OESOPHAGUS AND STOMACH
Bariatric surgery
Alexis Sudlow
Dimitri J Pournaras
Alan Osborne
Abstract
Obesity presents a growing public health crisis which has significant
impact for individuals and healthcare provision worldwide. Mounting
evidence from randomized controlled trials would suggest that bariat-
ric surgery, irrespective of the procedure performed, is the most effec-
tive treatment currently available for obesity and related comorbidity.
Given the increasing prevalence of obesity within all populations, clini-
cians in all specialties will treat patients with obesity and likely those
who have had bariatric surgery. There are numerous barriers to
improving obesity care, including stigma and a lack of understanding
amongst healthcare professionals and patients regarding the safety,
efficacy and indications for bariatric surgery. It is essential that doctors
and surgeons caring for those with obesity have an understanding and
appreciation of the procedures performed, including the mechanism of
action and outcomes for patients. Finally, an understanding of the
emergency postoperative complications will help further improve
outcomes.
Keywords Bariatric surgery; obesity; Roux-en-Y gastric bypass;
sleeve gastrectomy; weight loss
Introduction
Obesity is rapidly becoming one of the most challenging issues
facing the global population from both a healthcare and socio-
economic point of view including personal implications for the
lives of those affected. On a population level, health awareness
campaigns aimed at prevention as well as lifestyle interventions
for those already affected appear to have had little impact on
reversing or even slowing down this trend. It is estimated at
present, 29% of adults within England are considered to have
obesity and perhaps more worryingly, the demographics appear
to be shifting with 17% of 2e15 year old children now affected
by obesity.1
Obesity is a complex, multi-system disease directly associated
with the development of numerous comorbidity, including type 2
diabetes mellitus (T2DM) and cardiovascular disease, which
have a significant impact on not only the patient’s quality of life,
but also the duration. Despite research looking for sustainable
Alexis Sudlow BSc MRCS is a Surgical Registrar and Royal College of
Surgeons Research Fellow at Southmead Hospital, North Bristol
NHS Trust, Bristol, UK. Conflicts of interest: none declared.
Dimitri Pournaras PhD FRCS is a Consultant Bariatric Surgeon at
Southmead Hospital, North Bristol NHS Trust, UK. Conflicts of
interest: none declared.
Alan Osborne MMED FRCS is a Consultant Bariatric Surgeon at
Southmead Hospital, North Bristol NHS Trust, Bristol, UK. Conflicts
of interest: none declared.
SURGERY 38:11
lifestyle interventions, to date none have proven to be effective in
reducing mortality. Conversely, bariatric surgery has been
consistently supported by a growing body of evidence as an
intervention to produce not only effective and sustained weight
loss, but also critical metabolic changes resulting in a resolution
or improvement in T2DM, reduction of cardiovascular risk fact-
ors and, ultimately, improved long-term survival compared to
those with obesity treated without surgery.
Obesity e stigma as a barrier to care
Obesity remains a highly stigmatized disease despite mounting
evidence to support that it is the result of a highly complex
interaction between physiological pathways, genetic factors and
environmental influences. There is a widely held and pervasive
view amongst the public and, perhaps more worryingly, medical
professionals that it is primarily the end result of a deficiency of
personal will power. Society and the media perpetuate this unfair
portrayal of patients with obesity, correlating the disease with a
range of highly negative attributes. The effect of this is not to be
underestimated and has significant effects on an individual’s
personal perception and sense of self-worth. Studies have also
shown weight stigma can result in patients with obesity receiving
poor medical care.2 This attitude that obesity is entirely self-
inflicted and not only the disease but the individuals affected
are unworthy of treatment remains one of the most significant
obstacles. Treating obesity as a disease does not absolve patients
of all personal responsibility, but it gives them the ability to play
an active role in the management of a chronic disease, supported
by effective medical or surgical treatment strategies.3
Aims of treating obesity
Obesity is often viewed as primarily a disease characterized by
excess adiposity and as such, management has traditionally been
focused on weight loss or reduction in BMI which are also used
as the main indicators of treatment success. This approach is
being recognized as an overly simplistic method of assessing a
complex disease process. The goals of treatment have since
shifted from weight loss to health gain and sustained improve-
ment in metabolic parameters as well as cardiovascular risk
factors,5 obstructive sleep apnoea, subfertility, idiopathic intra-
cranial hypertension, type 2 diabetes mellitus and urinary in-
continence. In addition, there are conditions whereby obesity
precludes an individual from undergoing surgical intervention
which could be life changing or saving such as organ transplant
and joint replacement. Again, in these conditions, bariatric sur-
gery may be considered as a bridge to definitive treatment as it
not only improves the safety of surgery but long-term outcomes
as well.
