Malabsorptive Bariatric Surgery Research Articles

Minerals and trace elements in pregnancy in women with previous bariatric surgery consequences on maternal and foetal health

BackgroundBariatric surgery (BS) may decrease the risk of these obesity-related complications; however, due to its effect on nutrient intake and absorption, it can also have adverse consequences on maternal and foetal health. The aim of this study is to describe the evolution of electrolytes and trace elements serum levels throughout pregnancy after BS, according to the surgical technique and to evaluate the effect of nutritional deficiencies on the risk of maternal-foetal complications. MethodsThis is a retrospective observational study of the clinical evolution and maternal-foetal complications in a group of women with pregnancies that occurred after BS. Clinical evolution during pregnancy, body weight, and plasma electrolytes, vitamins, and trace elements, as well as their influence on maternal-foetal outcomes were evaluated. Composite neonatal variable (CNV) was defined to evaluate unfavourable foetal outcome. Published reference values for micronutrients during pregnancy have been used. ResultsThe study includes data on 164 singleton pregnancies in 91 women. A hundred and twenty-seven pregnancies got to full term. The average birth weight was 2966 (546) g., 26.8% < P10 and 13.8% < P3 of a reference population. New-born of gestations after malabsorptive bariatric surgery had a higher risk of having a percentile of birth weight < P3. Plasma electrolytes, trace elements and vitamins throughout pregnancy showed differences depending on the surgical technique, with lower haemoglobin, ferritin, calcium, zinc, copper, vitamin A and vitamin E in the malabsorptive techniques. A high percentage of deficiency was observed, especially in the third trimester (Hb < 11 g/dl: 31.8%; ferritin < 30 mg/ml: 85.7%; zinc < 50 μg/dl: 32.4%, vitamin D < 30 ng/ml: 75.5% and < 20 ng/ml: 53.3%). A decreased plasma copper in the first trimester or zinc in the third trimester were associated with a lower percentile of new-born birth weight. A higher risk of CNV was observed in predominant malabsorptive BS and in pregnancies that had presented at least one vitamin D level lower than 20 ng/ml throughout pregnancy (30.4% vs. 7.1%, p=0.018). ConclusionsTrace elements and vitamin deficiencies are common in pregnant women after bariatric surgery, especially of iron, zinc, and vitamin D. These deficiencies might negatively affect foetal development. Further studies are needed to better define the role of micronutrients in maternal-foetal health after bariatric surgery.

Post-Bariatric Panniculectomy: Postoperative Complications by Weight Loss Surgery Type.

Over 250,000 patients undergo bariatric surgery each year in the United States. Approximately 21% will undergo subsequent body contouring after massive weight loss. Patients with prior bariatric surgery are at a greater risk for complications relative to the general population. However, it is unknown if bariatric surgery type is associated with differential complication risk after panniculectomy. A retrospective chart review of post-bariatric who underwent abdominal panniculectomy at a single large quaternary care center was performed. Postoperative complications were graded according to the Clavien-Dindo classification. Descriptive statistics, multivariable logistic regression, and power calculations were performed. In total, 216 patients were included. Restrictive bariatric surgery accounted for 48.6% while 51.3% had a history of malabsorptive bariatric surgery. The overall rate of complications was 34.3% (restrictive: 36.2%; malabsorptive: 32.8%, p=0.66). Wound complications were observed in 25.5% (n=55) of patients. Systemic complications occurred in 11.1% of patients overall, with statistically similar rates between restrictive and malabsorptive groups. After adjusting for both patient and operative factors, no significant difference in total complications (OR=1.15, 95% CI: 0.47 to 2.85, p=0.76), systemic complications (OR=0.26, 95% CI: 0.05 to 1.28, p=0.10), or wound complications (OR=2.31, 95% CI: 0.83 to 6.41, p=0.11) was observed. Complications following panniculectomy in bariatric surgery patients is high and predominantly related to wound healing. No significant difference between type of bariatric surgery and complication risk was found.

