Advertisement

Obesity Surgery

, Volume 28, Issue 4, pp 1149–1174 | Cite as

Challenges in Transition of Care for Pediatric Patients after Weight-Reduction Surgery: a Systematic Review and Recommendations for Comprehensive Care

  • Sarah B. Cairo
  • Indrajit Majumdar
  • Aurora Pryor
  • Alan Posner
  • Carroll M. Harmon
  • David H. Rothstein
  • on behalf of the Delivery of Surgical Care Committee of the American Academy of Pediatrics Section on Surgery
Review Article

Abstract

Obesity in pediatric patients is rising with nearly one third of children in the USA classified as overweight and up to 16–18% of the adolescent population obese with at least one comorbid condition. Consequently, bariatric procedures in this population have increased without consistent recommendations for follow-up and transition to adult providers. This review describes the known and potential long-term consequences of bariatric surgery in pediatric patients, reviews the current literature on transitions of care for adolescent patients with chronic illnesses. Additionally, this review summarizes recommendations from the literature for developing a standardized program for transitioning care for post-bariatric surgical patients and offers useful tools and guidelines for doing so.

Keywords

Pediatric obesity Bariatric surgery Outcomes Transitions in care 

Notes

Compliance with Ethical Standards

Disclosures

The authors have no relevant financial or other disclosures to report.

Conflict of Interest

None of the authors have any disclaimers or conflicts of interests to report nor were any funds, proprietary or otherwise, used to fund this research.

Disclaimers

None of the authors have any disclaimers, conflicts of interest, or use of previously copyrighted material to report. No grant support or financial relationships were employed in the conduct of this research.

Presentations

This work has not been submitted for presentation.

Supplementary material

11695_2018_3138_MOESM1_ESM.docx (120 kb)
ESM 1 (DOCX 120 kb).

