Conversion and Revisional Surgery: Roux-en-Y Gastric Bypass

  • Andrew T. Strong
  • John H. Rodriguez


Gastric bypass has proven to be an effective operation in terms of both weight loss and resolution of comorbid conditions. However a subset of patients will require revision for complications and technical mishaps incurred at the index operation. In other patients, gastric bypass will fail to produce adequate weight loss or will have weight regain. In some this will lead to recurrence or development of de novo comorbid conditions. These patients may also benefit from revisional operations.


Gastric bypass Revisional bariatric surgery Gastrogastric fistula Marginal ulcer Limb shortening Limb lengthening 


  1. 1.
    Mason EE, Ito C. Gastric bypass in obesity. Surg Clin North Am. 1967;47(6):1345–51.CrossRefPubMedGoogle Scholar
  2. 2.
    Pories WJ, Swanson MS, MacDonald KG, Long SB, Morris PG, Brown BM, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg. 1995;222(3):339–50; discussion 350–2.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases. Obes Surg. 1994;4(4):353–7.CrossRefPubMedGoogle Scholar
  4. 4.
    Horgan S, Vanuno D. Robots in laparoscopic surgery. J Laparoendosc Adv Surg Tech A. 2001;11(6):415–9.CrossRefPubMedGoogle Scholar
  5. 5.
    Nguyn K, Hinojosa MW. Laparoscopic staged Roux-en-Y: a staged procedure for super-super obese patients. In: Nguyen NT, EJ DM, Ikramuddin S, Hutter M, editors. SAGES manual: a practical guide to bariatric surgery. New York: Springer Science; 2008. p. 137–41.CrossRefGoogle Scholar
  6. 6.
    Brethauer SA, Kothari S, Sudan R, Williams B, English WJ, Brengman M, et al. Systematic review on reoperative bariatric surgery: American Society for Metabolic and Bariatric Surgery Revision Task Force. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2014;10(5):952–72.CrossRefGoogle Scholar
  7. 7.
    Schwartz RW, Strodel WE, Simpson WS, Griffen WO. Gastric bypass revision: lessons learned from 920 cases. Surgery. 1988;104(4):806–12.PubMedGoogle Scholar
  8. 8.
    American Society for Metabolic and Bariatric Surgery. Estimate of bariatric surgery numbers, 2011–2015 [Internet]. Resources. 2016 [cited 2017 Jun 1]. Available from: estimate of bariatric surgery numbers, 2011–2015.Google Scholar
  9. 9.
    Hedberg J, Gustavsson S, Sundbom M. Long-term follow-up in patients undergoing open gastric bypass as a revisional operation for previous failed restrictive procedures. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2012;8(6):696–701.CrossRefGoogle Scholar
  10. 10.
    Stefanidis D, Malireddy K, Kuwada T, Phillips R, Zoog E, Gersin KS. Revisional bariatric surgery: perioperative morbidity is determined by type of procedure. Surg Endosc. 2013;27(12):4504–10.CrossRefPubMedGoogle Scholar
  11. 11.
    Hallowell PT, Stellato TA, Yao DA, Robinson A, Schuster MM, Graf KN. Should bariatric revisional surgery be avoided secondary to increased morbidity and mortality? Am J Surg. 2009;197(3):391–6.CrossRefPubMedGoogle Scholar
  12. 12.
    Gagner M, Gentileschi P, de Csepel J, Kini S, Patterson E, Inabnet WB, et al. Laparoscopic reoperative bariatric surgery: experience from 27 consecutive patients. Obes Surg. 2002;12(2):254–60.CrossRefPubMedGoogle Scholar
  13. 13.
    Khaitan L, Van Sickle K, Gonzalez R, Lin E, Ramshaw B, Smith CD. Laparoscopic revision of bariatric procedures: is it feasible? Am Surg. 2005;71(1):6–10; discussion 10–2.Google Scholar
  14. 14.
    Clapp B, Yu S, Sands T, Wilson E, Scarborough T. Preoperative upper endoscopy is useful before revisional bariatric surgery. JSLS. 2007;11(1):94–6.PubMedPubMedCentralGoogle Scholar
  15. 15.
    Kellogg TA. Revisional bariatric surgery. Surg Clin North Am. 2011;91(6):1353–71, xCrossRefPubMedGoogle Scholar
  16. 16.
    Dakin GF, Eid G, Mikami D, Pryor A, Chand B. American Society for Metabolic and Bariatric Surgery (ASMBS) Emerging Technology and Procedures Committee. Endoluminal revision of gastric bypass for weight regain--a systematic review. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2013;9(3):335–42.CrossRefGoogle Scholar
  17. 17.
