindumpingsyndrome:analysisoflong-termresults .alimentPharmacolTher24:1367–1375

243 . Ukleja A 2005 dumping syndrome: pathophysiology andtreatment .nutrClinPract20:517–525

244 . Carvajal SH, Mulvihill SJ1994Postgastrectomysyndromes:dumping and diarrhea . Gastroenterol Clin north am23:261–279

245 . Service GJ, Thompson GB, Service FJ, Andrews JC, Collazo-Clavell ML, Lloyd RV2005Hyperinsulinemichypoglycemiawith nesidioblastosis after gastric-bypass surgery . n engl JMed353:249–254

246 . Patti ME, McMahon G, Mun EC, Bitton A, Holst JJ, Gold-smith J, Hanto DW, Callery M, Arky R, Nose V, Bonner-Weir S, Goldfine AB2005severehypoglycaemiapost-gastricbypass requiringpartialpancreatectomy: evidence for inap-propriate insulin secretion andpancreatic islethyperplasia .diabetologia48:2236–2240

247 . Kellogg TA, Bantle JP, Leslie DB, Redmond JB, Slusarek B, Swan T, Buchwald H, Ikramuddin S2008Postgastricbypasshyperinsulinemic hypoglycemia syndrome: characterizationand response to a modified diet . surg Obes Relat dis4:492–499

248 . Pories WJ 2008Bariatric surgery: risks and rewards . JClinendocrinolMetab93:s89–s96

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AcknowledgmentsThemembersoftheTaskForcethankTheendocrinesociety’sClinicalGuidelinessubcommitteeandClinicalaffairsCoreCommitteeandCouncilfortheircareful,criticalreviewofearlierversionsofthismanuscriptandtheirhelpfulcommentsandsuggestions .WealsothanktheleadershipoftheamericanGastroenterologicalassociationinstituteandtheeuropeansocietyofendocrinologyfortheirreviewandcomments .inaddition,wethankthemanymembersofTheendocrinesocietywhoreviewedthedraftversionofthismanuscriptwhenitwaspostedonthesociety’swebsiteandwhosentagreatnumberofadditionalcommentsandsuggestions,mostofwhichwereincorporated into thefinalversionof themanuscript .Finally,we thankthe staffat thesocietyoffice for theirhelpfulsupportduringthedevelopmentofthisguideline .

financial disclosure of Task forceDavid Heber, M.D., Ph.D. (chair)—Financial or Business/ Organizational interests: Herbalife international;significant Financial interest or leadership Position: Medical nutrition Council, american society fornutrition(Chair,2006–2007);Frank L. Greenway, III, M.D.—FinancialorBusiness/Organizationalinterests:aBiC international Consultants, BaROnova, Basic Research inc ., Catalyst Pharmaceutical Partners, GeneralnutritionCorp .,HealthandnutritionTechnology,lipothera,nastechPharmaceuticals,OrexigenTherapeutics,GlaxosmithKline,leptosBiomedical,novonordisk,schering-PloughResearchinstitute;significantFinancialinterestorleadershipPosition:JennyCraig(Chairman);Lee M. Kaplan, M.D., Ph.D.—FinancialorBusiness/Organizationalinterests:MerckResearchlabs,Gidynamics,Johnson&Johnson,davol,strykerdevelopment,Gelesis,BlueCross&Blueshield;significantFinancialinterestorleadershipPosition:nonedeclared;Edward Livingston, M.D., F.A.C.S.—FinancialorBusiness/Organizationalinterests:nonedeclared;significantFinancialinterestorleadershipPosition:nonedeclared;Javier Salvador, M.D., Ph.D.—FinancialorBusiness/Organiza-tionalinterests:nonedeclared;significantFinancialinterestorleadershipPosition:nonedeclared;Christopher Still, D.O., M.S.—Financial or Business/Organizational interests: ethion-endosurgery; significant FinancialinterestorleadershipPosition:ObesityactionCoalition,surgicalReviewCorp .,aBPnsamericanBoardofPhysiciannutritionspecialists .

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