Delta weight loss unlike genetic variation associates with hyperoxaluria after malabsorptive bariatric surgery

The risk of enteric hyperoxaluria is significantly increased after malabsorptive bariatric surgery (MBS). However, its underlying determinants are only poorly characterized. In this case–control study, we aimed at identifying clinical and genetic factors to dissect their individual contributions to the development of post-surgical hyperoxaluria. We determined the prevalence of hyperoxaluria and nephrolithiasis after MBS by 24-h urine samples and clinical questionnaires at our obesity center. Both hyperoxaluric and non-hyperoxaluric patients were screened for sequence variations in known and candidate genes implicated in hyperoxaluria (AGXT, GRHPR, HOGA1, SLC26A1, SLC26A6, SLC26A7) by targeted next generation sequencing (tNGS). The cohort comprised 67 patients, 49 females (73%) and 18 males (27%). While hyperoxaluria was found in 29 patients (43%), only one patient reported postprocedural nephrolithiasis within 41 months of follow-up. Upon tNGS, we did not find a difference regarding the burden of (rare) variants between hyperoxaluric and non-hyperoxaluric patients. However, patients with hyperoxaluria showed significantly greater weight loss accompanied by markers of intestinal malabsorption compared to non-hyperoxaluric controls. While enteric hyperoxaluria is very common after MBS, genetic variation of known hyperoxaluria genes contributes little to its pathogenesis. In contrast, the degree of postsurgical weight loss and levels of malabsorption parameters may allow for predicting the risk of enteric hyperoxaluria and consecutive kidney stone formation.

Impact of gastrointestinal symptoms and psychological disturbances on patients’ quality of life after restrictive or malabsorptive bariatric surgery

Impact of gastrointestinal symptoms and psychological disturbances on patients’ quality of life after restrictive or malabsorptive bariatric surgery

Human gut microbiota after bariatric surgery alters intestinal morphology and glucose absorption in mice independently of obesity

ObjectiveBariatric surgery is an effective treatment for type 2 diabetes (T2D) that changes gut microbial composition. We determined whether the gut microbiota in humans after restrictive or malabsorptive bariatric surgery...

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<h3>Objective</h3> Bariatric surgery is an effective treatment for type 2 diabetes (T2D) that changes gut microbial composition. We determined whether the gut microbiota in humans after restrictive or malabsorptive bariatric surgery was sufficient to lower blood glucose. <h3>Design</h3> Women with obesity and T2D had biliopancreatic diversion with duodenal switch (BPD-DS) or laparoscopic sleeve gastrectomy (LSG). Faecal samples from the same patient before and after each surgery were used to colonise rodents, and determinants of blood glucose control were assessed. <h3>Results</h3> Glucose tolerance was improved in germ-free mice orally colonised for 7 weeks with human microbiota after either BPD-DS or LSG, whereas food intake, fat mass, insulin resistance, secretion and clearance were unchanged. Mice colonised with microbiota post-BPD-DS had lower villus height/width and crypt depth in the distal jejunum and lower intestinal glucose absorption. Inhibition of sodium-glucose cotransporter (Sglt)1 abrogated microbiota-transmissible improvements in blood glucose control in mice. In specific pathogen-free (SPF) rats, intrajejunal colonisation for 4 weeks with microbiota post-BPD-DS was sufficient to improve blood glucose control, which was negated after intrajejunal Sglt-1 inhibition. Higher <i>Parabacteroides</i> and lower <i>Blautia</i> coincided with improvements in blood glucose control after colonisation with human bacteria post-BPD-DS and LSG. <h3>Conclusion</h3> Exposure of rodents to human gut microbiota after restrictive or malabsorptive bariatric surgery improves glycaemic control. The gut microbiota after bariatric surgery is a standalone factor that alters upper gut intestinal morphology and lowers Sglt1-mediated intestinal glucose absorption, which improves blood glucose control independently from changes in obesity, insulin or insulin resistance.

Long-Term Outcomes of Revisional Malabsorptive Bariatric Surgery: Do the Benefits Outweigh the Risk?

