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 Table of Contents  
Year : 2016  |  Volume : 1  |  Issue : 1  |  Page : 26-30

Poster Presentation

Date of Web Publication25-Oct-2016

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2542-4629.193044

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How to cite this article:
. Poster Presentation. Saudi J Laparosc 2016;1:26-30

How to cite this URL:
. Poster Presentation. Saudi J Laparosc [serial online] 2016 [cited 2023 Jun 4];1:26-30. Available from: https://www.saudijl.org/text.asp?2016/1/1/26/193044

  Why RouxY gastric bypass is falling out of favour? Top

Osamah Alsanie, Johnny Haddad

Somna Care, Procare Hospital, Al Khobar Saudi Arabia

Background: Recent success with sleeve gastrectomy and single anastomosis gastric bypass has prompted many surgeons to reduce the number of RouxY gastric bypass performed due to the long term sequelae of RYGB and presence of long term sequelae and difficult to manage weight regain.

Data: A case series of all cases of RouxY gastric bypass who presented to our clinic for weight regain, poor weight loss or complications associated with the procedure in comparison with patients who had weight regain or complications secondary to sleeve gastrectomy.

Results: 76 cases of post RYGB have presented to our centre over 5 years. 47 of these cases were internal hernias, of which 35 cases were our own patients and 12 cases were self-referrals. One of those patient ended up with short bowel syndrome and had to be reversed. In the remaining 11 patients, the average time between symptoms and diagnosis was 18 months and in one patients the presentation was 9 years post op fifteen cases presented with failure to lose weight after gastric bypass. Nine of these patients had history of band surgery in the past and upon evaluation had large pouches including a hiatal hernia. In one patient, the revision failed to produce good results and in two patients recurrence of weight regain occurred after 3 years. Three patients presented with anastomotic ulcers difficult to treat. And two patients had to be reversed due to intractable neuroglycopenia. Six patients presented with intractable anaemia that only responded to blood transfusion and three patients presented with complications related to the bypassed stomach and biliary tree.

Conclusion: Complications of RouxY gastric bypass are not limited to the preoperative period and their management require expertise that may not be present for those who have not been trained in this procedure. With reducing numbers of RouxY gastric bypass being performed, we fear the difficulty in diagnosis of some of these complications may result in catastrophic events.

  Gastroesophageal reflux is not a contraindication for sleeve gastrectomy Top

Osamah Alsanie, Johnny Haddad

Somna Care, Procare Hospital, Al Khobar Saudi Arabia

Background: Early work with sleeve gastrectomy has suggested the procedure to be associated with high incidence of new reflux and exacerbation of early reflux and such patients are directed to gastric bypass surgery against their wishes.

Data: We evaluated two cohorts: Group 1 is patients who had preoperative gastrooesophageal reflux and were managed by sleeve gastrectomy to identify the incidence of cure from reflux with loss of weight and the chance of exacerbation. Group 2 represented patients with no symptoms f reflux and we reviewed the incidence of new reflux in such patients and management of such patients. In all patients, we dissect the hiatus to treat hiatal hernial defects.

Results: We had 112 patients with symptomatic reflux necessitating intake of medication preoperatively but not documented by work up. In all patients but 2 the symptoms have disappeared. Only two patients remain dependent on proton pump therapy. One patient had revisional surgery as his procedure and felt improvement though still dependent on PPI therapy and does not wish for intervention. We had 283 patients with no reflux symptoms preoperatively. The incidence of new reflux occurred in 7 patients and occurs mainly with prolonged fasting especially in Ramadan requiring PPI therapy. There was no correlation between operative findings and symptom occurrence.

Conclusion: Most preoperative reflux can be cured by loss of weight and sleeve gastrectomy does not have increased reflux contrary to previous reports.

