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Tag: Weight loss surgery

Enhanced Cognitive Function after Bariatric Surgery

March 18, 2016 6:51 am

The adverse effects of obesity reduce the body’s natural potential of optimal physical, mental health and cognitive function. Obesity is associated with a greater risk of health problems such as hypertension, stroke, diabetes, and sleep apnea. These issues attribute to an increased risk of dementia and cognitive dysfunction.

Glucose homeostasis plays a key role in the neural mechanisms of the brain. Insulin signals nutrients by circulating within the body in proportion to body fat mass. In addition to other regulatory mechanisms, this allows the brain to control feeding behavior by stimulating energy storage and metabolic homeostasis. Metabolic imbalances modify insulin sensitivity and lead to impaired glucose output inhibition [Qatanani and Lazar et al., 2007 (1)].

System effects of free radicals
System effects of free radicals

Free radicals are formed when weak molecular bonds are split. Their instability causes them to attack neighboring stable molecules and lead to a chain reaction of disturbing living cells. Antioxidants, such as vitamins C and E, defend the body from the damaging effects of free radicals by acting like scavengers. They protect cells from tissue damage that can potentially lead to disease.

Moreover, insulin resistance links oxidative stress, which is the continuous imbalance between free radical production and the body’s antioxidant defenses to detoxify its harmful effects. Enhanced oxidative stress is a result of accumulated fat, which impairs the secretion of insulin and damages glucose uptake in muscle and fat. Increased oxidative stress is the underlying cause of pathogenesis in vascular cell walls that lead to the development of cardiovascular problems, plaque formation. Data suggests, in a study conducted by Dr. Convit (2) in 2002, that management of blood sugar levels may enhance memory and possibly decrease the risk of Alzheimer’s disease.

In congruence with these findings, added stress due to excess weight can negatively affect the anatomy and physiology of the body. A study in 2010, led by Dr. Thompson (3), concluded that obesity is associated with “atrophy in brain areas targeted by neurodegeneration: hippocampus, frontal lobes, and thalamus” [Raji et al., 2010 (3)]. These brain regions play a critical role in the maintenance of memory, executive function, and sensory interpretation, respectively.

Central respiratory function is also disrupted by the mechanical effects of obesity. Reduced lung expansion is especially destructive during sleep. Obstructive sleep apnea is a disorder where breathing stops for brief periods because of an obstructed upper airway. Excess weight and increasing body mass index (BMI) restricts expansion of the chest wall and increases airway resistance, which decreases lung volume [Zammit et al. 2010 (4)]. This boosts respiratory muscle workload for consistent breathing. Complications of sleep apnea include fatigue, heart problems, metabolic syndrome, and more.

Cognitive impairments lead to deficits in executive function, response, reflex time, planning, and memory [Spitznagel et al. 2013 (5)]. Blood sugar levels, oxidative state, respiration and other mechanisms influence our cognitive abilities. Weight loss from bariatric surgery may reduce the comorbidities of an obese patient. The primary outcomes are improvements with diabetes, blood pressure, glucose levels, sleep apnea, BMI, and excess weight resolutions.

Schematic of how cognition is effected by obesity. Source (1)
Schematic of how cognition is effected by obesity. Source (1)

Weight loss surgery reverses the stressors of the body to permit the development and preservation of cognitive function. By improving anatomical aspects of physical health, the overall mental well-being of patients is remarkably enhanced.

A number of studies have looked at the short [Gunstad 2011(6)] and intermediate  [Alosco 2013, (7)] term improvement in memory function after weight loss surgery

