Glycative Stress Research
Online edition : ISSN 2188-3610
Print edition : ISSN 2188-3602
Received : October 7, 2020
Accepted : November 6, 2020
Published online : December 31, 2020
doi:10.24659/gsr.7. 4_ 278

Original article

Experience with laparoscopic sleeve gastrectomy for morbid obesity in a
general hospital
Shingo Iwata 1, 2), Akeo Hagiwara 2)
1) Department of Surgery, Takeda General Hospital, Kyoto, Japan
2) Faculty of Life and Medical Sciences, Doshisha University, Kyoto, Japan

Abstract

Objective: The purpose of this study is to examine the outcome of laparoscopic sleeve gastrectomy (LSG) for morbid obesity.
Method: We examined the treatment results of patients who underwent SLG at our hospital. The items to be examined
included postoperative weight changes and obesity-related complications (type 2 diabetes, hypertension, dyslipidemia).
Results: The subjects were 33 morbidly obese patients (8 males and 25 females) who underwent LSG from August 2014 to
February 2020. The mean age at the first visit was 44.0 ± 3.5 years (20-65 years), the mean weight was 107.9 ± 7.6 kg (85142 kg), and the mean body mass index (BMI) was 41.5 ± 3.3 kg/m2 (35.3-52.6 kg/m2 ). No postoperative complications wereobserved in all cases. The weight reduction effect in the first year after surgery was 34.8 ± 10.2 kg (11.2-53.3 kg), the mean
BMI reduction was 13.9 ± 3.7 kg/m 2 (4.5-20.0 kg/m 2), and the mean percentage of excess weight loss was 84.8 ± 20.7 %(38.9-143.0 %). Metabolic disease remission rates were 93.3% in type 2 diabetes, 65.2% in hypertension, and 60.0 % in
dyslipidemia.
Conclusion: The results of LSG were as good as those of other institutions in terms of weight reduction and improvement ofobesity-related diseases.

KEY WORDS: morbid obesity, weight reduction before surgery, laparoscopic sleeve gastrectomy, bariatric surgery

Introduction

According to world statistics, the population with a bodymass index (BMI) of 25 kg/m 2 or higher was 860 million
in 1980, in 2013 it surged to 2.1 billion, and human beings
continue to gain weight on a global scale 1). It is estimated that
3.4 million people died of obesity in 2010 1), and continued
obesity leads to increased mortality 2, 3). Obesity also causes
complications including type 2 diabetes mellitus (T2DM),
hypertension, dyslipidemia, sleep apnea syndrome, fatty
liver, knee osteoarthritis, and low back pain. Furthermore,
it is a factor that increases the risk of cancer 4). If diabetes
becomes chronic, it will lead to a decrease in quality of life
(QOL), i.e. dialysis, blindness, and amputation of the lower
limbs, and medical expenses will inevitably rise. In order toextend healthy life expectancy and control medical expenses,
the treatment and measures to suppress the progressionof metabolic domino 5) are required. Traditional therapies
including diet, exercise, drug, and behavior interventions

have been performed, and in recent years, surgical therapy
has been added as one of the treatments for obesity.
It is often difficult to obtain long-term weight reduction
effects with medical treatment for morbid obesity with a BMI
of 35 kg/m2 or higher, however, it has been found that surgicaltreatment has a long-term weight reduction effect 6, 7, 8). Surgicaltreatment for obesity, bariatric surgery, has been performedin Europe and the United States since the 1960s. Then, with
the increase in the obese population and the establishment of
the safety of laparoscopic surgery, bariatric surgery has rapidly
become widespread. The number of bariatric surgeries
performed worldwide was 150,000 in 2003, 340,000 in 2011,
and reached 470,000 in 2013 9).
On the other hand, bariatric surgery has not been
generalized in Japan. However, facing the increase in thenumber of morbidly obese people and knowing the successof bariatric surgery in Europe and the United States,
laparoscopic sleeve gastrectomy (LSG) was certified as an

Corresponding author: Shingo Iwata, MD, PhD.
Department of Surgery, Jyujyo Takeda Rehabilitation Hospital,
32 Hattanda-cho, Kissyoin Minami-ku, Kyoto 601-8325, Japan
TEL: +81-75-671-2351 FAX: + 81-75-671-2961
e-mail: s-iwata@takedahp.or.jp
Co-authors: Hagiwara A, hagiwara4f@gmail.com

Glycative Stress Research 2020; 7 ( 4 ) : 278- 2 82(c) Society for Glycative Stress Research_ 278 _Glycative Stress Researchadvanced medical treatment in 2010 and covered by insurance
in 2014. Nowadays, the number of bariatric surgeries isincreasing every year. Since it seems that our hospital is thefirst to introduce bariatric surgery in Kyoto prefecture, here
we report on the launch of bariatric surgery in this area andthe results of obesity surgery performed in our hospital.

