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Weight-loss surgery found to slash cancer risk and mortality

09/06/2022

Bariatric surgery, also commonly referred to as weight-loss surgery, can help to reduce the risk of developing six different types of cancer associated with obesity, new research suggests. For the study, more than 1,600 obese people who had either gastric bypass surgery or sleeve gastrectomy surgery were compared to a control group of over, 2,100 obese individuals with obesity who did not undergo surgery. Both groups were matched in terms of age, sex and BMI. According to the study, the findings of which were presented at the 2022 annual meeting of the American Society for Metabolic and Bariatric Surgery (ASMBS), people who underwent bariatric surgery were also less likely to develop any type of cancer compared to their obese peers who had not had surgery. In fact, the study found that only 5.2 percent of people who had bariatric surgery went on to develop some type of cancer during the 10-year study period, compared to 12.2 percent of those who did not have weight loss surgery. Furthermore, the overall 10-year survival rate for patients who underwent surgery was 92.9 percent, while it was just 78.9 percent for the non-surgical group. Commenting on the study, Dr. Shanu Kothari, president of the ASMBS, said: “Patients live longer after bariatric surgery because they have less cardiac events and less cancers.” *Image by Bruno /Germany from Pixabay

Gastric Surgery Should be Offered Regardless of Weight, Says Leading UK Surgeon

25/10/2016

A leading bariatric surgeon in the UK has urged the government to offer gastric surgery to patients regardless of their weight. According to Professor Francesco Rubino, the Chair of Bariatric and Metabolic Surgery at Kings College, thousands of type-2 diabetes patients in the UK are missing out on vital weight loss surgery because they do not meet the NHS's guidelines when it comes to weight. That's because, at present, only type-2 diabetes patients who have a BMI of over 30 are currently eligible for bariatric surgery. Rubino says that weight loss surgery is "the closest thing to a cure" and should be used more often. In the UK, there are around 3.6 million people with type-2 diabetes, which costs the NHS up to £10 billion a year to treat. However, approximately 15% of sufferers are "normal weight" and so don't qualify for weight loss surgery under the NHS's current guidelines. "The biggest barrier we have is primarily one of stigma against obesity. The vast majority of the public believes this is a cosmetic intervention and unfortunately many physicians think the same way," said Rubino. Rubino also highlighted that weight loss surgeries, which manipulate the stomach or small intestine, do not just help people lose weight, but actually influence insulin production by altering hormones in the person's gut. "More than 50% of people with type 2 diabetes can enjoy long term remission. Another 30 or 40% enjoy a major improvement," he added.

Study Finds Bariatric Surgery Decrease Gout Risk

13/10/2016

A study in Sweden has found that obese individuals who underwent bariatric surgery had a 34% less likelihood of developing gout - a condition that is often associated with and aggravated by being overweight. For the study, researchers analysed two groups of individuals: one which had undergone bariatric surgery and one which had followed intensive lifestyle modifications, including advice on food choices, energy intake and exercise. They found that over 26 years of follow-ups, there were 138 new cases of gout in the group that had undergone the surgery and 201 new cases in the matched, non-surgery group. Interestingly, the patients in the surgery group had higher body mass indexes; larger waist circumferences; and worse glucose and cholesterol levels. Speaking about their findings, the team, which was headed up by Lena M.S. Carlsson, MD, of the University of Gothenburg, said: "The beneficial effects of bariatric surgery are not limited to weight loss, but they extend to improvement in metabolic parameters and to lower risk of developing type 2 diabetes, cardiovascular disease, and cancer." Other studies have previously suggested that bariatric surgery can lead to lower serum uric acid levels, which are the primary cause of gout.

