April 2014

April 2014

Volume 3Issue 4

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E Evidence-based bariatric surgery in 2014by Robert Li, MD ......................................................page 6

A physician family’s bariatric experienceby Russ Granich, MD .......................................... page 10

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Editorial CommitteeRuss Granich, MD, ChairSharon Clark, MDEdward Morhauser, MDGurpreet Padam, MDSue U. Malone, Executive DirectorShannon Goecke, Managing Editor

SMCMA Leadership

Amita Saxena,, MD, President; Vincent Mason, MD, President-Elect; Michael Norris, MD; Secretary- Treasurer; Gregory C. Lukaszewicz, MD, Immediate Past President

Alexander Ding, MD; Manjul Dixit, MD; Russ Granich, MD; Edward Koo, MD; C.J. Kunnappilly, MD; Susan Nguyen, MD; Michael O’Holleran, MD; Chris Threatt, MD; Kristen Willison, MD; David Goldschmid, MD, CMA Trustee; Scott A. Morrow, MD, Health Officer, County of San Mateo; Dirk Baumann, MD, AMA Alternate Delegate

Editorial/Advertising Inquiries

San Mateo County Physician is published ten times per year by the San Mateo County Medical Association. Opinions expressed by authors are their own and not necessarily those of the SMCMA. San Mateo County Physician reserves the right to edit contributions for clarity and length, as well as to reject any material submitted.

Acceptance and publication of advertising does not constitute approval or endorsement by the San Mateo County Medical Association of products or services advertised.

For more information, contact the managing editor at (650) 312-1663 or [email protected].

Visit our website at smcma.org, like us at facebook.com/smcma, and follow us at twitter.com/SMCMedAssoc.

© 2014 San Mateo County Medical Association

April 2014 / Volume 3, Issue 4

Columns

S A N M A T E O C O U N T Y

PhysicianPresident’s Message: The sum of small efforts .............................................. 4Niki Saxena, MD

Feature Articles

Evidence-based bariatric surgery in 2014 ..................................................... 7Robert Li, MD

A physician family’s bariatric experience .................................................... 10Russ Granich, MD

Of Interest

Index of Advertisers, Classifed Ads. ............................................................. 14

4 SAN MATEO COUNTY PHYSICIAN | APRIL 2014

The California Medical Association held its Annual Western Leadership Academy in San Diego earlier this month. The Leadership Academy is an amazing collection of seminars, panels and keynote speakers that represent a broad section of healthcare innovators and leading thinkers. This year’s keynote address was given by none other than Hilary Rodham Clinton. No matter what

your political inclinations might be, I can tell you she is an impressive speaker. She fielded many questions from the audience, including what advice she would give to women interested in pursuing leadership roles in medicine:

1. Toughen up.

2. Get educated about the position you seek.

3. Get mentors, supporters, advisors and constructive critics.

4. Take criticism seriously but not personally.

President’s Message by Niki Saxena, MD

The Sum of Small Efforts

Success is the sum of small efforts repeated day in and day out.

— Robert Collier

The more I reflected on it, the more I thought it was good advice for all physicians in the audience, regardless of gender. The healthcare landscape is changing and bringing with it a new vocabulary: value-based reimbursement, vertical integration, alternate delivery systems, the triple aim, bending the cost curve…it’s just a dizzying array of catch phrases that all seem to try and address one thing: how are we going to deliver the same high quality care for less money?

Obesity is one of those issues that consumes a great deal of healthcare resources. According to a recent study published in the journal Pediatrics by Duke Global Health Institute and Duke-NUS Graduate Medical School in Singapore, the medical costs associated with childhood obesity total about $19,000 per child over his or her lifetime. The costs are about $12,900 per person for children of normal weight who become overweight or obese in adulthood. Multiply these medical costs by the number of all obese 10-year-olds in the U.S. today, and the lifetime medical costs reach roughly $14 billion for this age alone. To put that into perspective, that’s nearly twice the Department of Health and Human Services’ $7.8

billion budget for the Head Start program in fiscal year 2012. And these are just an estimate of medical costs; they don’t take into account lost productivity or wages due to associated health concerns such as Type 2 diabetes and cardiovascular events.

