Summary Appeal Letter - Studies and Standards

Here is my final letter (I hope) in my year+ insurance appeal. I was finally told that I qualify for a revision but that they need more studies on whether VSG is appropriate after band failure. Sheesh, can't they do a search on PubMed for themselves? At any rate, I put it all together in a huge letter. I'm thinking this letter could help others...

Please forgive the formatting, it didn't cut and past over well...

[Opening paragraph contains specifics about my case and attorney]

The OPM has recommended that this case be re-submitted for further medical review and the information contained in this letter contains additional information as requested by the OPM. In this letter we will also show the following:

A. That a revision surgery is medically necessary and, in fact, that the medical necessity was already established by Regence in October of 2009. Vertical sleeve gastrectomy is a covered procedure.

B. That the Sleeve Gastrectomy is a medically appropriate course of treatment. Of the four weight loss surgeries currently available, the vertical sleeve gastrectomy procedure is the most appropriate given the patient’s history and the study data currently available.

Revision is Medically Necessary

As stated above, revision surgery meets the requirements of medical necessity. Ms. Udy’s lap band failed in early 2009 as confirmed by endoscopy and fluoroscopy procedures. Removal of the failed gastric band and weight loss surgery revision were deemed medically necessary by the patient’s primary care physician and surgeon, Drs. Brogren and Billing.
In addition to physician-established medical necessity, the following must also be considered:

1. Medical necessity for a revision has already been established by Regence when they covered removal of the failed gastric band in October of 2009. As per common medical standards for bariatric surgery, correction of a failed primary bariatric procedure includes revision as well as repair. Revision is necessary to provide continuation of care for the original diagnosis of morbid obesity under which the primary procedure was covered. By covering the explant of the gastric band, Regence has already established medical necessity for a revision; it is not reasonable to claim that medically necessity doesn’t exist as a reason for denying coverage of the second half of the revision process.

2. Federal BCBS plans routinely provide coverage for the sleeve gastrectomy and for weight loss surgery revisions, including revisions from gastric band to a gastric sleeve. (See the appendix for the list of states and surgeons where gastric sleeve procedures have been covered).
As per prior communication with Federal BCBS, vertical sleeve has been a covered gastric restrictive procedure since January of 2008. It is clearly covered under the plan benefits which include:

“Gastric restrictive procedures, gastric malabsorptive procedures, and combination restrictive and malabsorptive procedures to treat morbid obesity.”

Note that there are no exclusions referring to the sleeve gastrectomy -- either as a primary or revisionary procedure.

3. The patient meets the standard medical criteria set forth for weight loss surgery revision.
In 2008 the American Society for Metabolic & Bariatric Surgery presented medical guidelines for bariatric surgery. Recommendation R163 specifically recommends revision of a bariatric surgical procedure if there were medical complications resulting from the initial surgical procedure. Insurance companies appear to have considered this recommendation when developing their own medical policies for bariatric revision.

Regence’s own medical policy for bariatric surgery includes this reference to revision:

“Reoperation to address complications of a bariatric procedure may be considered medically necessary. These include, but are not limited to, staple-line failure, obstruction, stricture, non-absorption resulting in hypoglycemia or malnutrition, weight loss of 20% or more below ideal body weight, band erosion, band migration.”

Nowhere in Regence’s bariatric policy or in the Federal BCBS plan is weight or BMI ever suggested as a possible prerequisite to revision surgery. It would be unreasonable to require a patient to regain all of their weight in order to have coverage to remove a failed lap band just as it would be unreasonable to ask a cardiac patient to have another heart attack before a failed pacemaker is replaced.

Most insurance companies appear to have policies that support this basic bariatric revision guideline: if the primary bariatric procedure fails, revision surgery is deemed medically necessary without re-introduction of the same weight and diet requirements of the initial procedure. Even Medicare, whose policies often set the standard for coverage, clearly states the following:

“Previous gastric restrictive procedures that have failed for anatomic or technical reasons (e.g., obstruction, staple dehiscence, etc.) are determined to be medically appropriate for revision without consideration of the initial preoperative criteria.”
(See additional policy examples in the appendix at the end of this letter.)

