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Bariatric Surgery Flashcards

1
Q

Postprandial RUQ pain and nausea months after RYGB should raise concern for

A

Gallstones

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2
Q

Recommended iron intake through supplements postop

A

40-65 daily

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3
Q

Bariatric procedure that is sometimes done as an outpatient

A

Band

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4
Q

Symptoms of internal hernia

A

Vary, but generally pain N/V and signs of obstruction

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5
Q

Treatment of postop stricture/stenosis

A

EGD with dilation

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6
Q

Pleural effusion soon after surgery is concerning for this complication

A

Leak

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7
Q

Urinary calcium postop screening

A

24 hour urinary calcium recommended at 6 months and then annually after that

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8
Q

Thiamine supplementation post op

A

Recommended as mineral component of multivitamin

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9
Q

Change in Grehlin with Bariatric surgery

A

Decreased

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10
Q

Indications for Biliopancreatic Diversion (with duodenal switch)

A

Sometimes used for severely obese (BMI >50)

Sometimes used for revision of other procedure if failed to lose weight or had weight regain

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11
Q

Test for bacterial overgrowth syndrome

A

Lactulose breath test

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12
Q

Timing of weight regain

A

Usually about 2 years postop

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13
Q

Perioperative management of hormone replacement therapy and OCPs

A

Estrogen therapy should be discontinued before bariatric surgery (1 cycle of oral contraceptives in premenopausal women; 3 weeks of hormone replacement therapy in postmenopausal women) to reduce the risks for post-operative thromboembolic phenomena

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14
Q

Contraindications for Bariatric surgery

A

Hasn’t tried multiple rounds of lifestyle modification +- meds

Poor adherence (severe psych, dementia, substance abuse …)

Eating disorder

Crohns

Smoker (not able to quit)

(Many) prior abdominal surgeries can complicate things

Pediatric patient not yet done with puberty and linear growth

Patients >60 years old less commonly done, but possible if good functional age

General medical contraindications to surgery

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15
Q

Esophageal dilation is seen after this type of procedure

A

Band

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16
Q

Treatment of Dumping syndrome

A

Decrease simple cabs, increasing protein/fat/fiber, not drinking fluids with meals, avoiding dairy, and eating smaller more frequent meals

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17
Q

Thiamine deficiency seen most often after this type of procedure

A

RYGB or BPD

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18
Q

Extended release and enteric coated medicaitons post op

A

Absorption may be altered so use should be avoided

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19
Q

Treatment for bile salt toxicity

A

Cholestyramine

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20
Q

Timing of return to work after bariatric surgery

A

Usually directed to stay out of work for 1-2 weeks after band and 2-4 weeks after sleeve/RYGB

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21
Q

Change in gastric emptying after Bariatric surgery

A

Increases

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22
Q

Timing of onset of symptoms of internal hernia

A

Varies greatly. Can be soon after surgery or years later. Most often about a year after procedure

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23
Q

The most common cause of SBO after bariatric surgery is

A

Internal hernia

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24
Q

What percentage of lap bands end up needing revision?

A

1/3

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25
Q

Thiamine postop screening

A

Only if specific findings

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26
Q

Expected weight loss with RYGB

A

~35% total body weight (~65% excess body weight)

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27
Q

Preop Testing recommended by 2013 Guideline from AACE/TOS/ABMBS

A 
CBC
Lipids
CMP
UA
PT/INR
Blood type
Iron
B12
Folic Acid
Vit D
H pylori screening of high prevalence area
CXR
EKG
OSA screening (with sleep study if positive)

Eval for other obesity related comorbidities based on clinical suspicion

TSH only if clinical suspicion

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28
Q

Vit B12 supplementation postop

A

As needed to check levels within normal range

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29
Q

Change in energy expenditure after Bariatric surgery

A

Decreases (less tissue to support)

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30
Q

Timing of postop thiamine deficiency

A

Thiamine Deficiency and Wernicke Korsakoff most often in the 3 months immediately following surgery