Thank you to Contributor: Mariam Michelle Gyulnazaryan

References for Cognitive Function

  1. Qatanani M, Lazar MA. Mechanisms of obesity-associated insulin resistance. Genes & Dev. 2007; 21: 1443-1455.
  2. Convit A, Wolf OT, Tarshish C, de Leon MJ. Reduced glucose tolerance is associated with poor memory performance and hippocampal atrophy among normal elderly. PNAS. 2013; 100 (4): 2019-2022.
  3. Raji CA, Ho AJ, Parikshak N, Becker JT, Lopez OL, Kuller LH, Hua X, Leow AD, Toga AW, Thompson PM. Brain structure and obesity. Hum Brain Mapp. 2010; 31(3): 353-364.
  4. Zammit C, Liddicoat H, Moonsie I, Makker H. Obesity and respiratory diseases. Int J Gen Med. 2010; 3:335-343.
  5. Spitznagel MG, Alosco M, Strain G, Devlin M, Cohen R, Paul R, Crosby RD, Mitchell JE, Gunstad J., Cognitive function predicts 24-month weight loss success following bariatric surgery. Surg Obes Relat Dis. 2013; 9(5): 765-770.
  6. John Gunstad, Gladys Strain, Michael J. Devlin, Rena Wing, Ronald A. Cohen, Robert H. Paul, Ross D. Crosby, James E. Mitchell, 2011, ‘Improved memory function 12 weeks after bariatric surgery’, Surgery for Obesity and Related Diseases, vol. 7, no. 4, pp. 465-472
  7. Michael L. Alosco, Mary Beth Spitznagel, Gladys Strain, Michael Devlin, Ronald Cohen, Robert Paul, Ross D. Crosby, James E. Mitchell, John Gunstad, 2013, ‘Improved memory function two years after bariatric surgery’, Obesity, vol. 22, no. 1, pp. 32-38
  8. Furukawa S, Fujita T, Shimabukuro M, Iwaki M, Yamada Y, Nakajima Y, Nakayama O, Makishima M, Matsuda M, Shimomura I. Increased oxidative stress in obesity and its impact on metabolic syndrome. J Clin Invest. 2004; 114(12): 1752-1761.
  9. Mitchell JE, de Zwaan M. Psychosocial assessment and treatment of bariatric surgery patients. 2011;6: 103-109.
  10. Nguyen JCD, Killcross AS, Jenkins TA. Obesity and cognitive decline: role of inflammation and vascular changes. Front Neurosci. 2014; 8: 375.
  11. Chan JSY, Yan JH, Payne VG. The impact of obesity and exercise on cognitive aging. Front Aging Neurosci. 2013; 5: 97.

Shared Success Story – Albert L.

March 07, 2016 10:46 am

Lose weight, eat smaller portions, eat healthy, go to the gym, don’t eat bread, don’t eat starches, try this diet try that diet….. on and on.
It is so easy for dietitians, nutritionists, cardiologists, family members to speak these words. Being the one with the weight issue, it would drive me crazy hearing all the smart advice everyone had for me. I tried it all without success! Some for one day, some for longer, the results were always the same. I would lose a few pounds and in the end I would gain more. I imagine that the advice givers really didn’t understand the fatigue and appetite that comes with the extra pounds. At 39 years old, 245lbs, on blood pressure and cholesterol meds, all I could see was a life of diabetes and heart disease. Oh, the days I spent in department stores looking at designer clothes I couldn’t wear, talking to women who wouldn’t see past my belly, being the guy at the pool with his shirt on and most of all facing a very rocky future.

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Before surgery
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8 months after surgery

The day I walked into Dr Keshishian’s office was the day my life changed. He looked me in the eyes and told me it’s all going to be better. I had my surgery in June and my recovery was unusually fast. The pounds were dropping daily and within 6 weeks my cardiologist took me off my blood pressure and cholesterol medications. At eight months after surgery,  I am so close to my goal of 180lbs. I have to admit that I would have reached my goal months ago. But a trip to Australia, wining and dining my new fiancé put me off track. But I’m happy to say I’m well on my way to success. Because I am feeling so much healthier, I have joined a gym. Since surgery, I don’t have a huge appetite so I am eating smaller and healthier portions. The future is looking very very bright. Thank you Doc.”

-Albert L.

Fluids and Electrolytes After Weight Loss Surgery

January 29, 2016 7:06 am

Fluids and Electrolytes after weight loss surgery are an important part of recovery and lifestyle after undergoing a weight loss surgical procedure. Potassium is an important electrolyte found in higher concentrations within the fluid of the cells. It is important in muscle contraction, heart rhythm, nerve function and co-enzyme function.

Fluids and Electrolytes

The following webinar (link) discusses the balance of fluids and electrolytes with particular attention to post weight loss surgery concerns. Deficiencies can cause heart arrhythmias, muscle weakness and cramping, intestinal paralysis, and neurological deficits.

