Dumping is a side-effect of Weight Loss (Bariatric) Surgery.

BENEFITS OF BARIATRIC SURGERY

Weight loss surgery can be a life-changing event. Weight loss operations are powerful tools to change diet and life-style. These operations empower obese people to lose large proportions of their body weight and to then sustain the loss. Also, there can be improvement or even cure of serious illnesses like diabetes, high blood pressure and high cholesterol. The risks for life-threatening problems like cancer and heart attack reduce significantly after weight loss surgery.

BALANCING BENEFITS AND SIDE-EFFECTS OF BARIATRIC SURGERY

But, weight loss surgery does have several side-effects. Like many other decisions, it is important to weigh the pros and cons carefully before going ahead with a weight loss operation.  Once the problem is understood properly, it can be given the correct weightage in balancing it with the benefits. Also, proper understanding enables us to anticipate the problem and to deal with it. Often a side-effect can be avoided by taking proper preventative action.

DUMPING WITH GASTRIC BYPASS, SLEEVE GASTRECTOMY & GASTRIC BAND

In this post, we will discuss the side-effect called dumping. This side-effect can happen all the three common bariatric operations: gastric band, gastric bypass and sleeve gastrectomy. Although, dumping does seem to happen more frequently with the gastric bypass than with the sleeve gastrectomy, and it happens least with the band. Similarly, dumping tends to be more severe with the bypass than with the sleeve or the band.

HOW OFTEN DOES DUMPING HAPPEN AFTER BARIATRIC SURGERY?

There are many studies on dumping after bariatric surgery, and different figures have been reported. Severe hypoglycaemia is seen in about 1% of patients after gastric bypass surgery.

TYPES OF DUMPING

There are two types of dumping syndromes:

Early Dumping

After a weight loss operation, there can be rapid entry of food into the small bowel. This can stimulate the secretion of fluid from blood vessels into the bowel. Also, various hormones can get released from the wall of the bowel. These changes in fluids and hormones can produce abdominal pain, diarrhoea, loud bowel sounds, bloating and nausea. Also, there can be palpitations, sweating, flushing and faintness.

Late Dumping

There can be excessive release of insulin because of the rapid entry of carbohydrates into the small bowel. High levels of insulin cause a drop in the blood sugar levels and produce hypoglycaemia. Unlike early dumping, the symptoms do not occur immediately after eating. Instead, the symptoms show up about 1-3 hours after a meal. The common symptoms are hunger, weakness, confusion, tremors (shaking), faintness, palpitations and sweating.

WHAT IS THE TREATMENT OF DUMPING?

Proper advice about diet from a specialist bariatric dietician is very important. Small meals should be taken at regular intervals. About 6 small meals per day are advised usually. Water or other liquids should not be taken for at least 30 minutes after a meal. Simple carbohydrates (sweets), which are absorbed rapidly from the bowel, should be avoided. Instead, complex carbohydrates should be taken, and dietician can advise on a balanced diet. If hypoglycaemia cannot be controlled be controlled by diet modification only, then advice from a specialist in Endocrinology may be needed. The endocrinologist may advice treatment with drugs called Acarbose or Somastostatin. Rarely, continuous tube feeding or re-operation may be needed.

Reliable information and advice is critical to make a decision about weight loss surgery. Visit our Health on the Net certified website for high quality information on Bariatric Surgery:

https://www.abeezarsarela.co.uk

Being overweight or obese can impact almost all aspects of life. There can be mental health problems that range from low confidence to anxiety to depression. Simple physical activities like walking briskly, or climbing stairs, or playing with children can put an overweight person out of breath. Serious illnesses like diabetes, high blood pressure, high cholesterol, heart attack, stroke, liver disease, obstructive sleep apnoea, cancer, and several more, are caused by obesity.

How much can weight loss surgery help? In a nutshell, it can be a life-changing event. A weight loss operation empowers obese people to lose enormous portions of their excess weight. Weight loss surgery brings about profound changes in the levels of hormones that control feelings of fullness and hunger. After a weight loss operation, a small healthy meal can give lasting satisfaction until the next meal time. In this way, weight loss surgery is a powerful tool to control eating. It takes away the struggle of dieting, and the yo-yo effect of putting weight back on. Apart from losing weight, serious illness like diabetes and high blood pressure are cured in the majority of people. The risks of life-threatening problems, like cancer and heart attack, come down after weight loss surgery. Many people say that they have got their lives back after a weight loss operation.