Clinicians must also be mindful of the importance of weight
loss maintenance when evaluating the usefulness of any inter-
vention for obesity. Weight loss is considered to be clinically
significant when a patient has lost 3e5% of their body weight as
this has been demonstrated to be the threshold at which patients
experience improvements in glycaemic control and cardiovas-
cular risk factors.4 While numerous interventions, including
lifestyle changes, have been shown to produce weight loss above
this threshold, only a small minority of patients will be able to
sustain this weight loss in the long term.
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 OESOPHAGUS AND STOMACH
NICE (CG189) guidelines for bariatric surgery
Bariatric surgery is a treatment option if ALL of the following criteria
are fulfilled:
C BMI 40, or 35  BMI <40 with significant disease that could be
improved by weight loss
C Failure to achieve or maintain adequate and clinically beneficial
weight loss despite all appropriate non-surgical measures for at
least 6 months
C The patient has been receiving or will receive intensive manage-
ment in a specialist obesity service
C The patient is generally fit for anaesthesia and surgery
C The patient commits to long-term follow-up
C Consider an expedited assessment for BMI of 30e34.9 who have
recent onset type 2 diabetes
C Consider an assessment for people of Asian family origin with
recent onset type 2 diabetes at a lower BMI than 30
Box 1
Obesity is a chronic disease, and like other chronic diseases
will require life-long treatment strategies that may need to be
applied in a stepwise approach as the efficacy of some treatment
modalities will invariably fatigue with time. Bariatric surgery is
often perceived as a last resort for advanced disease, which
effectively limits further treatment for those who have already
undergone surgery. Clinicians should instead view bariatric
surgery as one element in an overall treatment strategy, which
may also include revisional surgery or weight loss medications to
sustain or augment what can be achieved with surgery.5,6
Bariatric surgery
Bariatric surgery as a treatment for obesity is now largely
unrecognizable in comparison to when it first gained widespread
acceptance nearly 30 years ago, as a result of fundamental
technical advances as well as a greater understanding of the
disease process.
Rather than being thought to act by physically restricting food
intake or causing malabsorption, we now understand that bar-
iatric surgery has multisystemic effects, acting centrally within
the hypothalamus to control appetite, hunger and satiety as well
as within the gut via hormones, bile acids and changes in the
microbiome.7
Once seen as an extreme and risky weight loss procedure used
as a last resort, bariatric surgery is now recognized as a very safe
procedure, and the adoption of the laparoscopic approach has
resulted in many procedures being performed with a <24 hours
stay with a morbidity and mortality rate in line with that of
laparoscopic cholecystectomy.9
Surgical pathways and indications for surgery
Referral pathways have long been dictated by outdated models
which are heavily reliant on BMI-related thresholds. In light of
the importance of non-BMI-related factors such as the presence
of comorbidity or ethnicity, recent reviews have introduced the
need for an expedited assessment for patients with a BMI of 30
e34.9 who have recent onset type 2 diabetes or an assessment
SURGERY 38:11
for people of Asian family origin with recent onset type 2 dia-
betes at a BMI <30. The current NICE guidelines for referral for
bariatric surgery within the NHS are shown in Box 1. Essential to
the success of any procedure is active engagement of the patient
and commitment to long-term follow-up which includes careful
monitoring of micronutrients and supplementation due to the
risk of deficiency.
The referral pathway varies slightly across different health
systemd although all use a similar tiered approach, which is
broadly the same for managing patients once referred. Central to
the weight management pathway is the multidisciplinary team
(MDT) including psychologists, dieticians, bariatric specialist
nurses, endocrinologists and surgeons. Once a patient has been
referred to the weight management services, they receive indi-
vidualized care and input from all members of the MDT and may
proceed to weight loss surgery if it is indicated, wanted by the
patient and recommended by the MDT. The tiered structure
approach to the MDT management of obesity services can be
seen in Figure 1.
