surgical treatment of obesity: when and how? the surgeon’s ... c/hall c... · selection criteria...
TRANSCRIPT
![Page 1: Surgical Treatment of Obesity: When and How? The Surgeon’s ... c/hall c... · Selection Criteria for Surgical Management • 1991 NIH Consensus Conference Criteria • BMI > 40](https://reader035.vdocuments.net/reader035/viewer/2022070715/5ed78da02d495209194576db/html5/thumbnails/1.jpg)
CODHY 2006
Surgical Treatment of Obesity:
When and How?
The Surgeon’s Perspective
John Morton, MD, MPH, FACS
Director of Bariatric Surgery
Stanford School of Medicine
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CODHY 2006
Stanford Bariatric GroupStanford Bariatric Group
• Open and Laparoscopic
Gastric Bypass
• Robotic-Assisted Gastric
Bypass
• Laparoscopic Adjustable
Gastric Banding
• Adolescent Bariatric
Surgery
• Sleeve Gastrectomy
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CODHY 2006
Degrees of Obesity –Body Mass
Index
NORMAL
18.5 – 24.9
OVERWGT
25 – 29.9
OBESE
30 – 34.9
SEVERE LY
OBESE
35 – 39.9
MORBIDLY
OBESE
≥≥≥≥ 40
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CODHY 2006
BMI and Mortality
Calle, N Engl J Med 1999;341:1097-1105.
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CODHY 2006
Target: Diabetes and Metabolic
Syndrome
Sattar, Circulation, 2003
24X
!
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CODHY 2006
Target: Inflammation and
Metabolic Syndrome
Sattar, Circulation, 2003
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CODHY 2006
Target: Obesity, Diabetes and
Mortality
Rogers, J.BioSoc Sci, 2003
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CODHY 2006
0
5
10
15
Cardiovascular Disease Mortality
Increased with Metabolic Syndrome
Lakka HM et al. JAMA 2002;288:2709-2716.
Cum
ula
tive
Ha
zard
, %
0 2 6 8 12Follow-up, year
YESYES
Metabolic
Syndrome:
NONO
Cardiovascular Disease Mortality
RR (95% CI), 3.55 (1.98–6.43)
4 10
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CODHY 2006
The Obesity Epidemic
• Three in five Americans are either overweight
or obese
• In the past 20 years, adult obesity has doubled
• 300,000+ premature deaths annually
– 400,000 deaths/year from smoking, but is decreasing
– 90,000 deaths/year from colon and breast cancer
combined
• 75% of obese children become morbidly obese adults
The Surgeon General’s Call to Action to Prevent Overweight and Obesity.
A Rapidly Expanding Problem
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CODHY 2006
World Health Organization
Deaths from obesity related problems
2.5 million annual (7,500/day)
222,000 in Europe
300,000 in USA
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CODHY 2006
1990 Obesity Trends Among U.S.
Adults
No Data <10% 10%-14% 15-19% ≥20%
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CODHY 2006
1991 Obesity Trends Among U.S.
Adults
No Data <10% 10%-14% 15-19% ≥20%
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CODHY 2006
1992 Obesity Trends Among U.S.
Adults
No Data <10% 10%-14% 15-19% ≥20%
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CODHY 2006
1993 Obesity Trends Among U.S.
Adults
No Data <10% 10%-14% 15-19% ≥20%
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CODHY 2006
1994 Obesity Trends Among U.S.
Adults
No Data <10% 10%-14% 15-19% ≥20%
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CODHY 2006
1995 Obesity Trends Among U.S.
Adults
No Data <10% 10%-14% 15-19% ≥20%
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CODHY 2006
1996 Obesity Trends Among U.S.
Adults
No Data <10% 10%-14% 15-19% ≥20%
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CODHY 2006
1997 Obesity Trends Among U.S.
Adults
No Data <10% 10%-14% 15-19% ≥20%
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CODHY 2006
1998 Obesity Trends Among U.S.
Adults
No Data <10% 10%-14% 15-19% ≥20%
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CODHY 2006
1999 Obesity Trends Among U.S.
Adults
No Data <10% 10%-14% 15-19% ≥20%
.