There are three common weight loss operations: gastric band, gastric bypass and sleeve gastrectomy. All operations are done entirely by laparoscopy or keyhole surgery. The hospital stay is 1-2 days and the usual recovery period is 2-4 weeks. With gastric bypass and sleeve gastrectomy, weight loss starts soon after surgery. Diabetes can come under control almost immediately after the operation, even before there is much weight loss. With a gastric band, weight loss and control of illnesses is slower.

What are the steps towards weight loss surgery? Seek professional help. Look at high-quality and reliable websites to find out accurate information. Choose your surgeon carefully. The surgeon’s website can often give you a good idea about his professional attitude and expertise. Make an initial appointment to discuss whether weight loss surgery is the right decision, and to explore which one of the three operations is most suitable for you. Take your time. Do not make a decision immediately. Reflect on your discussion with the surgeon, and re-read his website so that all the information sinks in fully. Then call back and book a date. Good luck!

Visit out Health on the Net Foundation certified website:

https://www.abeezarsarela.co.uk

Controlling weight can be a struggle. It is a major problem of the present age. Overweight and obesity can impact so many parts of life: self-confidence, relationships, ability to do things and health. Obesity increases the risk for serious illness such as diabetes, high blood pressure, heart attack, stroke, cancer and many more.

It’s not easy. Losing weight can be difficult enough. Maintaining body weight, and not putting the lost weight back on and gaining even more, is often the more difficult part. If best efforts at weight control have not succeeded, then it’s time to think about weight loss surgery. A weight loss operation provides a powerful tool to get fullness with small meals and to keep hunger away until it is time for the next meal.

There are two important decisions that need to be made:

• Is weight loss surgery really required? Body mass index (BMI), medical history and life-style need to be analysed carefully to answer this question.
• Which weight loss operation should be chosen? There are three commonly done weight loss operations: gastric band, sleeve gastrectomy and gastric bypass. All the operations are done entirely by keyhole surgery. But, there are important differences in what is done to the stomach in each of these operations. As a result, there are important differences in benefits and risks of these operations. The choice of an operation will vary for different people. One size does not fit all. To make an informed choice, the pros and cons of each operation should be weighed carefully in the light of each person’s individual circumstances.

High quality and trustworthy professional advice is critical to make the correct decisions. A good way to start the journey is to find out information. The internet is a maze and many of us struggle to find helpful sites. Detailed and accurate facts that are presented in simple language, and easy to understand pictures, can be very valuable. Read the information carefully and make a list of questions. Next, make an appointment to see a weight loss surgeon and have a detailed discussion. Then, go home and think carefully before making a final decision.

For high quality and reliable information, visit our Health on the Net Foundation certified website:

www.abeezarsarela.co.uk

Why should acid reflux NOT be ignored?

Acid reflux is a common problem. Heartburn is most common symptom of acid reflux. Heartburn is burning type of pain behind the breast bone. The pain often radiates up from the tummy to the neck. Another common symptom of acid reflux is bringing up of bitter liquid or food. This is called regurgitation. Also, acid reflux can cause difficulty to swallow, chest pain, chronic cough, asthma and decay of teeth. Overall, acid reflux can reduce well-being and quality of life in many ways. But, the most important harm from acid reflux is the risk for cancer of the oesophagus (the gullet or foodpipe). Untreated acid reflux significantly increases the risk for one type of cancer called adenocarcinoma of the oesophagus. Fortunately, many studies have shown that proper treatment of acid reflux can reduce the risk for cancer.

When should you think of an operation for acid reflux?

Medicine called Proton Pump Inhibitors (PPI) can be very effective to control acid reflux. Commonly used PPI drugs are omeprazole, lansoprazole, pantoprazole and esomeprazole. But, PPIs do not control acid reflux in some people. There are many reasons for poor response to PPIs. In others, PPIs may control acid reflux very well. But, symptoms return if medicines are not taken regularly. Although treatment with PPIs is generally safe, there is some concern about serious side-effects with long-term use of PPIs. An operation can give good relief when PPIs are not effective. Also, an operation can give freedom from chronic PPI treatment.

What are the benefits of the LINX magnetic bead ring for acid reflux?