References

  1. 1.
    Tsai WS, Inge TH, Burd RS. Bariatric surgery in adolescents: recent national trends in use and in-hospital outcome. Arch Pediatr Adolesc Med. 2007;161(3):217–21.  https://doi.org/10.1001/archpedi.161.3.217.CrossRefPubMedGoogle Scholar
  2. 2.
    Schilling PL, Davis MM, Albanese CT, et al. National trends in adolescent bariatric surgical procedures and implications for surgical centers of excellence. J Am Coll Surg. 2008;206(1):1–12.  https://doi.org/10.1016/j.jamcollsurg.2007.07.028.CrossRefPubMedGoogle Scholar
  3. 3.
    Kelleher DC, Merrill CT, Cottrell LT, et al. Recent national trends in the use of adolescent inpatient bariatric surgery: 2000 through 2009. JAMA Pediatr. 2013;167(2):126–32.  https://doi.org/10.1001/2013.jamapediatrics.286.CrossRefPubMedGoogle Scholar
  4. 4.
    Childhood obesity facts. 2017; https://www.cdc.gov/healthyschools/obesity/facts.htm, 2017.
  5. 5.
    Michalsky M, Kramer RE, Fullmer MA, et al. Developing criteria for pediatric/adolescent bariatric surgery programs. Pediatrics. 2011;128(Suppl 2):S65–70.  https://doi.org/10.1542/peds.2011-0480F.CrossRefPubMedGoogle Scholar
  6. 6.
    Zwintscher NP, Azarow KS, Horton JD, et al. The increasing incidence of adolescent bariatric surgery. J Pediatr Surg. 2013;48(12):2401–7.  https://doi.org/10.1016/j.jpedsurg.2013.08.015.CrossRefPubMedGoogle Scholar
  7. 7.
    Fielding GA, Duncombe JE. Laparoscopic adjustable gastric banding in severely obese adolescents. Surg Obes Relat Dis. 2005;1(4):399–405; discussion 405-397.  https://doi.org/10.1016/j.soard.2005.04.006.CrossRefPubMedGoogle Scholar
  8. 8.
    Freedman DS, Mei Z, Srinivasan SR, et al. Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the Bogalusa Heart Study. J Pediatr. 2007;150(1):12–17.e12.CrossRefPubMedGoogle Scholar
  9. 9.
    Vanhala M, Vanhala P, Kumpusalo E, et al. Relation between obesity from childhood to adulthood and the metabolic syndrome: population based study. BMJ. 1998;317(7154):319–20.  https://doi.org/10.1136/bmj.317.7154.319.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    McMahon MM, Sarr MG, Clark MM, et al. Clinical management after bariatric surgery: value of a multidisciplinary approach. Mayo Clin Proc. 2006;81(10 Suppl):S34–45.  https://doi.org/10.1016/S0025-6196(11)61179-8.CrossRefPubMedGoogle Scholar
  11. 11.
    Friedrich AE, Damms-Machado A, Meile T, et al. Laparoscopic sleeve gastrectomy compared to a multidisciplinary weight loss program for obesity–effects on body composition and protein status. Obes Surg. 2013;23(12):1957–65.  https://doi.org/10.1007/s11695-013-1036-6.CrossRefPubMedGoogle Scholar
  12. 12.
    Spear BA, Barlow SE, Ervin C, et al. Recommendations for treatment of child and adolescent overweight and obesity. Pediatrics. 2007;120(Suppl 4):S254–88.  https://doi.org/10.1542/peds.2007-2329F.CrossRefPubMedGoogle Scholar
  13. 13.
    Weiss R, Dziura J, Burgert TS, et al. Obesity and the metabolic syndrome in children and adolescents. N Engl J Med. 2004;350(23):2362–74.CrossRefPubMedGoogle Scholar
  14. 14.
    Knöpfli BH, Radtke T, Lehmann M, et al. Effects of a multidisciplinary inpatient intervention on body composition, aerobic fitness, and quality of life in severely obese girls and boys. J Adolesc Health. 2008;42(2):119–27.CrossRefPubMedGoogle Scholar
  15. 15.
    Weiss AL, Taguchi M, Aslam S, et al. Adolescent bariatric surgery: identifying comorbidities and evaluating success of an interdisciplinary treatment team. J Adolesc Health. 2016;58((2)Google Scholar
  16. 16.
    Fried M, Hainer V, Basdevant A, et al. Inter-disciplinary European guidelines on surgery of severe obesity. Int J Obes. 2007;31(4):569–77.CrossRefGoogle Scholar
  17. 17.
    Dimick JB, Osborne NH, Nicholas L, et al. Identifying high-quality bariatric surgery centers: hospital volume or risk-adjusted outcomes? J Am Coll Surg. 2009;209(6):702–6.  https://doi.org/10.1016/j.jamcollsurg.2009.09.009.CrossRefPubMedGoogle Scholar
