Canadian Adult Obesity Clinical Practice Guidelines 1 KEY MESSAGES FOR HEALTHCARE PROVIDERS • Adherence to consistent post-operative behavioural changes (behaviour modification for nutrition plans, physical activity and vitamin intake) can optimize obesity management and health while minimizing post-operative complications. • Working in partnership, the bariatric surgical centre, the local bariatric medicine specialist, the primary care provider and the patient living with obesity need to establish and commit to a shared care model of chronic disease manage- ment for long-term follow-up. • The primary care provider should refer patients with post-bariatric surgery complications back to the bariatric surgical centre, or to a local bariatric medicine specialist. Bariatric Surgery: Postoperative Management Judy Shiau i , Laurent Biertho ii i) Division of Endocrinology and Metabolism, University of Ottawa ii) Department of Surgery, Laval University Cite this Chapter Shiau J, Biertho L. Canadian Adult Obesity Clinical Practice Guidelines: Bariatric Surgery: Postoperative Management. Downloaded from: https://obesitycanada.ca/guidelines/postop. Accessed [date]. Update History Version 1, August 4, 2020. Adult Obesity Clinical Practice Guidelines are a living document, with only the latest chapters posted at obesitycanada.ca/guidelines. RECOMMENDATIONS 1. Healthcare providers can encourage people who have un- dergone bariatric surgery to participate and maximize their access to behavioural interventions and allied health services at a bariatric surgical centre (Level 2a, Grade B). 1,2 2. We suggest that bariatric surgical centres communicate a comprehensive care plan to primary care providers on pa- tients who are discharged, including: bariatric procedure, emergency contact numbers, annual blood tests required, long-term vitamin and mineral supplements, medications, behavioural interventions and when to refer back (Level 4, Grade D, consensus). 3. We suggest that after a patient has been discharged from the bariatric surgical centre, primary care providers should annually review: nutritional intake, activity, compliance with multivitamin and mineral supplements, and weight, as well as assess comorbidities, order laboratory tests to assess for nutritional deficiencies and investigate abnormal results and treat as required (Level 4, Grade D, consensus). 4. We suggest that primary care providers consider referral back to the bariatric surgical centre or to a local specialist for technical or gastrointestinal symptoms, nutritional issues, pregnancy, psychological support, weight regain or other medical issues as described in this chapter related to bariatric surgery (Level 4, Grade D, consensus). 5. We suggest that bariatric surgical centres provide follow-up and appropriate laboratory tests at regular intervals post-sur- gery with access to appropriate healthcare professionals (dietitian, nurse, social worker, surgeon, bariatric physician, psychologist/psychiatrist) until discharge is deemed appro- priate for the patient (Level 4, Grade D, consensus).
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Canadian Adult Obesity Clinical Practice Guidelines 1
• Working in partnership, the bariatric surgical centre, thelocalbariatricmedicinespecialist,theprimarycareproviderandthepatient livingwithobesityneedtoestablishandcommittoasharedcaremodelofchronicdiseasemanage-mentforlong-termfollow-up.
• The primary care provider should refer patients withpost-bariatric surgery complications back to the bariatricsurgicalcentre,ortoalocalbariatricmedicinespecialist.
4. We suggest that primary care providers consider referralbacktothebariatricsurgicalcentreor toa localspecialistfortechnicalorgastrointestinalsymptoms,nutritionalissues,pregnancy, psychological support, weight regain or othermedicalissuesasdescribedinthischapterrelatedtobariatricsurgery(Level4,GradeD,consensus).
5. Wesuggestthatbariatricsurgicalcentresprovidefollow-upandappropriatelaboratorytestsatregularintervalspost-sur-gery with access to appropriate healthcare professionals(dietitian,nurse,socialworker,surgeon,bariatricphysician,psychologist/psychiatrist) until discharge is deemedappro-priateforthepatient(Level4,GradeD,consensus).
Canadian Adult Obesity Clinical Practice Guidelines 2
Post-bariatric surgery health behaviour changes
Post-bariatric surgery diet
Centres that perform bariatric surgerywill typically provide pa-tients with a dietary protocol to follow. Initially, over severalweeks,patientstransitionfromliquid,tosoftandthentoasol-id diet.Over the long term, patients are encouraged to followa structuredpost-bariatric surgicaldiet involving smallportions,three tofivebalancedandstructuredmealsandhealthysnacks(chew foods slowly and avoid sweets). For beverages, patientsshouldnoteatanddrinkatthesametime(avoidliquidswithin30minutesofeatingsolids).Carbonatedbeveragesandcaffeinateddrinks are to be avoided, as the phosphoric acid and caffeine,respectively,canincreasetheriskofulcerations.