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CODHY 2006
2000 Obesity Trends Among U.S.
Adults
No Data <10% 10%-14% 15-19% ≥20%
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CODHY 2006
2001 Obesity Trends Among U.S.
Adults
No Data <10% 10%-14% 15-19% 20-24% ≥25%
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CODHY 2006
• Interventions
– Diet supervised by Nutritionist
– Tailored activity plan
– Behavioral Modification
– Medications
– Surgery
Morbid Obesity
Medical Options
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CODHY 2006
Morbid Obesity
Behavior modification somewhat helpful
– Medical Wt loss Trials generally short term
• Avg wt loss of 10 kg at 1 year
– Longer studies demonstrate insufficient wt
loss
– Overall, 95 % can’t maintain wt loss
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CODHY 2006
High Attrition Rates of
Commercial Weight Reduction
Programs
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50
Weeks after commencement of Weight Watchers program
% Attrition Rate
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CODHY 2006
Ghrelin: Biological Cause of Post-
Diet Weight Regain
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CODHY 2006
Diethylprion – pulm hypertension, psychosis
Dexfenfluramine – valv hrt dis, pulm htn
Fenfluramine – valv hrt dis, pulm hypertension
Fluoxetin – diarrhea, seizures, hyponatremia
Mazindol – pulm hypertension, AF, syncope
Orlistat – diarrhea, lowers fat soluble vitamins (K
Phentermine – cardio-pulm effects not excluded
Sibutramine – arrythmias, hypertension
• ALL Require life-long use
Diet Medications
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CODHY 2006
Solution!
SURGERY
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CODHY 2006
Surgery: First Responder to Public
Health Epidemics
• Cancer
• Tuberculosis
• Coronary Disease
• Morbid Obesity
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CODHY 2006
Surgical Referral
Obese Type II DMLung CA
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CODHY 2006
Selection Criteria for Surgical
Management
• 1991 NIH Consensus Conference Criteria
• BMI > 40 kg/m2 or BMI > 35 kg/m2 with
co-morbidities
• Failure of nonsurgical methods
• Absence of endocrine disorder causing obesity
• Psychologic stability
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CODHY 2006
History- Bariatric Surgery
• Jejunoileal bypass mid 1954
• Gastric bypass Mason mid 1967
• Vertical Banded Gastroplasty, Mason
1982
• Biliopancreatic diversion Scopinaro 1996
• Duodenal Switch
• Lap band 1990
• Laparoscopic gastric bypass 1994
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CODHY 2006
Ideal Surgery
• Safe
• Effective
• No FollowUp
• Cheap
• It does not exist!
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CODHY 2006
Surgical Treatment of Obesity
• Lap Band • Roux en Y Gastric Bypass (RGB)
•Sleeve
Gastrectomy•BPD/DS
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CODHY 2006
Evidence for Choosing Operation
• Few Data
• Difficult to Perform RCT in Surgery
– Blinding
– Funding
– Patients Vote with their feet
• Outcomes Research will be critical in the
absence of RCTs
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CODHY 2006
Adjustable
Silicon Gastric
Banding (ASGB)
• Restrictive
• Adjustable
• 50% EWL @ 1 year
• No anemia, dumping
or malabsorption
• Few Technical
complications
• Few long-term data
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CODHY 2006
Sleeve Gastrectomy
• New Procedure
• No Malabsorption
• Vitamin Deficiencies
• No adjustments
• EWL 30-80%
• May be converted to
Lap-Band or Gastric
Bypass
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CODHY 2006
Duodenal Switch
• Malabsorptive
• 80% EWL
• Technically Difficult
• Fat Soluble Vitamin
Deficiencies
• Reserved for the
Super-Obese
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CODHY 2006
Gastric Bypass
(RGB)
• Restrictive and
Malabsorptive
• 75-80% EWL
• Mechanical Problems
• Potential Micronutrient
Deficiency
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CODHY 2006
Laparoscopic Gastric Bypass • Wittgrove/Clarke 1993
• 80 % excess wt loss
• Wolfe, RCT, 2001
• Less Wound/Pulmonary
Complications
• Less Pain
• Earlier Return to Work
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CODHY 2006
Post operative complications
• Leaks
• DVT/Pulmonary
embolus
• Acute gastric
distension
• GI Bleeding
• Wound problems
• Bowel Obstruction
• Incisional Hernia
• Internal Hernia
• Staple line disruption
• Stomal ulceration
• Stomal stenosis
• Metabolic
complications
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CODHY 2006
Stanford Results: University
HealthSystem Consortium
0.250Mortality-%
10.555.4Complications-
%
3.50.9Readmissions-
%
15.180.8ICU Stay-%
3.553.2Length of Stay-
Days
UHCStanford
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CODHY 2006
Surgery Assessment Criteria
• What are the alternatives?
– Surgery
• Is it safe?
– Morbidity and Mortality
• Is it effective?
– Outcomes
• Is it durable?