  Post laparoscopic sleeve gastrectomy leakage ranges from 3% to 5% internationally and there are many types of leakage management which depend on the time of diagnosis (acute, sub-acute or chronic) Top

Abdulmenem Abualsel

King Hamad University Hospital, Al Sayh, Bahrain

We had a case of a 47 years old male not K/C/O any medical illness; he has a history of laparoscopic cholecystectomy, appendectomy and several para-umbilical hernia repairs. Had a BMI of 45.8 ,weight 131 kg ,after being reviewed by the dietitian and based upon his own wishes he underwent a laparoscopic sleeve gastrectomy ,the procedure was smooth and uneventful , gastrographin study on the next day showed no obvious leakage but 2 days post OP , patient developed tachycardia, tachypnea and started having abdominal pain with vomiting , CT with oral and IV contrast was done and showed a leakage at the gastro-esophageal junction area ,then patient underwent laparoscopic repair of the leak by PDS suturing, but unfortunately the patient had re-leak again with a collection beside the site of the leak , which was drained under CT Guidance, an uncovered stent was placed endoscopically, but leakage persisted. The stent was removed, because patient has continuous vomiting and it was found tow gastric ulcers with migration of the stent. After 4 weeks he underwent a laparoscopic conversion to Roux-en-Y Gastric Bypass below the site of leak and drain was kept along with feeding jejunostomy tube insertion. Afterwards CT showed that the spleen, anterior abdominal wall, stomach and left diaphragmatic leaflet formed an amalgamated mass, with present of GE leakage. Patient was started on jejunostomy tube feedings, and pure honey and Zamzam water were given only per oral, for three weeks which ended up with complete healing of the leakage site without the need of any further surgical intervention. Pt start on oral regular diet and the jejunostomy tube was removed.

  Single versus multistage total body lift post massive weight loss following bariatric surgery: What can be offered: One centre experience Top

Osamah Alsanie, Abdullah Alsheikhy, Johnny Haddad

Somna Care, Procare Hospital, Al Khobar Saudi Arabia

Background: Until 2001, Body contouring surgery consisted of piece meal procedures targeting different areas for correction. Since then, total Body Lift has been accepted as a full rehabilitation procedure at contouring the comprehensive approach to address the total body laxity that results following massive weight loss whether as a single versus multistage procedure.

Materials and Methods: Case review of all cases performed by a team of two surgeons over a period of 10 years. Grades of laxity are described as well a comparison between multistage versus single stage total body lift is described with before and after images.

Results: 61 cases were performed: 41 cases were performed as single stage of which 4 were revisional surgery and 20 cases were multistage procedures of which 6 cases were revisional. The incidence of complications remains high at 60% of wound complications and 10% loss of flaps. There were no mortalities and average blood use per case was 1.1 unit. There was no difference between single and multistage surgery. The overall satisfaction with overall results approached 95% immediately following the procedure and dropped to 70% by 3 months then improved to 87% at one year.

Conclusion: Despite the improved satisfaction with total body lift following massive weight loss, it is still a highly morbid procedure and improving the outcome remains the most important challenge.

  Determinants of Vitamin D deficiency among undergraduate medical students in Saudi Arabia Top

BinSaeed AA 1,2 , Torchyan AA 1,2 , AlOmair BN 2 , AlQadhib NS 2 , AlSuwayeh FM 2 , Monshi FM 2 , AlRumaih FI 2 , AlQahtani SA 2 , AlYousefi N 2 , Al-Drees A 3

Background and Objective:
The objectives of our study were to determine possible factors associated with low Vitamin D levels in medical students!

Subject and Methods: A cross-sectional study was performed among 255 first- to fifth-year male undergraduate medical students of one of the major universities in Saudi Arabia. Serum 25-hydroxyvitamin D (25(OH)D) levels were measured using electrochemiluminiscence. Multiple logistic regression analysis was performed!

Results: Majority of Saudi medical students (75.2%) had 25(OH)D levels <30 nmol/l, defined as risk for deficiency by the Institute of Medicine. Multivariate analysis showed that the odds of having 25(OH)D serum levels of ≥30 nmol/l were seven times higher both in students who took vitamin D (odds ratio (OR)=7.2, 95% confidence interval (CI)=1.8-29.9, P=0.006) or multivitamin supplements (OR=6.9, 95% CI=1.7-27.3, P=0.006) within 1 year. Students with a history of vitamin D testing >1 year before the study or moderate/vigorous physical activity (PA) had 4.4 (OR=4.4, 95% CI=1.7-11.4, P=0.003) and 2.7-fold (OR=2.7, 95% CI=1.3-5.3, P=0.006) higher odds of having 25(OH)D levels ⩾30 nmol/l, respectively. There was no significant association between 25(OH)D serum levels and average time spent outdoors per day (P=0.369) and type of(clothing (long-sleeved vs short-sleeved; P=0.800!