Methods

Launch of bariatric surgery
In 2009, we started to devise a plan for the introductionof bariatric surgery and collected a lot of information
regarding this surgery. In 2012, an obesity treatment team was
set up with a focus on surgical treatment. We visited medical
facilities with abundant experience in bariatric surgery, gained
experience, sent surgical cases to them, and tried to masterthe procedure of patient selection, preoperative preparation,and postoperative follow-up. Concurrently, we participatedin academic meetings and seminars for obesity treatment as
an obesity treatment team and worked to share the knowledgeof the team. It was approved by the ethics committee of this
hospital and conformed to the facility standards, followed by
an application to the Ministry of Health, Labor and Welfare
and reception for facility certification. In 2014, LSG began
to be covered by medical insurance and we opened an
outpatient department for bariatric surgery. The first LSG was
performed in August 2014, almost two years after the team
was launched. Around the same time, we opened a homepage
and conducted public relations activities in the media andmedical associations.

Subjects
Of the 123 patients who visited our outpatient departmentof obesity surgery, we selected 33 patients (26.8 %) who
met the insurance coverage requirement, indicated below,
and received LSG. Japan's insurance is applied to patients
who meet the following three conditions; firstly, medical
treatment for 6 months or more does not provide sufficienteffect; secondly, BMI is 35 kg/m2 or more; thirdly, those whoare accompanied with one or more of diabetes, hypertension,
dyslipidemia, and sleep apnea syndrome. The male -female
ratio is 8 males and 25 females, the mean age is 44 ± 3. 5 years(20 - 65 years), the mean weight is 107.9 ± 7.6 kg (85-142 kg ),and the mean BMI is 41. 5 ± 3.3 kg /m2 (35.3 - 52.6 kg /m2 ).
The obesity-related complication rates were 54.5% (18 cases)in diabetes, 81.8 % (27 cases) in hypertension, 93.9 % (31 cases)
in dyslipidemia, and 45.5% (15 cases) in sleep apnea syndrome.
Other complications were fatty liver in 25, depression in four,
mental illness in three, cerebral infarction in one, cerebral
hemorrhage in one, heart disease in two, and borderline
diabetes in two. One patient rebounded and underwent resleeve surgery.

Surgical technique 10)
LGS is a surgery method to remove the side of thegreater curvature of the stomach and create a banana-shaped
stomach. All surgeries are conducted by the laparoscopic

five port approach in the position with the head up in orderto reduce the burden on the lungs. Separate the greater
omentum along the stomach wall in the cranial direction,using an ultrasonic coagulation incision device. Separate thegreater omentum up to the His angle at a proximal part ofthe stomach and up to about 4 cm from the oral side fromthe pyloric ring at a distal part. Ask a gastroenterologist
to insert an endoscope up to the pyloric region, and fixate
it at the side of the lesser curvature. The endoscope canbe followed as a guide to cutting off the stomach using an
autosuture. Reinforce the staple line by continuous sutureusing 3-0 absorbing thread. Confirm the presence or absenceof constriction and bleeding and that the stapler does not
become lodged in the esophagus. Retain the drain along the
cutting line of the stomach.

Ethical standards
Before the surgery, written informed consent was obtained
from the patients. This study was implemented in compliancewith the Helsinki Declaration (as revised in 1975 and 1983)
and was approved by the hospital’s ethics committee.

Results
The surgical results of LSG in our hospital are shown
below.
No postoperative complications were observed in allcases. The body weight decreased from 107.9 ± 7. 6 kg before
surgery to 73.1 ± 9.7 kg one year after surgery, and the mean
weight loss was 34.8 ± 10.2 kg (11.2-53. 5 kg). BMI decreased
from 41. 5 ± 3.3 kg/m2 preoperatively to 27.6 ± 2.8 kg/m2
after surgery, and the mean decreased BMI was 13. 9 ± 3.7kg/m2 (4.5 - 20.0 kg/m2 ). Excess weight decreased from 42.9kg ± 13.0 kg preoperatively to 6.8 kg ± 7.4 kg after surgery,with the mean percentage of excess weight loss of 84.8 ±20.7 % (38.9-143.0 %). Here, the percentage of excess weightloss was calculated as the weight when the ideal weight was
25 with a BMI.
The remission rate of metabolic diseases 1 year after
surgery was 93.3 % for T2DM, 65.2 % for hypertension, and60.0 % for dyslipidemia. Figure 1 compares the percentageof excess weight loss of 46,133 LSG cases performed by 130
surgeons worldwide with the results of our hospital 11).