After bariatric surgery, patients need to followa low-fat,mod-erate carbohydrate and high-protein diet. Post-operative pro-teinrecommendationsrangefrom1.2to1.5g/kg/daybasedongoalbodyweight(minimumof60gprotein/dayforlaparoscopicsleevegastrectomy/Roux-en-Ygastricbypass,and80–120g/dayforduodenal switch).Consultinga registereddietitian can sup-portchangesineatingbehavioursandguidepatientsontheirnu-tritionneeds.3Thereisnoadvantagetoprescribingalternatediets(e.g.lowcarbohydrate,highprotein),probioticsoraminoacids.4-6
Other behavioural changes to consider
Alcohol intakeshouldbeminimaloravoidedduetochanges inpharmacokinetics. For example, inwomenwho are post Roux-en-Ygastricbypass,twoalcoholicbeveragesareequivalentinab-sorptiontofouralcoholicbeverages.7Sevenpercentofpatientsreportnewhigh-riskalcoholuseoneyearafterbariatricsurgery,though,onamorepositivenote,halfwhoreportedhigh-riskalco-holusebeforesurgerydiscontinuedhigh-riskdrinking.7
Activity: Long term, a standard of 150 to 300minutes of ac-tivity/week is recommended for post-bariatric surgical patients.Post-operativehigher-volumeexercise canhelppromote furtherweightloss8-10butsustainingthislevelactivityisdifficult.11
Smoking cessation:Abstentionfromcigarettes isrecommend-ed.Cigarette smoking can increase riskofpepticulcerdisease,particularlymarginalulcers.
Theevidence for the roleof vitamin supplementation (amount,duration)variesdependingonwhichvitamin,mineralortypeofbariatricprocedurearestudied.Generally, sometypeofvitaminsupplementation is needed for all bariatric surgical procedures,with tailoring for those thathaveahypoabsorptive component(Roux-en-Ygastricbypass,duodenalswitch).
Practically,itmakessensethatastandardizedminimumprescrip-tion of vitamins be set for all bariatric surgeries. It is a naturalhumantendencytoeventuallyforgettakingsupplements.Settingastandardmeansthatclinicianscanbeconsistent intheirmes-sagingabouttakingvitamins.Deficienciesofvitaminsandsomemineralscan leaveseriousandpotentiallynonreversiblesideef-fects.Frequencyoflaboratorymonitoringmayvarydependingontheindividualandtypeofprocedure,butatminimumanannualcheck shouldbeconducted toensure thatpatientsarenotbe-comingmalnourished.Tables1and2summarizetherecommen-
KEY MESSAGES FOR PATIENTS LIVING WITH OBESITY WHO HAVE HAD BARIATRIC SURGERY
1.Ifyouhavehadbariatricsurgery,itisimportantforyoutotakeyournutritionalsupplementslifelongandtocontinuetofollowthepost-bariatricsurgicalnutritionplan,exerciseand any other recommendations given by your originalspecialistteam.Bydoingthis,youwillincreaseyourchancesofstayinghealthyandreducecomplicationsthatcanarisefrombariatricsurgery.
2.Attend all scheduled appointments and programmingoffered by your bariatric surgical site. Once you are dis-charged from the bariatric surgical site, schedule annualappointments with your primary care provider to checkyour bloodwork, reassess your medications and addressanyissuesrelatedtochangesinyourweight.
3. After bariatric surgery, it is possible that there can be anegativeimpactonmood,relationships,bodyimage,de-velopmentofaddictionsandreducedabilitytocopewithstress.Ifyouarestruggling,discussthiswithyouroriginalspecialistteamor,ifyouhavebeendischarged,withyourprimarycareprovider.
4.Rememberthatyourlowestweightpost-surgerywilloccurbetween 12 to 18months. After this, there is a naturalincreaseinweightthatoccurs.Ifyouaregainingexcessiveamountsofweight,discussthiswithyourbariatricteamorprimarycareprovider.