Conclusions: Vitamin D deficiency was highly prevalent in Saudi medical students. Modifiable factors such as vitamin D intake and PA could be targeted for intervention. Further studies with standardized laboratory measurements of 25(OH)D are needed to explore the role of vitamin D testing in behavioral change, which may lead to increased.

  Revisional bariatric surgery in the hand of young bariatric surgeon Top

Hosam Elghadban


Redo surgery after failed open vertical banded gastroplasty for morbid obesity is technically demanding and becoming common particularly in Egypt because many surgeons are still practicing such operation till now. The incidence of complications are higher, and the possibility of doing the planned bariatric procedure may not be feasible in one session due to inflammation, scarring, and bleeding. Both patient and surgeon need to be aware that a new operation will be a difficult task, and realistic goals have to be presented to the patient.

Objectives: Evaluate the safety of doing revisional bariatric surgery by the hand of young surgeon after good training and adequate planning to achieve good outcome.

Methods: Detailed evaluation of the preoperative data and operative notes were done. Imaging and endoscopic studies were necessary to study the problem and give an accurate map of the existing anatomy. Laparoscopic approach was the preferred method.

Results: Weight regain after VBG was the reason for revision in all cases. Our patients were 1, 8 and 15 years postoperative. Mean age 55 ± 11.7 years and mean BMI 44.6 ± 5.5. Pouch dilatation was detected in all cases. Mean operative time was 155 ± 20 minutes. Two cases received blood transfusion. Mean Hospital stay was. All cases were converted into minigastric bypass with common channel 3 meter measured from the ileocecal valve.

Conclusion: Revisional bariatric surgery is technically challenging. Good outcome can be achieved by young bariatric surgeon after good training.

[TAG:2]The feasibilty and safety of the obalon® [/TAG:2]

Nourah Alsharqawi, Salman Al Sabah, Ahmed Al Mulla

Al Amiri Hospital, Kuwait City, Kuwait

Introduction: The Obalon® is a new intra-gastric balloon, which involves a self-inflating balloon after swallowing the Obalon® capsule. This eliminates the necessity for an endoscopy for insertion. This new device is placed for a 12 week period and extracted via endoscopy. This study aims at evaluating the efficacy and safety of the Obalon® .

Methods: A retrospective analysis was performed on a total of 58 patients that underwent Obalon® insertion and removal from December 2014 to July 2015. Data included weight, Body Mass Index (BMI) and complication rate.

Results: 58 Kuwaiti patients underwent Obalon® insertion, of which the mean age was 36 (15-66) and 43 (80%) were females. Mean preprocedure weight and BMI were 87 kg and 33, respectively. A total of 54 out of 58 attempts (93%) to swallow the balloon were successful. All patients were followed up by a dietician and received two Obalons. There was a significant mean Weight loss of 1.4 kg, 0.3 kg and 0.3 kg at one month, two months and three months, respectively (p-value <0.001). After removal of the Obalon® , a mean weight loss of 4 kg and a BMI of 31 were documented. Of the 58 patients, two patients (4%) achieved a weight loss of more than 10 kg. A total of two patients (4%) removed the Obalon® prior to completion of the 12 weeks due to nausea and epigastric pain and three patients lost follow up.

Conclusion: The Obalon® is feasible and safe. A significant mean weight loss at months one, two and three was noted. However, larger prospective studies are needed and the role of adding a third Obalon® should be further investigated.

  Preoperative endoscopy in the assessment of bariatric patients: What is special in Oman? Top

Ahmed Dawood, Marwa Alazzawi, Raad Al Mehdi

The Royal Hospital, Muscat, Oman

Introduction: Obesity and metabolic syndrome now rank high on the scale of health challenges in Oman. The country also has the highest prevalence of Gastric cancer among the Arab countries. Bariatric services at the Royal Hospital started in 2012. Since then, Preoperative Oesphago- gastric endoscopy (OGD) was placed as an essential prerequisite to surgery. This article aims to shed the light on the indications, effect on operative outcomes and comparison with postoperative results.

Methods: Retrospective analysis from a prospective database, of all Bariatric patients undergoing surgery between 2012 and end 2014.