Sleeve Gastrectomy is Medically Appropriate

The patient’s surgeon and primary care physician have recommended the following (also refer to letters which were submitted during the appeal process as well as physician notes included in the case file):

· Immediate removal of the failed lap band in order to prevent further damage to the patient’s stomach and esophagus.

· Revision to a different weight loss surgery (specifically sleeve gastrectomy) as necessary to prevent recurrence of morbid obesity and recurrence of comorbidities.

There are four weight loss surgeries currently performed today. Roux en Y bypass and duodenal switch bypass provide both gastric restriction and malabsorption. The remaining two procedures, gastric banding and sleeve gastrectomy provide gastric restriction only.

For Mrs. Udy, the gastric sleeve was determined to be the most appropriate revision procedure of the four procedures routinely covered by Federal BCBS for the following reasons:

1. Recent studies show that the gastric band procedure has a significantly high failure rate.

2. Without revision, patients with a failed lap band regain weight and suffer ongoing morbid obesity.

3. Replacement of the lap band is contraindicated in patients with a slip and/or esophageal dilation.

4. In this case, the patient only requires gastric restriction for successful treatment of morbid obesity.

5. Recent studies indicate that the sleeve gastrectomy is, in general, a safe weight loss surgery with statistically high success rate and a reasonably low rate of complications.

6. Recent studies also indicate that the sleeve gastrectomy is a medically appropriate revision procedure for former gastric band patients.

7. As per common standards of medical care, the treating physician determines which of the available and approved treatment options is most appropriate for the patient.

8. A malapsoptive procedure such as the Roux en Y gastric bypass or the duodenal switch was deemed unnecessarily risky because the patient was previously successful with a restrictive-only procedure.

The remainder of this letter presents study data and additional information as requested by the OPM for each of the eight reasons listed above.

1. Recent studies show that the gastric band procedure has a significantly high failure rate.

1.1. Allergan, the manufacturer of the Lap Band, published the following as part of their Patient Safety Information.
“In the United States clinical study, with 3-year follow-up reported, 88% of the 299 patients had one or more adverse events, ranging from mild, moderate, to severe. Nausea and vomiting (51%), gastroesophageal reflux (regurgitation) (34%), band slippage/pouch dilatation (24%) and stoma obstruction (stomach-band outlet blockage) (14%) were the most common post-operative complications. In the study, 25% of the patients had their band systems removed, two-thirds of which were following adverse events.”

1.2. Published in the journal Obesity Surgery in 2008, the study Long-Term Results of Bariatric Restrictive Procedures: A Prospective Study[i] lap band failure rates were documented at 54% with the most frequent complications being pouch dilatation (21%) and anterior slippage (17%). 44% of the patients required repair or revision.

1.3. In the study Analysis of poor outcomes after laparoscopic adjustable gastric banding published in June of 2010 by George Washington University[ii], the authors indicate a high complication rate for gastric banding procedures including reoperation for 16.7% of the patients in the study. The majority of the patients also failed to achieve a 50% excess weight loss. They also noted that 11% of the patients in the study required revision to the sleeve gastrectomy.

1.4. In another study that included patients observed over 9 years, Long-Term Results and Complications Following Adjustable Gastric Banding[iii], 52.9% patients had at least one complication requiring reoperation and the band was removed for 28.6%.

1.5. Most significant is a recent study A 10-year experience with laparoscopic gastric banding for morbid obesity: high long-term complication and failure rates[iv]. In this study, a group of physicians from Switzerland led by Dr. M. Suter, MD, PD, FACS, examined the long-term complications related to LapBand weight-loss surgery. The study demonstrated that LapBand long-term complications increase over time. Overall, 33.1% of patients had at least one long-term complication related to gastric banding. This study concludes:

“LGB appeared promising during the first few years after its introduction, but results worsen over time, despite improvements in the operative technique and material. Only about 60% of the patients without major complication maintain an acceptable EWL in the long term. Each year adds 3-4% to the major complication rate, which contributes to the total failure rate. With a nearly 40% 5-year failure rate, and a 43% 7-year success rate (EWL >50%), LGB should no longer be considered as the procedure of choice for obesity. Until reliable selection criteria for patients at low risk for long-term complications are developed, other longer lasting procedures should be used.”