Dumping syndrome is divided into early and late phases. Earlydumpingsyndromeoccurswithinthefirsthourafterameal.Be-causeofthehyperosmolalityofthefood,rapidfluidshiftsoccurfromtheplasmacompartmentintotheintestinallumen,resultinginhypotensionandasympatheticnervoussystemresponse.Earlydumping is characterized by gastrointestinal symptoms such asabdominalpain,bloating,borborygmi,nauseaanddiarrhea,andvasomotor symptoms, such as fatigue, desire to lie down aftermeals (a classic symptom), flushing, palpitations, perspiration,tachycardia, hypotension, and, rarely, syncope. In contrast, latedumpingusuallyoccursonetothreehoursafteramealandisaresult of an incretin-driven hyperinsulinemic response after car-bohydrateingestion.Hypoglycemia-relatedsymptomsarerelatedto neuroglycopenia (fatigue, weakness, confusion, hunger andsyncope)andautonomic/adrenergicreactivity(perspiration,palpi-tations,tremorandirritability).12
There should be a high level of suspicion for an ulceration forpatientswhousenon-steroidalanti-inflammatorydrugs(NSAIDS).Referraltothebariatricsurgicalsiteshouldbeconsideredwhenclinical red flags appear such as unexplained, frequent,moder-ate-to-severe abdominal pain, daily intolerance to most solidfoods,dailynauseaandvomiting,and/orasignificantamountofweightregain(>25%–50%oftotalweightloss)inashortspaceof time. Every bariatric patient suffering from persistent vomit-ing severeenough to interferewith regularnutrition shouldbepromptlystartedonoralorparenteralthiaminesupplementation,evenintheabsenceorbeforeconfirmatorylaboratorydata.14
Bone health
Post-bariatricsurgery,bonedemineralization15–17andfracturerisk,18particularlyafterduodenal switch,are increased.Amajorcauseofbonelossisimpairedintestinalcalciumabsorption,whichleads to stimulation of parathyroid hormone (secondary hyper-parathyroidism)andboneresorption.17Theevidenceformonitor-ing,preventionandtreatmentisnotwelldescribed.Atminimum,adequateproteinintakeincombinationwithroutinephysicalac-tivityinadditiontotheroutinesupplementationofcalciumcitrateandvitaminDarerecommended.17,19ItisrecommendedtoadjustcalciumandvitaminD intaketoachievenormalserumcalcium,vitaminDandparathyroidhormonelevels.Calciumcitrateispre-ferredovercalciumcarbonateasitisbetterabsorbedintheab-senceofgastricacid.ElevatedparathyroidhormoneinthesettingofinappropriatelyhighserumcalciumandnormalvitaminDlevelsissuggestiveofprimaryhyperparathyroidismandrequiresfurtherinvestigation.
Theroleofbonemineraldensitytestingpriortobariatricsurgeryiscontroversial,20particularlyduetotechnicaldifficultieswhenpa-tientsareatahigherbodymassindex(BMI).Wesuggestorderingbonemineraldensitytestingonapatientattwoyearspost-surgery,whenweightisatitsnadir.Subsequentbonemineraldensitytest-ingcanbeorderedbasedonclinicalneed.20Ifapatientdoeshaveosteoporosis, then intravenous bisphosphonates (zolendronate 5mgonce a year, ibandronate 3mg every threemonths) are thepreferredchoice,asthere isariskofanastomoticulcerwithoralbisphosphonates.Priortostartingbisphosphonatetherapy,itisim-portantthatvitaminDlevelsbefullyrepletetopreventthedevel-opmentofhypocalcemia,hypophosphatemiaandosteomalacia.21
Nephrolithiasis
Patientswhohavehadbariatricsurgeryareathigherriskofnewonsetnephrolithiasis,withthemeanintervalfromsurgerytodi-agnosisofnephrolithiasisrangingfrom1.5to3.6years.Theriskofnephrolithiasis,typicallycalciumoxalatestones,variesbypro-cedure, being the highest for hypoabsorptive procedures (22%to28.7%),intermediateforRoux-en-Ygastricbypass(7.65%to