Results: Out of 99 patients operated in this period, pre-op OGD was done in 85(85%) of the cases. Abnormalities were recorded in 110 episodes. Among these were Esophagitis in 14 (16%), Hiatus hernia in 14 (16%), Lax lower sphincter in 34 (40%), Polyps in 4 (5%), Gastritis in 43 (50%) and Duodenitis in 4 (5%). Helicobacter pylori (H.P) was detected by CLO test in 77 (90.5%). The latter was again found in 65% of biopsies taken from 66 cases. These infections had to be treated prior to surgery in addition to mucosal inflammations. While gastric biopsies' intestinal metaplasia was seen in 4 (6%), no cancer was identified preoperatively.

Discussion: Although no major change of surgical plan was ultimately planned, yet preoperative findings of mucosal inflammation obliged prior full medical management of these, while endoscopic findings of crural and sphincter weaknesses, as well as Esophagitis, necessitated a strict operative regimen of hiatal assessment and hiatoplasty during surgery. Our findings of the presence of H.P in a significant percentage in this study is a strong index that supports endoscopy prior to surgery especially in our country where metaplasia and cancer are still a major Gastric challenge.

  Outcome of single-step procedure of conversion of laparoscopic adjustable gastric band to laparoscopic sleeve gastrectomy Top

Mohamed Al Emadi, Parvaneh Amani 1

Department of General and Bariatric Surgery, Al Emadi Hospital, Doha, Qatar

Background: Laparoscopic Adjustable Gastric Band (LAGB) was the most frequently performed bariatric surgery with significant failure rate in the long-term, which required an alternative conversion procedure to remediate it. Recently, Laparoscopic Sleeve Gastrectomy (LSG) has been addressed as the most effective conversional procedure for gastric banding. The aim of this study is to review the outcome of Single-Step procedure for Conversion of Laparoscopic Adjustable Gastric Band to Laparoscopic Sleeve Gastrectomy.

Methods: The study uses retrospective analysis of 214 patients who underwent conversional procedure of LAGB to LSG. Out of which, 155 patients underwent the Single-Step conversional procedure of LAGB to LSG by a single-surgeon during the period of August 2010 until April 2015 at Al-Emadi Hospital, Qatar. Demographics data, indication for revision, operation time, length of hospital stay, post operation complications, and percent of excess weight loss were collected from the patient file, surgeon log book, and the referral complications feedback from the main public hospital. Descriptive statistics and t-test of means analysis were used to analyze the data using SPSS software version 22.

Results: A total of 155 patients underwent conversion procedure of LAGB to LSG in single step, comprising of 111 (71.6%) female and 44 (28.4%) male with a mean age of 36 years (20-58), and a mean pre-LAGB body mass index (BMI) of 48.1 kg/m 2 (35.6-75.3). Patients grouped into four revision categories: category (1) involved patients who had successful weight loss (previously planned for second phase surgery), category (2) involved patients experienced weight regains, category (3) involved patients witnessed poor weight loss, and category 4 - involved patients experienced insufficient weight loss. Overall, compared to LAGB, LSG resulted in 35.7% excess BMI loss within the first 4-8 months of surgery. More specifically, compared to LAGB, indication categories 1, 2, 3, and 4, patients experienced 29.7%, 24.8%, 36.1%, and 42.9% excess BMI loss within the first 4-8 months of surgery, respectively. The highest excess BMI loss was experienced by patients in category 4, and the lowest was experienced by patients in category 2. There was a statistically significant difference between the post-LAGB BMI and the BMI after six months follow up of conversion surgery (p < 0.001). Also, there was a statistically significant difference between % excess weight loss post-LAGB and % excess weight loss six months post-LSG (p < 0.001). Similar patterns were observed when comparing all indication categories. The mean operation time was 87 minutes (45-180), and the mean operation time combined with one or two procedures was 105 minute with 2.4 days hospital stay (1 to 5 days). There was no major complication, such as leaking, and bleeding. There was also no mortality after 30 days.

Conclusions: With the finding from the above data, the single step conversional procedure of LAGB to LSG at Al-Emadi Hospital is effective. There is significant weight loss in patients with no complications. However, a long-term follow up study is required to confirm these promising results.

  Management of severe obesity case presentation and suggestion for algorithm Top

Ali Manea

Abha, Saudi Arabia

36 years old male patient who underwent Laparoscopic gastric banding 6 years before presentation to us. He lost some weight then started to regain weight again till he reach a very high number.

