New guidelines expand eligibility for weight loss surgery. Will insurance coverage follow? (2023)

  • Two surgical groups have updated the guidelines for bariatric surgery for the first time in three decades.
  • The guidelines mean vastly more people are eligible for weight loss surgery.
  • But whether Medicare and the insurance industry will expand their coverage to match the guidelines remains to be seen.

Two groups of bariatric surgeons have overhauledweight loss surgery guidelines for the first time in more than 30 years, saying the previous standards are out of date and inadequate to cope withAmerica's growing levels of obesity.

The new standards, released early Friday, will vastly increase the number of people eligible for the operations.

Weight loss surgery hasbecome dramatically safer in recent decades and shown to reverse or improve dozens of weight-related diseases, but guidelines last set in 1991 haven't been updated to reflect the improvements. That's why theAmerican Society for Metabolic and Bariatric Surgeryand the International Federation for the Surgery of Obesity and Metabolic Disorders, which represents 72 countries,decided to make the new recommendations.

The old guidelines were "trapped in the past," saidDr. Shanu Kothari, immediate past president of the American Society for Metabolic and Bariatric Surgery. "We'vemade tremendous strides in the fields of metabolic and bariatric surgery in three decades. So, we feel it's time to update these."

INSIDE AMERICA'S OBESITY EPIDEMIC:How weight loss isn'tso simple

The new guidelines reduce the weight limit to qualify for the surgery and dropthe requirement that all but the heaviest people must have a medical problem resulting from their obesity. Children and adolescentsare also now eligible for surgery.

Kothari said he hopes insurance companies will update their coverage to comply with the new standards.Other medical organizations like the American Heart Association and the American Diabetes Association update their treatment guidelines every year or two, and insurance coverage usually reflects those changes.

New guidelines expand eligibility for weight loss surgery. Will insurance coverage follow? (1)

Confusion over who qualifies for surgery

Today, many patients and their doctors are confused about who qualifies for surgery and who doesn't.

(Video) ASMBS / IFSO Guidelines on Indications for Metabolic and Bariatric Surgery 2022

"It's a mess," saidDr. Ali Aminian, who was involved in drafting the new guidelines.

At last count,before the pandemic, 42% of Americans met the definition for having obesity and about 10% have diabetes, which increases the risk for a wide range of medical problems, from heart disease to amputations. More than 200 diseases have been tied to excess weight.

Weight loss operations that used to require five to seven days of hospitalization and several months of recovery are now done with keyhole incisions, often with robotic assistance, Aminian said.

Patients routinely go home the next day and can resume their normal lives, without post-surgical pain, in two or three days, he said. Death rates from surgery have fallen 20- to 30-fold, from 2 or 3 per 100 patients to about 1 in 1,000.

Changing the guidelines won't remove the lack of public awareness, stigma or fear aroundbariatric surgeryor guarantee insurance coverage, but it will remove one barrier to care, saidAminian, who directs theBariatric and Metabolic Institute at the Cleveland Clinic.

"Even if you have simply failed conventional means, regardless of your comorbidity status, we think surgery should be considered," said Kothari, also chair of surgery at Prisma Health in Greenville, South Carolina

New guidelines still based on BMI

The new guidelines, like the old ones, are based on body mass index, a measure of weight versus height.

Previously, to qualify for surgery patients had to have a BMI of at least 40 or a BMI of 35 or more and at least one obesity-related medical condition such as hypertension or heart disease. Diabetes was not included, though the surgery has since been shown to make a dramatic different in metabolism, often rapidly reversing diabetes.

(Video) Gastric bypass surgery: the procedure

Under the new guidelines, anyone with a BMI over 35 should be considered for surgery, whether or not they have health problems, according to the new guidelines, along with people whose BMI tops 30, the official definition of obesity, if they have not being able to achieve significant or long-lasting weight loss.

For people of Asian descent, the surgeons dropped the BMI requirement for surgery to 27.5because they often have weight-related health problems starting at a lower body mass.

New guidelines expand eligibility for weight loss surgery. Will insurance coverage follow? (2)

Children and adolescents with severe obesity are also eligible for surgery under the new criteria. They were generally excluded from the earlier ones because of a lack of data.

Weight-related diseases are easier to reverse if treated in adolescence, Aminian said.