2. Without revision, patients with a failed lap band regain weight and suffer ongoing morbid obesity. In the study Weight loss and quality of life after gastric band removal or deflation[v], nearly 88% of patients whose lap bands were removed regained weight. This study, like several others, indicate that revision is necessary to treat morbid obesity over the patient’s lifetime.

3. Replacement of the lap band is contraindicated in patients with a slip and/or esophageal dilation. As noted in many of the studies cited above, slips and esophageal dilation are a relatively common complicate for lap band surgery patients – as high as 20% of all patients will suffer from one or the other or both. Because esophageal dilation is not treatable and because it is a progressive disorder, reinstruction of a lap band is contraindicated. The only treatment for lap band slips and esophageal dilation is removal or de-inflation of the lap band which, as shown in item 2 above, results in a return to morbid obesity in 88% of patients studied. Sleeve gastrectomy is the only restrictive revision procedure available for patients who suffer these complications.

4. In this case, the patient only requires gastric restriction for successfully treatment of morbid obesity. Until the failure of the gastric band, the patient had successfully reduced her excess weight by 90% and all of her comorbidities had been resolved. Therefore a revision to the only other gastric restrictive procedure available, the gastric sleeve, was deemed both appropriate and medically necessary.

5. Recent studies indicate that the sleeve gastrectomy is a safe weight loss surgery with statistically high success rate and a reasonably low rate of complications.

5.1. In a position statement from 2009, the American Society for Metabolic and Bariatric
Surgery (ASMBS) determined that sleeve gastrectomy is an "approved bariatric surgical procedure" based on 35 studies covering 2,400 patients.

5.2. 5-year results from one of the longest ongoing studies were presented in 2007. That study, Laparoscopic Vertical Sleeve Gastrectomy for Morbid Obesity: a Report of a Five-Year Experience with 750 Patients” presented by Lee, Cirangle and Jossart concludes that:
“Laparoscopic VSG demonstrates comparable weight loss to the Gastric Bypass after three years with 0% mortality. Long term morbidity is almost nonexistent compared to the Gastric Bypass.”

5.3. In the study Laparoscopic Sleeve Gastrectomy as Revisional Procedure for Failed Gastric Banding and Vertical Banded Gastroplasty[vi] published in 2009 a study of 41 patients with a failed gastric band concluded that “Conversion of GB and VBG into LSG is feasible and safe. LSG is effective in the short term with a mean %EWL of 42.7% at 13.4 months.”

5.4. In the study Laparoscopic sleeve gastrectomy: a retrospective review of 1- and 2-year results published in the journal Surgical Endoscopy in 2009 the authors conclude that:
“Our results show that LSG is a safe and effective weight-loss procedure with results similar to those of gastric bypass.”.[vii]

5.5. The study Laparoscopic Sleeve Gastrectomy as a Single-Stage Bariatric Procedure [viii] published in 2009 concludes that:
“laparoscopic sleeve gastrectomy has achieved satisfactory weight loss results with an acceptable complication rate in the medium-term.”

5.6. In a study published through the University of Rome in 2010 entitled Laparoscopic sleeve gastrectomy as first stage or definitive intent in 300 consecutive cases[ix], the authors conclude:
“SG is a safe and effective treatment for morbid obesity at mid-term follow-up. SG is effective for comorbidities resolution, especially for the treatment of diabetes.”

5.7. In a 5 year study published in 2009 entitled Sleeve Gastrectomy as Sole and Definitive Bariatric Procedure: 5-Year Results for Weight Loss and Ghrelin[x], the authors report success with mean excess weight loss at nearly 60% after 5 years as well as post-operative ghrelin levels which also remained low during the 5 year study period.