Obesity is not a simple issue. There are several factors that contribute to it, including socioeconomic conditions, emotional and psychological issues that can lead to addictive behaviors around food, even genetics that can alter satiety cues. If we are to make any meaningful progress in treating obesity, perhaps we need to think outside the box. Vertical integration takes on more meaning here. Enlisting the help of our mental health colleagues should be part of the treatment plan. Families also need education to make healthy choices, as well as access to affordable fruits and vegetables and a safe environment for exercise. In an ideal world, a patient’s genetics would also be used to evaluate the best diet. Many experts believe that such a comprehensive treatment plan is the only way to develop a more permanent and successful way to eventually eliminate childhood obesity.

“

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All these treatment modalities are available to patients, but not all are covered by insurance and they are not always affordable by those who need them the most. What is covered can be more procedural based, such as bariatric surgery. In July of 2013 the AMA voted to classify obesity as a disease, and for patients who suffer from this disease, bariatric surgery can be an incredible life changing treatment modality. But one treatment may not fit all patients, and the challenge will be to accurately identify those who can benefit most from this procedure as opposed to other less invasive therapeutic modalities.

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BARIATRIC SURGERYEvidence-based bariatric surgery in 2014

Obesity remains a significant problem in the United States despite increasing public awareness and medical attention focused on the subject. Obesity has been linked with a host of medical comorbidities and is a major risk factor for early mortality. While nonsurgical weight loss methods can result in up to 10% decrease in weight, the vast majority of patients are unsuccessful in their goals of long-term, persistent weight loss. The recent classification by the American Medical Association of obesity as a disease is a sign of the seriousness of the national debate on obesity.

Within San Francisco and San Mateo counties, both patients and the medical community are fortunate to have had access to excellent bariatric surgeons and long-standing, dedicated multi-disciplinary bariatric programs. Starting with early pioneers such as Dr. Basil Meyerowitz in the 1970s, bariatric surgery programs are widespread throughout both counties, with eight programs currently certified by either the American Society of Surgeons Bariatric Surgery Center Network or the Surgical Review Corporation Bariatric Surgery Center of Excellence Program.1,2

This article will review the surgical treatment for obesity both from a national as well local perspective, present current outcomes and data, and discuss some ongoing controversies within the field.

Obesity can be defined in terms of Body Mass Index (BMI), which is calculated as weight in kg/height

in meters2. BMI >25 kg/ m2 is classified as overweight, with BMI>30 kg/ m2 being defined as obese. An estimated two-thirds of Americans are obese or overweight. Within San Mateo County, adult obesity (i.e., Body Mass Index > 30 kg/ m2) from 1998 to 2013 has grown from 13% to an estimated 22% with increased prevalence in the African American and Hispanic populations. (Figure 1 and 2) Approximately $168 billion dollars are spent on obesity and obesity- related comorbidities annually in the United States. Most patients referred for bariatric surgery have had multiple attempts at non-surgical weight loss and been unsuccessful, a reflection of the extremely low efficacy of standard diet and exercise for weight loss.

Guidelines for bariatric surgery were established by the 1991 NIH Consensus Development Panel on surgery for obesity. Indications for

by Robert Li, MD


bariatric surgery include a BMI >40 kg/ m2 without medical comorbidities or BMI >35 kg/ m2 with at least one medical comorbidity such as sleep apnea, cardiac problems, hypertension, diabetes, or other ailments interfering with physical function. The newest Clinical Practice Guidelines suggest that patients with uncontrolled diabetes or metabolic syndrome with a lower BMI of between 30-34.9 kg/m2 may be offered surgery, but there is no long-term data to support routine operation.3