"We have a lot of data to support that the outcomes of kids who underwent surgery were much better than the outcomes of patients who had surgery for their obesity in their 40s and 50s," he said."If we wait a long time, some of those consequences of obesity are not reversible."

MORE:How will the obesity epidemic end? With kids.

Dr. Fatima Cody Stanford, a weight loss specialist at Massachusetts General Hospital, said she wishes the surgeons had moved away from using BMI as a determining factor for surgery.

"I hate BMI," she said, noting that it was initially developed as a standard for 19th century Belgian soldiers and is irrelevant in the face of America's current, diverse population. "It's an arbitrary thing. It doesn't define one's health."

(Video) After 30 years — new guidelines for weight-loss surgery

New guidelines expand eligibility for weight loss surgery. Will insurance coverage follow? (3)

Instead, she said, she would rather see a decision for surgery based on true measures of health, such as high blood sugar levels, evidence of inflammation, high cholesterol and fatty liver disease. She's seen people with a BMI of 22 fare poorly by those standards, she said, and those with a BMI well over 30 who are healthy.

Her experience with surgery has been mixed, Stanfordsaid.

She had one patient whose diabetes was uncontrollable for years, even though he followed doctors' instructions to the letter. Surgery reversed his diabetes completely.

But many others have surgery and years later, their weight creeps back up, along with hormonal problems, as the body fights back against weight loss. They benefit from medication, she said, and maybe could have done fine on medication alone.

Regaining weight after surgerycan affect someone's self-worth, she said.

Barriers remain

Inadequate medical training and lack ofinsurance coverage remains a huge barrier to weight loss, whether from surgery, medication or both, Stanford said.

Doctors are not routinely taught how to help patients lose weight, though more than 100 million Americans struggle with their weight. Her practice is so busy that she doesn't accept new patients and MassachusettsGeneral's weight loss center has 4,000 people on its wait list.

Health coverage for obesity is uneven across the country, but Medicare and insurers rarely cover obesity-related treatments or surgery, unless the person also has severe weight-related health issues. In Massachusetts, for instance, Medicare covers surgery but not medications, while top-tier health plans cover both, Stanford said.

(Video) These 3 People Went To Mexico For Weight-Loss Surgery And Now They Regret It | Megyn Kelly TODAY

MORE:New drugs and surgery can deliver major weight loss. But they come at a cost.

It's ironic, Kothari said, that data from the Veterans Administration helped establish the effectiveness of surgery, but the VA doesn't cover the cost of obesity surgery.

Historically, he said, coverage was denied because theinability to lose weight was seen as an issue of willpower, but decades of research shows instead that it is driven by biology.

"We have plenty of data to show obesity is a disease and needs to be treated as such," Kothari said. The aim of the new surgical guidelines "is to improve access topatients who deserve it based on contemporary evidence and ... to impact and change coverage policies."

Contact Karen Weintraub at kweintraub@usatoday.com.

Health and patient safety coverage at USA TODAY is made possible in part by a grant from the Masimo Foundation for Ethics, Innovation and Competition in Healthcare. The Masimo Foundation does not provide editorial input.

Read more from USA TODAY'S health team

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FAQs

Do I meet the criteria for weight loss surgery? ›

Weight loss surgery is available on the NHS if: you have a body mass index (BMI) of 40 or more, or a BMI between 35 and 40 and an obesity-related condition that might improve if you lost weight (such as type 2 diabetes or high blood pressure)

What is the threshold for bariatric? ›

A person is classified as having obesity and may be referred to as a bariatric patient when they have a body mass index (BMI) that is equal to or greater than 30. BMI is used to measure weight in relation to height.

How long is the NHS waiting list for bariatric surgery? ›

Candidates could wait 18+ months. The reality is that most people who request a gastric band (also known as also called metabolic or bariatric surgery will not be approved. Even for those lucky few who are accepted, they can expect to wait around two years for the surgery. So why does it take so long?

Who is not a good candidate for weight loss surgery? ›

If you are over the age of 65—although exceptions can be made. If you have a BMI of less than 35. If you drink excessive amounts of alcohol or take illicit drugs. If you have pre-existing medical conditions that generate a high risk situation for surgery.

Can you get denied for weight loss surgery? ›

Background: Many patients who seek weight loss surgery are denied an operation because of insurance barriers, psychological concerns, and poor medical fitness for surgery.