Bariatric procedures
There is ongoing debate regarding the ‘ideal’ bariatric procedure,
but the reality is that at present, there is no level 1 evidence to
suggest the overall superiority of one over another. There are
differing effects regarding weight loss and the potential metabolic
implications, which vary between procedures, but this must also
be weighed against the risk of short and long-term complications
as well as individual patient factors. In practical terms, the ideal
operation is one which suits the needs of the patient and the
expertise of the surgeon. The variety of surgical procedures
available allows for the provision of treatment tailored to the
patient and their individual disease.
Sleeve gastrectomy
Although initially conceived as part of a two-stage duodenal
switch, sleeve gastrectomy (SG) has widely become accepted as a
procedure in its own right in recognition of the associated sig-
nificant weight loss and metabolic effects. In recent years, SG has
accounted for an increasing percentage of the bariatric proced-
ures performed and is now one of the most common according to
the International Federation for the Surgery of Obesity and
Metabolic Disorders (IFSO) World Surgery Report.8 SG is
perceived by some to be faster, less technically demanding and
therefore associated with fewer postoperative complications
which may be contributory factors in the recent rise in popu-
larity. It is worth noting that while studies have largely indicated
no significant difference with regards to weight loss or resolution
of T2DM compared to Roux-en-Y gastric bypass, SG is generally
contraindicated in patients who suffer from gastro-oesophageal
reflux disease (GORD). SG may result in new onset or a wors-
ening of pre-existing acid reflux which may also subsequently
increase the risk of developing Barrett’s metaplasia.9 Mechanistic
studies would suggest that SG acts in a similar manner to bypass,
producing neurohormonal changes in GLP-1 (glucagon-like
peptide-1) and PYY (peptide YY) as well as reduced ghrelin
production due to removal of the gastric fundus.10
The procedure itself involves mobilizing the greater curve of
the stomach to allow stapled division of the stomach, usually
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 OESOPHAGUS AND STOMACH

Tiered structure of obesity management in the NHS

Clinical care components Commissioned services

Preoperative assessment Bariatric medical and

Tier 4 multidisciplinary team
Surgery
Specialist assessment Tier 3
Specialist Multidisciplinary team
Services

assessment Tier 2
Multicomponent weight
Lifestyle interventions,
management services
Diets, Pharmacotherapy

reinforcement of healthy Tier 1 Environmental and

eating and physical activity Universal interventions population wide services
messages and initiatives

Figure 1

starting 4e7 cm from the pylorus, proceeding towards the left
crus, using a bougie (usually >32 Fr) to help guide the sizing of
the remnant stomach (Figure 2). The dissected segment is
removed. Complications of SG include staple line leak and
bleeding in the early postoperative period. Longer-term compli-
cations include stricture formation and de-novo or worsening of
pre-existing GORD. IFSO now recommends that following SG,
patients undergo routine surveillance endoscopy one year post-
operatively and then every 2e3 years thereafter.21
Figure 2
Roux-en-Y gastric bypass
Although Roux-en-Y gastric bypass (RYGB) is widely seen as a
safe procedure which provides reliable weight loss, diabetes
remission and weight loss maintenance, it is typically viewed as
being more technically demanding as it requires the formation of
two anastomoses. It is also considered the procedure of choice in
patients with GORD rather than SG. Much like SG, RYGB is
thought to exert its primary actions due to bypass of the proximal
duodenum. Duodenal exclusion results in neurohormonal
changes mediated by GLP-1 and PYY that act centrally in the
hypothalamus, increasing satiety, slowing gastric emptying and
producing important changes in glucose homeostasis.11 The pa-
tient feels less hungry and if they do eat, they feel full faster due
to these changes in gut hormones.
The procedure consists of the formation of a small gastric
pouch which is separated from the distal stomach. A loop of
jejunum is brought up and anastomosed to the gastric pouch
(gastrojejunostomy) to form the alimentary or Roux limb,
allowing the passage of ingested food to bypass the duodenum,
preventing it from mixing with biliary secretions. A second
anastomosis is created 100e120 cm down the alimentary limb,
joining the biliary limb (jejuno-jejunostomy) which allows the
mixing of food and bile within the common channel (Figure 3).
Two mesenteric defects are created during the procedure which
should be closed to reduce the risk of subsequent internal
herniation.
