Skip to main content

Advertisement

SpringerLink
Log in

Obesity Surgery and Anesthesiology Risks: a Review of Key Concepts and Related Physiology

  • Review Article
  • Published:
Obesity Surgery Aims and scope Submit manuscript

Abstract

The obesity epidemic is swelling to epic proportions. Obese patients often suffer from a combination of hypertension, dyslipidemia, and type 2 diabetes mellitus (T2DM), also known as the “metabolic syndrome.” The metabolic syndrome is an independent predictor of cardiac dysfunction and cardiovascular disease and a risk factor for perioperative morbidity and mortality. In this paper, we discuss the perioperative risk factors and the need for advanced care of obese patients needing general anesthesia for (bariatric) surgical procedures based on physiological principles.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Nightingale CE, Margarson MP, Shearer E, et al. Peri-operative management of the obese surgical patient 2015: Association of Anaesthetists of Great Britain and Ireland Society for Obesity and Bariatric Anaesthesia. Anaesthesia. 2015;70(7):859–76.

    CAS  PubMed  PubMed Central  Google Scholar 

  2. Vreeswijk SJ, van Rutte PW, Nienhuijs SW, et al. The safety and efficiency of a fast-track protocol for sleeve gastrectomy: a team approach. Minerva Anestesiol. 2018;84(8):898–906.

    PubMed  Google Scholar 

  3. van Wezenbeek MR, Pouwels S, Buise MP, et al. Conventional versus fast track anaesthesia in an unselected group of patients undergoing revisional bariatric surgery. International Journal of Surgery Open. 2015;1:22–7.

    Google Scholar 

  4. Versteegden DPA, Buise MP, Nienhuijs SW. Shift towards older bariatric patients. Obes Surg. 2018;28(2):555–6.

    CAS  PubMed  Google Scholar 

  5. Brandt HG, Jepsen CH, Hendriksen OM, et al. The use of ultrasound to identify veins for peripheral venous access in morbidly obese patients. Dan Med J. 2016;63(2)

  6. Lundstrom LH, Moller AM, Rosenstock C, et al. High body mass index is a weak predictor for difficult and failed tracheal intubation: a cohort study of 91,332 consecutive patients scheduled for direct laryngoscopy registered in the Danish Anesthesia Database. Anesthesiology. 2009;110(2):266–74.

    PubMed  Google Scholar 

  7. De Jong A, Molinari N, Pouzeratte Y, et al. Difficult intubation in obese patients: incidence, risk factors, and complications in the operating theatre and in intensive care units. Br J Anaesth. 2015;114(2):297–306.

    PubMed  Google Scholar 

  8. Cook TM, Woodall N, Frerk C. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth. 2011;106(5):617–31.

    CAS  PubMed  Google Scholar 

  9. Dixon DR, Braude D. THE BARIATRIC AIRWAY. It’s not all about the intubation. JEMS 2015;40(8):58–60.

  10. Aceto P, Perilli V, Modesti C, et al. Airway management in obese patients. Surg Obes Relat Dis : Off J Am Soc Bariatric Surg. 2013;9(5):809–15.

    Google Scholar 

  11. Mutter TC, Chateau D, Moffatt M, et al. A matched cohort study of postoperative outcomes in obstructive sleep apnea: could preoperative diagnosis and treatment prevent complications? Anesthesiology. 2014;121(4):707–18.

    PubMed  Google Scholar 

  12. Alexander JK. The cardiomyopathy of obesity. Prog Cardiovasc Dis. 1985;27(5):325–34.

    CAS  PubMed  Google Scholar 

  13. Alpert MA, Terry BE, Kelly DL. Effect of weight loss on cardiac chamber size, wall thickness and left ventricular function in morbid obesity. Am J Cardiol. 1985;55(6):783–6.

    CAS  PubMed  Google Scholar 

  14. Frey WC, Pilcher J. Obstructive sleep-related breathing disorders in patients evaluated for bariatric surgery. Obes Surg. 2003;13(5):676–83.