5.8. In Spain, a National Registry has been created to track outcomes of the sleeve gastrectomy. In a study of the registry, entitled The study Short- and mid-term outcomes of sleeve gastrectomy for morbid obesity, sleeve gastrectomy[xi] the results of 540 patients studied found the resolution of morbid obesity to be 81%. It concluded that sleeve gastrectomy “provides good short- and mid-term results with a low morbid-mortality rate.” Another finding showed that the best results “are obtained in younger patients with lowest BMI” – making it an appropriate surgery for Ms. Udy.

5.9. In Sleeve gastrectomy: a new surgical approach for morbid obesity presented by the University of Vermont College of Medicine, the authors stated:

“An extensive literature review was conducted and the information currently available surrounding LSG, such as history, indications and contraindications, mechanism of weight loss, technique and outcomes and controversial issues are discussed. LSG is an accepted procedure for the surgical management of morbid obesity. It is gaining popularity as a primary, staged and revisional operation for its proven safety and simplicity, as well as short-term and mid-term efficacy. Excess weight loss and remission of comorbidities have been reported to take place in a frequency comparable with other well-established procedures.”

5.10. In the study A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: Results after 1 and 3 years[xii] the authors concluded that:

“Weight loss and loss of feeling of hunger after 1 year and 3 years are better after sleeve gastrectomy than gastric banding. In that study the date is compelling, showing weight loss at 1 and 3 years out with the gastric sleeve at nearly double the weight loss with gastric banding.
5.11. In the study Weight loss over time for adjustable gastric bands, Roux-en-Y gastric bypasses, and sleeve gastrectomies: A comparative analysis [xiii] published by the American Society of Metabolic and Bariatric Surgery, researcher Snyder reported on data from an analysis of almost 7,000 patients who underwent Roux-en-Y gastric bypass, adjustable gastric banding, or sleeve gastrectomy over a five-year period. Analysis of weight loss over time showed gastric banding to have the lowest rate of weight loss (0.16/day average over 302 days), which was significantly less compared with 0.41/day over 226 days with gastric bypass and 0.39/day over 99 days with sleeve gastrectomy (P less than 0.001). Bypass and sleeve gastrectomy achieved comparable weight loss (P=0.34).

6. Recent studies also indicate that the sleeve gastrectomy is a medically appropriate revision procedure for former gastric band patients.

6.1. In the paper Laparoscopic Sleeve Gastrectomy[xiv] presented in 2009 by the Bariatric & Metabolic Institute of the Cleveland Clinic the authors stated:
“In conclusion, LSG can be performed with minor complications and low mortality. It has been demonstrated to be a safe and effective procedure in the short and midterm and an adequate alternative for failed LAGB.”

6.2. The study Two-Year Results on Morbidity, Weight Loss and Quality of Life of Sleeve Gastrectomy as First Procedure, Sleeve Gastrectomy After Failure of Gastric Banding and Gastric Banding[xv] published in 2009 stated in its conclusion:

“Initial BMI was significantly higher in the Sleeve Gastrectomy group but was no longer significantly different from the BMI of the Gastric Banding group at 12 and 24 months. Excess BMI loss was higher after Sleeve Gastrectomy than after Gastric Banding. This reduction of BMI was considered to be a success for Gastric Banding. Thus, results of Sleeve Gastrectomy should be considered as a success. Quality of life was not significantly different between the three groups. These results validated Sleeve Gastrectomy as first procedure or after failure of Gastric Band.”

6.3. The study Feasibility of Laparoscopic Sleeve Gastrectomy as a Revision Procedure for Prior Laparoscopic Gastric Banding[xvi] published in 2006 followed patients for a year following failed gastric banding and concluded that:

“Laproscopic Sleeve Gastrectomy proved to be feasible and safe after Laproscopic Adjustable Gastric Banding”.

6.4. The study Feasibility and technique of laparoscopic conversion of adjustable gastric banding to sleeve gastrectomy[xvii] concludes:

“The results of this study support the safety of LSG in the case of an inadequate %EWL after Laproscopic Adjustable Gastric Banding.”