The conventional operation for acid reflux is called laparoscopic Nissen fundoplication. In this operation, the upper part of stomach is wrapped around the lower end of the oesophagus. This wrap creates a barrier to backflow from the stomach into the oesophagus.

Nissen fundoplication is a safe and effective procedure. But, it does have some really troublesome side-effects. Belching or burping may not be possible after Nissen fundoplication. There can be bloating of the tummy from trapped wind, and excessive flatulence. With time, the effectiveness of the fundoplication can ‘wear off’, and acid reflux can return. Many people have to re-start treatment with PPI drugs. Some might need to have another anti-reflux operation, called revisional surgery.

LINX is a new procedure that can avoid side-effects of the Nissen fundoplication. Like the fundoplication, the LINX procedure is done entirely by keyhole surgery. A special magnetic bracelet is placed around the lower end of the oesophagus. Unlike a fundoplication, the LINX procedure does not require extensive dissection and division of blood vessels. So, there is lower risk of complications. Also, the risk of gas-bloat and inability to belch is significantly lower with LINX than with Nissen fundoplication. As with any new procedure, there is no information on long-terms problems with LINX. But, up to 5 years, LINX seems to give the benefits of fundoplication and avoids several side-effects.

Risks of Obesity

Obesity increases the risk for several illnesses. Type 2 diabetes, high blood pressure, high cholesterol, obstructive sleep apnea, liver disease, depression and many other health problems are more common in obese people than in normal weight people. It is well known that weight loss surgery, also called bariatric surgery, is effective for more than only weight loss. Weight loss operations – gastric band, gastric bypass and sleeve gastrectomy – can improve, and even cure, diseases that go along with obesity.

Risk for Cancer in Obese People

What about cancer? Does obesity have any impact on the risk for getting cancer? There have been various studies on this topic. A recently published paper in the British Medical Journal(1) has analysed the linkage between obesity and cancer in detail. Many questions remain unanswered, but the bottom line is quite clear. Obesity increases the risk of cancer. The researchers found strong evidence for the association between obesity and eleven types of cancer: oesophageal adenocarcinoma (cancer of the food-pipe or gullet), multiple myeloma (a type of blood cancer), and cancers of the gastric cardia (the upper part of the stomach), colon and rectum (the large bowel), pancreas gland, biliary tract, breast, endometrium, ovary and kidney. The researchers suggest that those at higher risk for cancer could be targeted for personalized prevention strategies.

Weight Loss Surgery and Cancer Risk Reduction

Can weight loss surgery reduce the risk for cancer in obese people? There are few studies that look at this problem. It is not entirely clear whether the risk is reduced for all cancers, and whether all obese people can benefit. Women seems to benefit more than men. In fact, one large study has shown that the risk for cancer is reduced only in women and not in men.(2) Other studies may shown reduced cancer risk in both men and women, but the benefit remains greater in women.(3) Much work remains to be done in this area. But, the message is fairly clear: obesity increases the risk for cancer. Weight loss surgery has many benefits, and reduction of cancer risk is one of these many benefits.

References

1. Kyrgiou M, Kalliala I, Markozannes G, Gunter MJ, Paraskevaidis E, Gabra H, et al. Adiposity and Cancer at Major Anatomical Sites: Umbrella Review of the Literature. Br Med J (Clin Res Ed). 2017;356.
2. Sjostrom L, Gummesson A, Sjostrom CD, Narbro K, Peltonen M, Wedel H, et al. Effects of Bariatric Surgery on Cancer Incidence in Obese Patients in Sweden (Swedish Obese Subjects Study): A Prospective, Controlled Intervention Trial. The Lancet Oncology. 2009;10(7):653-62.
3. Maestro A, Rigla M, Caixas A. Does Bariatric Surgery Reduce Cancer Risk? A Review of the Literature. Endocrinology & Nutrition. 2015;62(3):138-43.

Hair loss is a common problem after weight loss surgery. It can be worrying if large numbers of hair from the scalp come loose whilst brushing or combing. The shedding of hair from the head can lead to hair thinning and bald patches.

Should you be concerned about hair loss, or is this an expected side-effect of bariatric surgery?

Hair loss can happen with the gastric band, gastric bypass or sleeve gastrectomy. Although, hair loss is more common generally with the gastric bypass and sleeve gastrectomy than with the gastric band. For most people, hair loss happens during the first 6 months after the weight loss operation. After 6 months, the hair usually regrows. So, most often there is no cause for alarm.