    PubMed  Google Scholar 

  15. Mehra R, Benjamin EJ, Shahar E, et al. Association of nocturnal arrhythmias with sleep-disordered breathing: The Sleep Heart Health Study. Am J Respir Crit Care Med. 2006;173(8):910–6.

    PubMed  PubMed Central  Google Scholar 

  16. Chlif M, Keochkerian D, Choquet D, et al. Effects of obesity on breathing pattern, ventilatory neural drive and mechanics. Respir Physiol Neurobiol. 2009;168(3):198–202.

    PubMed  Google Scholar 

  17. Chlif M, Keochkerian D, Feki Y, et al. Inspiratory muscle activity during incremental exercise in obese men. Int J Obes (Lond). 2007;31(9):1456–63.

    CAS  Google Scholar 

  18. Chlif M, Keochkerian D, Mourlhon C, et al. Noninvasive assessment of the tension-time index of inspiratory muscles at rest in obese male subjects. Int J Obes (Lond). 2005;29(12):1478–83.

    CAS  Google Scholar 

  19. Lin CK, Lin CC. Work of breathing and respiratory drive in obesity. Respirology (Carlton, Vic). 2012;17(3):402–11.

    Google Scholar 

  20. Sood A. Altered resting and exercise respiratory physiology in obesity. Clin Chest Med. 2009;30(3):445–54, vii

    PubMed  PubMed Central  Google Scholar 

  21. Hlavac MC, Catcheside PG, McDonald R, et al. Hypoxia impairs the arousal response to external resistive loading and airway occlusion during sleep. Sleep. 2006;29(5):624–31.

    PubMed  Google Scholar 

  22. Yang AL, Lo MJ, Ting H, et al. GABA(A) and GABA(B) receptors differentially modulate volume and frequency in ventilatory compensation in obese Zucker rats. J Appl Physiol(Bethesda, Md : 1985). 2007;102(1):350–7.

    CAS  Google Scholar 

  23. Lee SD, Nakano H, Farkas GA. Adenosinergic modulation of ventilation in obese zucker rats. Obes Res. 2005;13(3):545–55.

    CAS  PubMed  Google Scholar 

  24. Nakano H, Lee SD, Farkas GA. Dopaminergic modulation of ventilation in obese Zucker rats. J Appl Physiol (Bethesda, Md : 1985). 2002;92(1):25–32.

    CAS  Google Scholar 

  25. Norman RG, Goldring RM, Clain JM, et al. Transition from acute to chronic hypercapnia in patients with periodic breathing: predictions from a computer model. J Appl Physiol(Bethesda, Md : 1985). 2006;100(5):1733–41.

    CAS  Google Scholar 

  26. Somers VK, White DP, Amin R, et al. Sleep apnea and cardiovascular disease: an American Heart Association/American College Of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council On Cardiovascular Nursing. In collaboration with the National Heart, Lung, and Blood Institute National Center on Sleep Disorders Research (National Institutes of Health). Circulation. 2008;118(10):1080–111.

    PubMed  Google Scholar 

  27. Camm AJ, Kirchhof P, Lip GY, et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology ESC. Europace. 2010;12(10):1360–420.

    PubMed  Google Scholar 

  28. Tanigawa T, Yamagishi K, Sakurai S, et al. Arterial oxygen desaturation during sleep and atrial fibrillation. Heart. 2006;92(12):1854–5.

    CAS  PubMed  PubMed Central  Google Scholar 

  29. Gami AS, Hodge DO, Herges RM, et al. Obstructive sleep apnea, obesity, and the risk of incident atrial fibrillation. J Am Coll Cardiol. 2007;49(5):565–71.

    PubMed  Google Scholar 

  30. Schumann R, Kwater AP, Bonney I, et al. Respiratory volume monitoring in an obese surgical population and the prediction of postoperative respiratory depression by the STOP-bang OSA risk score. J Clin Anesth. 2016;34:295–301.