Can you get gastric bypass at 200 lbs? ›

To be eligible for bariatric surgery, you must be between 16 and 70 years of age (with some exceptions) and morbidly obese (weighing at least 100 pounds over your ideal body weight and having a BMI of 40).

What is the maximum weight to get a gastric bypass? ›

There is no maximum weight you have to be to qualify for weight loss surgery and most units that can carry out weight loss surgery have equipment that can easily handle patients who are in excess of 50 stone.

What is a bariatric restroom? ›

Featuring an elongated bowl, self-draining flush rim and Big John® hinged toilet seat (up to 1,200 lbs weight limit), the Bariatric Tank Style ADA Toilet can withstand loads up to 5,000 lbs.

How long does gastric sleeve last? ›

How long does gastric sleeve surgery take? Compared to other weight loss surgery procedures, a sleeve gastrectomy is a relatively short and simple operation. It takes about 60 to 90 minutes. Your surgeon may still want you to stay in the hospital for one to two days afterward.

What happens at a pre op assessment for bariatric surgery? ›

Pre-assessment appointment. This is usually about four weeks before surgery and carried out by the pre-assessment nurse. Its purpose is to check that you are clinically fit for surgery and an opportunity to ask any last minute questions. Blood tests and blood pressure are taken at this time.

How quickly can I get gastric sleeve surgery? ›

How long do I have to wait before having bariatric surgery? From the time of the initial consultation, the average wait time is 6-8 weeks. During this time, you will undergo preoperative testing to evaluate whether surgery is a suitable option.

Which is better gastric sleeve or band? ›

you usually lose weight more quickly after a gastric bypass or sleeve gastrectomy than after gastric banding. more people tend to achieve significant weight loss with a gastric bypass or sleeve gastrectomy than with a gastric band.

Why do I need a psych eval for bariatric surgery? ›

Psychological evaluation of patients before bariatric surgery is a critical step, not only to identify contraindications for surgery, but also — and more so — to better understand their motivation, readiness, behavioral challenges, and emotional factors that may impact their coping and adjustment through surgery and ...

Can you fail a psychological evaluation for bariatric surgery? ›

The evaluation is not a pass or fail test. It is more of a discussion to help you identify potential problems that might lead to difficulty after surgery. Since many obese individuals may suffer from depression, anxiety, binge eating, and other problems, these are typically NOT reasons to delay or deny surgery.

What are 3 common long term complications of gastric bypass? ›

Longer term risks and complications of gastric bypass can include: Bowel obstruction. Dumping syndrome, causing diarrhea, nausea or vomiting.
...
Risks
  • Excessive bleeding.
  • Infection.
  • Adverse reactions to anesthesia.
  • Blood clots.
  • Lung or breathing problems.
  • Leaks in your gastrointestinal system.
25 Jun 2022

Why would I be denied for weight-loss surgery? ›

But why might a patient not qualify for bariatric surgery? BMI: First and most obviously, they simply may not have a BMI that is high enough. A BMI of 35 or more with one or more obesity related conditions or BMI of 40 or greater regardless of obesity related conditions is required to have surgery.

What if insurance doesn't cover weight-loss surgery? ›

Cash paying for surgery

If your insurance does not provide coverage for bariatric surgery, there are other options available to you. Depending on plan language, consultations, nutritional counseling and pre- and post-operative tests, labs and follow-up visits may be covered, although surgery is not.

What is the mortality rate after bariatric surgery? ›

Obesity Death Rate vs. Bariatric Surgery Mortality Rate
1-2 Years After the Surgery10 Years After the Surgery
Gastric Bypass32%25%
Vertical-Banded Gastroplasty25%16%
Banding20%14%
17 Aug 2021

How much weight do you lose in 3 months after gastric sleeve? ›

Weight Loss Percentage Rate After Gastric Sleeve

As a result, you can expect a quick surge in your weight loss in the first 3 months following surgery. You could lose an average of 25-35%* excess weight – between 30 and 40 pounds.

How much weight do you lose in the first month after gastric bypass? ›

Patients can expect to lose around 17% of their excess body weight during the first month after gastric bypass surgery. A patient who is 5'8' weighing 250 pounds with an ideal weight of 150 lbs can expect to lose about 17 pounds during the first month.