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31
Q

Best contraceptive after bariatric surgery

A

Procedures with a malabsorptive feature (Sleeve and RYGB) may decrease absorption of OCP, so other options preferred

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32
Q

Perioperative sulfonylurea use

A

Should be stopped after surgery to avoid hypoglycemia

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33
Q

What most consistently predicts maintenance of weight loss of Bariatric surgery

A

Exercise

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34
Q

Cause of tachycardia, dizziness, diaphoresis, and palpitations 10-30 min after eating

A

“Early” Dumping syndrome

Quick movement of food through stomach into the bowel –> hyperosmolality of the food and rapid fluid shift into the bowel –> hypotension and sympathetic nervous response

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35
Q

Effects on long term Bariatric outcomes and complications for patient who lose weight preop? Should it be required to qualify for surgery?

A

There is a lack of consensus about the role of preop weight loss in improving outcomes with mixed evidence.

Preop weight loss may slightly decrease complications by decreasing adipose tissue and liver size.

Some studies show patients who are able to lose weight prior to surgery have more weight loss after surgery.

Per ASMBS, the requirement of insurance companies to lose weight to qualify for surgery is discriminatory, arbitrary, and not scientifically founded with delays in procedures. Some of the insurers who require preop weight loss don’t reimburse for these services, so are clearly more doing it to limit access not improve outcomes

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36
Q

Change in recommendations for carb intake in patients with dumping syndrome

A

Less simple carbs

More complex carbs

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37
Q

Rank procedures in frequency of nutritional deficiencies post op

A

Band (least)
Sleeve
RYGB
Biliopancreatic diversion (most)

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38
Q

Use of NSAIDs and smoking increase the risk of this particular postop complication

A

Marginal ulcer

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39
Q

Bariatric procedures with the most post op (30 day mortality)

A

Biliopancrratic diversion with duodenal switch and RYGB

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40
Q

Leak can present with pain in the abdomen and/or _

A

Shoulder

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41
Q

Meds for short gut (if needed)

A

Antidiarrheals

PPI/H2 blocker

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42
Q

What is short gut syndrome and how is it treated

A

Diarrhea and possibly malnutrition caused by a lack of absorptive surface seen after RYGB in the weeks after surgery. Body can adapt overtime and improve. Hydration, dietary modification, acid suppressing medications (H2 or PPI) and antidiarrheals are used

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43
Q

Effect of bariatric surgery on appetite

A

Decreased

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44
Q

This procedure has the highest rate of (long term) post op complications

A

Band, why falling out of favor

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45
Q

Mechanism of Bariatric surgery

A

Mechanical Restriction

Malabsorption

Change in microbiota

Change in GI hormones

Increased brown thermogenesis

…

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46
Q

Dumping syndrome most common after what type of procedure

A

RYGB (And BPD-DS)

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47
Q

Calcium supplementation postop

A

Calcium citrate 1200-1500 mg

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48
Q

Change is GLP-1 with Bariatric surgery

A

Increased

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49
Q

Effects of Bariatric surgery on a women’s offspring

A

Children born to women s/p Bariatric surgery are less likely to be obese

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50
Q

Preferred initial test for suspected leak

A

Upper GI series (X-ray) with oral contrast or CT with oral contrast

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51
Q

Bariatric surgery is generally not performed before what age in pediatric patients

A

Usually no earlier than 13 in girls and 15 in boys when they have reached >95% skeletal maturity

However, newer guidelines call this standard practice into question

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52
Q

Internal hernia are seen after this type of Bariatric surgery

A

RYGB

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53
Q

How to manage mild N/V and food intolerance in the weeks following surgery

A

Not uncommon after bariatric surgery. Due to a variety of causes. If mild and able to tolerate thin liquid diet probably don’t need to return to the hospital. If symptoms mild kept on liquid diet for 1-2 weeks, and then slowly transitioned to solids. Likely caused by surgical edema which should resolve