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The Daily Recommended Amount for Potassium is  4,700mg

Here is a list of Lower-carb potassium sources: This is not meant to be in inclusive list.  There are many higher carb sources of potassium also.

  • Beet Greens- 1/2C 655 mg
  • Trout 3oz – 375 mg
  • Salmon  719 mg per average filet
  • Halibut or Yellowfin Tuna 3oz – 500mg
  • Clams 3oz- 534 mg
  • Avocados 1 whole- 974 mg
  • Squash 1C- 325mg
  • Broccoli 1 cup 475m
  • Watermelon Radish 3 oz – 233mg
  • Sweet Potatoes- one potato 694mg
  • Yogurt 1C – 579mg
  • Tomato paste 1/4C – 342 mg
  • Whole milk 1C – 366 mg
  • Chicken breast meat 1 cup chopped – 358 mg
  • Cauliflower 1 cup raw– 303 mg
  • Peanut butter 2 T – 208 mg
  • Asparagus spears 6 – 194 m
  • Daikon Radish – 3″ – 280 mg
  • Nuts  100-300 mg per 30g / 1 oz serving, depending on the type
  • Dark leafy greens  160 mg per cup of raw, 840 mg per cooked
  • Kohlrabi 3oz- 98mg
  • Mushrooms 1 C- 273 mg
  • Spinach – 1 cup 167 mg Potassium
  • Walnuts 2 oz-250 mg

Sleep Apnea

January 27, 2016 8:11 am

Snoring is often viewed as an inconvenience but it can be a potentially serious issue. It may be the presenting sign of a condition known as Sleep Apnea. Unfortunately, a serious sleeping condition often gets overlooked, which can triple the risk of death for the affected! Certain signs such as consistent loud snoring, daytime fatigue, and weight gain may be indications of this serious illness.

Sleep Apnea is usually chronic issues that results in  one or more pauses in breathing during sleep. People with this disorder can repeatedly stop breathing while sleeping which usually results in a reduced oxygen supply to the brain and the tissues of the body.

Each pause in breathing is called an “apnea” and can last for several seconds to several minutes. When breathing is paused, carbon dioxide builds up in the bloodstream and chemoreceptors in the blood stream instantly respond to the high carbon dioxide levels. The brain is then signaled to wake the sleeping person and breathe in air in order to release the carbon dioxide built up. Breathing normally restores oxygen levels and the person falls asleep again.

Symptoms of Sleep Apnea:

  • Loud snoring, which is usually more prominent in obstructive sleep apnea
  • Episodes of breathing cessation during sleep witnessed by another person
  • Abrupt awakenings accompanied by shortness of breath, which more likely indicates central sleep apnea
  • Abrupt awakenings with a rapid pounding or racing heart rate
  • Awakening with a dry mouth or sore throat
  • Morning headache
  • Difficulty staying asleep (insomnia)
  • Excessive daytime sleepiness (hypersomnia)
  • Attention problems
  • Irritability

Complications of sleep apnea can result in a variety of health problems, including:

  • High blood pressure
  • Stroke
  • Arrhythmias
  • Obesity
  • Heart Problems
  • Diabetes
  • Depression
  • Headache
  • Weight Gain

Obesity can cause  a specific type of Sleep Apnea called Obstructive Sleep Apnea. Obstructive Sleep Apnea (OSA) is a common chronic disorder that often requires lifelong care.  It is well documented that daytime fatigue can be prevalent in obese patients even though they may not demonstrate symptoms of sleep apnea. However, there is strong data demonstrating the fact that obese patients run a proportionately much higher risk of having sleep apnea.

Bariatric or Weight loss surgery has been shown to be  an effective treatment for OSA in patients who are obese and often also resolves the underlying co-morbidities of sleep apnea. While scientific reasoning for this requires further study it is theorized that the weight loss is associated with a decrease in upper airway collapsibility and obstruction mostly caused by tissues size, which is one of the major causes of Obstructive Sleep Apnea.

Effective weight loss through bariatric surgery has helped many patients achieve complete resolution and improvement of their co-morbidities such as diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea. Studies show sleep investigations performed approximately one year after the bariatric surgery revealed a significant decrease in the number of “apnea” episodes per hour of sleep and an improvement in all sleep quality related measurements as well. Bariatric surgery is perfectly suited for obese patients with OSA.