Bariatric Surgery Best for Long-Term Weight Loss

05/09/2016

The benefits of weight loss surgery for obese and overweight individuals have been known for a long time. However, a new study now shows that the results of bariatric surgery are not just short-term, and much of the weight appears to stay off for at least 10 years. In fact, the study goes on to state that bariatric surgery is more effective than other surgical procedures and non-surgical techniques when it comes to weight loss and long-term weight management. Published in the journal JAMA Surgery, the findings are notable because they include the results of a decade-long follow-up, in addition to two separate areas of study. Lead author of the study Matt Maciejewski, who is a professor of medicine at Duke University School of Medicine, in Durham, N.C., said: “This study suggests that patients interested in bariatric surgery, especially gastric bypass surgery, should be able to lose a significant amount of weight and keep that weight off for a very long time." For the study, the researchers first compared thousands of veterans who had received bariatric surgery to another group that hadn't. After a year, the bariatric surgery group had lost 31% of their starting weight, while the other group had lost just 1%. After 10 years, the bariatric surgery group had managed to maintain a nearly 21% greater weight loss than their non-surgical counterparts, highlighting the long-term benefits that weight loss surgery can have. The researchers then looked into how effective different types of weight loss surgery are. They found that after four years, patients who had undergone a gastric bypass had lost nearly 28% of their starting weight, while those who a had sleeve gastrectomy lost about 18% and those with gastric banding lost about 11%.

Study shows bariatric weight loss surgery saves lives

07/06/2016

A new study has found that obese patients who undergo bariatric weight loss surgery have a greater chance of survival than those who do not. According to the research from a team at the University of Gothenburg in Sweden, weight loss surgery decreased the chance of death by as much as 57% compared with not having it. Being obese or overweight has been linked to many diseases, including heart attack, stroke and several different cancers, and can increases a person's risk of death as a result. Of the 48,693 patients (aged 18 to 74 years old), 22,581 underwent bariatric surgery - a gastric band was fitted in 92.8% of cases. The remaining 26,112 obese patients had no surgery at all. The researchers, led by Dr Christina Persson, found that the mortality rate in the group that did not have surgery was 4.21% compared to just 1.1% for the surgical group. That's equivalent to 7.7 deaths per 1,000 people each year versus just 2.1. Cardiovascular disease was the most common cause of death in the non-surgical group, followed by cancer, while external causes of mortality, such as suicide and accidents, were found to be the most common causes of death in the surgical group. "The study indicates that the overall all-cause mortality is considerably lower among obese individuals who undergo bariatric surgery compared to non-surgical obese individuals, and the differences lies mainly in cardiovascular disease and cancer," said Dr Persson. The findings of the study were presented at the recent European Obesity Summit in Sweden. To find out how France Surgery can help you undergo bariatric weight loss surgery, contact us today.

More obese people in the UK should undergo weight loss surgery, say surgeons

12/05/2016

Surgeons in the UK have said that the number of weight loss operations performed on the NHS each year needs to rise dramatically, so that people become healthier and the health service itself saves money. Writing recently in the British Medical Journal, the bariatric surgeons said that less than 1% of people who could benefit from weight loss surgery are getting treatment, and the numbers are actually dropping, despite rising rates of obesity and diabetes. [Related article: Mediterranean diet reduces heart attacks and strokes] The surgeons also highlighted that the UK is lagging behind its European counterparts when it comes to weight loss surgery, and that there are 2.6 million people in the country who stand to benefit from surgery. According to the surgeons, people who have stomach shrinking operations lose 25-35% of their body weight, on average, in just a year. In comparison, the average loss through diets and weight loss drugs is just 7% a year. It's thought that a quarter of adults in the UK are now classified as obese - the second highest rate in Europe behind Hungary - and this reality is putting a huge strain on NHS resources and funds. The National Institute for Health and Care Excellence (Nice) has previously indicated that surgery should be considered for severely obese people who have unsuccessfully tried all other means to lose weight. Find out more about bariatric surgery with us in France here.

Study: Mental Health Conditions Common Before Bariatric Surgery, but Fall Afterwards

20/01/2016

Patients who are seeking and undergoing bariatric surgery commonly suffer from mental health conditions, such as depression and binge eating disorders. However, following successful bariatric surgery, the rates of these conditions fall, according to a study published in JAMA. Bariatric surgery is a highly accepted method of promoting weight loss in obese individuals and can also serve to reduce their risk of developing conditions such as heart disease, stroke, type 2 diabetes and certain kinds of cancer. Dr. Aaron J. Dawes, from the David Geffen School of Medicine at the University of California, Los Angeles, led a research team which wanted to discover how common mental health conditions were in people seeking and undergoing bariatric surgery. The findings of their research show that 23% of bariatric surgery patients were affected by a current mental health disorder, with depression (19%); a binge-eating disorder (17%); and anxiety (12%) the most common. Following surgery, a fall in the rate of depression was observed. Of the 27 studies analysed by the research team, seven revealed an 8-74% drop in the rate of depression after surgery, while six reflected a 40-70% reduction in the rate of depressive symptoms. The report authors noted: "Previous reviews have suggested that self-esteem, mental image, cognitive function, temperament, support networks and socioeconomic stability play major roles in determining outcomes after bariatric surgery." They suggest incorporating these factors into future studies, which would help form part of "an optimal strategy for evaluating patients' mental health prior to bariatric surgery."   Photo via: Bassett Healthcare Network 