    PubMed  Google Scholar 

  31. van den Broek RJ, Buise MP, van Dielen FM, et al. Characteristics and outcome of patients admitted to the ICU following bariatric surgery. Obes Surg. 2009;19(5):560–4.

    PubMed  Google Scholar 

  32. Rider OJ, Francis JM, Ali MK, et al. Beneficial cardiovascular effects of bariatric surgical and dietary weight loss in obesity. J Am Coll Cardiol. 2009;54(8):718–26.

    PubMed  Google Scholar 

  33. Karason K, Wallentin I, Larsson B, et al. Effects of obesity and weight loss on cardiac function and valvular performance. Obes Res. 1998;6(6):422–9.

    CAS  PubMed  Google Scholar 

  34. Kardassis D, Bech-Hanssen O, Schonander M, et al. Impact of body composition, fat distribution and sustained weight loss on cardiac function in obesity. Int J Cardiol. 2012;159(2):128–33.

    PubMed  Google Scholar 

  35. Koliaki C, Liatis S, Kokkinos A. Obesity and cardiovascular disease: revisiting an old relationship. Metabolism: clinical and experimental. 2018.

  36. Aggarwal R, Harling L, Efthimiou E, et al. The effects of bariatric surgery on cardiac structure and function: a systematic review of cardiac imaging outcomes. Obes Surg. 2015;

  37. Lang RM. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2015;16(2):233–70.

    PubMed  Google Scholar 

  38. Martin J, Bergeron S, Pibarot P, et al. Impact of bariatric surgery on N-terminal fragment of the prohormone brain natriuretic peptide and left ventricular diastolic function. Can J Cardiol. 2013;29(8):969–75.

    PubMed  Google Scholar 

  39. Leichman JG, Wilson EB, Scarborough T, et al. Dramatic reversal of derangements in muscle metabolism and left ventricular function after bariatric surgery. Am J Med. 2008;121(11):966–73.

    CAS  PubMed  PubMed Central  Google Scholar 

  40. Wang TJ, Parise H, Levy D, et al. Obesity and the risk of new-onset atrial fibrillation. Jama. 2004;292(20):2471–7.

    CAS  PubMed  Google Scholar 

  41. Wanahita N, Messerli FH, Bangalore S, et al. Atrial fibrillation and obesity--results of a meta-analysis. Am Heart J. 2008;155(2):310–5.

    PubMed  Google Scholar 

  42. Verdecchia P, Dagenais G, Healey J, et al. Blood pressure and other determinants of new-onset atrial fibrillation in patients at high cardiovascular risk in the Ongoing Telmisartan Alone And In Combination with Ramipril Global Endpoint Trial/Telmisartan Randomized Assessment Study in ACE iNtolerant subjects with cardiovascular disease studies. J Hypertens. 2012;30(5):1004–14.

    CAS  PubMed  Google Scholar 

  43. Frost L, Benjamin EJ, Fenger-Gron M, et al. Body fat, body fat distribution, lean body mass and atrial fibrillation and flutter. A Danish cohort study. Obesity (Silver Spring, Md). 2014;22(6):1546–52.

    Google Scholar 

  44. Murphy NF, MacIntyre K, Stewart S, et al. Long-term cardiovascular consequences of obesity: 20-year follow-up of more than 15 000 middle-aged men and women (the Renfrew-Paisley study). Eur Heart J. 2006;27(1):96–106.

    CAS  PubMed  Google Scholar 

  45. Wilhelmsen L, Rosengren A, Lappas G. Hospitalizations for atrial fibrillation in the general male population: morbidity and risk factors. J Intern Med. 2001;250(5):382–9.

    CAS  PubMed  Google Scholar 

  46. Rosengren A, Hauptman PJ, Lappas G, et al. Big men and atrial fibrillation: effects of body size and weight gain on risk of atrial fibrillation in men. Eur Heart J. 2009;30(9):1113–20.