  18. 18.
    Wulkan ML, Walsh SM. The multi-disciplinary approach to adolescent bariatric surgery. Semin Pediatr Surg. 2014;23(1):2–4.  https://doi.org/10.1053/j.sempedsurg.2013.10.012.CrossRefPubMedGoogle Scholar
  19. 19.
    Mühlig Y, Wabitsch M, Moss A, et al. Weight loss in children and adolescents. Dtsch Arztebl Int. 2014;111(48):818–24.PubMedPubMedCentralGoogle Scholar
  20. 20.
    Reinehr T. Effectiveness of lifestyle intervention in overweight children. Proc Nutr Soc. 2011;70(4):494–505.  https://doi.org/10.1017/S0029665111000577.CrossRefPubMedGoogle Scholar
  21. 21.
    Reinehr T, Bucksch J, Müller A, et al. 7-Year follow-up of a lifestyle intervention in overweight children: comparison to an untreated control group. Clin Nutr. 2017;Google Scholar
  22. 22.
    Childerhose JE, Alsamawi A, Mehta T, et al. Adolescent bariatric surgery: a systematic review of recommendation documents. Surg Obes Relat Dis. 2017;13(10):1768–79.  https://doi.org/10.1016/j.soard.2017.08.008.CrossRefPubMedGoogle Scholar
  23. 23.
    Styne DM, Arslanian SA, Connor EL, et al. Pediatric obesity-assessment, treatment, and prevention: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017;102(3):709–57.  https://doi.org/10.1210/jc.2016-2573.PubMedGoogle Scholar
  24. 24.
    Inge TH, Zeller MH, Jenkins TM, et al. Perioperative outcomes of adolescents undergoing bariatric surgery: the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study. JAMA Pediatr. 2014;168(1):47–53.  https://doi.org/10.1001/jamapediatrics.2013.4296.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Pratt JS, Lenders CM, Dionne EA, et al. Best practice updates for pediatric/adolescent weight loss surgery. Obesity (Silver Spring). 2009;17(5):901–10.  https://doi.org/10.1038/oby.2008.577.CrossRefGoogle Scholar
  26. 26.
    Inge TH. Bariatric surgery for morbidly obese adolescents: is there a rationale for early intervention? Growth Horm IGF Res. 2006;16(Suppl A):S15–9.CrossRefPubMedGoogle Scholar
  27. 27.
    Estimate of bariatric surgery numbers, 2011–2015. 2016; https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers, 2017.
  28. 28.
    Vinzens F, Kilchenmann A, Zumstein V, et al. Long-term outcome of laparoscopic adjustable gastric banding (LAGB): results of a Swiss single-center study of 405 patients with up to 18 years' follow-up. Surg Obes Relat Dis. 2017;13(8):1313–9.  https://doi.org/10.1016/j.soard.2017.04.030.CrossRefPubMedGoogle Scholar
  29. 29.
    Paulus GF, Konings G, Bouvy ND, et al. Long-term follow-up is essential to assess outcome of gastric banding in morbidly obese adolescents: a retrospective analysis. Obes Facts. 2016;9(5):344–52.  https://doi.org/10.1159/000448193.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Michalsky MP, Inge TH, Teich S, et al. Adolescent bariatric surgery program characteristics: the Teen Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study experience. Semin Pediatr Surg. 2014;23(1):5–10.  https://doi.org/10.1053/j.sempedsurg.2013.10.020.CrossRefPubMedGoogle Scholar
  31. 31.
    Inge TH, Courcoulas AP, Jenkins TM, et al. Weight loss and health status 3 years after bariatric surgery in adolescents. N Engl J Med. 2016;374(2):113–23.  https://doi.org/10.1056/NEJMoa1506699.CrossRefPubMedGoogle Scholar
  32. 32.
    Sugerman HJ, Sugerman EL, DeMaria EJ, et al. Bariatric surgery for severely obese adolescents. J Gastrointest Surg. 2003;7(1):102–107; discussion 107-108.  https://doi.org/10.1016/S1091-255X(02)00125-7.CrossRefPubMedGoogle Scholar
  33. 33.
    Alqahtani AR, Elahmedi MO, Al Qahtani A. Co-morbidity resolution in morbidly obese children and adolescents undergoing sleeve gastrectomy. Surg Obes Relat Dis. 2014;10(5):842–50.  https://doi.org/10.1016/j.soard.2014.01.020.CrossRefPubMedGoogle Scholar
  34. 34.