Patients referred to bariatric surgery programs are required to undergo a multidisciplinary evaluation process including medical, surgical, dietary, and psychological assessment prior to surgery. It is important to emphasize to patients that bariatric surgery is not just about the operation. To be effective, patients must make dietary, lifestyle, and behavioral changes in order to ensure long-term success. Likewise,

success of bariatric surgery is not solely dependent on the surgeon. A multidisciplinary team approach is crucial in the proper evaluation and preparation of the bariatric surgery patient. This team approach is emphasized in the two current accreditation processes for bariatric surgery programs, the American College of Surgeons/American Society of Bariatric and Metabolic Surgery Bariatric Surgery Center Network program and the Surgical Review Corporation Bariatric Surgery Center of Excellence program. During the assessment process, patients are evaluated for Axis I and II disorders, willingness to make behavioral and lifestyle changes, dietary habits, and current life stressors. All patients should undergo tobacco cessation at least two months prior to surgery; estrogen should be stopped at least one month prior to surgery. Patients with moderate to severe sleep apnea should be identified and treated with CPAP prior to surgery. Diabetes should be controlled with the HgbA1c less than 8 at the time of surgery.3 Contraindications to surgery include patients not candidates for surgery based on severe medical or surgical conditions, severe untreated psychological issues, current drug or alcohol problems, binge eating disorders, and inability to comply with postoperative or preoperative diet and behavioral modification changes. While evidence for improvements in outcomes from mandated percentage weight loss prior to surgery is controversial, it is common for patients to be counseled to lose weight prior to surgery, especially in high BMI patients. The informed consent discussion between surgeon and patient is especially important in bariatric surgery given the variety of different surgical options available and different risks and benefits of each procedure. Patients should also be counseled on the necessity of taking postoperative vitamins after surgery, including multivitamins, B1, B212, calcium, and iron.

Overall, bariatric surgery in the United States has risen steadily to meet demand and currently is among the most well studied surgical interventions of recent times. Data from the American Society of Metabolic and Bariatric Surgery (ASMBS) document a rise in total number of bariatric surgeries from 158,000 in 2011 to 179,000 in 2013, while surgeries performed in 1998 were less than 20,000.4 The most common primary bariatric operations include the gastric bypass, gastric sleeve, and laparoscopic gastric banding. The percentage of gastric bypass has been relatively steady for the past several years at approximately 34.2% of all cases in 2013. The number of laparoscopic gastric bands has fallen precipitously to 14% in 2013, down from a high of 35.4% in 2011, likely due to evidence of poor long-term outcomes and limited weight loss.

13%

17%19% 19%

22%

Datasource: San Mateo County Health System

25%

20%

15%

10%

5%

0%

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30

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1998 2001 2004 2008 2013

Table 1: Adult Obesity, San Mateo County, 1998-2013

Datasource: San Mateo County Health System

Asian/PI

White

AfricanAmerican

HispanicLatino

Table 2: Obesity by Race/Ethnicity, San Mateo County, 2013

12%

21%

31%

30%


Gastric sleeves are currently the most frequently performed operation at 42.1% of total cases. Other bariatric surgery procedures, such as revisional surgery or duodenal switch, comprise less than 10% of the total number of operations.

In general, the gastric bypass is favored in patients with severe heartburn or gastroesophageal reflux or patients with diabetes, especially insulin-dependent diabetics. The gastric sleeve is useful in patients with previous major abdominal surgery or complex medical problems such as transplant patients, but this operation is also increasingly popular for its simplicity, weight loss only slightly less than that of the gastric bypass, and evidence of short-term and medium-term safety.

The gastric bypass surgery has been performed the longest of all common current bariatric surgeries. It involves creating a small gastric pouch and then dividing the proximal jejunum; a “roux” limb then is brought up and connected to the gastric pouch and a second anastomosis is performed between the jejunum and the “roux” limb to maintain gastrointestinal continuity. The primary mechanism for weight loss is restriction of PO intake, although there is some element of malabsorption of nutrients as well. The gastric sleeve is a more simple operation in which the stomach is resected over a sizing tube, creating a narrow “sleeve”-like stomach. The sleeve is only a restrictive operation. The lap band is a mechanical device consisting of a band connected

to a subcutaneous port via plastic tubing. The band is placed around the top portion of the stomach and can be inflated or deflated by injecting saline into the port. The lap band is also strictly a restrictive device.