The correlation between Sleep Apnea and obesity has been well documented and supported through modern science. Clinical data, medical trials, and patient testimonials all underscore major improvements in the symptoms of Sleep Apnea after bariatric surgery.

Success Story: Hasmik

January 13, 2016 2:47 pm

Failed Band: My earliest memory of feeling ashamed of being “too heavy” is from kindergarten. For over 30+ years I have struggled with  gaining weight, trying to lose weight, or going mad maintaining my weight. There is no shortcut that does not come back to bite you in the butt. There is no diet that effectively changes you permanently. For me exercise is a mindful struggle I sometimes successfully commit to over small periods of time.

I was desperate and ready for a real change. I wanted a genuine difference in the way I consumed and related to food and decided the lap band was the way to go. It was marketed as a “non intrusive, non permanent, easily reversible weight loss tool” and that is EXACTLY what I thought I needed and wanted. I was so very wrong, after my surgery I was considered a “success”. In fact up until the removal of my second slipped failed band, esophagus damage, and poor nutrition; I was considered a success. I look back and think how troubling this was/is. How very damaging to the person struggling and dealing with weight issues. Truly, it messed with my mind and my ability to speak up, admit to myself and out loud the band was NOT working for me. In fact, if I’m completely truthful, it was dangerous and turned me into a residue of the person I once was. I was not able to eat comfortably or  eat out any place I happen to be. With the Band, I would need to consider how long I was going to be away from home because I could only eat small bites in small quantities to ensure I did not get stuck or worse vomit what I put inside my mouth. Yes, I had lost almost 100 lbs, but I had given my quality of life as payment. My guilt ensured I would never speak up or complain since I felt “fortunate” and grateful to have had this second chance at life. In my mind, speaking up meant possibly losing the tool (lap band) that allowed me to change my life and reality. Because for the first time in memory, I was the same weight at the start, middle, and end of the year. I did not have to buy different sizes of clothing or underclothing. I could predict what I might wear since my size was stable and my clothes fit. The reality is and was far from this corrupted self truth. I was unhealthy with the restrictive nature of how the lap band worked. In fact my band slipped twice after a severe stomach virus. I later learned of many other symptoms I was making excuses for and quite frankly straight out ignored.

I met Dr. Keshishian (Dr. K) at my lowest weight and at the lowest point in my health. I finally realized, the lap band needed to come out after it had slipped again. It was clear I needed a doctor who would be straight with me and cared for my health and not his/her “success” rates and have the expertise to deal with my failed band. I researched and called several bariatric surgeons then attempted to make appointments with each to discuss the urgent band removal surgery I needed (not as simple as you would think). I was also hopeful I might have the option to undergo the bariatric sleeve surgery because I knew I would not be able to keep my weight under control on my own.  I was unwilling to undergo the emotional and mental torment of gaining and losing weight for the rest of my days. I succeeded in making three appointments and truthfully after meeting and speaking to Dr. K and his office staff I canceled them immediately. Let me start with the staff as that REALLY is important; they help you feel comfortable with the doctor, the procedure, and overall experience. They represent and reflect how the doctor you’re about to see will treat his patients. The expected standard within Dr. Keshishian’s office immediately made me feel like I called the right place. I was taken by the knowledgable, kind tone and efficient manner in which they requested the necessary information to effectively help me get from the starting point to the end goal. When I got to my appointment, Dr. Keshishian BLEW MY MIND. He not only presented himself as an approachable person I  immediately felt at ease with but also reveal my concerns and questions.  He treated me like a person. This may sound strange but this doctor made me feel like a human being with real concerns. He listened to me, asked questions rather than talked at me, and explained how and what was happening to my body and mind. He spent 3 hours with me to answer all my questions (even if I repeated them), draw diagrams, show me video to better help me understand what was happening, and then just sat with me while I cried for a moment. I cried because my 30+ years journey of ups and downs, crazy and insanity finally led me to the door of a man who understood and knew how to help without judgment. WHICH DOCTOR DOES THIS! None that I know.