His weight was 376 kg and his calculated BMI was 133 kg/m 2 . Patient became completely bed-ridden 3 months earlier and was totally dependent on others. Patient transfer to the hospital was arranged using help from civil defense and Red Crescent. He was admitted to the hospital for almost one year for preoperative rehabilitation and dieting therapy then banded sleeve gastrectomy was done for him. He did very well and was discharged from the hospital 5 days after surgery. His weight one year after surgery was 79 kg.

  Retrospective review of 400 preoperative endoscopies and its findings: You decide! Top

Ali Khammas


There is no guidelines supporting preoperative upper GI endoscopies routinely but the recommendation depending on type of the procedure and or the patient symptoms. The non-bariatric literature though is clearly showing that symptoms are unreliable in detecting gastric ulcers and erosive esophagitis. We reviewed our data of 400 consecutive routine preoperative endoscopies and found in 20% esophagitis mainly grade 1 , hiatal hernia 15.6%, barrets 0.3%, gastric ulcer 3%, erosive gastritis 13%, erosive duodenitis 19%, duodenal ulcer 1% and one gastric cancer case and one case of aberrant pancreas tissue. And also a case of eroded band. The conclusion is that that the surgeon after reviewing our data shall decide for themselves depending on the hospital guidelines.

  The incidence of laparoscopic cholecystectomy after laparoscopic sleeve gastrectomy in Lebanon Top

Mohammad Hayssam Elfawal, Bassem Safadi, Ramzi Alami, Houssam Abtar


Background: Rapid weight loss is a recognized risk factor for cholelithiasis. The incidence of gall stone formation after gastric bypass and gastric banding had been studied. To our knowledge, in the literature, there is no studies to analyze the incidence of symptomatic gall stones requiring cholecystectomy developed after sleeve gastrectomy.

Methods: A retrospective chart review of patients who underwent LSG between January 2009 and May 2012 at two bariatric centers in Lebanon. Patients who had concomitant cholecystectomy, previous bariatric surgery or documented gall stones before surgery were excluded from the study. The outcome measure was the development of symptomatic gallstones requiring cholecystectomy.

Results: A total of 370 LSG done in the study period 292 of which met the inclusion criteria. 23 patients developed symptomatic gall stones requiring cholecystectomy.

Conclusion: The overall incidence of cholecystectomy after sleeve gastrectomy is 7.9%. Concomitant cholecystectomy should not be done as a routine viewing the low incidence of symptomatic gall stone after sleeve gastrectomy. Abdominal ultra-sound may not be a necessary part of the preoperative work up.

  Pancreatic pleural fistula: As a one of complication of bariatric surgery Top

Mohammed Abdulraof Alismail

R3 Saudi Board, Saudi Arabia

Pleuropulmonary complications of pancreatitis are rare. Pancreaticopleural fistula (PPF) could be a consequence of pancreatitis in post-bariatric patients. Pancreatic stenting by using endoscopic retrograde cholangiopancreatography (ERCP) is difficult in abnormal upper gastrointestinal anatomy, and percutaneous route is difficult in mesh repair of incisional abdominal hernia. We represent a case of a 35-year-old female with biliopancreatic diversion admitted with recurrent episode of pancreatitis, complicated with pseudocyst and development of a pancreaticopleural fistula. Successful medical management was achieved, and she made a full recovery. This case demonstrates that the rarity of such a condition leads to delay as well as challenges in diagnosis and management.

  Unusual differential diagnosis for tachycardia, abdominal pain or fever post sleeve gastrectomy: One surgeon experience Top

Osamah Alsanie, Johnny Haddad

Somna Care, Procare Hospital, Al Khobar Saudi Arabia

Background: Tachycardia, tachypnea, abdominal pain or sepsis are reasons for concern post sleeve gastrectomy. We describe the causes for each symptom occurring in our patients and the algorithm we have employed in managing our patients presenting with one or more of these symptoms.

Materials and Methods: All cases with deviation from normal in the first two weeks were reviewed and reported. Algorithm for investigation is outlined and the outcome of intervention reported as part of the retrospective review.