Despite public and even health care practitioner perception to the contrary, bariatric surgery has been proven to be extremely safe, with an overall 30-day mortality of 0.12%. The vast majority of operations are performed laparoscopically at the present time (the rate of conversion to open surgery is just 1.4% for the gastric bypass and .96% for the gastric sleeve). Thirty-day complication rate, readmissions, and reoperations for gastric bypass were 5.9%, 6.5%, and 5%, respectively. The gastric band had the lowest thirty-day complication, readmission, and reoperation rates (1.4%, 1.7% and 0.9%), while the gastric sleeve is positioned between bypass and band in complications, readmissions, and reoperations (5.6%, 5.4%, and 3%).5 Length of stay for bariatric surgery was on average two days for gastric bypass and one day for laparoscopic adjustable gastric banding.6

Despite excellent perioperative safety associated with bariatric surgery, the aforementioned surgical operations do all have potential medium and long-term risk of surgical complications. Gastric bypass patients must be aware of the possibility of gastric ulcers associated with smoking or non-steroidal anti-inflammatory drug use, as well as the possibility of an internal hernia. An internal hernia, an event in which the small bowel is entrapped within a mesenteric or potential defect caused by the rearrangement of the small intestines during surgery, is a surgical emergency and can occur even years after surgery. Unexplained, severe abdominal pain in a patient with a history of gastric bypass should be evaluated with an emergency CT and bariatric surgeon consultation to evaluate for this possibility. The adjustable gastric band in long-term studies has been shown to be associated with up to a 40% major complication rate resulting in 50% band removal rate in 12-year follow-up.7 The gastric sleeve seems to be associated with fewer long-term adverse complications than the band or bypass. All patients must be vigilant about continuing to follow the prescribed diet and vitamin regimen after surgery to avoid vitamin or protein deficiency.

In discussing the results from the various types of bariatric surgery, it is useful to review both the weight loss as well as the effect of bariatric surgery on comorbidities. Percentage excess body weight loss is commonly used to calculate weight loss and can be described as the following: (initial weight-current

HELPFUL LINKS

Obesityhelp.com www.obesityhelp.com

American Society of Metabolic and Bariatric Surgery http://asmbs.org

ADA Diabetes Mellitus 2014 Guidelines www.ndei.org/dsl/searchslide.spx?slideid=3342&keyword=

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program www.mbsaqip.info

The Obesity Society www.obesity.org

Obesity Action Committee www.obesityaction.org


About the Author

Robert Li, MD, is Chief of Bariatric Surgery with Kaiser Permanente Medical Group in South San Francisco. A graduate of Duke University School of Medicine, he completed his residency at Stanford University Medical Center and a fellowship at UCSF Medical Center. He is a certified surgeon in the ASMBS

Bariatric Surgery Center of Excellence program.

weight)/(Initial weight- Ideal Body weight) x 100. Ideal body weight can be derived from the Metropolitan Height and Weight tables using the patient’s height and an ideal BMI of 25kg/m2. For gastric bypass, average expected percentage of body weight loss is about 70-80%, with nadir at around two years post operatively.8 Early results of gastric sleeve have suggested results closer to 65-70%.9 Laparoscopic adjustable gastric band has much lower percentage of excess body weight loss, averaging between 40-50%.10

The effect of bariatric surgery on obesity-related medical comorbidities is also well studied and has been no less profound. Long-term results from the landmark Swedish Obese Subjects trial on patients who have undergone bariatric surgery has demonstrated a 30% decrease in all-causes mortality and a 50% decrease in mortality from cardiovascular events.11,12 Randomized controlled trials studying bariatric surgery versus medical therapy demonstrated patients who had undergone gastric bypass surgery had a 75% diabetes remission rate compared to 0% for patients in the medical therapy cohort.13 Longer term studies of type 2 diabetes remission have documented that 68% of patients experience an initial complete diabetes remission within five years of surgery, but about one-third redevelop diabetes within five years with an average duration of remission being 8.3 years.14 The societal advantages of bariatric surgery appear to be less clear in that both health care utilization and health care costs or pharmaceutical costs appear to be greater in patients who have undergone surgery versus a matched control group, at least in the first six years after surgery.15,16