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54
Q

Most common cause of perioperative mortality

A

DVT/PE or leak

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55
Q

Effects of Bariatric surgery on OSA

A

Improved apnea hypopnea scores but usually does not completely resolve it

Consider redoing sleep study before stopping CPAP

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56
Q

Effect of Bariatric surgery on cancer

A

Decreased breast, endometrial, prostate, pancreatic, and colon cancer

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57
Q

Prophylaxis for nephrolithiasis postop

A

Low oxalate diet

Stay hydrated

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58
Q

Change in insulin secretion after Bariatric surgery

59
Q

Medications used for Dumping syndrome

A

Fiber supplement can help

Acarbose or Octreotide sometimes used to treat dumping syndrome

60
Q

Vitamin C supplementation post op

A

Can increase absorption of iron

61
Q

Postprandial hyperinsulinemic hypoglycemia is also called

A

“Late” dumping syndrome

62
Q

Treatment of suspected leak

63
Q

Marginal ulcer seen most often after this type of Bariatric procedure

A

RYGB or BPD

64
Q

Recommendations for Pregnancy after Bariatric surgery?

A

Wait at least 12 months. High risk for nutritional deficiencies in mom and baby

65
Q

Rank procedures in order of weight loss and effect on medical comorbidities

A

Biliopancreatic diversion (biggest)
RYGB
Sleeve
Band (least)

66
Q

Effects of Bariatric surgery on depression

A

Improved, although suicide increases

SSRI bioavailability is lessened by bariatric surgery

67
Q

Treatment for bacterial overgrowth postop

A

Rifaximin
Cipro
Metronidazole

68
Q

Bariatric Surgery Criteria for Peds patients per AAP guideline

A

140% of the 95% for age/gender, BMI of 40 or class 3 obesity

If have clinically significant disease (OSA, DM, HTN, GERD, SCFE, NASH…), then only need to have 120% of the 95%, BMI of 35 or class 2 obesity

Should be done with most of linear growth

BMI criteria r the same as adults

69
Q

Timing of kidney stones post op

A

Usually years postop

70
Q

Effects of Bariatric surgery on HLD

A

Remission in roughly 40-80% of patients depending on procedure

Improvement in most

71
Q

Effect of Bariatric surgery on alcohol absorption and elimination

A

In bypass surgery it is absorbed faster and eliminated slower with a slight increased risk for alcohol dependence

Sleeve and band have not shown these risks

72
Q

Post op diet

A

Kept NPO initially, then thin liquid diet for 1-2 weeks before slowly advancing

Protocol driven staged meal progression should be supervised by registered nutrition per guidelines

73
Q

Effect of Bariatric surgery on mortality

A

Long term significant decreased (although slight increase in the weeks immediately following surgery)

74
Q

Change in CCK after Bariatric surgery

75
Q

This vitamin deficiency should be suspected in patients with fatigue and loss of vibration/positional sense

A

Vit B12 cobalamin

76
Q

Should the gallbladder prophylactically be removed during Bariatric surgery

A

No, per ABMS choosing wisely guideline

77
Q

Tachycardia and pain in the immediate post op period should raise concern for these 2 complications

A

PE and leak

78
Q

B12 Screening postop

79
Q

Dietary changes after Bariatric surgery

A

Patients should be counseled to eat 3 small meals during the day

chew small bites of food thoroughly before swallowing.

Need to eat slowly

Avoid fluids during meals (wait 30 min) as decreases sense of fullness.

Avoid concentrated sweets which can cause dumping syndrome.

Avoid carbonated beverages as can cause gastric bloating.

Lactose intolerance is often worsened by bariatric surgery. Usually directed to limit dairy especially in the weeks following surgery

80
Q

How to handle smoker who wants Bariatric surgery

A

Significantly increases multiple complications. Need to stop before surgery, preferably at least6 weeks before hand

81
Q

What is the most common vitamin def after RYGB

A

Iron

Due to less red meat and exclusion of duodenum

82
Q

Effects of Bariatric surgery on osteoarthritis

83
Q

Post Op diarrhea causes and treatments

A

Lactose intolerance is often worsened by bariatric surgery. Usually directed to limit dairy especially in the weeks following surgery