My life post surgery is what I always hoped it would be. I am able to eat vegetables, leafy greens, fruit, grains and basically a well rounded diet. What’s amazing is that I naturally do not crave sweets, heavy creamy dressings, sauces and fill up quickly. There is after all a difference between the restriction of a lap band and the feeling of being full with the sleeve which Dr. K patiently explained. Today I am able to go any where,  at any time, enjoy the moment and the company rather than worry about what I’m not able to consume. My days of scanning to locate the nearest bathroom in case I need to dash to it are over.

As I write this today, I feel like a real person, not some transient hoping to savor my life at glimpses. I am a person that is balanced in my heart with the average person’s anxiety and mindful eating habits. The sleeve is not a magic end to weight gain, it does give you the fighting chance to make choices in life leading up to results you’re willing to work for.

~ Grateful and Mindful, Hasmik (September 2015 Sleeve Op Patient)

2015 ASMBS Summary

November 11, 2015 7:31 am

The 2015 ASMBS meeting was held November 2-6, 2015.  It was combined with TOS (The Obesity Society) and had more than 5,600 attendees from all over the world in every aspect of obesity treatment.  There were some interesting additions and deletions from this meeting compared to the past.

The one sentence that comes to my mind is “I told you so”.

One important addition was a DS course for Surgeons and Allied Health.  This was very exciting, except the content and questions seemed to gravitate to  SADI/SIPS/Loop rather than DS.  Dr. Cottam was one of the moderators of the course.  It seems that they have found the value in preserving the pyloric valve. It was clear that the discussion was driven by the need to come legitimize the single anastomosis procedures at this early stage with almost no data to prove long term outcome. With many of the Vertical Sleeve Gastrectomies having re-gain and the they are looking for a surgery that the “masses” can perform. This was actually the term used by one of the presenters, implying that the duodenal switch needed to be simplified so that all surgeons, those who have pushed all other procedures can not offer Duodenal Switch to their patients with less than desirable outcome.   Several surgeons also voiced their concern and dissatisfaction with the issues and complication of the RNY and want an alternative.  There was much discussion regarding SADI/SIPS/Loop being investigational and that it shouldn’t be as it is a Sleeve Gastrectomy with a Billroth II.  Dr. Roslin and Dr. Cottam discussed their SIPS nomenclature saying they wanted to stay away from something that had Ileostomy, suggesting bowel issues, or the word “SAD”i  due to negative connotations. The point to be made is that the SADI and SIPS and the loop are all the same.  I have also noticed other surgeons using SADS (Single Anastomosis Duodenal Switch).  There is a great deal of industry behind these procedures and many surgeons being trained in courses funded by industry. One surgeon stood up and informed the entire course that they need to be clear with their patients about the surgery they are performing, as he had been in Bariatric chat rooms and there is upset within the community about SADI/SIPS/Loop being toted as “the same or similar to Duodenal Switch”.

There was also presenter who said “We are doing something new about every five years.” No,  “we” are not. Some of us have stood by the surgery and techniques with the best long term outcomes and not gone with every “new” thing out there. The process of  Duodenal Switch may have changes, open Vs. Lap, drains, location of incisions, post operative care and stay, but the tested procedure with the best outcome has been the duodenal switch operation and not the shortcut versions. Although, those of us that are standing by long term results seems to be in the minority. Why do I stand by Duodenal Switch?  Because it works, when done correctly by making the length of the bowel proportional to the patient total bowel length, and height, and not just cookie cutter length for all patients,  with the right follow-up, patient education, vitamin and mineral regime and eating habits.

A new addition was the Gastric Balloon, which in the research presented had a 60-70% re-gain rate and a no more than 10-15% weight loss one year only. This data represents more than 70% weight regain when the balloon is taken out.  The Gastric Balloons can be left in between 4-6 months depending on the brand or type of balloon. The Gastric Balloon is not new to the Bariatrics and was first introduced in 1985. After 20 years and 3,608 patients the results were  and average of 17.6% excess weight loss. It seems that we are re-gurgiating old procedures. There are many new medications that were front and center in this meeting.

The Adjustable Gastric Bands were missing from the exhibit hall this year. It is my hope and feeling from the other attendees that we may be seeing the era of the Adjustable Gastric Band being placed in patients come to an end.  Although there are some still holding out that there are some patients that can do well with the Band.