Gastric Banding Surgery

03/06/2015

GASTRIC BANDING SURGERY Gastric Banding surgery (Lap band surgery) is one of the different bariatric surgery's techniques Principle: Restrictive technique that reduces the size of the stomach and slows the passage of food. Digestion of food is not affected. A lap band (adjustable in diameter) is placed around the upper part of the stomach, creating a small pouch. Only a small amount of food is required to fill this pouch and a feeling of fullness occurs quickly. Based on the same principle as an hourglass, foods will pass through the stomach very slowly. Characteristic: The only adjustable technique: Adjustable Gastric Banding Surgery is linked to a port placed under the skin via a small tube. This Gastric Banding can be tightened or untightened by injecting liquid into the port, through the skin. Radiological monitoring is necessary during follow-up. The Gastric Banding (or Lap band) can be removed through a new operation in the event of complications, lack of efficiency or at the patient's request. Expected weight loss: About 40 to 60 % excess weight loss, corresponding to a weight loss of approximately 20 to 30 kg1. If the Gastric Banding (Lap band) is removed, weight is usually regained. (studies with 10 years follow-up). Main operating time: about 15 minutes Main length of hospital stay: 1, 2 days All health facilities represented by France Surgery are recognized as Surgery Center of Excellence in obesity surgery by the EAC-BS European Accreditation Council for Bariatric Surgery.   CONSIDERING GASTRIC BANDING (LAP BAND) SURGERY IN FRANCE ? CLICK HERE FOR A FREE QUOTE To find out more about the advantages and disadvantages of Bariatric surgery in France: http://www.laparoscopic-surgeon.com/ www.soffco.fr (French Society for Bariatric Surgery) www.mangerbouger.fr (French National Nutrition Health Programme)  www.has-sante.fr (French National Health Autority)

Sleeve Gastrectomy

03/06/2015

SLEEVE GASTRECTOMY Sleeve Gastrectomy is a restrictive technique which consists of removing approximately two thirds of the stomach and, in particular, the part containing the cells that secrete the hormone that stimulates appetite (ghrelin). The stomach is reduced to a vertical tube and food passes quickly into the intestine. Appetite is also reduced. This technique does not interfere with the digestion process. Sleeve gastrectomy is sometimes the first step in a biliopancreatic diversion procedure. Expected Weight Loss: Around 45 to 65 % excess weight loss after 2 years, corresponding to a weight loss of approximately 25 to 35 kg. (studies with 2 years follow-up, for a person of average height (1.7 m) with a BMI of 40 kg/m) Mean operating time: 2 hours (Provided there are no complications during the operation). Mean length of hospital stay: 3 to 8 days (Provided there are no complications after the operation). Main complications risks : Ulcers, leakage or stenosis of the remnant stomach. Early postoperative bleeding. Possible nutritional deficiencies (to be monitored). Gastrooesophageal reflux (acids and foods coming back up the oesophagus) and inflammation of the oesophagus.Dilation of the stomach.   French health facilities represented by France Surgery are all recognized Surgery Center of Excellence in European obesity surgery by the EAC-BS European Accreditation Council for Bariatric Surgery.   CONSIDERING SLEEVE GASTRECTOMY IN FRANCE ?  CLICK HERE FOR A FREE QUOTE   To find out more about the advantages and disadvantages of the different Bariatric surgical techniques: http://www.laparoscopic-surgeon.com/ www.soffco.fr Société française et francophone de chirurgie de l’obésité www.mangerbouger.fr (French National Nutrition Health Programme) www.has-sante.fr (French Health Authority)  