Why does hair loss happen after a weight loss operation?

To understand this problem, it is helpful to learn about the normal process of hair growth. The hair fibres are produced by tiny pits called hair follicles in the scalp. The hair follicles have a natural life-cycle. Ordinarily, most hair follicles in the scalp are in a growth phase (called ‘anagen’). A small number of follicles are in a resting phase (called ‘telogen’). Stressful events, like surgery and rapid weight loss, can provoke more follicles to enter the resting phase. The resting follicles usually transit back to the growth phase in few months. When follicles begin to grow again, the old hair is shed and it is replaced by a new hair. Obviously, the new hair takes some time to grow to length of the lost hair!

What can you do to prevent hair loss?

There is no specific prevention or treatment for hair loss. It is part of the normal reaction of the body to weight loss surgery. You will be advised to take a multi-vitamin and mineral capsule or syrup after all weight loss operations. It is important to take this vitamin and mineral supplement regularly. Also, follow the advice of the dietician carefully so that you are getting sufficient proteins and calories. If the hair loss continues beyond 6 months following the operation, then speak to your doctor and dietician to see if any action is necessary.

For information about weight loss surgery in Leeds, visit www.abeezarsarela.co.uk or call 0113 388 2138

Obese people can face many difficulties in their workplace. Physical activity, mobility and travelling may just not be possible. Obesity can lead to several health problems: diabetes, high blood pressure, obstructive sleep apnea and others. Such health problems can create barriers to fully productive working. Also, obese people are at increased risk for mental health disorders, such as depression and anxiety. These can create a vicious cycle with work and impair efficiency and effectiveness. Unfortunately, stigmas are often attached to obesity. For example, employers may have a mistaken perception that obese people are lazy. Obese people can be denied opportunities to work, resulting in higher unemployment than the general population.

Weight loss surgery (bariatric surgery) usually is a life-changing event for obese people in many ways. For this blog post, the relevant question is: does weight loss surgery improve prospects for employment and productivity at work?

Work productivity can be looked at in different ways. First, consider unemployment. For unemployed people, the question is whether weight loss surgery can aid them to get a job. Second, consider people who are in work: can weight loss surgery help them to do better? A worker’s productivity can be scrutinized in two ways. How often is the person off work because of ill-health? This is called ‘absenteeism’. Or, the person might continue working, despite poor health, and his work suffers. For example, he may not be able to work efficiently, although he has come to work. This is called ‘presenteeism’.

Two studies have been published recently on the subject of work and weight loss surgery.(1, 2) Both studies report reduction in absenteeism and presenteeism after weight loss surgery. In other words, people need less time off work for ill health after weight loss surgery. Also, when at work, they work better. One of the two studies shows that about one in four unemployed people return to work after weight loss surgery.

In summary, obese people can suffer many disadvantages at work. Through weight loss surgery, obese people can improve prospects for employment and increased productivity.

For weight loss surgery in Leeds UK, call 0113 388 2127

References

1. Sharples AJ, Cheruvu CVN. Systematic Review and Meta-Analysis of Occupational Outcomes after Bariatric Surgery. Obesity Surgery. 2017;27(3):774-81.
2. Alfonso-Cristancho R, King WC, Mitchell JE, Ramanathan R, Sullivan SD, Belle SH, et al. Longitudinal Evaluation of Work Status and Productivity After Bariatric Surgery. JAMA. 2016;316(15):1595-7.

Obesity and mental health are closely linked. The UK’s National Obesity Observatory reports that that there is a bidirectional association between obesity and mental health. Obesity can lead to vulnerability to depression, low self-esteem, poor body image, unhealthy eating habits and exercise avoidance. Also, the other way around, mental health problems can lead to weight gain and obesity.

Depression is the most common mental health problem in obese patients having weight loss surgery. A recent meta-analytic study showed that depression is a problem for 19% of patients having weight loss surgery.(1) This number is in keeping with information from the UK’s National Bariatric Surgery Registry. The Registry has reported that 27% of women and 15% of men were on medication for depression.

After depression, binge eating is the second most common mental health problem in obese people having bariatric surgery. About 17% have a binge-eating problem. The third most common mental health problem is anxiety (12%). Other problems are suicidal ideation (9%), personality disorder (7%), substance abuse disorder (3%), post-traumatic stress disorder (1%) and psychosis (1%). All these mental health disorder are more common in people having weight loss surgery than in the general population.