Attending the 2015 ASMBS meeting this year, as it has every year, only reemphasized the importance of avoiding what has become the norm of chasing a simple solution that is fashionable and easy now. We stay convinced that the duodenal switch operation with the common channel and the alimentary length measured as a percentage of the total length is by far the best procedure with the proven track record. The patient should avoid the temptation of settling for an unproven procedure or device, because if history holds true, there will be a need for revision surgeries in the future.

 

 

 

 

Bowel Length in Duodenal Switch

November 09, 2015 6:25 am

Malnutrition is one of the most feared complication of the duodenal switch operation. It may present years after surgery. What is common is a mix of nutritional deficiencies which include fat soluble vitamins, and protein calorie malnutrition. These all point to possible excessive shortening of the common channel. In my practice we have seen patients that have had lengthening of their common channel to improve their metabolic picture. What is very obvious to us, is that we see disproportionately higher number of cases coming to us for revision from practices where the common and alimentary lengths are done as a “standard” numbers with no specific adjustments made for the patient, their anatomy and situation. I have said for years, that the length of the bowel that is measured to be become the common and the alimentary limb should be a percentage of the total length of small bowel, rather than a pre-determined measurement. Here is a visual description of how this works.

If a common channel and the alimentary limb is measured to be a percent of the total length then the chance of protein calorie malnutrition is minimized since this will take into account the bowels absorptive capacity which is being reduced. This decrease in the absorption is done as a fraction of the total length.

Raines et al. published  a study in 2014, that showed how small bowel length is related more closely to a patient’s height and not weight.  And yet, some surgeons totally based the length of the common channel and the alimentary limb arbitrarily based on the patient pre operative BMI and nothing else. Could this be the cause of why I see some patients coming to us for revision of their duodenal switch for malnutrition?

Shared Success Story- Stephanie U.

September 22, 2015 7:38 am

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Before Sleeve Gastrectomy

When I think back as far into my childhood as I can remember my weight was always a problem. I grew up being made fun of and missed out on the simple things that normal kids do growing up because my weight caused limitations.

Even into early adulthood I was still made fun of, but I learned to deal with it. I tried different methods of trying to lose weight. I went to a gym, tried  diet pills, followed diets, cut out foods, sodas, alcohol, etc.  Sure these things worked (very slowly) for a period of time, but then I would plateau and became discouraged and gain whatever little weight I lost plus some. By the time I was 27yrs old I found myself at my heaviest at 245lbs and I was also pregnant with my first child. I was lucky enough to have a healthy pregnancy.  However after I had my daughter, I went up to 265lbs and just couldn’t get it off. I felt the toll the weight was taking on my body. My hips would ache, go numb, my lower back would get stiff, I would become winded just walking upstairs, it was difficult to get up from sitting, my feet would be sore if I was standing too long. I began to realize this was just going to get worse as time went on and as my daughter got older parenting would become more difficult. It became an even bigger concern to be healthier now that I had a little one depending on me and looking up to me.
I decided to explore the option of surgery in late 2013. I knew it was something that my insurance would cover so long as I met the requirements so I set out to find a reputable surgeon in my area.
Surprisingly I reached out into a Facebook group and was overwhelmed with recommendations for Dr. Keshishian (I was originally interested in the DS surgery). I went for my consultation in December of 2013.  Upon meeting with Dr. Keshishian I knew I wouldn’t have wanted anyone else to perform this surgery on me. He was very upfront, honest, and straightforward with information regarding what was to come and the effort that needed to be put forth in order for this to work. The Gastric Sleeve was brought up and I decided to go with the sleeve surgery. I pushed forth and the staff at Dr. K’s office began the process of approval which happened to move very swiftly and smoothly.

I ended up having my surgery on 4/11/14 and I weighed 265lbs on the day of. Today, as I write this I am, approaching my 30th birthday healthier than I think I have ever been and I currently weigh 152lbs. The adjustment post-op was not an easy one, but it was well worthwhile. I am much more active, able to keep up and play with my daughter. I feel like I am living a normal life for once. I was scared, nervous, and had so many worries running through my head prior to surgery but now that I have gone through it I would make the same decision all over again in a second’s time.

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After Sleeve Gastrectomy