How much weight do you lose the first year after gastric bypass? ›

Average Weight Loss After Gastric Bypass

excess weight and can expect to lose around 100 pounds in their first year, ultimately weighing 250 pounds after surgery. Weight loss continues after their first year, with patients generally reaching their final weight after about two years post-op.

What is the minimum weight for gastric sleeve? ›

Have a body mass index (BMI) of 40 or higher, or have a BMI between 35 and 40 and an obesity-related condition, such as heart disease, diabetes, high blood pressure or severe sleep apnea. Weigh less than 450 pounds, the maximum weight that hospital radiology equipment can accommodate.

How much weight should I lose before gastric sleeve surgery? ›

Amount of pre-surgery weight loss

Some patients are required to lose 10 percent of their weight before weight-loss surgery is performed. For other patients, losing just 15 to 20 pounds right before surgery is enough to reduce the risk of complications.

What is the newest weight-loss surgery? ›

Endoscopic sleeve gastroplasty is a newer type of minimally invasive weight-loss procedure. In endoscopic sleeve gastroplasty, a suturing device is inserted into your throat and down to your stomach. The endoscopist then places sutures in your stomach to make it smaller.

What is a Big John toilet? ›

The Big John Toilet Seat is designed for the larger user with about 75% more seating area than a conventional toilet seat at 48cm (19 inches) wide. It is also slightly higher than a standard seat, with a raise of 3.8cm (1.5 inches). The Big John Toilet Seat has been contoured to provide extra comfort in the bathroom.

Do they make toilets for big people? ›

American Standard – Highest Capacity Toilet For Home Use

While commercial toilets are not “plug-and-play” in most homes they do provide an option for people over the weight limit of a traditional toilet to enjoy some security when going to the bathroom.

Why is divorce rate so high after bariatric surgery? ›

Increased incidence of divorce and separation after bariatric surgery might be associated with increased tension in already vulnerable relationships or to improvements that empower patients to leave unhealthy relationships.

Can stomach grow back after gastric sleeve? ›

As such the answer to can your stomach grow back after weight loss surgery is NO, it will not grow back to its original size, but rather hold a capacity that allows the patient to have a long term normal life once they achieve their weight loss success.

How painful is gastric sleeve recovery? ›

Patients often experience the most pain between days 3 and day 6. Pain during days 3 to 6 is common because you are up on your feet more, turning your trunk more, and generally more active than before. Typically, people report pain in the range of 5/10 with some people's pain getting up to a 7/10.

What tests do they do before gastric sleeve? ›

Certain basic tests are done prior to bariatric surgery: a Complete Blood Count (CBC), Urinalysis, and a Chemistry Panel, which gives a readout of about 20 blood chemistry values. All patients get a chest X-ray and an electrocardiogram. Many surgeons ask for a gallbladder ultrasound to look for gallstones.

What do I need to buy before gastric sleeve? ›

Things to Buy When Preparing for Bariatric Surgery
  • A variety of clear broths (chicken, beef, vegetable).
  • Zero calorie sports drinks. Look for beverages with 10 or fewer calories per 8 oz.
  • Sugar-free fruit drinks. Look for beverages with 10 or fewer calories per 8 oz.
  • Sugar-free popsicles and gelatins.
7 Jul 2021

What should I do a month before bariatric surgery? ›

Stage “1 month before” Weight Loss Surgery. This is what you should do:
  • Stop smoking.
  • Stop drinking alcohol (any kind), as it may cause bleeding during or after surgery.
  • Stop all carbonated beverages.
13 Jun 2015

What should I do 6 months before bariatric surgery? ›

6 to 12 Months Before Surgery

Ask your primary-care provider for a referral to an accredited bariatric-surgery program. Enroll in the bariatric-surgery program, attending all required classes and meetings. Start exercising three to five times a week for 25 to 30 minutes, with your doctor's clearance.

Which weight loss surgery has the fastest recovery time? ›

The procedure with the shortest recovery time is lap band surgery. On average, lap band surgery patients return to work in one week and are fully recovered in just two weeks. Hospital stays times often reflect this too – lap band patients with just 1-2 days and bypass/sleeve patients 2-4 days.

How do you sleep after gastric sleeve surgery? ›

Sleep on Your Back or Side

The best way to sleep after gastric sleeve surgery is on your back or side. This will help keep the stomach and lungs clear of pressure, which can cause discomfort. If you are a side sleeper, it is best to use a pillow between your legs to keep your spine aligned.