    Acquafresca PA, Palermo M, Rogula T, Duza GE, Serra E. Early surgical complications after gastric by-pass: a literature review. ABCD Arq Bras Cir Dig São Paulo. 2015;28(1):74–80.CrossRefGoogle Scholar
  18. 18.
    Griffith PS, Birch D, Sharma A, Karmali S. Managing complications associated with laparoscopic Roux-en-Y gastric bypass for morbid obesity. Can J Surg. 2012;55(5):329–36.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Sherman V, Dan AG, Lord JM, Chand B, Schauer PR. Complications of gastric bypass: avoiding the Roux-en-O configuration. Obes Surg. 2009;19(8):1190–4.CrossRefPubMedGoogle Scholar
  20. 20.
    Palermo M, Acquafresca PA, Rogula T, Duza GE, Serra E. Late surgical complications after gastric by-pass: a literature review. ABCD Arq Bras Cir Dig São Paulo. 2015;28(2):139–43.CrossRefGoogle Scholar
  21. 21.
    Moon RC, Teixeira AF, Goldbach M, Jawad MA. Management and treatment outcomes of marginal ulcers after Roux-en-Y gastric bypass at a single high volume bariatric center. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2014;10(2):229–34.CrossRefGoogle Scholar
  22. 22.
    Gilmore MM, Kallies KJ, Mathiason MA, Kothari SN. Varying marginal ulcer rates in patients undergoing laparoscopic roux-en-Y gastric bypass for morbid obesity versus gastroesophageal reflux disease: is the acid pocket to blame? Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2013;9(6):862–6.CrossRefGoogle Scholar
  23. 23.
    Steinemann DC, Bueter M, Schiesser M, Amygdalos I, Clavien P-A, Nocito A. Management of anastomotic ulcers after Roux-en-Y gastric bypass: results of an international survey. Obes Surg. 2014;24(5):741–6.CrossRefPubMedGoogle Scholar
  24. 24.
    D’Hondt MA, Pottel H, Devriendt D, Van Rooy F, Vansteenkiste F. Can a short course of prophylactic low-dose proton pump inhibitor therapy prevent stomal ulceration after laparoscopic Roux-en-Y gastric bypass? Obes Surg. 2010;20(5):595–9.CrossRefPubMedGoogle Scholar
  25. 25.
    Kalaiselvan R, Exarchos G, Hamza N, Ammori BJ. Incidence of perforated gastrojejunal anastomotic ulcers after laparoscopic gastric bypass for morbid obesity and role of laparoscopy in their management. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2012;8(4):423–8.CrossRefGoogle Scholar
  26. 26.
    Alasfar F, Sabnis AA, Liu RC, Chand B. Stricture rate after laparoscopic Roux-en-Y gastric bypass with a 21-mm circular stapler: the Cleveland Clinic experience. Med Princ Pract Int J Kuwait Univ Health Sci Cent. 2009;18(5):364–7.Google Scholar
  27. 27.
    Schwartz ML, Drew RL, Roiger RW, Ketover SR, Chazin-Caldie M. Stenosis of the gastroenterostomy after laparoscopic gastric bypass. Obes Surg. 2004;14(4):484–91.CrossRefPubMedGoogle Scholar
  28. 28.
    Nguyen NT, Stevens CM, Wolfe BM. Incidence and outcome of anastomotic stricture after laparoscopic gastric bypass. J Gastrointest Surg Off J Soc Surg Aliment Tract. 2003;7(8):997–1003; discussion 1003CrossRefGoogle Scholar
  29. 29.
    Kravetz AJ, Reddy S, Murtaza G, Yenumula P. A comparative study of handsewn versus stapled gastrojejunal anastomosis in laparoscopic Roux-en-Y gastric bypass. Surg Endosc. 2011;25(4):1287–92.CrossRefPubMedGoogle Scholar
  30. 30.
    Mathew A, Veliuona MA, DePalma FJ, Cooney RN. Gastrojejunal stricture after gastric bypass and efficacy of endoscopic intervention. Dig Dis Sci. 2009;54(9):1971–8.CrossRefPubMedGoogle Scholar
  31. 31.
    Chang J, Sharma G, Boules M, Brethauer S, Rodriguez J, Kroh MD. Endoscopic stents in the management of anastomotic complications after foregut surgery: new applications and techniques. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2016;12(7):1373–81.CrossRefGoogle Scholar
  32. 32.
    de Moura EGH, Orso IRB, Aurélio EF, de Moura ETH, de Moura DTH, Santo MA. Factors associated with complications or failure of endoscopic balloon dilation of anastomotic stricture secondary to Roux-en-Y gastric bypass surgery. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2016;12(3):582–6.CrossRefGoogle Scholar
  33. 33.