    Castellani RL, Toppino M, Favretti F, et al. National survey for bariatric procedures in adolescent: long time follow-up. J Pediatr Surg. 2017;52(10):1602–5.  https://doi.org/10.1016/j.jpedsurg.2017.03.005.CrossRefPubMedGoogle Scholar
  35. 35.
    Shoar S, Mahmoudzadeh H, Naderan M, et al. Long-term outcome of bariatric surgery in morbidly obese adolescents: a systematic review and meta-analysis of 950 patients with a minimum of 3 years follow-up. Obes Surg. 2017;Google Scholar
  36. 36.
    Kristensen SD, Jess P, Floyd AK, et al. Internal herniation after laparoscopic antecolic Roux-en-Y gastric bypass: a nationwide Danish study based on the Danish National Patient Register. Surg Obes Relat Dis. 2016;12(2):297–303.  https://doi.org/10.1016/j.soard.2015.10.059.CrossRefPubMedGoogle Scholar
  37. 37.
    Göthberg G, Gronowitz E, Flodmark CE, et al. Laparoscopic Roux-en-Y gastric bypass in adolescents with morbid obesity–surgical aspects and clinical outcome. Semin Pediatr Surg. 2014;23(1):11–6.CrossRefPubMedGoogle Scholar
  38. 38.
    Obeid A, McNeal S, Breland M, et al. Internal hernia after laparoscopic Roux-en-Y gastric bypass. J Gastrointest Surg. 2014;18(2):250–255; discussion 255-256.  https://doi.org/10.1007/s11605-013-2377-0.CrossRefPubMedGoogle Scholar
  39. 39.
    Shah K, Johnny Nergard B, Stray Frazier K, et al. Long-term effects of laparoscopic Roux-en-Y gastric bypass on metabolic syndrome in patients with morbid obesity. Surg Obes Relat Dis. 2016;12(8):1449–56.  https://doi.org/10.1016/j.soard.2016.03.017.CrossRefPubMedGoogle Scholar
  40. 40.
    Yilmaz H, Ece I, Sahin M. Revisional surgery after failed laparoscopic sleeve gastrectomy: retrospective analysis of causes, results, and technical considerations. Obes Surg. 2017;27(11):2855–60.  https://doi.org/10.1007/s11695-017-2712-8.CrossRefPubMedGoogle Scholar
  41. 41.
    Kanerva N, Larsson I, Peltonen M, et al. Changes in total energy intake and macronutrient composition after bariatric surgery predict long-term weight outcome: findings from the Swedish Obese Subjects (SOS) study. Am J Clin Nutr. 2017;106(1):136–45.  https://doi.org/10.3945/ajcn.116.149112.CrossRefPubMedGoogle Scholar
  42. 42.
    Folope V, Coëffier M, Déchelotte P. Nutritional deficiencies associated with bariatric surgery. Gastroenterol Clin Biol. 2007;31(4):369–77.CrossRefPubMedGoogle Scholar
  43. 43.
    Dogan K, Homan J, Aarts EO, et al. Long-term nutritional status in patients following Roux-en-Y gastric bypass surgery. Clin Nutr. 2017;  https://doi.org/10.1016/j.clnu.2017.01.022.
  44. 44.
    Gehrer S, Kern B, Peters T, et al. Fewer nutrient deficiencies after laparoscopic sleeve gastrectomy (LSG) than after laparoscopic Roux-Y-gastric bypass (LRYGB)-a prospective study. Obes Surg. 2010;20(4):447–53.CrossRefPubMedGoogle Scholar
  45. 45.
    Gong K, Gagner M, Pomp A, et al. Micronutrient deficiencies after laparoscopic gastric bypass: recommendations. Obes Surg. 2008;18(9):1062–6.  https://doi.org/10.1007/s11695-008-9577-9.CrossRefPubMedGoogle Scholar
  46. 46.
    Ziegler O, Sirveaux MA, Brunaud L, et al. Medical follow up after bariatric surgery: nutritional and drug issues. General recommendations for the prevention and treatment of nutritional deficiencies. Diabetes Metab. 2009;35(6 Pt 2):544–57.  https://doi.org/10.1016/S1262-3636(09)73464-0.CrossRefPubMedGoogle Scholar
  47. 47.
    Lynch RJ, Eisenberg D, Bell RL. Metabolic consequences of bariatric surgery. J Clin Gastroenterol. 2006;40(8):659–68.  https://doi.org/10.1097/00004836-200609000-00001.CrossRefPubMedGoogle Scholar
  48. 48.
    Mehaffey JH, Mehaffey RL, Mullen MG, et al. Nutrient deficiency 10 years following Roux-en-Y gastric bypass: who's responsible? Obes Surg. 2017;27(5):1131–6.  https://doi.org/10.1007/s11695-016-2364-0.CrossRefPubMedGoogle Scholar
  49. 49.