Decrease bile acid absorption. Cholestyramine sometimes used to bind bile and decrease diarrhea

Change in gut micobiotica and C Dif. Probiotics often given postop

Short Gut syndrome

Dumping syndrome

Pancreatic insufficiency

Imodium sometimes used daily postop

84
Q

Most common site of anastomitc leak

A

Gastro-jejunal anastomosis in RYGB

Can also occur at staple line in sleeve

85
Q

Vitamin D supplementation post op

A

At least 3000 units, and then additionally titrate to keep level above 30

86
Q

Work up of complicated dumping syndrome can include

A

Glucose challenge test and sometimes gastric emptying study or insulin/C-peptide studies

87
Q

Treatment of marginal ulcer

A

Carafate and PPI with treatment of H pylori if present

88
Q

How long to make vitamin supplements chewable postop

A

3-6 months

89
Q

Qualifications for getting Bariatric surgery

A

Per 2014 ACC/AHA/Obesity Society guidelines

  • BMI >=40
  • BMI >=35 + comorbidites

Per American Association of Clinical Endocrinologists guideline also candidate if BMI 30-35 with type 2 DM or metabolic syndrome. But evidence for this is limited

90
Q

Expected weight loss with sleeve

A

~25% of total body weight (~55% of excess body weight) over 1-2 years

91
Q

Use of this type of medication is thought to increase the risk of anastomotic leak in Bariatric patients and should be avoided post op

92
Q

What should be taken along with Orlistat

A

Multivitamin due to risk of fat soluble vitamin deficiency

Fiber (Psylium) supplement decreases side effects

93
Q

Vitamin K screening postop

A

Not recommended

94
Q

What is done during a Roux-en-Y Gastric Bypass procedure

A

End up disconnecting most of the stomach and duodenum from the esophagus. Create small remaining stomach pouch that connects directly to the small intestine bypassing duodenum and stomach. You don’t completely remove the stomach and duodenum so can continue to get secretions even though they no longer receive food

95
Q

What is bacterial overgrowth syndrome & what causes it

A

Bacterial overgrowth syndrome is a disorder in which poor movement of intestinal contents allows certain normal intestinal bacteria to grow excessively, causing diarrhea and poor absorption of nutrients (malabsorption).

96
Q

Change in Leptin after Bariatric surgery

97
Q

Expected time in the hospital for sleeve and RYGB

98
Q

This complication seen immediately after surgery is higher risk in severely obese patients and those with longer procedures

A

Rhabdo

Check CK post op especially in patients with BMI >55

99
Q

Trends in Popularity of Bariatric surgery overall

A

Only about 1% of people in the US who meet criteria end up having it done, despite 60% having insurance coverage for it

Number of Bariatric surgeries worldwide has plateaued

100
Q

Folic acid supplementation post op

A

Folic acid supplementation (400 mg/d) should be part of a routine mineral-containing multivitamin preparation

101
Q

This Bariatric procedure requires the most frequent follow up post op

A

Lap Band, requires frequent adjustments

102
Q

This vitamin deficiency should be suspected in patients with heart failure, nystagmus, sensory/motor deficits, and AMS

A

Thiamine B1

103
Q

Postop Screening of Vit A

A

Generally not recommended

Optional for RYGB

104
Q

What to suspect in the first couple weeks of Bariatric surgery if patient has severe abdominal pain (or shoulder), SOB, fever, and tachycardia

105
Q

Most popular bariatric procedure

106
Q

Vitamin E screening postop

A

Not recommended

107
Q

Bariatric surgery with the least post op (30 day) mortality

108
Q

Effects of Bariatric surgery on HTN

A

Remission is relatively common (50-75% depending on procedure)

109
Q

How to decrease rates of Rhabdo

A

Padded surgical tab
Limit operative time
Hydrate perioperatively

110
Q

Preferred testing if suspect marginal ulcer

A

EGD with H pylori biopsy

111
Q

Severe N/V and food intoelrance soon after band procedure is likely

A

Stomal obstruction/band stricture

112
Q

Multivitamin use postop

A

2 adult multivitamin plus minerals (containing iron, folic acid, copper, and thiamine) after RYGB and Sleeve. Band only needs 1 daily

113
Q

Effects of Bariatric surgery on GERD

A

RYGB decreases GERD

Sleeve worsens GERD

114
Q

A patient s/p bypass has microcytic or normocytic anemia, sensory ataxia, spastic gait, weakness fatigue, normal iron, normal folate, normal B12, and ringed sideroblasts on smear. This is caused by what?