    PubMed  Google Scholar 

  47. Tedrow UB, Conen D, Ridker PM, et al. The long- and short-term impact of elevated body mass index on the risk of new atrial fibrillation the WHS (women’s health study). J Am Coll Cardiol. 2010;55(21):2319–27.

    PubMed  PubMed Central  Google Scholar 

  48. Karasoy D, Bo Jensen T, Hansen ML, et al. Obesity is a risk factor for atrial fibrillation among fertile young women: a nationwide cohort study. Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology. 2013;15(6):781–6.

    Google Scholar 

  49. Tanner RM, Baber U, Carson AP, et al. Association of the metabolic syndrome with atrial fibrillation among United States adults (from the REasons for Geographic and Racial Differences in Stroke [REGARDS] Study). Am J Cardiol. 2011;108(2):227–32.

    PubMed  PubMed Central  Google Scholar 

  50. Chamberlain AM, Agarwal SK, Ambrose M, et al. Metabolic syndrome and incidence of atrial fibrillation among blacks and whites in the Atherosclerosis Risk in Communities (ARIC) Study. Am Heart J. 2010;159(5):850–6.

    PubMed  PubMed Central  Google Scholar 

  51. Miyasaka Y, Barnes ME, Gersh BJ, et al. Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence. Circulation. 2006;114(2):119–25.

    PubMed  Google Scholar 

  52. Schmidt M, Botker HE, Pedersen L, et al. Comparison of the frequency of atrial fibrillation in young obese versus young nonobese men undergoing examination for fitness for military service. Am J Cardiol. 2014;113(5):822–6.

    PubMed  Google Scholar 

  53. Knuiman M, Briffa T, Divitini M, et al. A cohort study examination of established and emerging risk factors for atrial fibrillation: the Busselton Health Study. Eur J Epidemiol. 2014;29(3):181–90.

    PubMed  Google Scholar 

  54. Ozcan KS, Gungor B, Altay S, et al. Increased level of resistin predicts development of atrial fibrillation. J Cardiol. 2014;63(4):308–12.

    PubMed  Google Scholar 

  55. Echahidi N, Mohty D, Pibarot P, et al. Obesity and metabolic syndrome are independent risk factors for atrial fibrillation after coronary artery bypass graft surgery. Circulation. 2007;116(11 Suppl):I213–9.

    PubMed  Google Scholar 

  56. Zacharias A, Schwann TA, Riordan CJ, et al. Obesity and risk of new-onset atrial fibrillation after cardiac surgery. Circulation. 2005;112(21):3247–55.

    PubMed  Google Scholar 

  57. Hernandez AV, Kaw R, Pasupuleti V, et al. Association between obesity and postoperative atrial fibrillation in patients undergoing cardiac operations: a systematic review and meta-analysis. Ann Thorac Surg. 2013;96(3):1104–16.

    PubMed  Google Scholar 

  58. Tsang TS, Barnes ME, Miyasaka Y, et al. Obesity as a risk factor for the progression of paroxysmal to permanent atrial fibrillation: a longitudinal cohort study of 21 years. Eur Heart J. 2008;29(18):2227–33.

    PubMed  PubMed Central  Google Scholar 

  59. Sandhu RK, Conen D, Tedrow UB, et al. Predisposing factors associated with development of persistent compared with paroxysmal atrial fibrillation. J Am Heart Assoc. 2014;3(3):e000916.

    PubMed  PubMed Central  Google Scholar 

  60. Thacker EL, McKnight B, Psaty BM, et al. Association of body mass index, diabetes, hypertension, and blood pressure levels with risk of permanent atrial fibrillation. J Gen Intern Med. 2013;28(2):247–53.

    PubMed  Google Scholar 

  61. Guglin M, Maradia K, Chen R, et al. Relation of obesity to recurrence rate and burden of atrial fibrillation. Am J Cardiol. 2011;107(4):579–82.

    PubMed  Google Scholar 

  62. Guijian L, Jinchuan Y, Rongzeng D, et al. Impact of body mass index on atrial fibrillation recurrence: a meta-analysis of observational studies. Pacing Clin Electrophysiol: PACE. 2013;36(6):748–56.