    Davidson LE, Adams TD, Kim J, et al. Association of patient age at gastric bypass surgery with long-term all-cause and cause-specific mortality. JAMA Surg. 2016;151(7):631–7.  https://doi.org/10.1001/jamasurg.2015.5501.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    American College of Surgeons: National Surgical Quality Improvement Program Pediatric. In:2016.Google Scholar
  51. 51.
    Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of observational studies in epidemiology (MOOSE) group. JAMA. 2000;283(15):2008–12.  https://doi.org/10.1001/jama.283.15.2008.CrossRefPubMedGoogle Scholar
  52. 52.
    Shemesh E, Annunziato RA, Arnon R, et al. Adherence to medical recommendations and transition to adult services in pediatric transplant recipients. Curr Opin Organ Transplant. 2010;15(3):288–92.  https://doi.org/10.1097/MOT.0b013e32833984a5.CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Pediatrics AAo, Physicians AAoF, Medicine ACoP-ASoI. A consensus statement on health care transitions for young adults with special health care needs. Pediatrics. 2002;110(6 Pt 2):1304–6.Google Scholar
  54. 54.
    Patel A, Dowell M, Giles BL. Current concepts of transition of care in cystic fibrosis. Pediatr Ann. 2017;46(5):e188-e192.CrossRefPubMedGoogle Scholar
  55. 55.
    Schultz AT, Smaldone A. Components of interventions that improve transitions to adult care for adolescents with type 1 diabetes. J Adolesc Health. 2017;60(2):133–46.  https://doi.org/10.1016/j.jadohealth.2016.10.002.CrossRefPubMedGoogle Scholar
  56. 56.
    Chu PY, Maslow GR, von Isenburg M, et al. Systematic review of the impact of transition interventions for adolescents with chronic illness on transfer from pediatric to adult healthcare. J Pediatr Nurs. 2015;30(5):e19–27.  https://doi.org/10.1016/j.pedn.2015.05.022.CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Blum RW, Garell D, Hodgman CH, et al. Transition from child-centered to adult health-care systems for adolescents with chronic conditions. A position paper of the Society for Adolescent Medicine. J Adolesc Health. 1993;14(7):570–6.CrossRefPubMedGoogle Scholar
  58. 58.
    Kirschenbaum DS, Gierut KJ. Five recent expert recommendations on the treatment of childhood and adolescent obesity: toward an emerging consensus–a stepped care approach. Child Obes. 2013;9(5):376–85.  https://doi.org/10.1089/chi.2013.0058.CrossRefPubMedGoogle Scholar
  59. 59.
    Peters A, Laffel L, Group ADATW. Diabetes care for emerging adults: recommendations for transition from pediatric to adult diabetes care systems: a position statement of the American Diabetes Association, with representation by the American College of Osteopathic Family Physicians, the American Academy of Pediatrics, the American Association of Clinical Endocrinologists, the American Osteopathic Association, the Centers for Disease Control and Prevention, Children with Diabetes, the Endocrine Society, the International Society for Pediatric and Adolescent Diabetes, Juvenile Diabetes Research Foundation International, the National Diabetes Education Program, and the Pediatric Endocrine Society (formerly Lawson Wilkins Pediatric Endocrine Society). Diabetes Care. 2011;34(11):2477–85.CrossRefPubMedPubMedCentralGoogle Scholar
  60. 60.
    Turner JR, Schatz DA, Cusi K, et al. Healthcare transition from pediatric to adult medical homes in diabetes mellitus. Endocr Pract. 2014;20(7):715–21.  https://doi.org/10.4158/EP13369.RA.CrossRefPubMedGoogle Scholar
  61. 61.
    Lee JS, Sheer JL, Lopez N, et al. Coverage of obesity treatment: a state-by-state analysis of Medicaid and state insurance laws. Public Health Rep. 2010;125(4):596–604.  https://doi.org/10.1177/003335491012500415.CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    Inge TH, Boyce TW, Lee M, et al. Access to care for adolescents seeking weight loss surgery. Obesity (Silver Spring). 2014;22(12):2593–7.  https://doi.org/10.1002/oby.20898.Google Scholar
  63. 63.
    Picot J, Jones J, Colquitt JL, et al. The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation. Health Technol Assess. 2009;13(41):1–190. 215-357, iii-ivCrossRefGoogle Scholar