Discussion
In starting bariatric surgery, we aimed to eliminate
complications. We started bariatric surgery with the intentionof stopping the surgery if complications occurred. Oncestarted, we decided to continue the surgery. Fortunately,
there were no postoperative complications. In the case of
LSG, possible early postoperative complications include
postoperative hemorrhage, anastomotic insufficiency,
wound infection, and stenosis of gastric tracts. According
to a questionnaire survey in Japan in 2020, the incidenceof postoperative complications of LSG in 2,867 cases was_ 279 _

Laparoscopic Sleeve Gastrectomy for Morbid Obesity in a General Hospital

Our hospital

Ingenuity during surgery

World

Percent excess weight loss (%)

100
80
60
40
20
0

3M

1Y

2Y

3Y

Fig. 1. Percentage of excess weight loss after LSG in our
hospital and the world.
Our hospital, n = 33. World, n = 46,133, a total number of
LSG cases performed by 130 surgeons. Percentage of excess
weight loss is calculated with the below formula:
Percentage of excess weight loss = [(preoperative BW –postoperative BW) / (preoperative BW– Ideal BW)] x 100. Ideal
BW was calculated by BMI = 25; BMI, body mass index; LSG,
laparoscopic sleeve gastrectomy; BW, body weight.

0.7 % for hemorrhage, 0.5 % for sutural insufficiency, 1.2 %for wound infection, and 1.1% for gastric stenosis. In theforeign literature on LSG in 900 cases 12), complications were
hemorrhage 0. 4 %, sutural insufficiency 0.8 %, gastric tract
stenosis 0.7 %, wound infection 0.1%. In another report of940 cases 13), hemorrhage was 3.57% and sutural insufficiency
was 1.17 %. And in the 2016 European review 14), hemorrhage
was 3.6 % and sutural insufficiency was 0 -3.7 %. It seems
that sutural insufficiency and hemorrhage tend to be lesscommon in Japan. We believe that the key to eliminatingcomplications is preoperative weight reduction and ingenuity
during surgery.

Weight reduction before surgery
Patients’ weight had rebounded repeatedly. If bariatricsurgery had not been conducted at the point of achievementof preoperative weight reduction by medical treatment, we
expect that their weight would have rebounded again. The
purpose of bariatric surgery is not only to achieve weight
reduction, but also to change the patient’s body so that itis hard to gain weight. Motivation is important for treating
obesity. Patients had a clear purpose for losing weight; i.e.,
to be able to undergo bariatric surgery, and focused onachieving steady preoperative weight reduction within a shortperiod of time. Patients that can decrease their body weight
are selected for bariatric surgery because it is judged thatthey would be able to withstand more severe postoperative
diet control. To conduct bariatric surgery safely, it isimportant to reduce the quantity of visceral fat so that thelateral segment of the liver, which undergoes compensatory
hypertrophy in the presence of fatty liver, can be reduced asmuch as possible.

The surgical position was a beach chair position
with high-head, thus reducing the burden on the lungs
and facilitating postoperative management. The mosttroublesome postoperative complication is probably
sutural insufficiency 15-17). Suture failure in LSG is difficult
to cure and resists treatment for a long time. The mostcommon part accompanied with sutural insufficiency is theesophagogastric junction. Therefore, an automatic suture
device with reinforcement was used for gastric dissection.
The His angle is cut at a site 1 cm away from the joint, anda seromuscular suture is ligated to reinforce the dissection
surface, thus forming a thin gastric tube. Reinforcement isstarted from the His angle, and seromuscular sutures areadded continuously to the nodule, then concurrently adding
seromuscular sutures or full-thickness sutures from about
half of the cut surface to the anal side. There is expected
to be no postoperative pain when the muscle layer is closed
and sutured from the inside of the abdominal cavity. For
preventing hemorrhage, the manipulation around the spleen
was performed carefully and cautiously. This is because it isdifficult to stanch the bleeding in spleen injury.