    Da Costa M, Mata A, Espinós J, Vila V, Roca JM, Turró J, et al. Endoscopic dilation of gastrojejunal anastomotic strictures after laparoscopic gastric bypass. Predictors of initial failure. Obes Surg. 2011;21(1):36–41.CrossRefPubMedGoogle Scholar
  34. 34.
    Patel RA, Brolin RE, Gandhi A. Revisional operations for marginal ulcer after Roux-en-Y gastric bypass. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2009;5(3):317–22.CrossRefGoogle Scholar
  35. 35.
    Chau E, Youn H, Ren-Fielding CJ, Fielding GA, Schwack BF, Kurian MS. Surgical management and outcomes of patients with marginal ulcer after Roux-en-Y gastric bypass. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2015;11(5):1071–5.CrossRefGoogle Scholar
  36. 36.
    Hunter J, Stahl RD, Kakade M, Breitman I, Grams J, Clements RH. Effectiveness of thoracoscopic truncal vagotomy in the treatment of marginal ulcers after laparoscopic Roux-en-Y gastric bypass. Am Surg. 2012;78(6):663–8.PubMedGoogle Scholar
  37. 37.
    Csendes A, Burgos AM, Altuve J, Bonacic S. Incidence of marginal ulcer 1 month and 1 to 2 years after gastric bypass: a prospective consecutive endoscopic evaluation of 442 patients with morbid obesity. Obes Surg. 2009;19(2):135–8.CrossRefPubMedGoogle Scholar
  38. 38.
    Nedelcu AM, Skalli M, Deneve E, Fabre JM, Nocca D. Surgical management of chronic fistula after sleeve gastrectomy. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2013;9(6):879–84.CrossRefGoogle Scholar
  39. 39.
    Rosenthal RJ, International Sleeve Gastrectomy Expert Panel, Diaz AA, Arvidsson D, Baker RS, Basso N, et al. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2012;8(1):8–19.CrossRefGoogle Scholar
  40. 40.
    Schecter WP, Hirshberg A, Chang DS, Harris HW, Napolitano LM, Wexner SD, et al. Enteric fistulas: principles of management. J Am Coll Surg. 2009;209(4):484–91.CrossRefPubMedGoogle Scholar
  41. 41.
    Edmunds LH, Williams GM, Welch CE. External fistulas arising from the gastro-intestinal tract. Ann Surg. 1960;152:445–71.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Bège T, Emungania O, Vitton V, Ah-Soune P, Nocca D, Noël P, et al. An endoscopic strategy for management of anastomotic complications from bariatric surgery: a prospective study. Gastrointest Endosc. 2011;73(2):238–44.CrossRefPubMedGoogle Scholar
  43. 43.
    Capella JF, Capella RF. Gastro-gastric fistulas and marginal ulcers in gastric bypass procedures for weight reduction. Obes Surg. 1999;9(1):22–7; discussion 28CrossRefPubMedGoogle Scholar
  44. 44.
    Carrodeguas L, Szomstein S, Soto F, Whipple O, Simpfendorfer C, Gonzalvo JP, et al. Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1,292 consecutive patients and review of literature. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2005;1(5):467–74.CrossRefGoogle Scholar
  45. 45.
    Pauli EM, Beshir H, Mathew A. Gastrogastric fistulae following gastric bypass surgery-clinical recognition and treatment. Curr Gastroenterol Rep. 2014;16(9):405.CrossRefPubMedGoogle Scholar
  46. 46.
    Ribeiro-Parenti L, De Courville G, Daikha A, Arapis K, Chosidow D, Marmuse J-P. Classification, surgical management and outcomes of patients with gastrogastric fistula after Roux-En-Y gastric bypass. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2017;13(2):243–8.CrossRefGoogle Scholar
  47. 47.
    Brethauer SA, Nfonsam V, Sherman V, Udomsawaengsup S, Schauer PR, Chand B. Endoscopy and upper gastrointestinal contrast studies are complementary in evaluation of weight regain after bariatric surgery. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2006;2(6):643–8; discussion 649–50CrossRefGoogle Scholar
  48. 48.
    Corcelles R, Jamal MH, Daigle CR, Rogula T, Brethauer SA, Schauer PR. Surgical management of gastrogastric fistula. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2015;11(6):1227–32.CrossRefGoogle Scholar
  49. 49.