Results: We had 30 cases of tachycardia>120 in the first 2 weeks. Drop in hemoglobin represented the commonest cause followed by leak then pneumonia. Rare causes included dehydration secondary to functional or mechanical narrowing, intra-abdominal collection, medication related, rhabdomyolysis, wound sepsis, and port site hernia. There were 24 cases who complained of Left upper quadrant abdominal pain in the first 2 weeks. 24 of them had associated tachycardia and 6 had a normal heart rate of whom 2 patients had leak and 2 patients had obstructive renal calculi, one pneumonia and one diabetic gastropathy.

Conclusion: Tachycardia and left upper quadrant pain should always be investigated thoroughly in post sleeve patients as they often result from treatable conditions.

  Gastric resection can provide a good solution to most weight regain following bariatric procedures Top

Osamah Alsanie, Johnny Haddad

Somna Care, Procare Hospital, Al Khobar Saudi Arabia

Background: The results of sleeve gastrectomy has improved in the last few years and this has prompted many surgeons to consider further restrictions procedures to address weight.

Data: All patients who presented for revisional surgery for weight regain or failure to lose weight following earlier bariatric procedures including gastric band, RouxY gastric bypass, sleeve gastrectomy, gastric plication, vertical banded gastroplasty and biliopancreatic diversion. All patients underwent gastric sleeving appropriate for their anatomy. We reviewed our results with respect to percentage excess weight loss and effect on adverse events of prior procedures in addition to complications associated with our procedures.

Results: A total of 84 revisional cases underwent sleeving of the stomach or proximal gastric pouch as the only intervention or the main part of their intervention by one single surgeon. All patients at one year lost more than 50% of their excess weight loss but 2 patients lost 25% and 20% of their excess weight loss. The percentage of patients who are no longer considered obese by BMI reached 92%. The percentage of patients who achieved ideal weight defined as BMI 25 approached 83% at 2 years.

Conclusion: Sleeving the stomach should be the first choice in Saudi Arabia especially with the socially unacceptable and nutritional disabling consequences of malabsorptive bariatric procedures.

  Introduction of parts in gasless abdomen: It is safe and applicable? Top

Ali Manea Alahmary

GNP Hospital, Jeddah, Saudi Arabia

Introduction of the first port to the abdomen can be done using many techniques. One of the major concerns in bariatric surgeries is entering the peritoneum, which carry a risk and consume time. We adopted for the last 8 years one technique, which is the introduction of the first port into the gasless abdomen. We are presenting our results for the period from 1/8/2012 till 31/11/2015. All bariatric cases done during this time were reviewed and we are presenting our results which showed that this technique is safe and applicable.

  The role of the dietetic unit in facing the obesity epidemic in Oman: Progress and challenges at the Royal Hospital in Muscat Top

Sanna Al Yafaey, Ameera Al Nasiry, Mohammed Al Siyabi

Department of Clinical Dietetic, Royal Hospital, Muscat, Sultanate of Oman

Obesity has reached epidemic rates Worldwide. The Gulf countries are definitely within this frame, as they have some of the highest numbers of obese residents compared with other regions. According to recent research, the prevalence of obesity in the Gulf ranges among children and adolescents between 5% to 14% in males and 3% to 18% in females. Adult females show the highest range with a prevalence range between 2%-55%, while adult males are within 1%-30%. Oman being part of the GCC faces an increase in morbid obesity with alarming rates. The 2014 WHO estimates show that the prevalence of obesity in Oman is 25% in Males and 38% among females. The Dietetics Department at the Royal Hospital, the biggest centre in the country, covers a wide range of nutritional support services to all categories of referrals including Obesity. Between 2009 and 2012 the trend of increase in referrals was on an average 180 patients per year. This leaped to 722 between 2012 and 2013. This is the first presentation on the role of a Dietetic unit in this filed from Oman. The paper would shed the light on this dramatic trend over the past few years. It would attempt to identify some of the causative factors including changes in lifestyle, eating habits, and physical activity. It would specifically analyze the role of the unit in managing Bariatric patients both before and after surgery and the challenges faced in ensuring outcomes are met.


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Why RouxY gastri...
Post laparoscopi...
Single versus mu...
Determinants of ...
Revisional baria...
The feasibilty a...
Preoperative end...
Outcome of singl...
Management of se...
Retrospective re...
The incidence of...
Pancreatic pleur...
Unusual differen...
Gastric resectio...
Introduction of ...
The role of the ...

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