Laparoscopic sleeve gastrectomy (LSG)
The characteristics of LSG are comparatively simple andclear, and compared with bariatric bypass surgery, it has few
complications after surgery. Its weight reduction effect canbe expected enough that it is said to be better suited for casesthat are more likely to be complicated with the disorders
associated with obesity despite a low degree of obesity, likethat of the Japanese.
Generally, it is understood that creating a banana-shaped
stomach is aimed at restricting the intake of food and losing
weight, but it is said that an appetite stimulating hormone
called ghrelin is secreted in a large amount at the stomach
fundus, so appetite can be reduced if it is removed. Ghrelin isalso the hormone restricting the secretion of insulin, whichsuggests ghrelin’s involvement in the mechanism of theamelioration of diabetes 18, 19). Recently, attention was paid
to the fact that blood bile acid increases after LSG surgery
and in research conducted by a group of Seeley RJ, it was
found that, in an experiment using SG mice, the activities offarnesoid X receptor (FXR) were enhanced and large changes
in metabolism, such as glucose tolerance, occurred 20).
A mechanism that brings about changes in bacteria in
intestines was presented 21). In this research, the experimentused genetically modified FXR knockout mice and showedthat the increase of bile acid was more essential than diet
restriction effects because FXR knockout mice following
SG did not show weight reduction effects. It is reported
that similarly to the case of bypass surgeries, the increaseof incretins, such as glucagon-like peptide 1 (GLP-1), wereobserved even after LSG 22).

Results of LSG

As shown in Fig. 1, the postoperative effect of weight
reduction was comparable to that of 46,133 LSG cases
performed by 130 surgeons around the world 11). In a

_ 280 _Glycative Stress Researchprospective randomized multicenter study, the effects of
LSG on improving complications were 60.0 % for T2DM,
65.2% for hypertension, and 43.8 % for dyslipidemia 23).
According to the results of LSG conducted at nine centers
in Japan, the remission rate of obesity-related metabolic
diseases was 85% for T2DM, 66 % for hypertension, and
63% for dyslipidemia 24). According to a latest report 25)
dealing with the large number of LSG cases in Japan (322cases), the complication improvement rate was 75.6 % for
T2DM, 41.8 % for hypertension, and 59.7% for dyslipidemia.
It seems that the results of our hospital are not inferior tothose of other facilities. Compared to Europe and the UnitedStates, Japanese subjects were considered to have a higher
rate of remission by LSG for diabetes.
Obesity is not only a metabolic disease, but also an
exacerbating factor for locomotor disorders such as knee
osteoarthritis and lumbar joint abnormalities. In a case we
encountered, total joint replacement was required for knee
osteoarthritis, but the patient with a super- obese BMI
higher than of 50 kg/m2 was at high risk of post- replacement
complications. It was predicted that functional recovery
could not be expected even after surgery. Therefore, LSG
was conducted, and after sufficient weight reduction, knee
surgery was performed. This is our experienced case with nopostoperative complications and good functional recovery 26).
The following is a case in which a lung mass was
accidentally found on computed tomography scan (CT)during preoperative weight reduction for the purpose of
LSG 27). Two and a half months after the LSG was undertaken
to reduce the body weight in advance, lung surgery was
performed; a rapid intraoperative pathological examination
revealed malignancy, therefore a right upper lobectomy underthoracoscopy was performed. If the tumor is diagnosed as
malignant, surgery for the malignant tumor will usually
be prioritized. The idea of prioritizing bariatric surgery
to avoid the risk of morbid obesity and safely performing
tumor surgery after weight reduction may be indicated infairly limited cases, such as early-stage cancer. In this case,CT did not give information to the radiologist whether thesmall mass in the lung was malignant, and he was instructed
to follow up with CT once a month. LSG preceded thelobectomy because there was no change in tumor size,
patients were rebounding repeatedly, and there was a highpossibility that they would rebound again if they did notundergo bariatric surgery after preoperative weight reduction.
As a result, 2.5 months after the operation, upper lobectomy
was safely performed without complications. In such cases,
LSG appears to be a more suitable procedure because it
results in faster weight loss than the use of an intragastricballoon or laparoscopic adjustable gastric banding; involves
a simple procedure and a shorter operating time; and causes
fewer postoperative complications than bypass surgery, suchas laparoscopic Roux- en-Y gastric bypass. LSG might besuperior to various other bariatric surgical procedures interms of its ability to shorten the interval between diagnosis
and curative treatment for malignant tumors in morbidly
obese patients.