What are the disadvantages of gastric sleeve? ›

Risks of Gastric Sleeve:
  • Blood clots.
  • Gallstones (risk increases with rapid or. substantial weight loss)
  • Hernia.
  • Internal bleeding or profuse bleeding of the. surgical wound.
  • Leakage.
  • Perforation of stomach or intestines.
  • Skin separation.
  • Stricture.

How do you get rid of belly fat after gastric sleeve? ›

How to lose weight after Gastric Sleeve Surgery
  1. Follow strictly the post-op diet without any excuses.
  2. Adding plenty of protein to their diet will help the patient lose weight in addition to belly fat.
  3. No snacking. ...
  4. Exercise regularly. ...
  5. Stay Hydrated by drinking water. ...
  6. A healthy sleeping pattern is another key to success.
25 Apr 2021

Can you remove a lap band and do a gastric sleeve at the same time? ›

Yes. Most of the time, the surgeon can perform both procedures at the same time.

Does depression disqualify you from bariatric surgery? ›

It's standard for people undergoing bariatric surgery to receive mental health screening or counseling before the procedure. But people living with depression or another existing mental health issue still may be approved for surgery.

How do you pass a psychological evaluation? ›

Whenever you take a test, spend a little time evaluating what you did that worked well and how you might apply those skills again in the future.
  1. Start by Looking Over the Test. Tetra Images / Getty Images. ...
  2. Pace Yourself. moodboard / Getty Images. ...
  3. Don't Skip Around. ...
  4. Use the Process of Elimination. ...
  5. Read Each Question Carefully.
8 Apr 2020

Can I get bariatric surgery if I have depression? ›

It is important to emphasize that having a diagnosis of depression or bipolar disorder does not mean that bariatric surgery is not safe or effective. Research shows that people with depression are just as successful losing weight after surgery.

What disqualifies bariatric surgery? ›

Issues such as eating disorders, a history of blood clots, heart problems, or certain health conditions can disqualify a patient as a candidate for bariatric surgery.

What surgeries require psychological evaluation? ›

A psychological evaluation is typically requested for the following surgical procedures:
  • Bariatric Surgery.
  • Cosmetic Surgery.
  • In vitro fertilization.
  • Organ Transplant.
  • Spinal Cord Stimulator Placement.

What are the psychological effects of bariatric surgery? ›

While one might assume that weight loss, improved health, and increased QoL would improve mood, a minority of patients experience serious psychological complications including, but not limited to, depression,1 suicidality,2 and alcohol abuse,3 particularly after the “honeymoon period” of 1 to 2 years after surgery.

What is Candy Cane syndrome? ›

Candy cane syndrome is a rare complication reported in bariatric patients following Roux-en-Y gastric bypass. It occurs when there is an excessive length of roux limb proximal to gastrojejunostomy, creating the possibility for food particles to lodge and remain in the blind redundant limb.

Which weight loss surgery has the least complications? ›

The Vertical Sleeve Gastrectomy is the most widely used, and safest, in the bariatric world. As with any major surgery, gastric bypass and other weight-loss surgeries pose potential health risks, both in the short term and long term.

What is the dumping syndrome? ›

Dumping syndrome is a condition in which food, especially food high in sugar, moves from your stomach into your small bowel too quickly after you eat. Sometimes called rapid gastric emptying, dumping syndrome most often occurs as a result of surgery on your stomach or esophagus.

Can you fail a psychological evaluation for bariatric surgery? ›

The evaluation is not a pass or fail test. It is more of a discussion to help you identify potential problems that might lead to difficulty after surgery. Since many obese individuals may suffer from depression, anxiety, binge eating, and other problems, these are typically NOT reasons to delay or deny surgery.

Why do I need a psych eval for bariatric surgery? ›

Psychological evaluation of patients before bariatric surgery is a critical step, not only to identify contraindications for surgery, but also — and more so — to better understand their motivation, readiness, behavioral challenges, and emotional factors that may impact their coping and adjustment through surgery and ...

Is weight-loss surgery a pre existing condition? ›

Obesity is considered a pre-existing condition for most patients, therefore with private health funds, you are usually required to hold your policy for between 12-24 months to be eligible for surgery.