PurposeTo evaluate the long-term outcomes of revisional malabsorptive bariatric surgery.Materials and MethodsMalabsorptive bariatric procedures are increasingly performed in the revisional setting. We collated and analysed prospectively recorded data for all patients who underwent a revisional Biliopancreatic diversion + / − duodenal switch (BPD + / − DS) over a 17-year period.ResultsWe identified 102 patients who underwent a revisional BPD + / − DS. Median follow-up was 7 years (range 1–17). There were 21 (20.6%) patients permanently lost to follow-up at a median of 5 years postoperatively. Mean total weight loss since the revisional procedure of 22.7% (SD 13.4), 20.1% (SD 10.5) and 17.6% (SD 5.5) was recorded at 5, 10 and 15 years respectively. At the time of revisional surgery, 23 (22.5%) patients had diabetes and 16 (15.7%) had hypercholesterolaemia with remission of these occurring in 20 (87%) and 7 (44%) patients respectively. Nutritional deficiencies occurred in 82 (80.4%) patients, with 10 (9.8%) patients having severe deficiencies requiring periods of parenteral nutrition. Seven (6.9%) patients required limb lengthening or reversal procedures. There were 16 (15.7%) patients who experienced a complication within 30 days, including 3 (2.9%) anastomotic leaks. Surgery was required in 42 (41.2%) patients for late complications.ConclusionRevisional malabsorptive bariatric surgery induces significant long-term weight loss and comorbidity resolution. High rates of temporary and permanent attrition from follow-up are of major concern, given the high prevalence of nutritional deficiencies. These data question the long-term safety of malabsorptive bariatric procedures due to the inability to ensure compliance with nutritional supplementation and long-term follow-up requirements.Graphical abstract Key points• Revisional bariatric surgery workload is increasing• Revisional malabsorptive surgery is efficacious for weight loss and comorbidity resolution• Revisional malabsorptive surgery is associated with high rates of nutritional deficiencies• Attrition from follow-up in this specific cohort of patients is of particular concern due to the risk of undiagnosed and untreated nutritional deficienciesSupplementary InformationThe online version contains supplementary material available at 10.1007/s11695-022-06019-7.

Impact of gastrointestinal symptoms and psychological disturbances on patients’ quality of life after restrictive or malabsorptive bariatric surgery

AimThe aim of this study was to evaluate and compare the presence and impact of Gastrointestinal (GI) symptoms, physical and psychological disturbances on patients’ QoL after sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion with duodenal switch (BPD/DS). MethodsA prospective, observational, cross-sectional, comparative study was carried-out. GI symptoms and patients’ QoL were evaluated by the SF-36 questionnaire and the GI quality of life index (GIQLI). Correlation between GI symptoms, psychological disturbances and QoL scores was analysed. Results95 patients were included (mean age 50.5 years, range 22–70; 76 females). Presence of GI symptoms was a consistent finding in all patients, and postprandial fullness, abdominal distention and flatulence had a negative impact on patients’ QoL. Patients after SG showed a worsening of their initial psychological condition and the lowest QoL scores. Patients after RYGB showed the best GI symptoms-related QoL. ConclusionsBoth restrictive and malabsorptive bariatric surgical procedures are associated with GI symptoms negatively affecting patients’ QoL. Compared to SG and BPD/DS, patients after RYGB showed the best GI symptoms-related QoL, which can be used as additional information to help in the clinical decision making of the bariatric procedure to be performed.

Current management of choledocholithiasis after bariatric surgery

The increasing prevalence of obesity all over world has led to a growing number of metabolic and bariatric surgeries. Bariatric surgery is more effective for weight loss than medical therapy, with Roux-en-Y gastric bypass (RYGB) being considered the gold standard of care over the past decade. Bariatric surgery and the subsequent weight loss are associated with an increased risk for the development of gallstone formation. Common bile duct stones prevalence around 10% among patients with symptomatic gallbladder stones. Choledocholithiasis can be technically challenging problem to treat in patients post-laparoscopic RYGB (LRYGB) or a biliopancreatic diversion (BPD/DS) due to the altered upper gastrointestinal anatomy. This review describes the different treatment options of common bile duct stones after malabsorptive bariatric surgery, success rate, and adverse effects of each treatment modality including enteroscopy-assisted endoscopic retrograde cholangiopancreatography (EA-ERCP), percutaneous transhepatic cholangiography (PTC), endoscopic ultrasound-directed transgastric retrograde cholangiopancreatography (EDGE), and laparoscopic-assisted ERCP (LAERCP).

Exocrine pancreatic function and dynamic of digestion after restrictive and malabsorptive bariatric surgery: a prospective, cross-sectional, and comparative study.