reduction and postoperative follow-up by multidisciplinary
treatment of a team, consisting of a surgeon, a diabetologist,a registered dietitian, a physical therapist, a clinicalpsychologist, a psychiatrist, and a certified nurse, areimportant. The secret to successful surgery is to explain themeaning of dietary restrictions repeatedly many times andto be fully convinced before surgery. In order to preventthe postoperative rebound, it is important to regularly visit
outpatient clinics for follow-up and guidance to continue
weight reduction. We experienced a case of a woman withage of 20s who had social psychological problems but
succeeded in reducing weight through team medical care 28).
The weight reduction effect of bariatric surgery progresses
from half a year to one year, while diabetes progresses toremission about one month after surgery. In daily clinicalpractice, blood glucose levels normalize one week after
bariatric surgery. As can be seen from reports from our
hospital or other institutions, it has been reported that theremission rate of T2DM is higher than that of other obesityrelated diseases 2, 29-33). When we face to the obesity treatment,
it is important to understand that the purpose is not merely
to improve the body image of obesity, but rather to restore
healthy life expectancy.

Conclusion
An obesity treatment team, centering on surgery, wasset up at a regional hospital and probably started the firstbariatric surgery in Kyoto prefecture. The results of LSG at
this hospital were as good as those of other institutions interms of weight reduction effect and improvement effect ofobesity-related diseases.

Conflict of interest

The key to the success of bariatric surgery is a thoroughexplanation before and after surgery and a management
system by team medical care. Namely, the preoperative weight_ 2 81 _The authors have no conflict of interest in this work.

Examination of Postprandial Blood Glucose Prediction Model

Reference
1) Ng M, Fleming T, Robinson M, et al. Global, regional, andnational prevalence of overweight and obesity in children
and adults during 1980-2013: A systematic analysis for the
Global Burden of Disease Study 2013. Lancet. 2014; 384:766-781.
2) Carlsson LMS, Peltonen M, Ahlin S, et al. Bariatric surgery
and prevention of type 2 diabetes in Swedish obese
subjects. N Engl J Med. 2012; 367: 695-704.
3) Tobias DK, Pan A, Jackson CL, et al. Body-mass index andmortality among adults with incident type 2 diabetes. N Engl
J Med. 2014; 370: 233-244.
4) Bhaskaran K, Douglas I, Forbes H, et al. Body-mass index
and risk of 22 specific cancers: A population-based
cohort study of 5.24 million UK adults. Lancet. 2014; 384:755-765.
5) Itoh H. Metabolic domino: New concept in lifestyle
medicine. Drugs Today. 2006; 42: 9-16.
6) Habbard VS, Hall WH. Gastrointestinal surgery forsevere obesity. Obes Surg. 1991; 1: 257-265.
7) Sjöström L, Narbo K, Sjöström CD, et al. Effect of bariatricsurgery on mortality in Swedish obese subjects. N Engl
J Med. 2007; 357: 741-752.
8) Sjöström L, Peltonen M, Jacobson P, et al. Bariatricsurgery and long-term cardiovascular events. JAMA.
2012; 307: 56-65.
9) Angrisani L, Santonicola A, Iovino P, et al: Bariatric surgery
worldwide 2013. Obes Surg. 2015; 25: 1822-1832.
10) Iwata S, Hagiwara A, Kato H. Early metabolic response
after laparoscopic sleeve gastrectomy in obese diabetes.
Glycative Stress Res. 2016; 3: 186-192.
11) Gagner M, Deitel M, Erickson AL, et al. Survey on
laparoscopic sleeve gastrectomy (LSG) at the FourthInternational Consensus Summit on Sleeve Gastrectomy.
Obes Surg. 2013; 23: 2013-2017.
12) Frezaa EE, Reddy S, Gee LL. Complications after sleeve
gastrectomy for morbid obesity. Obes Surg. 2009; 19: 684687.
13) Shi X, Karmali S, Sharma AM, et al. A review oflaparoscopic sleeve gastrectomy for morbid obesity. Obes
Surg. 2010; 20: 1171-1177.
14) Kehagias I, Zygommalas A, Karavias D, et al. Sleeve
gastrectomy: Have we finally found the holy grail ofbariatric surgery? A review of the literature. Eur Rev Med
Pharmacol Sci. 2016; 20: 4930- 4942.
15) Jacobs M, Bisland W, Gomez, et al. Laparoscopic sleeve
gastrectomy: A retrospective review of 1- and 2-year results.
Surg Endosc. 2010; 24: 781-785.
16) Casella G, Soricelli E, Rizzelio M, et al. Nonsurgicaltreatment of staple line leaks after laparoscopic sleeve
gastrectomy. Obes Surg. 2009; 19: 821-826.
17) Serra C, Baltasar A, Andreo L, et al. Treatment of gastricleaks with coated self-expanding stents after sleeve
gastrectomy. Obes Surg. 2007; 17: 866-872.
18) Langer FB, Reza Hoda MA, Bohdjalian A, et al. Sleeve
gastrectomy and gastric banding: Effect on plasma ghrelinlevels. Obes Surg. 2005; 15: 1024 -1029.
19) Karamanakos SN, Vagenas K, Kalfarentzos F, et al. Weight
loss, appetite suppression, and changes in fasting andpostprandial ghrelin and peptide-YY levels after Roueen-Y gastric bypass and sleeve gastrectomy. A prospective
double blind study. Ann Surg. 2008; 247: 401-407.