– Long Term Outcomes
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CODHY 2006
Is it safe? Mortality
Maggart, Ann of Int Med, 2004
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CODHY 2006
These studies demonstrate that there are vulnerable patient
populations and potential additional costs associated with
surgery but suggest that surgical volume helps mitigate these
risks and costs," wrote Bruce M. Wolfe, M.D., of Oregon Health
& Sciences University in Portland and John M. Morton, M.D.,
M.P.H., of Stanford in an accompanying editorial.
"Bariatric surgery may be a potentially life-saving intervention in
the right patients and in the right surgeons' hands," they
added. "The studies presented in this issue indicate that
experience and technique count."
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CODHY 2006
Nationwide Inpatient Sample
LOS>7 Days
Morton, JACS 2006
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CODHY 2006
Nationwide Inpatient Sample
Any Complications
Morton, JACS 2006
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CODHY 2006
Nationwide Inpatient Sample
Mortality
Morton, JACS 2006
Stanford
250+
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CODHY 2006
Does It Work?
• Comorbidity Resolution
• Weight Loss
• Survival Benefit
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CODHY 2006
Does It Work? Weight Loss
Sjostrom, NEJM, 2004
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CODHY 2006Schauer, Annals of Surgery 2001
Does It Work? Comorbidity Resolution
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CODHY 2006
Obesity surgery can lower heart risk
Study: Gastric bypass more effective than statins in cutting
cholesterol
Patients who got the surgery showed improved levels of three new
measures of heart disease risk -- C-reactive protein, lipoprotein A
and homocysteine, the team at Stanford University School of
Medicine found.
They measured these proteins, as well as cholesterol levels, in 371
patients before surgery and again a year later and found
improvements to normal range in all of them.
Updated: 3:05 p.m. ET July 18, 2005
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CODHY 2006
Coronary Artery Disease: Obesity
and Smoking
• Primary modifiable CAD risk factors: obesity and smoking
– While smoking decreases, obesity is increasing (JAMA 05)
– Rise in obesity may negate gains in life expectancy
(NEJM 2005) 10
15
20
25
30
35
40
45
1971 1976 1988 1999
Smoking, %
BMI > 30, %
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CODHY 2006
Morbid Obesity
• The only effective and enduring long-term
therapy is bariatric surgery
• Gastric bypass substantially improves several
cardiovascular risk factors:
– Excess Weight
– Lack of Exercise
– Hypertension
– Diabetes
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CODHY 2006
Methods
Prospective study - August 2003 to March 2005
• No statin therapy post-op
• All with B12 and MVI supplementation
• 371 patients with roux-en-Y gastric bypass– 100% laparoscopic
• Cardiac risk factor assessment @ pre-op, 3, 6, and 12 months post-op– BMI, HgA1C
– Total cholesterol, LDL, HDL, triglycerides
– C-reactive protein, lipoprotein A, homocysteine
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CODHY 2006
Biochemical Cardiac Risk Factors
• Traditional Biochemical Risk Factors
– ↑↑↑↑ LDL
– ↓↓↓↓ HDL
– ↑↑↑↑ Total Cholesterol / HDL Ratio
– ↑↑↑↑ Triglycerides
– ↑↑↑↑ HgA1C
• However, nearly half of all myocardial
infarctions and strokes occur in people with a
normal LDL
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CODHY 2006
Emerging Cardiac Risk Factors
• C-Reactive Protein (CRP)
• Lipoprotein A (LipoA)
• Homocysteine (Hcys)
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CODHY 2006
President Bush’s Lipid Panel
• total cholesterol: 178 (<200)HDL: 56 (>40)Large HDL: 32 ( >30)LDL: 100 (<130)total cholesterol/HDL ratio: 3.2Triglycerides: 71 (<150)Lipoprotein (a): 17.9 (<30)hs-CRP: 0.4 ( < 1.0)Homocysteine: 9.3 (5-15)
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CODHY 2006Ridker, P. M. Circulation 2001;103:1813-1818
Comparison of Biochemical Risk
Factors
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CODHY 2006
Methods: Study Population
47 (35-88)BMI
23%Use of Statins
33%Diabetic
2%Known CAD
50%Hypertensive
84%Female
43 (16-63)Age
Mean (Range) or
Percentage