    Esquivel CM, Ampudia C, Fridman A, Moon R, Szomstein S, Rosenthal RJ. Technique and outcomes of laparoscopic-combined linear stapler and hand-sutured side-to-side esophagojejunostomy with Roux-en-Y reconstruction as a treatment modality in patients undergoing proximal gastrectomy for benign and malignant disease of the gastroesophageal junction. Surg Laparosc Endosc Percutan Tech. 2014;24(1):89–93.CrossRefPubMedGoogle Scholar
  50. 50.
    Moon RC, Frommelt A, Teixeira AF, Jawad MA. Indications and outcomes of reversal of Roux-en-Y gastric bypass. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2015;11(4):821–6.CrossRefGoogle Scholar
  51. 51.
    Shoar S, Nguyen T, Ona MA, Reddy M, Anand S, Alkuwari MJ, et al. Roux-en-Y gastric bypass reversal: a systematic review. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2016;12(7):1366–72.CrossRefGoogle Scholar
  52. 52.
    Pernar LIM, Kim JJ, Shikora SA. Gastric bypass reversal: a 7-year experience. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2016;12(8):1492–8.CrossRefGoogle Scholar
  53. 53.
    Carter CO, Fernandez AZ, McNatt SS, Powell MS. Conversion from gastric bypass to sleeve gastrectomy for complications of gastric bypass. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2016;12(3):572–6.CrossRefGoogle Scholar
  54. 54.
    Magro DO, Geloneze B, Delfini R, Pareja BC, Callejas F, Pareja JC. Long-term weight regain after gastric bypass: a 5-year prospective study. Obes Surg. 2008;18(6):648–51.CrossRefPubMedGoogle Scholar
  55. 55.
    Christou NV, Look D, Maclean LD. Weight gain after short- and long-limb gastric bypass in patients followed for longer than 10 years. Ann Surg. 2006;244(5):734–40.CrossRefPubMedPubMedCentralGoogle Scholar
  56. 56.
    conference NIH. Gastrointestinal surgery for severe obesity. Consensus development conference panel. Ann Intern Med. 1991;115(12):956–61.CrossRefGoogle Scholar
  57. 57.
    Reinhold RB. Critical analysis of long term weight loss following gastric bypass. Surg Gynecol Obstet. 1982;155(3):385–94.PubMedGoogle Scholar
  58. 58.
    Mann JP, Jakes AD, Hayden JD, Barth JH. Systematic review of definitions of failure in revisional bariatric surgery. Obes Surg. 2015;25(3):571–4.CrossRefPubMedGoogle Scholar
  59. 59.
    Wang B, Levine MS, Rubesin SE, Williams NN, Dumon K, Raper S. Utility of barium studies for patients with recurrent weight gain after Roux-en-Y gastric bypass. Clin Radiol. 2015;70(1):67–73.CrossRefPubMedGoogle Scholar
  60. 60.
    Yimcharoen P, Heneghan HM, Singh M, Brethauer S, Schauer P, Rogula T, et al. Endoscopic findings and outcomes of revisional procedures for patients with weight recidivism after gastric bypass. Surg Endosc. 2011;25(10):3345–52.CrossRefPubMedGoogle Scholar
  61. 61.
    Topart P, Becouarn G, Ritz P. Pouch size after gastric bypass does not correlate with weight loss outcome. Obes Surg. 2011;21(9):1350–4.CrossRefPubMedGoogle Scholar
  62. 62.
    León F, Maiz C, Daroch D, Quezada N, Gabrielli M, Muñoz C, et al. Laparoscopic hand-sewn revisional gastrojejunal plication for weight loss failure after Roux-en-Y gastric bypass. Obes Surg. 2015;25(4):744–9.CrossRefPubMedGoogle Scholar
  63. 63.
    Parikh M, Heacock L, Gagner M. Laparoscopic “gastrojejunal sleeve reduction” as a revision procedure for weight loss failure after Roux-en-y gastric bypass. Obes Surg. 2011;21(5):650–4.CrossRefPubMedGoogle Scholar
  64. 64.
    Al-Bader I, Khoursheed M, Al Sharaf K, Mouzannar DA, Ashraf A, Fingerhut A. Revisional laparoscopic gastric pouch resizing for inadequate weight loss after Roux-en-Y gastric bypass. Obes Surg. 2015;25(7):1103–8.CrossRefPubMedPubMedCentralGoogle Scholar
  65. 65.
    Müller MK, Wildi S, Scholz T, Clavien P-A, Weber M. Laparoscopic pouch resizing and redo of gastro-jejunal anastomosis for pouch dilatation following gastric bypass. Obes Surg. 2005;15(8):1089–95.CrossRefPubMedGoogle Scholar
  66. 66.