20) Bozadjieva N, Heppner KM, Seeley RJ. Targeting FXR

and FGF19 to treat metabolic diseases-lessons learned
from bariatric surgery. Diabetes. 2018; 67: 1720-1728.
21) Ryan KK, Tremaroli V, Clemmensen C, et al. FXR is amolecular target for the effects of vertical sleeve
gastrectomy. Nature. 2014; 509: 183-188.
22) Ugi S, Yamamoto H, Kusunoki C, et al. Laparoscopic
sleeve gastrectomy leads to rapid improvement of glucose
tolerance and insulin secretion with enhanced glucagonlike peptide (GLP-1) secretion. Diabetol Int. 2010; 1: 99103.
23) Peterli R, Wölnerhanssen BK, Vetteret D, al. Laparoscopic
sleeve gastrectomy versus Roux-Y-Gastric bypass formorbid obesity-3-year outcomes of the prospective
randomized Swiss Multicenter Bypass or Sleeve Study(SM-BOSS). Ann Surg. 2017: 265: 466-473.
24) Haruta H, Ksama K, Ohta M, et al. Long-term outcomesof bariatric and metabolic surgery in Japan: Results ofmulti-institutional survey. Obes Surg. 2017; 27: 754-762.
25) Saiki A, Yamaguchi T, Tanaka S, et al. Backgroundcharacteristics and postoperative outcomes of insufficientweight loss after laparoscopic sleeve gastrectomy inJapanese patients. Ann Gastroenterol Surg. 2019; 3: 638647.
26) Iwata S, Hagiwara A, Nakamae K. Prior bariatric surgery
is effective on morbidly obese patients following total
knee arthroplasty. Glycative Stress Res. 2020; 7: 116-122.
27) Iwata S, Hagiwara A, Harima Y. Thoracoscopic radical
surgery for a morbidly obese patient with early lungcancer after laparoscopic sleeve gastrectomy: A casereport. Surgical Case Reports. 2020; 6: 189-194.
28) Iwata S, Hagiwara A, Kato H, et al. A case with juvenileonset and standard medical therapy resistant obesity
associated with type 2 diabetes undergoing laparoscopic
sleeve gastrectomy. Glycative Stress Res. 2018; 5: 30-35.
29) Mingrone G, Panunzi S, De Gaetano A, et al. Bariatricsurgery versus conventional medical therapy for type 2
diabetes. N Engl J Med. 2012; 366: 1577-1585.
30) Kashyap SR, Bhatt DL, Wolski K, et al. Metabolic effectsof bariatric surgery in patients with moderate obesity andtype 2 diabetes: Analysis of a randomized control trial
companying surgery with intensive medical treatment.
Diabetes Care. 2013; 36: 2175-2182.
31) Keidar A, Hershkop KJ, Marko L, et al. Roux-en-Y gastricbypass vs sleeve gastrectomy for obese patients with type2 diabetes; A randomized trial. Diabetologia. 2013; 56:
1914-1918.
32) Schauer PR, et al. Bariatric surgery versus intensive medical
therapy for diabetes: 3-year outcomes. N Engl J Med. 2014;
370: 2002-2013.
33) Rubino F, Nathan DM, Eckel RH, et al. Metabolic surgery
in the treatment algorithm for type 2 diabetes: A jointstatement by international diabetes organization. Diabetes
Care. 2016; 39: 861-877.

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