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CODHY 2006
Cardiovascular Risk Markers:
Percent Abnormal Pre-op
Hcys
HDL Ratio
LipoALDL
TC Trig
CRP
0
10
20
30
40
50
60
70
80
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CODHY 2006
Improvement in Cardiac Risk
Factors: Total Cholesterol
187
168 166 166
0
50
100
150
200
0 3 mos 6 mos 12 mos
TC
Linear (TC)
Morton, SOARD, 2006
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CODHY 2006
Improvement in Cardiac Risk
Factors: LDL
124
105 102
88
0
20
40
60
80
100
120
140
0 3 mos 6 mos 12 mos
LDL
Linear (LDL)
Morton, SOARD, 2006
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CODHY 2006
Improvement in Cardiac Risk
Factors: HDL
45
41
45
54
0
10
20
30
40
50
60
0 3 mos 6 mos 12 mos
HDL
Linear (HDL)
Morton, SOARD, 2006
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CODHY 2006
Improvement in Cardiac Risk
Factors: Triglycerides
141
116
92 92
0
20
40
60
80
100
120
140
160
0 3 mos 6 mos 12 mos
TG
Linear (TG)
Morton, SOARD, 2006
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CODHY 2006
Improvement in Cardiac Risk
Factors: Total Cholesterol/HDL
4.24
3.53.1
0
1
2
3
4
5
0 3 mos 6 mos 12 mos
TC/HDL
Linear (TC/HDL)
Morton, SOARD, 2006
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CODHY 2006
Improvement in Cardiac Risk
Factors: Hemoglobin A1C
65.7 5.6 5.5
0
1
2
3
4
5
6
7
0 3 mos 6 mos 12 mos
HgA1c
Linear (HgA1c)
Morton, SOARD, 2006
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CODHY 2006
Improvement in Cardiac Risk
Factors: Homocysteine
10.19.4
98.4
0
1
2
3
4
5
6
7
8
9
10
11
12
0 3 mos 6 mos 12 mos
HC
Linear (HC)
Morton, SOARD, 2006
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CODHY 2006
Improvement in Cardiac Risk
Factors: Lipoprotein A
23
15
12.9
10
0
5
10
15
20
25
0 3 mos 6 mos 12 mos
LpoA
Linear (LpoA)
Morton, SOARD, 2006
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CODHY 2006
Improvement in Cardiac Risk
Factors: High Sensitivity
C Reactive Protein
8.2
4.9
2.5
1.4
0
5
10
0 3 mos 6 mos 12 mos
CRP
Linear (CRP)
Morton, SOARD, 2006
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CODHY 2006
Improvement in Cardiac Risk
Factors: Triglycerides/HDL
3.1
2.6
2.2
1.7
0
1
2
3
4
5
0 3 mos 6 mos 12 mos
TG/HDL
Linear (TG/HDL)
Morton, SOARD, 2006
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CODHY 2006
Percent Improvement in Cardiac
Risk: 1 year S/P Gastric Bypass
0
10
20
30
40
50
60
70
80
90
LpA HgA TC HDL HC LDL TG BMI Met* CRP
Morton, SOARD, 2006
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CODHY 2006
Conclusion
• Morbidly obese patients have
significantly elevated cardiovascular risk
• Emerging cardiac risk factors may assist
in cardiac risk stratification
• Gastric bypass substantially improves the
traditional and emerging biochemical
risk factors for cardiovascular disease
• Gastric Bypass Reduced CRP 80%
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CODHY 2006
Does It Work? Survival Benefit
Christou, Ann Surg, 2004
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CODHY 2006
Is it Durable?
• Pories- Ann Surg 1995
– 14 year Follow Up
– 304 lbs 205 lbs, year 14
– At year 14, 83% resolution of DM
• Sugerman- Ann Surg 2003
– 7 year Follow up
– BMI Decrease from 51 to 35
– 86% resolution of DM, 66% resolution of HTN
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CODHY 2006
Cost-effectiveness: QALY<50K
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CODHY 2006
Long Term Outcomes and Follow
Up for Bariatric Surgery
• ONLY effective and enduring weight loss
therapy for morbidly obese
• Safe
• Effective
• Durable
• Cost-Effective
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CODHY 2006
Stanford Bariatric Surgery
AfterCare
• 2 weeks, 6 weeks, 3 months, 6 months, 1
year, Once a Year
• Re-Referral to PT, Nutrition, Psych
• Education = Prevention
– Chronic Disease Management
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CODHY 2006
Summary
• Surgery requires careful patient selection and
education
• Surgery is a TOOL, not a cure
• Long term commitment with healthcare team
• Potential for gain outweighs risks of operation
• Many problems cured through surgical
management of obesity
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CODHY 2006
Testimonial
• 3 years S/P
LRNYGB
• 75% Excess Wgt
Loss
• Complete Resolution
– IDDM
– OSA
– HTN
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