The recently published meta-analytic study shows that depression improves after weight loss surgery.(1) Similarly, there is improvement in binge eating disorders and anxiety. These mental health problems may not be cured by weight loss surgery but the severity is reduced. Weight loss can improve body image, self-worth, empowerment and inter-personal relationships. The extent of weight loss after bariatric surgery in people in mental health problems does not seem to be any different from the general population. Having said that, some notes of caution are important. There can be some relapse of mental health disorders with time. Also, there is concern about increase in attempts at self-harm and suicide after weight loss surgery.(2)

In summary, mental health problems are common in obese people. The most common problem is depression, followed by binge eating and anxiety. There is good evidence weight loss surgery improves mental health in obese people.

REFERENCES:

1. Dawes AJ, Maggard-Gibbons M, Maher AR et al. Mental Health Conditions Among Patients Seeking and Undergoing Bariatric Surgery: A Meta-Analysis. JAMA. 2016;315(2):150-63.
2. Bhatti JA, Nathens AB, Thiruchelvam D et al. Self-harm emergencies after bariatric surgery: A population-based cohort study. JAMA Surgery. 2016;151(3):226-32.

The gastric bypass celebrates its 50^th birthday in 2017. A gastric bypass procedure for weight loss was first done in 1967. The operation was performed by traditional open surgery, and this continued until the 1990s. Keyhole surgery was first used to do the gastric bypass in 1994. The operation was now called the laparoscopic gastric bypass. This operation became the gold standard for weight loss surgery in the modern era. In 2017, all weight loss surgery is done by laparoscopy. About 50% of all weight loss operations in the UK are gastric bypasses. The other operations are the gastric band and the gastric sleeve.

What is a Gastric Bypass?

In a gastric bypass, surgical staplers are used to make a very small compartment at the top end of the stomach. This small compartment is called the gastric pouch. The pouch is disconnected from the rest of the stomach. The small bowel is then joined to the gastric pouch. Food and drink enter the small gastric pouch and then pass directly in to the small bowel. The lower part of the stomach and the upper part of the small bowel are bypassed – hence the name of the operation.

What is Roux-en-Y Gastric Bypass?

The full name for the gastric bypass is the Roux-en-Y gastric bypass. This is sometimes abbreviated to RYGB or LRYGB. ‘Roux-en-Y’ refers to the way of joining or ‘plumbing’ the small bowel to the stomach. The small bowel is a tube that is 25-35 feet long. This tube can be joined to the stomach pouch in two ways. One way is to join the small bowel tube directly to the gastric pouch. Such a join is called a ‘loop gastro-jejunostomy’. The second way is to divide the small bowel at the point that needs to be joined to the stomach pouch. The lower cut end of the small bowel is joined to the stomach. This part of the bowel carries food out of the stomach and is called the alimentary limb. The upper cut end of the small bowel receives bile from the liver and digestive juices from the pancreas. This is called the biliopancreatic or BP limb. The BP is now joined to the alimentary limb about 3 feet below join with the stomach. This second way of joining the bowel to the stomach is called a ‘Roux-en-Y gastrojejunostomy’.

What is the difference between a Roux-en-Y and a Loop Gastrojejunostomy?

The difference between a loop and Roux-en-Y can be confusing. Simply, in the loop there is only one anastomosis or join: that between the stomach and the small bowel. This join is called the gastrojejunostomy. In the Roux-en-Y there are two joins: the gastrojejunostomy and a separate join between the alimentary and BP limbs of the small bowel. The join between the two bowel limbs is called the jejuno-jejunostomy.

What is the Mini Gastric Bypass?

The main difference between the Roux-en-Y Gastric Bypass and the Mini Gastric Bypass is in the way the small bowel is joined to the stomach. In the Mini Gastric Bypass, the join is a loop and not Roux-en-Y. The Mini Gastric Bypass is technically simpler than the Roux-en-Y Gastric Bypass because there is only join – the gastrojejunostomy – in the Mini Bypass. The second join – the jejuno-jejunostomy is avoided in the Mini Bypass. A second difference is that the gastric pouch in the Mini Bypass is made considerably longer than in Roux-en-Y Bypass.

What are the Pros and Cons of the Mini Gastric Bypass?