Bariatric surgery has evolved from what I remember starting out in practice at the turn of the millennium as sort of an orphan backwater of general surgery to now what is a highly respected subspecialty surgical field with outstanding evidence-based patient safety and comorbidity improvement outcomes. Many of the trends sweeping through the current general surgical landscape such as Enhanced Recovery after surgery ERAS) programs, accreditation for centers for specialty surgical services, and national patient databases have been influenced by their early counterparts in bariatric surgery. However, despite the progress, there remain many areas in which further progress can be made. The Centers for Medicare and Medicaid Services (CMS) in September of 2013 dropped the requirement for Medicare patients to undergo bariatric surgery only at accredited centers, citing lack of evidence for improved outcomes at such centers. This move has been

opposed by both the American College of Surgeons, the American Society of Metabolic and Bariatric Surgery, and other leading medical societies. As of this time, this issue remains unresolved with CMS remaining the only major insurer not requiring bariatric surgery to be performed at accredited institutions. While I believe this is less of an issue in the Northern California area, which is host to many excellent accredited bariatric surgery programs, I feel that continued accreditation will help maintain the excellent patient safety outcomes that the bariatric community has been able to achieve thus far and will also help facilitate long-term follow-up of weight loss and comorbidity resolution. Secondly, despite the steadily increasing numbers of bariatric surgery procedures, access to bariatric surgery remains an issue. It is estimated that less than only 1% of eligible patients within the United States undergo bariatric surgery. The recent recognition by the AMA of obesity as a disease and the recommendation of discussion of bariatric surgery in the 2014 ADA Diabetes Management Guidelines are both helpful and timely.17 Hopefully, recommendations such as these from national medical bodies, as well as the increasing body of evidence of the effectiveness of bariatric surgery, will encourage both patients and practitioners to consider bariatric surgery where it may not have been considered previously. Both the bariatric community as well as the wider medical community should encourage patients who could potentially benefit from bariatric surgery to do their own research and discuss the option of bariatric surgery with their medical practitioner. ■

Bibliography appears on page 14.


We all need to eat to survive. Primitive man, especially the hunter-gatherers, would have feast or famine: when food

was available, one had to eat as much as possible to survive the inevitable famine. I believe, that for some of us, that imperative has survived in our genes. If I am driving with a donut on the seat beside me, I only have two options: eat it or get rid of it. I cannot sit there and ignore it. The donut beckons me, I know it will be delicious and fulfill some inner need. I had to work really hard to keep my weight a mere 315 pounds, including losing hundreds of pounds over the years, but it always came back. I am very disciplined and have great willpower in other aspects of my life, but this primal urge cannot be totally suppressed, except in the rare person, especially since we do need to eat. Unlike a drug addict who can survive without the drug, I do need food to stay alive.

In college I was very active and weighed in at about 180 pounds; in medical school, my weight crept up and I peaked at 240 a few years into my private practice. I did well for a few years, but then Desert Storm came along. I was a reservist and was relegated to eating military food or restaurant food. I shot up to 275 pounds within a few years, I was diagnosed with sleep apnea, and over the following 15 years my weight slowly crept up to 315. I never considered bariatric surgery, but when a close friend had a lap band, I started thinking about it. I was reluctant to have a bypass as I didn’t want my anatomy rearranged, so I ended up getting a lap band.

It changed my life, but it was not an easy journey. When you first have surgery and are healing, the weight just drops off. Then your band is tightened (water is injected into a balloon inside the band via a subcutaneous port) and you start eating a more normal diet (but one high in protein). The band works by creating a small pouch at the top of your stomach, so you get full easily. The opening from the pouch to the rest of the stomach is small. This is where I would run into trouble. If I didn’t chew my food really well, it might get stuck in the opening. You chew food to make it easier to digest in your stomach. A large globus of well-chewed food is fine because you can swallow a rather large amount. You don’t naturally chew your food thoroughly enough to break it up into pieces tiny enough to pass through the stoma. Some foods are difficult to chew that well, such as steak, unless it is very tender, or bok choy, which is very fibrous. Some foods, such as bread, seem to “regroup” in the pouch into a large bolus. When it gets stuck, it is a horrible feeling. I start salivating, my sinuses run profusely, I have this terrible feeling in my gut, similar to the feeling when food gets “stuck” in the esophagus. I call this sensation “gluppy.” (Onomatopoeia!) Often I would have to quickly run to the rest room and see what I could do, as I knew it would be moments before my food would start coming up. Sometimes drinking some water would help loosen the food and allow it to pass, but sometimes it made it worse. Forcing myself to vomit (not really like normal emesis since there really is no