    PubMed  Google Scholar 

  63. Schnabel RB, Aspelund T, Li G, et al. Validation of an atrial fibrillation risk algorithm in whites and African Americans. Arch Intern Med. 2010;170(21):1909–17.

    PubMed  PubMed Central  Google Scholar 

  64. Schnabel RB, Sullivan LM, Levy D, Pencina MJ, Massaro JM, D'Agostino RB, Sr., Newton-Cheh C, Yamamoto JF, Magnani JW, Tadros TM, Kannel WB, Wang TJ, Ellinor PT, Wolf PA, Vasan RS, Benjamin EJ Development of a risk score for atrial fibrillation (Framingham Heart Study): a community-based cohort study. Lancet (London, England) 2009;373(9665):739–745.

    Google Scholar 

  65. George-Phillips KL, Bungard TJ. Use of low-molecular-weight heparin to bridge therapy in obese patients and in patients with renal dysfunction. Pharmacotherapy. 2006;26(10):1479–90.

    CAS  PubMed  Google Scholar 

  66. Schijns W, Deenen MJ, Aarts EO, et al. The effect of obesity on anti-Xa concentrations in bariatric patients. Obes Surg. 2018;28(7):1997–2005.

    CAS  PubMed  Google Scholar 

  67. Thereaux J, Lesuffleur T, Czernichow S, et al. To what extent does posthospital discharge chemoprophylaxis prevent venous thromboembolism after bariatric surgery?: results from a nationwide cohort of more than 110,000 patients. Ann Surg. 2018;267(4):727–33.

    PubMed  Google Scholar 

  68. van Huisstede A, Biter LU, Luitwieler R, et al. Pulmonary function testing and complications of laparoscopic bariatric surgery. Obes Surg. 2013;23(10):1596–603.

    PubMed  Google Scholar 

  69. Watson RA, Pride NB, Thomas EL, et al. Relation between trunk fat volume and reduction of total lung capacity in obese men. J Appl Physiol(Bethesda, Md : 1985). 2012;112(1):118–26.

    CAS  Google Scholar 

  70. Pedoto A. Lung physiology and obesity: anesthetic implications for thoracic procedures. Anesthesiol Res Pract. 2012;2012:154208.

    PubMed  PubMed Central  Google Scholar 

  71. Lavie CJ, De Schutter A, Parto P, et al. Obesity and prevalence of cardiovascular diseases and prognosis-the obesity paradox updated. Prog Cardiovasc Dis. 2016;58(5):537–47.

    PubMed  Google Scholar 

  72. Lavie CJ, Milani RV, Ventura HO. Obesity and cardiovascular disease: risk factor, paradox, and impact of weight loss. J Am Coll Cardiol. 2009;53(21):1925–32.

    PubMed  Google Scholar 

  73. Lee GK, Cha YM. Cardiovascular benefits of bariatric surgery. Trends Cardiovasc Med. 2016;26(3):280–9.

    PubMed  Google Scholar 

  74. Alpert MA, Lambert CR, Panayiotou H, et al. Relation of duration of morbid obesity to left ventricular mass, systolic function, and diastolic filling, and effect of weight loss. Am J Cardiol. 1995;76(16):1194–7.

    CAS  PubMed  Google Scholar 

  75. Flegal KM, Kit BK, Orpana H, et al. Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis. Jama. 2013;309(1):71–82.

    CAS  PubMed  PubMed Central  Google Scholar 

  76. Alpert MA, Terry BE, Mulekar M, et al. Cardiac morphology and left ventricular function in normotensive morbidly obese patients with and without congestive heart failure, and effect of weight loss. Am J Cardiol. 1997;80(6):736–40.

    CAS  PubMed  Google Scholar 

  77. Buise MP, van den Broek RJC, de Zoete JP, et al. Advanced care admission following bariatric surgery. Neth J Crit Care. 2010;14(2):85–91.