Gastric Bypass

03/06/2015

GASTRIC BYPASS SURGERY Gastric Bypass technique is used to reduce the stomach’s size and the food absorption in the digestive tube in order to trigger a significant weight loss. Often described as 'more comfortable' than Lap Band surgery by patients, this surgery is irreversible and implies a lifelong medical follow up and potential vitamins’ intake. The digestive bypass created during surgery leads to food derivation directly to the middle part of the small intestine. This surgery exists since 1990 and is performed on thousands of patients every year in France. We then have significant medical data to access its risk and benefits. GASTRIC BYPASS is conducted under general anaesthetic, usually via laparoscopy. This technique is recommended because it reduces the amount of pain experienced and allows the patient to return to normal activity quickly. In some cases, during the operation it is necessary to open up the abdomen (laparotomy) for safety reasons. The time spent in hospital will vary from 2 to 10 days depending on the type of operation and the general health of the patient. It may be extended. You should plan to have at least 2 weeks off work when you come out of hospital. Expected Weight Loss: Around 70 to 75 % excess weight loss, corresponding to a weight loss of approximately 35 to 40 kg (studies with 20 years follow-up for a person of average height 1.7 m with a BMI of 40 kg/m2). Mean operating time: 1,5 to 3 hours (Provided there are no complications during the operation). Mean length of hospital stay: 4 to 8 days (Provided there are no complications after the operation). Mean complications risk : Surgical complications: ulcers, leakage or stenosis at the junction between the stomach and the intestine, bleeding, occlusion of the intestine. Nutritional deficiencies. Functional complications: hypoglycaemia after meals, dumping syndrome, constipation French healthcare facilities represented by France Surgery are all recognized Surgery Center of Excellence in European obesity surgery by the EAC-BS European Accreditation Council for Bariatric Surgery. CONSIDERING GASTRIC-BYPASS IN FRANCE ? CLICK HERE FOR A FREE QUOTE   To find out more about the advantages and disadvantages of the different Bariatric surgical techniques: http://www.laparoscopic-surgeon.com/ www.soffco.fr French Society for Bariatric surgery www.mangerbouger.fr (French National Nutrition Health Programme)  www.has-sante.fr (French Health Autority)

Weight-Loss Surgery Could Save the NHS Money Says TV Doctor

02/02/2015

The National Health Service (NHS) in the UK is seemingly struggling to cope with the demand for its services. Since the beginning of the year, 14 hospitals in the UK have declared ‘major incidents’ because they are unable to cope with the “unprecedented pressure” being placed upon them this year. Surgical procedures and outpatient appointments have been cancelled amid the turmoil and some hospitals have even set up makeshift wards to accommodate patients. But now, one of the UK’s best-loved TV doctors has spoken out about the economic benefits to the NHS of weight loss surgery for obese individuals. Countless studies have shown that being overweight has a significantly detrimental effect on a person’s life, including increased risk of type 2 diabetes, cancer, heart problems and stroke. Furthermore, one in four adults and one in five children in the UK are considered obese – a fact that puts a huge burden on the already struggling NHS. Obesity-related problems are thought to cost the NHS around £6 billion a year and Dr Christian Jessen – who presents Channel 4’s Weighing Up The Enemy – believes it makes economic sense to offer gastric band and gastric bypass operations to obese individuals. He said: “It is very clear to me we need to invest more now in this type of procedure in order to save considerable amounts in the future”. It is thought that within two to three years, bariatric surgery pays for itself and so the argument for it to be undertaken on the NHS or privately carries a lot of weight.

Weight Loss Surgery Found to Benefit Lower Urinary Tract Symptoms

22/12/2014

The benefits of weight loss surgery have been known for quite some time now and it’s a procedure that has helped many people regain their confidence and start living normal lives again. However, new research has shown that people with metabolic syndrome are more prone to lower urinary tract problems and that weight loss surgery can be used to significantly improve lower urinary tract symptoms. The first of the two studies was conducted by Dr. François Desgrandchamps and his colleagues at the Saint-Louis Hospital in Paris, France. They studied 4,666 men over a period of 12 days in 2009 and found that there was a strong link between metabolic syndrome and lower urinary tract symptoms. Furthermore, lower urinary tract symptoms were more severe in men with metabolic syndrome. The second study, conducted by a team at Wakefield Hospital in New Zealand, analysed 72 weight loss surgery patients before and after their procedures. They found that after just 6 weeks patients with lower urinary tract symptoms showed significant improvement. Metabolic syndrome is thought to affect around 34% of adults in the U.S. and puts them at greater risk of strokes, heart attacks, type 2 diabetes and cardiovascular disease. It is diagnosed when an individual displays three or more metabolic risk factors, which include high cholesterol, high blood pressure, abdominal obesity and high blood glucose levels. For more information about bariatric procedures in France, contact France Surgery.