Gastrointestinal anatomical changes after restrictive and malabsorptive bariatric surgery lead to important disturbances in the process of digestion and absorption of nutrients and could lead to exocrine pancreatic insufficiency (EPI). The aim of the present study was to evaluate and to compare pancreatic function and the dynamic of digestion and absorption of nutrients after restrictive and malabsorptive bariatric surgical procedures. University Hospital of Santiago de Compostela, Santiago de Compostela, Spain. A prospective, observational, cross-sectional, comparative study of patients after sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion with duodenal switch (BPD/DS) was carried out. Patients with obesity who did not undergo surgery were included as control group. Pancreatic function and the dynamic of digestion and absorption of nutrients were evaluated by the 13C-mixed triglyceride (13C-MTG) breath test. Six-hour 13C-cumulative recovery rate (13C-CRR), 13C exhalation peak, and 1-hour maximal 13C-CRR were calculated. One-hundred five patients were included (mean age, 49.8 yr; 84 women). Six-hour 13C-CRR was significantly reduced after BPD/DS (P < .001) but not after SG and RYGB. EPI was present in 75% of patients after BPD/DS, 8.3% of patients after RYGB, and 4.3% of patients after SG. Compared with the control group who did not undergo surgery, digestion and absorption of nutrients tended to occur earlier after SG, whereas it was delayed after RYGB and mainly after BPD/DS (P < .001). Bariatric surgery significantly alters the dynamic of the digestive process. EPI is very common after BPD/DS, frequent after RYGB, and less frequent after SG. This information is clinically relevant since EPI is a treatable condition associated with symptoms, nutritional deficiencies, and complications.

Diabetes remission after malabsorptive bariatric surgery

Obesity and diabetes are two closely related disorders. Lifestyle changes and drug treatment do not achieve successful diabetes remission. A treatment option for these patients is bariatric surgery (BS). The partial and complete remission rates vary, depending on the type of technique used (restrictive or malabsorptive), with malabsorptive surgery being more effective in terms of both weight reduction and diabetes remission (DR). Different scales (DiaRem, Ad-DiaRem or 5y-Ad-DiaRem) predict the probability of DR after BS, particularly after gastric bypass surgery. Some studies report higher DR rates in surgery with a greater malabsorptive component. Our aim was to study the benefits of BS at one year and 5 years in terms of the weight and blood glucose profile in patients with obesity and type 2 diabetes mellitus; assess percentage DR according to ADA criteria; determine the DR predictive capacity of different scores; and examine which variables predict DR at one and five years after biliopancreatic diversion (BPD). Percentage overweight reduction and the decrease in both blood glucose and HbA1c were greater with BPD. Complete diabetes remission was approximately 80% at one and 5 years after BS. In general, the scores that determine the probability of DR show poor discriminative capacity in malabsorptive surgery. Presurgery HbA1c predicts DR at one and 5 years after BPD. The type of surgery performed should be individualized, based on the severity of diabetes and the specific characteristics of each patient.

Risk Factors for Kidney Stone Formation following Bariatric Surgery.

Kidney stones are painful, common, and increasing in incidence. Obesity and bariatric surgery rates are also on the rise in the United States. Although bariatric surgery is associated with improvements in metabolic outcomes, malabsorptive bariatric surgery procedures are also associated with increased risk of kidney stones. Restrictive bariatric surgeries have not been associated with kidney-stone risk. Higher risk of kidney stones after malabsorptive procedures is associated with postsurgical changes in urine composition, including high urine oxalate, low urine citrate, and low urine volume. Certain dietary recommendations after surgery may help mitigate these urine changes and reduce risk of kidney stones. Understanding risk of kidney stones after surgery is essential to improving patient outcomes after bariatric surgery.

The Risks of Stone Diagnosis and Stone Removal Procedure After Different Bariatric Surgeries.