BARIATRIC SURGERY

A physician family’s bariatric experience

by Russ Granich, MD

While discussing the topic of bariatric surgery with the rest of the SMCMA editorial committee recently, I related some of my experience, having had a lap-band. When I talked about the struggles of eating and weight, my colleagues didn’t realize what I have been dealing with my whole life.


About the Author

Russ Granich, MD, is Chief of the Home Care Department at Kaiser Permanente Medical Group in South San Francisco. He is also medical director of Hospice and Home Health. Board-certified in internal medicine and hospice & palliative care, he completed his education at Boston University School of Medicine at his residency at CPMC. He is also a

chair of the SMCMA Editorial Committee and a member of the SMCMA Board of Directors.

gastric contents, so I call it “erping”) usually helped, as it would relieve the pressure a little and seemed to “rearrange” the food. Sometimes it didn’t work and I just had to suffer until it passed. My weight dropped to 238 and then stabilized in the high 240s. I had my band adjusted several times, and my weight crept up to 255. Luckily, I have finally found the “sweet spot.” I have a limited capacity, I can always break up something stuck with a large glass of water, and I feel good. My weight has dropped into the high 230s; I was 235 this morning. Why this last adjustment (about a year ago) has worked so well, I can’t tell you. I have been at this same place before, but the body adapts and changes and right now, mine is perfect for me. I can only eat a small breakfast. As the day progresses, my capacity increases. I can’t drink when I eat as it makes me gluppy. I have to avoid certain foods and I don’t do well with sandwiches. I try to make good choices, but still enjoy some junk food and sweets. Would I do it again? I’m happy

with my results, but if I did it again, I would have a bypass instead of a lap band. I would have lost more weight and, with a family history of DM, a bypass is attractive. That takes me to my wife, who had both.

She started with a lap band and did well initially, but developed what is referred to as “band intolerance.” That is when the stomach reacts unpredictably to the band, so the effective opening can vary. We were in Chicago when her worst episode occurred. She was doing fine but then was unable to take anything but thin liquids. We ended up seeing a bariatric surgeon there and he removed some fluid, but she still couldn’t pass food, so he had to totally deflate the balloon. It was impossible to find the place where she could eat but was restricted enough to lose weight. We did a literature search and found that this actually can occur in a significant number of patients, and the best option is to convert to a bypass. It also is recommended even if one no longer fits the initial criteria for a bypass by BMI. At our institution the numbers were much better (perhaps intolerance may also be technique related), so they had very few conversions. The surgeon agreed to change her to a bypass, but did not bypass as much intestines as usual because she had already lost a considerable amount of weight. She did remarkably well and dropped

some more weight. For the first year she had some difficulties. If she ate something sweet, she would get a lot of gas and GI distress, similar to a dumping syndrome. It was probably due to the osmotic load in her gut, but with time her intestines adapted. She has done much better with the bypass and has lost more weight than she would have with the lap-band. She never needs an adjustment but does need to take large amounts of supplements.

My eldest son (from a previous marriage) has had a weight problem since he was a child. He is built like me, but there are many more calorie-dense foods promoted in our society today, and he is less active than I was. At six feet tall, he topped out well over 300 pounds and weighed in at his bariatric evaluation at 340. At the age of 22 he underwent a gastric sleeve procedure. Of all of us, he has done the best. He dropped to 180 pounds, the bulk of that within the first six months. He had none of the complications we

had. With a newfound lease on life as a healthy adult, he is making better choices and doing well.