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13%)andthelowestforpurelyrestrictiveprocedures(laparoscop-ic adjustable gastric banding, laparoscopic sleeve gastrectomy)whereitapproachesthatofnon-operativecontrols.22Unabsorbedfatintheintestinebindswithcalcium,whichtypicallywouldbindoxalate.Oxalate is reabsorbed from the intestine and is subse-quently filtered by the kidney, resulting in hyperoxaluria. Withconcomitanthypocitraturia(fromintestinalalkali loss),thereisahigherpropensityforcalciumoxalatestoneformation.Basicther-apeuticstrategiestomanagehyperoxaluriaincludecalciumcitratesupplementation, increased hydration, limiting dietary oxalateandadheringtoa low-fatdiet.17,23Commonly, individualsoftenbelievethatkidneystonesarecausedbytakingtoomuchcalcium,and that calcium supplementation shouldbediscontinued. Theexactoppositeistrue,inthattheyshouldremainontheircalciumcitratesupplementation,whichnotonlyhelpsbindintestinaloxa-latebutalsoprovidescitratefortheurine.Thereissomeevidencetosuggest thatpyridoxine (B6)deficiencyplaysa role inkidneystone formation, highlighting the importance of taking vitaminsupplementation consistently.24 Certain probiotics (containingeitherLactobacillus aloneor in combinationwithStreptococcus thermophilus and Bifidobacterium)mayplayacomplimentaryroleinreducinggastrointestinaloxalateabsorptionifbasicstrategiesareinsufficient.25,26
Psychological complications and treatments post op
Thoughbariatric surgery isoneof themosteffective treatmentoptions for obesity, clinicians should be aware of the potentialpost-bariatric psychological issues thatmay arise, including de-pression, suicide,27,28 body image disorder, eating disorders,29
andsubstanceandalcoholabuse.7Resultsfrombariatricsurgerymaynotmeet apatient’s expectationsormaynot lead towardhoped improvements in quality of life, thus impactingmood.14 Beyond providing knowledge on diet and exercise, cliniciansshouldaddressimprovementinpatient’sself-esteemandself-mo-tivation.Patientswhohavehadpost-bariatriccomprehensivebe-havioural-motivationalnutritioneducationhavedecreasedriskfordepressionandimprovedweightlossoutcomes.1,30,31Primarycareprovidersmayneedtoreferthepost-bariatricsurgicalpatientformorein-depthpsychologicalcounselling,suchascognitiveordi-alecticalbehaviourtherapy.RefertoTheRoleofMentalHealthinObesityMedicine and EffectivePsychologicalandBehaviouralIn-terventionsforPeopleLivingwithObesitychaptersformoredetails.
Weight regain
Nadir weight (lowest weight point) occurs one to two yearspost-bariatricsurgery.Weightlossstopspartlybecauseofadaptivechanges inthe intestine,changedpatienthabits,andmetabolicadaptation.32Afterthis,itisnormaltoexpectsomeweightregain.However,thereisnoconsistentabsolutenumberintheliteraturethat defines pathological weight regain post bariatric surgery.Studiesthathavebeenconductedinthebariatricsurgerypopu-lationshowthatsignificantweightregain(≥15%gainofinitialweightlosspostbariatricsurgery)occursin25%–35%ofpeoplewhoundergosurgerytwotofiveyearsaftertheirinitialsurgicaldate.33 The SwedishObese Subjects study, the largest non-ran-
• Ensurethatthepatientcontinuestofollowtherecommendedpost-bariatricsurgerynutritionplanandvitaminintake.Checkbloodworktoensurethatvitaminandminerallevelsareinthenormal range. If a person is malnourished at baseline, thenmoreharmoccurstryingtohelpthepersonlosefurtherweight.Referraltoadietitiancanbehelpfulatthisstage.
• Consideration of medications for obesity managementpost-bariatricsurgerymaybemadeforpatientswhoaretryingto follow the post-bariatrc surgery nutrition plan and takingtheirvitaminsupplementation.Orlistatshouldnotbeused inpatientswhohavehadhypoabsorptiveprocedures.Retrospec-tivereportshavedemonstratedthatliraglutide35,36orbupropi-on/naltrexone37mayplayaroleinreducingweightregain.
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Medications
Followingbariatric surgery and the resultingweight loss,manystudiesdemonstrateareductionofmedicationsfordiabetes,dys-lipidemia,cardiovascularandantihypertensiveagents.Therearealimitednumberofpublicationsthatfocusonthepharmacody-namicsofmedicationspost-operatively(Table4).Ultimately,thereremainsa large interindividual variationand the therapeuticef-fectsofamedicationmustbeindividuallydoseadjusted.