How fat do you have to be to get a gastric sleeve? ›

Some criteria must be fulfilled before a patient is approved for surgery. Generally, gastric sleeve surgery is indicated for morbidly obese adults — people between 18 and 65 with a body mass index (BMI) of 40 or higher. For example, for a person standing 5-foot-9, that equates to a bodyweight of 270.

How long does it take to be approved for gastric bypass surgery? ›

The waiting period is generally about two to six months, depending upon precertification approval. During your initial consultation, the surgeon will determine whether health-related factors might delay your surgery.

What tests are done before bariatric surgery? ›

Certain basic tests are done prior to bariatric surgery: a Complete Blood Count (CBC), Urinalysis, and a Chemistry Panel, which gives a readout of about 20 blood chemistry values. All patients get a chest X-ray and an electrocardiogram. Many surgeons ask for a gallbladder ultrasound to look for gallstones.

How do you pass a psychological test? ›

How to Pass a Psychology Test
  1. Lay a Foundation for the Topic. ...
  2. Make Connections to Real Experiences. ...
  3. Personalize Your Class Notes. ...
  4. Take a Look at Notes Periodically. ...
  5. Get a Study Buddy or Two. ...
  6. Review the Information to Remember It. ...
  7. Get in the Right Mindset.

Does depression disqualify you from bariatric surgery? ›

It's standard for people undergoing bariatric surgery to receive mental health screening or counseling before the procedure. But people living with depression or another existing mental health issue still may be approved for surgery.

What is the divorce rate after bariatric surgery? ›

In fact, 81% of couples were still married 5 years after surgery. But where the U.S. population has a divorce rate of 3.5%, bariatric patients in the study had an 8% divorce rate. Likewise, those who'd never been married before the surgery had a marriage rate of 18%, compared to 7% in the U.S. population.

Can I get bariatric surgery if I have depression? ›

It is important to emphasize that having a diagnosis of depression or bipolar disorder does not mean that bariatric surgery is not safe or effective. Research shows that people with depression are just as successful losing weight after surgery.

Why do I have to wait 6 months for bariatric surgery? ›

Most insurance companies also require a barrage of tests as well as potentially a three- or six-month medical weight loss program to be undertaken before surgery. This testing allows the insurance company to determine that bariatric surgery is indeed the necessary and best option.

How long is recovery from a gastric sleeve? ›

Gastric sleeve recovery at home

“Patients may resume more vigorous activities after four to six weeks. They must also follow a specific diet.” Patients are also advised to take three to four weeks off from work, depending on their job.

How do insurance companies determine pre-existing conditions? ›

Insurers then use your permission to snoop through old records to look for anything that they might be able to use against you. If you have a pre-existing condition, they'll try to deny your claim on the grounds that you were already injured and their insured had nothing to do with it.

How painful is gastric sleeve surgery? ›

Typically, people report pain in the range of 5/10 with some people's pain getting up to a 7/10. Your doctor should have given you instructions regarding pain at this point as well. If the pain is unbearable or not what your surgeon told you to expect, you should let your surgeon know.

What's the lowest BMI for gastric sleeve? ›

Learn your body mass index

You typically qualify for bariatric surgery if you have a BMI of 35 or greater, with specific significant health problems like Type 2 diabetes, sleep apnea or high blood pressure.

How much does gastric sleeve cost in Mexico? ›

In comparison to other countries such as the United States, Mexico has the most affordable cost of sleeve surgery. While in the US most patients report spending up to $20,000 USD per sleeve surgery, you can expect to pay from $3,995 to $7,000 USD for the entire high-quality weight loss procedure in Tijuana, Mexico.

Videos

1. Real Health: The Truth About Weight Loss Surgery
(Independent.ie)
2. Insurance Requirements For Bariatric Surgery
(Charlotte Hodges MD, FASMBS)
3. Weight Loss with Bariatric Surgery | Sleeve Gastrectomy & Gastric Bypass | theSITREP
(U.S. Dept. of Veterans Affairs)
4. New Metabolic Surgery Guidelines- How They Will Affect Your Practice
(ClevelandClinicCME)
5. Johns Hopkins Center for Bariatric Surgery Online Information Session
(Johns Hopkins Medicine)
6. Bariatric Surgery: Update on Current Practice | Conference Preview
(GIBLIB)
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