Supporters of the Mini Bypass say that the operation is safer than the Roux-en-Y bypass because there is only one anastomosis. Some experts call the Mini Bypass the One Anastomosis Gastric Bypass (OAGB). The main worry with the Mini Bypass is that bile can enter the stomach. The Roux-en-Y method was designed specially to keep bile away from the stomach. Bile can cause cancer of the stomach and the oesophagus. But, the supporters of the Mini-Bypass say that the risk of cancer is negligible. Apart from being technically simpler, the Mini-Bypass is claimed to have lower risk of ulcer and stricture at the gastrojejunostomy. Short term data seem to show similar weight loss and improvement in illness, such a diabetes and high blood pressure, with both operations.

How to Choose a Weight Loss Operation?

Which is better: the Roux-en-Y Gastric Bypass or the Mini-Gastric Bypass? There is no definite answer to this question. One size does not fit all. Consider all the options, including gastric sleeve and gastric band, in order to make a final choice of a weight loss operation.

To discuss weight loss surgery with Mr Sarela, consultant bariatric surgeon in Leeds, call 0113 388 2127 to make a clinic appointment.

PCOS is a common endocrine disorder in young women. It can cause infertility. Most women with PCOS are obese. The gastric band, gastric bypass and sleeve gastrectomy are powerful tools for weight loss. Can weight loss surgery help in the treatment of PCOS and infertility?

What is PCOS?

PCOS is Polycystic Ovary Syndrome. It affects about 10% of women of reproductive age. The ovaries become enlarged and contain many fluid-filled sacs (follicles) that surround the eggs. The ovaries release eggs irregularly or even not at all (called anovulation). Menstrual periods can become very irregular or absent. Women with PCOS can have difficulty to get pregnant (infertility). Also, high levels of the male hormones (called androgens) are produced. These can cause excessive facial and body hair (called hirsuitism), thinning or loss of hair from the head, oily skin and acne.

What causes PCOS?

There is no single cause for PCOS. It is believed to be caused by a combination of environmental, genetic and other factors. Obesity may play a role in causing PCOS.

What is the connection between PCOS and Obesity?

About 60% of women with PCOS are obese. There seems to be a vicious cycle of PCOS and obesity. Both cause and increase the severity of the other.

What are the risks of PCOS?

Women with PCOS are at increased risk to develop type 2 diabetes, high blood pressure and high cholesterol levels. Also, PCOS can lead to endometrial hyperplasia (excessive proliferation of cells in the endometrial lining of the uterus), which carries risk of progression to cancer.

What is the treatment of PCOS?

There is no cure for PCOS, but the symptoms can be treated. The UK’s National Institute of Health & Care Excellence (NICE) recommends that women with PCOS and BMI more than 30 should be advised to lose weight. NICE explains that weight loss alone may restore ovulation (release of eggs from the ovaries) and improve the response to ovulation inducing drugs.

What is weight loss surgery?

Weight loss surgery, also called bariatric surgery, can be life changing for obese women in many ways. The operations are the gastric band, gastric bypass and sleeve gastrectomy.

Does weight loss surgery improve PCOS?

There are many studies of the effect of weight loss surgery on PCOS. A meta-analysis has shown that weight loss surgery reduces various symptoms of PCOS.(1) A recent study is based on data from the UK’s National Bariatric Surgery Registry.(2) PCOS is present in 16% of women between ages of 18 and 45 years having weight loss surgery. After weight loss surgery, the symptoms of PCOS were not seen in 15% of women. Also, menstrual periods became normal in 33% of women. The bottom line is that weight loss surgery is not a cure for PCOS but it can help to treat the symptoms of PCOS.

For a consultation on weight loss surgery with Mr Sarela, consultant bariatric surgeon in Leeds, call 0113 388 2127

References

1. Charalampakis V, Tahrani AA, Helmy A, Gupta JK, Singhal R. Polycystic Ovary Syndrome and Endometrial Hyperplasia: An Overview of the Role of Bariatric Surgery in Female Fertility. European Journal of Obstetrics Gynecology & Reproductive Biology. 2016;207:220-6.
2. Edison E, Whyte M, van Vlymen J, Jones S, Gatenby P, de Lusignan S, et al. Bariatric Surgery in Obese Women of Reproductive Age Improves Conditions that Underlie Fertility and Pregnancy Outcomes: Retrospective Cohort Study of UK National Bariatric Surgery Registry (NBSR). Obesity Surgery. 2016;26(12):2837-42.