Introduction: Nephrolithiasis is common after malabsorptive bariatric surgery; however, the comparative risk of stone formation after different bariatric surgeries remains unclear. We seek to compare the risk of stone diagnosis and stone procedure after gastric banding (GB), sleeve gastrectomy (SG), short-limb Roux-en-Y (SLRY), long-limb Roux-en-Y (LLRY), and biliopancreatic diversion with duodenal switch (BPDDS). Patients and Methods: Using an administrative database, we retrospectively identified 116,304 patients in the United States, who received bariatric surgery between 2007 and 2014, did not have a known kidney stone diagnosis before surgery, and were enrolled in the database for at least 1 year before and after their bariatric surgery. We used diagnosis and procedural codes to identify comorbidities and events of interest. Our primary analysis was performed with extended Cox proportional hazards models using time to stone diagnosis and time to stone procedure as outcomes. Results: The adjusted hazard ratio of new stone diagnosis from 1 to 36 months, compared to GB, was 4.54 for BPDDS (95% confidence interval [CI] 3.66-5.62), 2.12 for LLRY (95% CI 1.74-2.58), 2.15 for SLRY (95% CI 2.02-2.29), and 1.35 for SG (95% CI 1.25-1.46). Similar results were observed for risk of stone diagnosis from 36 to 60 months, and for risk of stone removal procedure. Male sex was associated with an overall 1.63-fold increased risk of new stone diagnosis (95% CI 1.55-1.72). Conclusions: BPDDS was associated with a greater risk of stone diagnosis and stone procedures than SLRY and LLRY, which were associated with a greater risk than restrictive procedures. Nephrolithiasis is more common after more malabsorptive bariatric surgeries, with a much greater risk observed after BPDDS and for male patients.

Thyroid surgery in obese patients: A review of the literature.

The incidence of obesity in the general population has tripled in the past four decades. The number of bariatric surgeries performed annually has quadrupled in the past ten years due to this obesity epidemic. Concomitantly, the number of patients who are obese or who have undergone bariatric surgery and have become candidates for thyroid surgery has also increased considerably. Among patients undergoing thyroidectomy in the French population, the proportion of obese patients currently represents 10 to 20%. In addition, the frequency of benign and malignant thyroid pathologies seems to be increased by obesity, with a Hazard Ratio of around 1.8 for thyroid cancers in obese women. While obesity does not seem to influence the specific post-operative morbidity of thyroidectomy, a history of malabsorptive bariatric surgery should encourage the greatest caution in patients who need to undergo thyroid surgery since it is associated with a significant risk of severe hypocalcemia (>60% in some studies) requiring intravenous calcium supplementation in about 20% of cases. In the latter situation, peri-operative vitamin D-calcium supplementation is essential. In addition, the replacement dose of Levothyroxine (T4) intended for replacement must also be adapted in obese patients, calculated not from the actual weight but from the ideal weight. The objective of this review is to discuss the influence of obesity on the evolution of nodular and neoplastic thyroid pathologies, on the morbidity of thyroid surgery as well as on post-operative drug treatments. The impact of bariatric surgery on these different aspects is also discussed.

Different Malabsorptive Obesity Surgery Interventions Result in Distinct Postprandial Amino Acid Metabolomic Signatures.

Biliopancreatic diversion with duodenal switch (BPD-DS) is an effective weight loss surgical procedure. Yet, BPD-DS is technically difficult to perform and carries a higher risk of nutrient deficiencies as compared with other surgical interventions. Single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is a modified BPD-DS procedure conceived with the aim of decreasing the technical complexity, while retaining the weight loss efficiency. Whether the two surgical procedures diverge in nutrient absorption rates and malnutrition risk is still matter of debate. Our aim was to determine if postprandial nutrient absorption rates are different in patients subjected to BPD-DS or SADI-S for weight loss. Plasma amino acid metabolomic profiling during mixed-meal tolerance test (MMTT) was performed in subjects (N = 18) submitted to BPD-DS (n = 9) or SADI-S (n = 9) 1.6 ± 0.1years earlier. Patients submitted to SADI-S or BPD-DS presented distinct postprandial metabolomic profiles. Postprandial excursions of total and essential amino acids-leucine, isoleucine, and valine-were higher after SADI-S as compared with BPD-DS. Our study demonstrates that a simplified malabsorptive bariatric surgery procedure SADI-S results in greater essential branched-chain amino acid absorption when compared with the classical BPD-DS intervention. These findings suggest that SADI-S can potentially lower lifetime risk of postoperative protein malnutrition, as well as have a positive impact on systemic metabolism and glucose homeostasis.

Longitudinal metabolic and gut bacterial profiling of pregnant women with previous bariatric surgery

ObjectiveDue to the global increase in obesity rates and success of bariatric surgery in weight reduction, an increasing number of women now present pregnant with a previous bariatric procedure. This...