New Report Shows Bariatric Surgery Has Many Benefits

10/11/2014

According to a recent study by the National Bariatric Surgery Registry (NBSR), almost 40% of people in the UK who undergo weight-loss surgery are, in fact, super-obese. Not only is this startling reality hard to comprehend but it also threatens to cripple the NHS in the future, unless this trend is curbed. However, the research also discovered that bariatric surgery actually has a significant effect on some of the chronic illnesses that are associated with being overweight; something that will help alleviate the overstretched NHS. Conditions such as type 2 diabetes are often linked with obesity and the study showed that after bariatric surgery two thirds of sufferers showed no sign of the condition two years later. Bariatric surgery, which usually involves gastric bands or reducing stomach sizes, is now actively being seen as a highly beneficial weight-loss solution as highlighted by the NBSR’s chairman Richard Welbourn: “For severely obese people, medical therapy, lifestyle changes and attempts at dieting rarely succeed in maintaining long-term, clinically beneficial weight loss due to the hormonal effects of being obese”. The NBSR’s report is based on over 18,000 operations conducted between 2010 and 2013, but NHS cuts could mean that the number of bariatric surgeries in the UK next year is restricted. It’s still the case that prevention is better than cure when it comes to medicine, but the NBSR’s study demonstrates that bariatric surgery, when required, is an effective and safe procedure for losing weight. Find out more about how we can facilitate bariatric surgery for you here in France.

Clinique des Cèdres

04/09/2014

Clinique des Cèdres, Toulouse Clinique des Cèdres was created in 1966 thanks to Dr Anduze-Acher. Since then it became the biggest private hospital in France with 603 beds and places. In 2003, its acquisition by Capio group – already settled in Toulouse with Polyclinique du Parc, Clinique St Jean du Languedoc, Clinique de Beaupuy – helped its development. Clinique des Cèdres provides state-of-the Art equipment to its medical teams.   Amongst the mini invasive surgical techniques: Robotic: In urology for the prostate cancer treatment, the kidney and bladder surgery In gynaecology for the uterus cancer surgery and the pelvic node dissection In ENT for the oral cavity, pharynx surgery, for the cellulo-node, nasopharyngeal surgery (cavum) Coelio-surgery for bariatric surgery Computer-aided surgery and strereotactic for the treatment of brain tumors Mini-invasive surgery for spine surgery (disc prothesis), orthopaedic surgery (perecutaneous foot surgery & trauma surgery) and rectal surgery (haemorrhoidal Doppler-assisted dearterization) 2. Advanced diagnosis techniques: Fluorescence technique in endoscopy for the early detection of lung cancers and bladder tumors 3D plan sensor in cardiology for the diagnosis and treatment of heart attacks and thoracic pains and in neuro radiology for the brain exploration and the therapeutic treatment of some brain vascular anomalies Non invasive Diagnosis-Imaging system: 64 strips scan Computerised diagnosis, evaluation, and follow-up care for knee cruciate ligament UNITS: 1. SURGICAL UNITS: more than 20 theatres covering a extremely wide variety of surgeries: Digestive surgery: ceolioscopy - endoscopy Orthopaedic surgery: arthroscopy Neurosurgery: neuronavigation device (O-arm concept) Ophthalmology ENT Outstanding surgical equipments include a stereotactic frame, a laminar flow, a laser, electronic microscopes and a DaVinci robot. 2. RECOVERY UNITS: the rooms are equipped with modern monitoring equipments and are under permanent anaesthetis supervision. Specialized nurses have the responsability of the post-operation personal follow-up care of the patient. 3. DIAGNOSIS AND MEDICAL IMAGING DEPARTMENT Angiography - Coronarography - Echigraphy - MRI - Mammography - Conventional and interventional radiology - Scan 4. NUCLEAR MEDICINE Functional and metabolic medical imagining, not accessible with conventional imaging equipment is performed in this department. 5. MEDICINE 6. INTENSIVE-CARE AND CONTINUOUS MONITORING UNIT 7. EMERGENCIES 8. HELIPAD 9. FUNCTIONAL PHYSIOTHERAPY 10. PSYCHIATRY 11. ONE-DAY HOSPITALISATION