    O’Brien P, Brown W, Dixon J. Revisional surgery for morbid obesity--conversion to the Lap-Band system. Obes Surg. 2000;10(6):557–63.CrossRefPubMedGoogle Scholar
  67. 67.
    Kyzer S, Raziel A, Landau O, Matz A, Charuzi I. Use of adjustable silicone gastric banding for revision of failed gastric bariatric operations. Obes Surg. 2001;11(1):66–9.CrossRefPubMedGoogle Scholar
  68. 68.
    Vijgen GHEJ, Schouten R, Bouvy ND, Greve JWM. Salvage banding for failed Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2012;8(6):803–8.CrossRefPubMedGoogle Scholar
  69. 69.
    Aminian A, Corcelles R, Daigle CR, Chand B, Brethauer SA, Schauer PR. Critical appraisal of salvage banding for weight loss failure after gastric bypass. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2015;11(3):607–11.CrossRefGoogle Scholar
  70. 70.
    Dapri G, Cadière GB, Himpens J. Laparoscopic placement of non-adjustable silicone ring for weight regain after Roux-en-Y gastric bypass. Obes Surg. 2009;19(5):650–4.CrossRefPubMedGoogle Scholar
  71. 71.
    Lemmens L. Banded gastric bypass: better long-term results? A cohort study with minimum 5-year follow-up. Obes Surg. 2017;27(4):864–72.CrossRefPubMedGoogle Scholar
  72. 72.
    Heneghan HM, Annaberdyev S, Eldar S, Rogula T, Brethauer S, Schauer P. Banded Roux-en-Y gastric bypass for the treatment of morbid obesity. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2014;10(2):210–6.CrossRefGoogle Scholar
  73. 73.
    Fobi MA, Lee H, Igwe D, Felahy B, James E, Stanczyk M, et al. Revision of failed gastric bypass to distal Roux-en-Y gastric bypass: a review of 65 cases. Obes Surg. 2001;11(2):190–5.CrossRefPubMedGoogle Scholar
  74. 74.
    Dapri G, Cadière GB, Himpens J. Laparoscopic conversion of Roux-en-Y gastric bypass to distal gastric bypass for weight regain. J Laparoendosc Adv Surg Tech A. 2011;21(1):19–23.CrossRefPubMedGoogle Scholar
  75. 75.
    Sugerman HJ, Kellum JM, DeMaria EJ. Conversion of proximal to distal gastric bypass for failed gastric bypass for superobesity. J Gastrointest Surg Off J Soc Surg Aliment Tract. 1997;1(6):517–24; discussion 524–6CrossRefGoogle Scholar
  76. 76.
    Rawlins ML, Teel D, Hedgcorth K, Maguire JP. Revision of Roux-en-Y gastric bypass to distal bypass for failed weight loss. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2011;7(1):45–9.CrossRefGoogle Scholar
  77. 77.
    Surve A, Zaveri H, Cottam D, Belnap L, Medlin W, Cottam A. Mid-term outcomes of gastric bypass weight loss failure to duodenal switch. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2016;12(9):1663–70.CrossRefGoogle Scholar
  78. 78.
    Roslin MS, Gagner M, Goriparthi R, Mitzman B. The rationale for a duodenal switch as the primary surgical treatment of advanced type 2 diabetes mellitus and metabolic disease. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2015;11(3):704–10.CrossRefGoogle Scholar
  79. 79.
    Parikh M, Pomp A, Gagner M. Laparoscopic conversion of failed gastric bypass to duodenal switch: technical considerations and preliminary outcomes. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2007;3(6):611–8.CrossRefGoogle Scholar
  80. 80.
    Dapri G, Himpens J, Cadière GB. Laparoscopic conversion of Roux-en-Y gastric bypass to biliopancreatic diversion. Surg Endosc. 2010;24(6):1490–3.CrossRefPubMedGoogle Scholar
  81. 81.
    Robert M, Pasquer A. Laparoscopic revision of Roux-en-Y gastric bypass to biliopancreatic diversion with duodenal switch: technical points. Obes Surg. 2017;27(1):271–2.CrossRefPubMedGoogle Scholar
  82. 82.
    Jawad MA, Nelson L, Moon RC, Teixeira AF. Techniques of single-stage laparoscopic conversion of Roux-en-Y gastric bypass to single anastomosis bilio-pancreatic diversion with duodenal switch. Obes Surg. 2017;27(4):1109–11.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of General SurgeryCleveland ClinicClevelandUSA
  2. 2.Department of Surgery, Section of Surgical EndoscopyCleveland ClinicClevelandUSA

Personalised recommendations