Early postoperative complications include staple line bleeding
and anastomotic leak. The potentially most serious late compli-
cation is internal herniation which occurs when small bowel
protrudes through the mesenteric defect that may compromise
bowel viability. In a small minority of patients, RYGB is associ-
ated with the development of chronic abdominal pain which may
be difficult to manage. It is also worth noting that future pro-
cedures such as ERCP may be challenging, although not

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 OESOPHAGUS AND STOMACH
Figure 3
impossible due to difficulty in accessing the duodenum via the
remnant stomach. In populations where there is a high risk of
gastric cancer, access to the remnant stomach may be of partic-
ular concern.
Adjustable gastric banding
Adjustable gastric banding (AGB) now accounts for <5% of the
bariatric procedures worldwide having been the most common in
2003e2008.12 A significant contributory factor in this decline is
the perception that AGB does not produce equivalent weight loss
to other procedures such as RYGB and SG in addition to the re-
intervention rate. In spite of this, there are still indications for
performing AGB as it is arguably a lower-risk procedure. Level 1
evidence to support the ongoing use of AGB can be found from a
randomized controlled trial (RCT) demonstrating near equivalent
weight loss to other bariatric procedures; however, this requires
patient review every 4e6 weeks.13 Long-term data would suggest
that nearly 50% weight loss can be maintained over 15 years.14
The widely held view that this level of weight loss is not
possible with AGB is in part due to the variability in post-
operative follow-up which is critical to its success. The mecha-
nisms by which gastric banding works are not completely
understood, but are thought to go beyond the simple effect of
mechanical restriction. AGB appears to promote satiety, thereby
reducing food intake which is mediated by the effect of the band
on the vagus nerve.
The pars flaccida approach allows the insertion of an adjust-
able band, positioned around the top of the stomach (Figure 4).
The band is then secured with gastrogastric stitches to reduce the
risk of migration or slippage. A port connected to the band is
SURGERY 38:11
accessible underneath the skin to allow for band adjustment
(filling/emptying) at subsequent follow-up visits.
Complications following AGB insertion include port site
infection, GORD, pouch dilatation, band slippage and, infre-
quently, band erosion. Studies indicate up to 50% of AGBs ulti-
mately may require reoperation however the indications are
highly variable.15,16
Biliopancreatic diversion and duodenal switch (BPD/
DS)
These procedures consist of largely similar steps to SG and RYGB
and produce comparable results with regards to weight loss,
resolution of comorbidity and risks. The biliopancreatic diver-
sion (BPD) is performed by creating a small gastric pouch which
does not include the pylorus. Duodenal switch (DS) is a two-
stage procedure beginning with the formation of a sleeve gas-
trectomy and therefore preservation of the pylorus. In the second
stage of the DS procedure, following formation of the sleeve
gastrectomy, the duodenum is divided and a loop of ileum
brought up to be anastomosed just distal to the pylorus and
proximal to the sphincter of Oddi. The alimentary limb allows the
passage of ingested food from the stomach to the distal ileum,
bypassing a long segment of the small bowel. The biliopancreatic
limb carrying the biliary secretions is then anastomosed to the
distal ileum, proximal to the ileocecal valve, creating a common
channel usually 80e100cm long. BPD is similar; but it is per-
formed as a single procedure and the loop of ileum is anasto-
mosed directly to the gastric pouch.
Both BPD and DS are infrequently performed, accounting for
less than 1% of bariatric surgeries worldwide.12 Although it is
well recognized that BPD/DS produces the most profound weight
loss and greatest improvement in glucose homeostasis and dia-
betes remission, one of the primary limitations of the procedure
is the significant risk of micronutrient and fat-soluble vitamin
deficiencies requiring strict lifelong supplementation. Even in
those adhering to nutritional guidelines, a proportion will remain
refractory to treatment and up to 10% require re-operation due to
these deficiencies.17 Although rare, the implications can be sig-
nificant with reports of patients developing night-blindness and
irreversible brain damage due to Wernicke’s encephalopathy.