  64. 64.
    Doble B, Wordsworth S, Rogers CA, et al. What are the real procedural costs of bariatric surgery? A systematic literature review of published cost analyses. Obes Surg. 2017;27(8):2179–92.CrossRefPubMedPubMedCentralGoogle Scholar
  65. 65.
    Mullen DM, Marr TJ. Longitudinal cost experience for gastric bypass patients. Surg Obes Relat Dis. 2010;6(3):243–8.  https://doi.org/10.1016/j.soard.2010.01.002.CrossRefPubMedGoogle Scholar
  66. 66.
    Brill JV, Ashmore JA, Brengman ML, et al. White Paper AGA: an episode-of-care framework for the management of obesity-moving toward high value, high quality care: a report from the American Gastroenterological Association Institute Obesity Episode of Care and Bundle Initiative Work Group. Clin Gastroenterol Hepatol. 2017;15(5):650–664.e652.Google Scholar
  67. 67.
    Kelsall AC, Cassidy R, Ghaferi AA. Variation in bariatric surgery episode costs in the commercially insured: implications for bundled payments in the private sector. Ann Surg. 2017:1.  https://doi.org/10.1097/SLA.0000000000002462.
  68. 68.
    Madan AK, Powelson JE, Tichansky DS. Cost analysis of laparoscopic gastric bypass practice using current Medicare reimbursement and practice costs. Surg Obes Relat Dis. 2008;4(2):131–6.  https://doi.org/10.1016/j.soard.2007.12.005.CrossRefPubMedGoogle Scholar
  69. 69.
    Bolt IL, van Summeren MJ. Competence assessment in minors, illustrated by the case of bariatric surgery for morbidly obese children. Best Pract Res Clin Gastroenterol. 2014;28(2):293–302.  https://doi.org/10.1016/j.bpg.2014.02.006.CrossRefPubMedGoogle Scholar
  70. 70.
    Paepegaey AC, Dubern B, Karsenty A, et al. Bariatric surgery in obese adolescents: when and how should the transition from pediatric to adult medical management be made? Arch Pediatr. 2015;22(12):1233–9.CrossRefPubMedGoogle Scholar
  71. 71.
    Got transition center for health care transition improvement. 2017; http://www.gottransition.org, 2017.
  72. 72.
    Schwartz LA, Brumley LD, Tuchman LK, et al. Stakeholder validation of a model of readiness for transition to adult care. JAMA Pediatr. 2013;167(10):939–46.  https://doi.org/10.1001/jamapediatrics.2013.2223.CrossRefPubMedPubMedCentralGoogle Scholar
  73. 73.
    Zeller MH, Hunsaker S, Mikhail C, et al. Family factors that characterize adolescents with severe obesity and their role in weight loss surgery outcomes. Obesity (Silver Spring). 2016;24(12):2562–9.CrossRefGoogle Scholar
  74. 74.
    Shrewsbury VA, Steinbeck KS, Torvaldsen S, et al. The role of parents in pre-adolescent and adolescent overweight and obesity treatment: a systematic review of clinical recommendations. Obes Rev. 2011;12(10):759–69.  https://doi.org/10.1111/j.1467-789X.2011.00882.x.CrossRefPubMedGoogle Scholar
  75. 75.
    Hankins JS, Osarogiagbon R, Adams-Graves P, et al. A transition pilot program for adolescents with sickle cell disease. J Pediatr Health Care. 2012;26(6):e45–9.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Sarah B. Cairo
    • 1
  • Indrajit Majumdar
    • 2
    • 3
  • Aurora Pryor
    • 4
  • Alan Posner
    • 5
  • Carroll M. Harmon
    • 1
    • 5
  • David H. Rothstein
    • 1
    • 5
  • on behalf of the Delivery of Surgical Care Committee of the American Academy of Pediatrics Section on Surgery
  1. 1.Department of Pediatric SurgeryJohn R Oishei Children’s HospitalBuffaloUSA
  2. 2.Division of Endocrinology/DiabetesUniversity at Buffalo Jacobs School of Medicine and Biomedical SciencesBuffaloUSA
  3. 3.Diabetes CenterJohn R Oishei Children’s HospitalBuffaloUSA
  4. 4.Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Stony Brook MedicineStony BrookUSA
  5. 5.Division of SurgeryState University of New York, University at Buffalo Jacobs School of Medicine and Biomedical SciencesBuffaloUSA

Personalised recommendations