    Google Scholar 

  78. Osher E, Stern N. Obesity in elderly subjects: in sheep’s clothing perhaps, but still a wolf! Diabetes Care. 2009;32(Suppl 2):S398–402.

    PubMed  PubMed Central  Google Scholar 

  79. Piper AJ, Grunstein RR. Big breathing: the complex interaction of obesity, hypoventilation, weight loss, and respiratory function. J Appl Physiol(Bethesda, Md : 1985). 2010;108(1):199–205.

    Google Scholar 

  80. Chung F, Abdullah HR, Liao P. STOP-Bang questionnaire: a practical approach to screen for obstructive sleep apnea. Chest. 2015;

  81. Chung F, Yang Y, Liao P. Predictive performance of the STOP-bang score for identifying obstructive sleep apnea in obese patients. Obes Surg. 2013;23(12):2050–7.

    PubMed  Google Scholar 

  82. Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108(5):812–21.

    PubMed  Google Scholar 

  83. Proczko MA, Stepaniak PS, de Quelerij M, et al. STOP-Bang and the effect on patient outcome and length of hospital stay when patients are not using continuous positive airway pressure. J Anesth. 2014;28(6):891–7.

    PubMed  PubMed Central  Google Scholar 

  84. Farina A, Crimi E, Accogli S, et al. Preoperative assessment of respiratory function in severely obese patients undergoing biliopancreatic diversion. Eur Surg Res. 2012;48(2):106–10.

    CAS  PubMed  Google Scholar 

  85. Hamoui N, Anthone G, Crookes PF. The value of pulmonary function testing prior to bariatric surgery. Obes Surg. 2006;16(12):1570–3.

    PubMed  Google Scholar 

  86. Catheline JM, Bihan H, Le Quang T, et al. Preoperative cardiac and pulmonary assessment in bariatric surgery. Obes Surg. 2008;18(3):271–7.

    PubMed  Google Scholar 

  87. Nepomnayshy D, Hesham W, Erickson B, et al. Sleep apnea: is routine preoperative screening necessary? Obes Surg. 2013;23(3):287–91.

    PubMed  Google Scholar 

  88. Peromaa-Haavisto P, Tuomilehto H, Kossi J, et al. Prevalence of obstructive sleep apnoea among patients admitted for bariatric surgery. A prospective multicentre trial. Obes Surg. 2015;

Download references

Contributions

Initial idea and design of the study: SP, MB, PT, PS, and MP

Drafting and finalizing the manuscript: SP, MB, PT, PS, and MP

Final approval: SP, MB, PT, PS, and MP

Author information

Authors and Affiliations

  1. Department of Surgery, Haaglanden Medical Center, Lijnbaan 32, 2512 VA, The Hague, The Netherlands

    Sjaak Pouwels

  2. Department of Anesthesiology, Intensive Care and Pain Medicine, Catharina Hospital, Eindhoven, The Netherlands

    Marc P. Buise

  3. Department of Anesthesia and Intensive Care, University Medical Center, Gdansk University, Gdansk, Poland

    Pawel Twardowski

  4. Department of Operating Rooms, Catharina Hospital, Eindhoven, The Netherlands

    Pieter S. Stepaniak

  5. Department of Surgery, University Medical Center, Gdansk University, Gdansk, Poland

    Monika Proczko

Authors
  1. Sjaak Pouwels
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Marc P. Buise
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Pawel Twardowski
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Pieter S. Stepaniak
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Monika Proczko
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Sjaak Pouwels.

Ethics declarations

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval Statement

For this type of study, formal consent is not required.

Informed Consent Statement

Does not apply.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Pouwels, S., Buise, M.P., Twardowski, P. et al. Obesity Surgery and Anesthesiology Risks: a Review of Key Concepts and Related Physiology. OBES SURG 29, 2670–2677 (2019). https://doi.org/10.1007/s11695-019-03952-y

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11695-019-03952-y

Keywords

Search

Navigation