One anastomosis gastric bypass (OAGB)
The one anastomosis gastric bypass (OAGB) is increasing in
popularity. Similar to RYGB, the procedure involves the forma-
tion of a gastric pouch to effectively exclude the proximal duo-
denum. A loop of small bowel is brought up and anastomosed to
the gastric pouch to create a gastro-jejunostomy, bypassing up to
200 cm of the proximal duodenum and jejunum. It has been
demonstrated to have similar metabolic effects to RYGB as a
result of bypassing the proximal bowel with the formation of one
anastomosis. Studies have suggested that weight loss is compa-
rable to RYGB and proponents would argue that it carries a lower
perioperative risk of leak and shorter operating time. This has to
be weighed up against the evidence suggesting a significantly
higher percentage of patients suffering from long-term nutritional
deficiencies following OAGB versus RYGB as well as post-
operative diarrhoea or steatorrhea.18 Studies have also demon-
strated that a number of patients have endoscopic findings
suggestive of bile acid reflux following OAGB due to the
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 OESOPHAGUS AND STOMACH
Figure 4
anatomical changes produced by the formation of the gastro-
jejunal anastomosis. Although a relatively new procedure for
which long-term data is lacking, there are concerns raised
regarding the implications of chronic bile acid reflux including
oesophageal and gastric malignancy. As such, IFSO now rec-
ommends that following OAGB, patients undergo routine sur-
veillance endoscopy one year postoperatively and then every two
to three years thereafter.19
Managing postoperative complications
While overall postoperative complications are rare, they can
present a significant diagnostic and management challenge as the
majority of general surgeons will only have limited experience
with bariatric surgery. Although ideally all complications of
bariatric surgery would be dealt with in a centre with expertise,
this is not feasible in many situations. Taking advice early on
from a bariatric unit is advisable when possible. However, this
should not delay investigation or indeed treatment in a patient
who is unwell. Immediate management for control of sepsis or to
relieve obstruction should be undertaken without delay as these
may be lifesaving interventions.
It is important to recognize that although symptoms such as
abdominal pain and vomiting in a patient following bariatric
SURGERY 38:11
surgery are not necessarily surgery related, this must be ruled
out. The most common cause of mortality in patients following
bariatric surgery is not directly procedure related but due to
venous thromboembolism (VTE).20 A high index of suspicion
should be maintained for patients presenting with symptoms
suggestive of VTE in the postoperative period for 2 months.
Procedure specific emergencies and management
Adjustable gastric band: The most common band related
complication, which presents as an emergency is a slipped
gastric band (Figure 5), occurring when the distal stomach her-
niates upward through the band causing proximal pouch dilata-
tion. Left untreated, this can result in ischaemia and necrosis.
Patients typically present with upper abdominal or chest pain,
dysphagia and regurgitation of all fluid. An erect chest X-ray may
be helpful in quickly establishing a diagnosis by allowing for
assessment of the band position. The ‘phi angle’ can determined
drawing a vertical line down the spine and measuring the angle it
forms with the horizontal axis of the band which may be indic-
ative of a slipped band. Normally the phi angle should measure
between 4 and 58 degrees. An angle greater than this or a band
that lies in a horizontal position is suggestive of slippage. Addi-
tionally, the band should appear as a single rectangular line
rather than a visible ‘O’-shaped ring. Although these signs may
allow for quick diagnosis, CT scan or oral contrast studies may
be more helpful. A high index of suspicion for band slippage
should be maintained until ruled out and immediate manage-
ment includes complete deflation of the band. This can be done
readily on the ward with a long, ideally non-coring Huber needle
to remove all of the fluid in the band. Deflation is not always
successful in relieving symptoms in which case the band needs to
be removed urgently in theatre.
Gastric bypasseRYGB or OAGB: Patients presenting with severe
abdominal pain, nausea or vomiting in the early postoperative
period following RYGB/OAGB require urgent CT scan, although
scans can be non-specific and even falsely reassuring. Early
referral to a bariatric unit is advisable and diagnostic laparoscopy
is recommended to allow for the identification and treatment of
critical emergencies such as anastomotic leak, mechanical
obstruction or acute bleeding. In the case of anastomotic leak,
urgent management requires visualization of the defect with
laparoscopy, washout and drains to control sepsis. Long-term
management and control of the leak is ideally undertaken in a
tertiary centre with a bariatric unit and may include endoluminal
vaccum therapy (Endovac). Longer term, after significant weight
loss, the loss of internal fat results in hernial defects tending to
increase in size, resulting in an increased risk of internal hernia.
CT scans may show a typical swirling pattern which is suggestive
of hernia however diagnostic laparoscopy is again indicated as
the CT appearances may be normal.