A

Copper deficiency

115
Q

Dumping syndrome seen most often after this type of Bariatric surgery

A

RYGB or BPD

116
Q

Expected weight loss with band

A

~15% total body weight (~40% excess body weight) at 2 years

117
Q

What is done during a laparoscopic adjustable band procedure?

A

Band placed at the top of the fundus of the stomach below the esophagus and connected to port in the upper abdomen which allows you to adjust the tightness of the band based on satiety

118
Q

Effects of Bariatric surgery on suicide

A

Roughly 50% increase

119
Q

“Swirl sign” on post op imaging is suggestive of _

A

Internal hernia

120
Q

What does a sleeve gastrectomy involve doing?

A

Partial vertical gastrectomy along the greater curvature of the stomach removing about 70% of its volume

121
Q

Risk of mortality in perioperative period

A

Much lower than other common procedures

30 day mortality:

  • CABG 2.8%
  • Lap chole 1.8%
  • Lap appy 1.5%
  • RYGB 0.3%
  • Lap Sleeve 0.2%
  • Lap Band <0.05%
122
Q

Effects of Bariatric surgery on quality of life

123
Q

Band brands

A

Lap Band

“Realized Band” (no longer available)

124
Q

Prophylaxis for post op gallstone formation

A

Not routinely recommended but some docs treat with Ursodeoxycholic acid for about 6 months postop

125
Q

Dumping syndrome is most often seen after what type of Bariatric surgery

A

RYGB (and biliopancretic diversion)

126
Q

This vitamin deficiency should be suspected in patients with peripheral edema

A

Thiamine B1

127
Q

Blood in stool should raise concern for this post op complication in the early postop period

A

Marginal ulcer

128
Q

Flank pain a few years after RYGB should raise concern for

A

Nephrolithiasis

129
Q

Copper supplementation post op

A

Copper supplementation (2 mg/d) should be included as part of routine multivitamin with mineral preparation

130
Q

Effects of Bariatric surgery on diabetes

A

Remission is relatively common (~40-80% depending on procedure)

High percentage of at least improvement and/or get off insulin

Recurrence of diabetes later is not uncommon but usually much less severe then before

131
Q

Management of internal hernia post-bariatric surgery

A

Urgent surgical referral. Can lead to bowel ischemia

132
Q

Pain meds after surgery

A

Usually liquid elixir Oxycodone, but can also take tylenol

No NSAIDs

133
Q

Should prophylactic antibiotics be used postop

A

No, per ABMS choosing wisely guideline

134
Q

N/V, abdominal pain and dysphagia a few weeks post op should raise concern for

A

Stricture/stenosis

135
Q

This is the only Bariatric procedure that is reversible

136
Q

Effects of Bariatric surgery on PCOS

A

Appears to improve PCOS

137
Q

Should you do routine screening for gallstones preop

138
Q

Iron screening post op

A

Highly recommended

139
Q

Cause of tachycardia, dizziness, diaphoresis, and palpitations 1-3 hours after eating

A

“Late” Dumping syndrome

Rapid absorption of sugars –> surge of insulin –> hypoglycemia

140
Q

Timing of gallstone related issues postop

A

Usually within 3-6 months of surgery

141
Q

Preferred form of Calcium supplement

142
Q

Change in Peptide YY after Bariatric surgery

143
Q

Importance of intraoperative or routine post op leak testing

A

Routine use of intraoperative or immediate postop leak testing with air/dye/endoscopy is not an evidence based practice, but is commonly done.

144
Q

Bone density screening postop

A

At 2 years

Obesity Medicine (5 decks)

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