Clinique Ambroise Paré

03/09/2014

Clinique Ambroise Paré, Paris The Ambroise Paré clinic situated in Bourg La Reine was founded in 1964 and belongs to the group Vedici since 2001. The establishment has a capacity of 66 beds and seats, a technical platform and a medical imaging service. The primary purpose of the institution and the major part of its activity is still represented today by the pole Maternity Obstetrics, providing gynaecological and obstetric emergencies; the clinic is also specialised in gynaecological surgery, esthetical and reparatory surgery, vascular surgery, bariatric surgery, ENT surgery, urology, orthopaedics and ophthalmology. The Ambulatory surgery is a way of care to shorten your hospitalisation for surgery to one day. So you go in the morning to be operated on the same day and you come out at night. The duration of hospital stay is reduced to a few hours. Key figures Surgical operation beds 16 Surgical ambulatory places 11 Surgical operating rooms 4 Bood bank 1 Recovery rooms 1 Imaging service 1 Ultrasound room 1 Doppler ultrasound 1 SURGERY:    - Gynaecology    - Esthetical    - Vascular    - Bariatric    - ENT    - Urology    - Orthopaedics    - Ophthalmology    - Dental The clinic disposes of a medical imagery unit, comprising 4 rooms: a general radiology room 1 mammography, breast imaging and bone densitometry room 1 room with dental sensor Plan, panoramic, Cone Beam and implantology 1 room of general ultrasound and Doppler echocardiography.

The Dos and Don’ts Following Gastric Band Surgery

03/07/2014

Gastric band surgery is a significant medical procedure and one that will ultimately change your life forever. That’s why you need to assess all the factors before you make the decision to proceed with gastric band surgery. However, while following medical advice leading up to your procedure is important, your aftercare is perhaps even more crucial. After all, you’ll be recovering from a major procedure and your body needs all the help it can get to heal correctly. It’s important that you adhere to strict dietary guidelines following your surgery. It’s of equal importance to take all-round good care of yourself. This is to allow the staple line in your stomach to be given a chance to heal, without being stretched through excessive eating or damaged by physical activity. Here are our top dos and don’ts following gastric band surgery: DON’T over exert yourself physically through lifting and stretching DO contact your medical professional if you have any concerns DON’T play with your stitches DO follow any advice given to you upon discharge DON’T expect to eat normally for quite some time DO drink plenty of fluids – 8 cups a day or as advised by your medical professional DON’T try and eat too much – your stomach will only be able to hold about one cup of food at a time DO eat protein-rich foods to help the healing process DON’T eat foods that are high-calorie or contain a lot of sugar DO chew your food thoroughly before swallowing DON’T eat too quickly DO ensure that you take recommended vitamin and mineral supplements You’re not going to be restricted forever, so it’s important that you take good care of yourself following your gastric band procedure. Find out more about Bariatric surgery and consider spending your vital recovery time in a beautiful country like France.

Bariatric

05/06/2014

What is weight loss surgery about? Obesity is a chronic disease. It can lead to difficulties in everyday life. It may also be affecting your general health and cause diseases such as diabetes, hypertension, high cholesterol, sleep apnoea ... Obesity surgery, often referred to as bariatric surgery, has been developed to help you lose weight permanently and control the diseases caused by obesity. However, to have surgery is an important decision and should only be made once all alternatives have been assessed. The Hospitals and clinics that are partners with France SURGERY are all recognised European Centres of Excellence in bariatric surgery by the EAC-BS European Accreditation Council for Bariatric Surgery.

Bariatric (fr)

17/04/2014

What is weight loss surgery about ? Obesity is a chronic disease. It can lead to difficulties in everyday life. It may also be affecting your general health and cause diseases such as diabetes, hypertension, high cholesterol, sleep apnoea ... Obesity surgery, often referred to as bariatric surgery, has been developed to help you lose weight permanently and control the diseases caused by obesity. However, to have surgery is an important decision and should only be made once all alternatives have been assessed. The Hospitals and clinics that are partners with France SURGERY are all recognised European Centres of Excellence in bariatric surgery by the EAC-BS European Accreditation Council for Bariatric Surgery.

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