Sleeve gastrectomy: Staple line leak following sleeve gastrec-
tomy typically occurs near the angle of His. Patients tend to
present with signs of abdominal sepsis which may or may not be
accompanied by radiological evidence of a leak on CT scan with
oral contrast. In patients with overt sepsis, prompt laparoscopy,
washout and drainage are mandated. Further management to
promote leak healing is more complex and is best dealt with by
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 OESOPHAGUS AND STOMACH
Figure 5 Slipped gastric band.
an experienced bariatric unit. Management decisions may be
guided by factors such as timing (early vs late), extent/severity of
leak and location. The use of Endovac has increased in popu-
larity in recent years as an effective method of managing
gastrointestinal leaks, including those arising as a result of SG.21
Future directions
Bariatric surgery as a speciality has developed rapidly in the past
20 years with the refinement of existing techniques, the adoption
of novel procedures and significant advances in our under-
standing of the pathophysiology contributing to the development
of obesity and T2DM. Bariatric surgery is considered by both the
American Diabetes Association and International Diabetes
Federation to be part of the standard treatment algorithm in
patients with obesity and T2DM with evidence from RCTs
consistently demonstrating bariatric surgery to be more effective
than medical therapy.22,23 In spite of this, there is no level 1
evidence at present to suggest the superiority of any one pro-
cedure over another with regards to normalizing or controlling
the metabolic effects of obesity. Most studies demonstrate that in
the short term, a significant proportion of patients will go in to
remission with regards to T2DM. However, the rates may vary
depending on the definition of remission used as well as the
length of follow-up. A proportion of patients who initially go in to
remission will experience a relapse of symptoms which may be
related to weight re-gain or non-weight-related factors such as
the duration of diabetes and previous insulin use which may
reflect underlying residual b cell function. It is important for
clinicians and patients to recognize that even in patients who
experience a relapse, glycaemic control remains good which is
SURGERY 38:11
likely to have long-term implications for reducing the develop-
ment of complications related to T2DM.
Follow-up and long-term monitoring
A commitment to long-term follow-up is an essential element in
the success of bariatric surgery and all patients should be fol-
lowed up by the multidisciplinary bariatric team for a minimum
of 2 years and by their GP thereafter. During follow-up visits,
patients should be reviewed regarding nutritional intake,
adherence to nutritional supplementation, medications and dis-
cussion of comorbidities, physical activity and any psychological
issues. In addition, patients should have access to peer or pro-
fessionally led support groups.
Following bariatric surgery, patients will need long-term
monitoring with regards to vitamins and minerals, however the
requirements are specific to the procedure with some such as
BPD/DS mandating much more strict monitoring. All patients are
advised to take a complete multivitamin and then supplemen-
tation with additional vitamins or minerals as dictated by blood
tests.24
Mounting evidence from RCTs consistently demonstrates the
safety and efficacy of bariatric surgery as the most effective
long-term treatment available for obesity and related comor-
bidity. However, they also indicate that the efficacy may reduce
over time. Additional technical advances with the adoption of
robotic surgery as well as novel procedures such as single
anastomosis sleeve ileal (SASI) bypass or single anastomosis
duodeno-ileal bypass with sleeve gastrectomy (SADI-S) may
further increase the range of treatments available to allow for
individualized care. Recent advances in our understanding of
obesity have contributed to developments of highly effective
and well-tolerated pharmacological agents for weight loss
which marks a potential turning point in how obesity will be
managed in the future. Although weight loss pharmacotherapy
has previously been widely seen as either ineffective or unsafe,
novel classes of drugs which mimic the effects of bariatric
surgery (GLP-1 agonists) or are complimentary to its actions
(sodium-glucose transport protein 2 (SGLT-2) inhibitors) have
recently become available, changing the way we are able to
treat obesity. For the first time, clinicians are adopting a multi-
modal approach to care whereby the outdated model of using
either medications or surgery is being replaced with combina-
tional treatment to enhance or sustain what can be achieved
with bariatric surgery.6,25
Bariatric surgery remains an underutilized resource with less
than 1% of patients in the UK who would benefit being offered
surgical intervention.26 Promisingly, we are at a potential turning
point in the treatment of obesity as there is a growing impetus to
ensure patients are adequately treated either by improving access
to surgery, offering novel weight loss pharmacotherapy or, in
some cases, combinational therapy.
All clinicians, irrespective of their speciality will treat patients
with obesity and likely those who have had bariatric surgery as
well. An understanding of the principles and potential compli-
cations of individual surgical approaches as well as a mindful-
ness of the importance of avoiding stigmatizing those with
obesity is a critical aspect of improving care. A
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 OESOPHAGUS AND STOMACH
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