Although we are an open and accepting society, there is still a stigma attached to obesity. Many of those who have never had a weight problem think it is only a matter

of willpower, but it is much more than that. Weight loss can make a profound difference in one’s life. It improves health and longevity. More importantly, it improves one’s own outlook. You feel better physically and emotionally. Others interact with you differently. It gives you a new lease on life. We are all grateful we had the opportunity to have surgery and we all have done well. Three family members with three different procedures, and three new lives ahead of us. ■

The lap-band changed my life, but it was not an easy journey.


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NOTES (CONTINUED FROM PAGE 9)

1. < http://www.mbsaqip.info/?page_id=56> Accessed April 5th, 2014.

2. < http://www.surgicalreview.org/locate/> Accessed April 5th, 2014.3. AACE/TOS/ASMBS Clinical Practice Guidelines for the perioperative

nutritional, metabolic, and nonsurgical support of the Bariatric Surgery patient-2013 Update: Cosponsored by the American Association of Clinical Endocrinologists, The Obesity Society, and American Society of Metabolic and Bariatric Surgery. SOARD 2013;9:159-91.

4. < http://asmbs.org/2014/03/estimate-of-bariatric-surgery-numbers/> Accessed April 7th, 2014.

5. Hutter M, Schirmer B, Jones, D, et al. First report from the American College of Surgeons-Bariatric Surgery Center Network: Laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg 2011;254(3):410-422.

6. Lancaster R, Hutter M. Band and bypasses: 30-day morbidity and mortality of bariatric surgical procedures as assessed by prospective, multi-center, risk-adjusted ACS-NSQIP data. Surg Endosc 2008;22(12):2554-63.

7. Himpens J, Cardiere G, Bazi M, Vouche M, Cadiere B, Dapri G. Long-term outcomes of laparoscopic adjustable gastric banding. Arch Surg 2011;146(7):802-7.

8. Puzziferri N, Austrheim-Smith I, Wolfe B, Wilson S, Nguyen N. Three-year follow up of a prospective randomized trial comparing laparoscopic versus open gastric bypass. Ann Surg 2006;243(2):181-288.

9. Peterli R, Borbely Y, Kern B, et al. Early results of the Swiss Multicentre Bypass or sleeve study (SM-BOSS): a prospective randomized trial comparing laparoscopic sleeve gastrectomy and roux-en-y gastric bypass. Ann Surg 2013;258(5):690-4.

10. Tice J, Karliner L, Walsh J, Petersen A, Feldman M. Gastric banding or bypass? A systemic review comparing the two most popular bariatric procedures. Am J Med 2008;121(10):885-93.

11. Sjoström, Peltonen M, Jacobson P, et al. Bariatric surgery and long-term cardiovascular events. JAMA 2012;307(1):56-64.

12. Sjostrom L. Review of the key results from the Swedish Obese Subjects (SOS) trial-prospective controlled intervention study of bariatric surgery. J Int Med 2013;273(3):219-34.

13. Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric surgery versus conventional medical therapy for Type 2 diabetes. NEJM 2012;366(17):1577-85.

14. Arterburn D, Bogart A, Sherwood N, et al. A multisite study of long-term remission and relapse of type 2 diabetes mellitus following gastric bypass. Obes Surg 2013;23:93-102.

15. Neovius M, Narbro K, Keating C, et al. Health care use during 20 years following bariatric surgery. JAMA 2012;308(11):1132-41.

16. Weiner J, Goodwin S, Chang HY, et al. Impact of bariatric surgery on health care costs of obese persons. JAMA 2013;148(6):555-562.

17. <http://www.ndei.org/dsl/searchslide.spx?Slideid=3342&keyword= > Accessed April 12, 2014.

For making us better. Thank you. To our physicians and others worldwide, happy Doctors’ Day.

Because you did more than just write a prescription. Or put in stitches. Or set a broken bone. Or operate. Because you brought my daughter into this world. Because you showed warmth. Because you gave me strength when I was weak. And listened. Because you comforted me when I was scared. And were kind.And cared. Because you healed more than just mybody—you restored my spirit. Thank you.

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April 2014

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