Forthefirstthreetoeightweekspost-surgery,medicationsshouldbeconsumedinacrushedorliquidformorbyopeningcapsulecontents.Itisimportantthattheliquidformdoesnotcontainab-sorbablesugarstoavoiddumpingsyndrome.38Somemedications,however,shouldnotbecrushed.39PostRoux-en-Ygastricbypassandduodenalswitch,thepharmacokineticprofileofmanymed-icinesmaybealtereddue tochanged intestinalabsorption sur-face,lipophilicityofdrugs,increasedpHinthestomach,reducedcytochromeP450 (CYP) enzymeactivity andfirst-pass intestinalmetabolism,timeafterbariatricsurgery,andchanges involumeof distribution.40 Immediate-release formulations are generallypreferredoverextendedrelease.Nonsteroidalanti-inflammatorydrugsshouldbeavoidedafterRoux-en-Ygastricbypassorduo-denal switchdue to riskofanastomoticulceration/perforations.For other bariatric procedures, non-steroidal anti-inflammitories(NSAIDs)useshouldbeaccompaniedwithprotonpumpinhibitors(PPIs)formucosalprotection.41PatientswhoneedtoremainonlowdoseaspirinforsecondarypreventionmaydosobutshouldhaveadditionalPPIprotection.EspeciallyforRoux-en-Ygastricby-passandduodenalswitchprocedures,patientstakinglong-termwarfarin require a postoperative dose reduction of >20%withcloselymonitoredinternationalnormalizedratio(INR).Directoralanticoagulants (DOACs)shouldbeavoidedduetothepotentialfor decreased drug absorption. If a betablocker after bariatricsurgeryisneeded,ahydrophiliccompoundlikeatenololmaybepreferred. Bioavailability of oral contraceptivesmay be reducedpost-bariatric surgery, and alternate methods of contraceptionneed tobeconsidered.Antidiabeticmedicationswitha risk forhypoglycemia(suchassulfonylureas)shouldbediscontinuedandinsulindosesadjusted.Metforminmaybecontinuedbutthedosemayneedtobereduceddueto increasedabsorption.42Primarycareprovidersmaybenefitfromworkingwithapatient’scommu-nitypharmacistformedicationadjustments.
Special considerations for bariatric surgery on fertility
Bariatricsurgeryshouldnotbeconsideredatreatmentforainfer-tility.54Many studies related to fertility inwomen post-bariatricsurgery are small, and appropriate control groups have not al-waysbeenincluded.Together,theevidencesuggeststhatbariatricsurgeryimprovesfertility,whetheritisthroughimprovementsofsexhormonalprofilesorresolutionofpolycysticovarysyndromemarkerswhichinfluencefertility(includinganovulation,hirsutism,hormonalchanges,insulinresistance,sexualactivityandlibido).55 The type of surgery does not appear to be related to changes
Special considerations in women who have had bariatric surgery and pregnancy
Comparedwithwomenwhohaveobesityandwhohavenotun-dergone bariatric surgery, womenwho became pregnant afterbariatricsurgeryhadalowerriskofgestationaldiabetes,hyper-tensivedisorders,andmacrosomia.However,riskofsmall-for-ges-tational-agenewbornsincreasesafterbariatricsurgery.62
Preconception care
Womenplanning conceptionpost-bariatric surgery shouldhavedailyoralsupplementationwithamultivitamincontaining1.0mgfolic acid, beginning at least three months before conception.Women should continue this regime until 12weeks gestation-alage.From12weeksgestationalage,continuingthroughthepregnancy, and for four to sixweekspostpartumor as longasbreastfeedingcontinues,continueddailysupplementationshouldconsistofamultivitaminwith0.8mgto1.0mgfolicacid.63B12levelsshouldbecheckedandcorrectedifdeficientpriortoinitia-tionofadditionalfolicacid.WomenareadvisedtoavoidvitaminandmineralpreparationswhichcontainvitaminAintheretinolforminthefirst12weeksofpregnancy,assupplementscontain-ingretinolmayincreasetheteratogenicrisk(especiallyinthefirsttrimester).Itisthereforerecommendedthatpregnantwomenandthoseplanningpregnanciesfollowingbariatricsurgeryaresupple-mentedwithvitaminAinthebeta-caroteneform.