Enteritis necroticans – megacolon with massive portal venous gas embolization in a patient after malabsorptive bariatric surgery

Enteritis necroticans – megacolon with massive portal venous gas embolization in a patient after malabsorptive bariatric surgery

History of Bariatric Surgery Is an Independent Risk Factor for Inadequate Colonoscopy Preparation: Presidential Poster Award

Introduction: Effective colon cancer screening requires adequate bowel preparation. In the setting of prior bariatric surgery, low-volume preparations or extended time delivery for high-volume preparations is recommended, although this recommendation is based on weak evidence. This study aims to evaluate bariatric surgery as a predictive risk factor for inadequate bowel preparation. Methods: Data were collected retrospectively for consecutive colonoscopies between March 1, 2013 and November 15, 2017. Only the index colonoscopy for each patient within the review period, and those scored using the Boston Bowel Preparation Scale (BBPS) were included. Incomplete data sets and patients with inflammatory bowel disease (IBD) were excluded. Inadequate preparation was defined as any one or more colon segments with a BBPS score of less than two. Patients with bariatric surgery occurring before the date of the colonoscopy were identified using ICD 9/10 codes. Data were analyzed using Wilcoxon rank-sum test for continuous variables and Fischer’s exact test for dichotomous variables. Multivariate logistic regression was performed to identify independent factors predictive of inadequate bowel preparation. Results: 70,714 colonoscopies occurred within the designated review period. 58,853 were excluded from analysis as shown in Figure 1. Of the remaining 11,861 colonoscopies, 363 (3.1%) had inadequate preparation. Factors associated with inadequate preparation on univariate analysis included: age, male sex, non-white race, body mass index (BMI), hypertension (HTN), diabetes mellitus (DM), and history of bariatric surgery (Table 1). After controlling for confounding risk factors, a history of bariatric surgery (OR = 2.98; 95% CI: 1.93-4.61) was found to be predictive of inadequate preparation (Table 1). In a subanalysis of malabsorptive vs. restrictive bariatric surgery patients, malabsorptive bariatric surgery was associated with a higher rate of inadequate preparation (12.79% vs. 4.58%, P = 0.023).515_A Figure 1 No Caption available.Conclusion: A history of bariatric surgery is an independent risk factor for inadequate bowel preparation. Furthermore, malabsorptive bariatric surgeries had higher rates of inadequate preparation when compared to restrictive bariatric surgeries. Further quality improvement initiatives should be directed at identifying the appropriate bowel preparation regimen in this population.515_B Figure 2. Risk factors for Inadequate Bowel Preparation.

Differential effects of restrictive and malabsorptive bariatric surgery procedures on the serum lipidome in obese subjects

Bariatric surgery (BS) is the most effective treatment for severe obesity. Our group and others have previously reported that the type of BS (restrictive vs malabsorptive) can lead to different effects on the lipid profile and glucose homeostasis in morbidly obese patients. Furthermore, BS exerts significant changes in lipid metabolism, which are not yet fully understood and that might be dependent of surgical technique. The objective of this study was to evaluate the differential changes in the serum lipidomic profile of morbidly obese subjects who underwent two different BS techniques: sleeve gastrectomy (SG) (restrictive) and biliopancreatic diversion (BPD) (malabsorptive). This study included 37 morbidly obese patients (body mass index≥40kg/m2) who underwent either SG (n=25) or BPD (n=12). Serum lipid extracts were assessed at baseline and 6months after BS and were analyzed in a ultra-high performance liquid chromatography time-of-flight mass spectrometry-based platform. SG not only restores the circulating levels of fatty acids and glycerolipids to similar levels to those observed in nonobese subjects but also results in a consistent increase of phospholipid and sphingolipid species, ranging from antioxidant plasmalogens to lipotoxic ceramides. BPD, however, leads to an overall reduction in circulating fatty acids, glycerolipids, phospholipids and sphingolipids, and a substantial increase of bile acids. Our lipidomic analysis suggests that the differential metabolic effects typically observed after restrictive vs malabsorptive BS procedures could be explained, at least partially, to BS-specific lipid changes and provides novel aspects of lipid remodeling in obesity during weight loss.

Factors associated with pancreatic exocrine insufficiency (PEI) in patients after restrictive and malabsorptive bariatric surgery

Factors associated with pancreatic exocrine insufficiency (PEI) in patients after restrictive and malabsorptive bariatric surgery