Canadian Adult Obesity Clinical Practice Guidelines 6
Nutritional monitoring during pregnancy
Standardcompletemultivitaminsroutinelyusedpost-bariatricsur-gery shouldbe substituted forprenatalmultivitamins to reducevitaminAintake,whichshouldnotexceed5000IU/day.Continueallotherregularsupplementationthatthepatienttypicallywouldbeon,andthenadjustaccordingtolaboratorytesting.Laboratorytesting at each trimester should includeCBC, ferritin, albumin,B12,25-Hydroxy (OH)vitaminD,calcium,parathyroidhormoneandfolate.Patientswhohavehadhypoabsorptivesurgeryshouldadditionallyhavezinc,copperandvitaminAlevels(andpossiblyvitaminEandK levelswithduodenal switch)monitoredduringpregnancy.14,55,64,65
IfthepatientisvitaminAdeficient,thensupplementationshouldbe in the form of beta-carotene vitaminA.64 Patients sufferingfromnauseaandintractablevomitingshouldhaveimmediateB1supplementation and carefulmonitoring of B1 levels. Nutritionadvicefromanexperiencedregistereddietitianshouldbeofferedtoreviewdeficiencies,vitaminsupplementationandensurearec-ommendeddailyproteinintakeof60g.54Possiblerecommendedgestationalweightgainwouldbebasedonpre-pregnancyBMIaspertheInstituteofMedicine.66
Other considerations during pregnancy
Inadditiontonutritionaldeficiencies, there isalsothepotentialforsevere,life-threateningcomplications,suchasinternalhernias,bowelobstructions, volvulus, intussusceptionandgastric perfo-
rations,whichgenerallyoccurone to threeyearsafterbariatricsurgery. Because of the upward pressure from the gravid uter-us,theselatesequelaemaypresentinpregnancyandduringtheimmediatepostpartumperiod.Abdominalpain inapost-bariat-ricsurgicalgravidwomanwouldneedtoincludethesepotentialcomplicationsinthedifferentialdiagnoses.Radiologicevaluationwithcomputedtomographyscanshouldbereviewedbybariatricsurgeonsorradiologistswithspecializedexpertiseinthisarea.67
Post-surgicalpatientsmaynottoleratethe50gglucosesolutioncommonlyadministeredat24–28weeksofgestation to screenforgestationaldiabetes.Alternativemeasurestoscreenforges-tationaldiabetesshouldbeconsideredforpatientswhohaveun-dergonehypoabsorptive-type surgery.Oneproposedalternativeishomeglucosemonitoring (fastingand two-hourpostprandialbloodsugar)forapproximatelyoneweekduringthe24–28weeksofgestation.54
Canadian Adult Obesity Clinical Practice Guidelines 7
Table 1: Post-Bariatric Surgery Nutrition and Exercise, Vitamin Supplementation and Monitoring for Prevention of Complications
Vitamins and minerals
Daily prevention recommendation post- bariatric surgery (solid line means difference in dosing; — means no evidence of difference in dosing between the types of bariatric surgery)
Description of supplement with suggested timing (most patients will require complete multivitamins [MVs] with additional supple-mentation of B12, D, calcium and iron)
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43. Parrott J,NRD, Frank L, et al.American Society forMetabolic andBariatricSurgery IntegratedHealthNutritionalGuidelinesfortheSurgicalWeightLossPatient 2016Update:Micronutrients. SurgObes RelatDis. 2017;13(5):727-741.doi:10.1016/j.soard.2016.12.018
44. CarlinAM,RaoDS,YagerKM, ParikhNJ, KapkeA. Treatment of vitaminDdepletionafterRoux-en-Ygastricbypass:arandomizedprospectiveclinicaltrial.SurgObesRelatDis.2009;5(4):444-449.
45. LugerM, Kruschitz R, KienbacherC, et al. VitaminD 3 Is Superior toCon-ventionalSupplementationAfterWeight LossSurgery inVitaminD-DeficientMorbidlyObesePatients:aDouble-Blind.ObesSurg.2017;27(5):1196-1207.doi:10.1007/s11695-016-2437-0
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46. Wolf E,UtechM, Stehle P, et al.OralHigh-DoseVitaminDDissolved inOilRaisedSerum25-Hydroxy-VitaminDtoPhysiologicalLevels inObesePatientsAfter Sleeve Gastrectomy-A Double-Blind, Randomized, and Placebo-Con-trolledTrial.ObesSurg.2016;26(8):1821-1829.
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60. Hillman JB, Miller RJ, Inge TH. Menstrual concerns and intrauterine con-traception among adolescent bariatric surgery patients. J Women’s Heal.2011;20(4):533-538.doi:10.1089/jwh.2010.2462