6.5. Similar outcomes were identified in the study Safety and short-term outcomes of laparoscopic sleeve gastrectomy as a revisional approach for failed laparoscopic adjustable gastric banding in the treatment of morbid obesity.[xviii]

6.6. In the Spanish study cited in section 5 above, Dr. Baltasar specific noted that the sleeve gastrectomy is also indicated “for the patients where the lap-band has given complications such us poor weight lost, perforation and removal or poor QOL.”

7. As per common standards of medical care, the treating physician determines which of the available and approved treatment options is most appropriate for the patient. Sleeve gastrectomy is one of several weight loss surgeries covered by Federal BCBS and is not excluded for primary or revisionary procedures. In Ms. Udy’s case, the surgeon chose sleeve gastrectomy and sleeve gastrectomy is covered. The OPM should not allow Regence to withhold a covered, and medically appropriate, treatment. The patient has the right to any of the procedures covered under her insurance plan for her diagnosis.

8. A malapsoptive procedure such as the Roux en Y gastric bypass or the duodenal switch was deemed unnecessarily risky because the patient was previously successful with a restrictive-only procedure.

8.1. In general, studies show that malabsorptive procedures carry a significantly higher risk of complications and death. The complication rate for Roux en Y A ranges from 6.5% to 14.5% (depending upon how the procedure is preformed) as compared to 1.5% for the sleeve gastrectomy.

8.2. The duodenal switch procedure is generally recommended in patients with a BMI of 50 or
above. In addition to a high rate of surgical complications, significant malabsorption leading to anemia, protein deficiency and metabolic bone disease in up to 5% of patients.

In Closing

The OPM has recommended that this case be re-submitted for medical review and has requested that we provide additional information indicating why the sleeve gastrectomy revision should be covered. Study after study, not all of which are cited here, reiterate the finding published by the ASMBMS in 2009 – that the sleeve gastrectomy is an approved and appropriate bariatric procedure. Additional studies verify both the safety and efficacy of the sleeve gastrectomy as well as it’s place in bariatric revisions.

Given the data included in this letter -- as well as all of the other information provided to the OPM since the appeal was submitted in October of 2009 – we request that the OPM immediately overturn Regence’s denial of coverage. To do otherwise is a violation of insurance policy and well documented bariatric standards of care, and will directly affect the patient’s health and well-being.

[closing and signature]

Appendix A
Example list of surgeons with Federal BCBS patients for whom VSG procedures were covered (including revision).

Dr. Andrew Hargroder
1014 West St. Clare Blvd., Ste 1000
Gonzales, LA 70737
1-225-743-2333

Surgical Specialists of Louisiana
Dr. Thomas Lavin
7015 Highway 190 East Service Road, Suite 200
Covington, Louisiana 70433
Phone: 985.234.3000

Oklahoma Weight Loss Options
Dr. Lana Nelson
3400 W Tecumseh Suite 205
Norman, OK 73072
(405) 360-7100

Dr. Andrew Averbach, M.D.
700 Geipe Rd., Suite 274
Catonsville, MD 21228
Phone: 410-368-8725

Dr. James Davidson, M.D.
8210 Walnut Hill Lane
Dallas, TX 75231
214-265-7546

Ashraf A. Hilmy, M.D.
Harlingen, TX 78550

George Eckles
1602 West Northfield Blvd.
Suite 504
Murfreesboro, TN 37129
Phone: (615) 867-1940

Dr. Wade Barker
1151 North Buckner BlvdDallas, Texas 75218Phone: 1-877-923-3227
Bariatric Institute at Cleveland Clinic
Dr. Raul J. Rosenthal
2950 Cleveland Clinic Boulevard
Weston, FL 33331
954.659.5000

Southern Arizona Surgical Weight Loss Center
Dr. Patrick Chiasson, Dr. Stephen E. Burpee
6320 N. La Cholla BLVD, Suite 380
Tucson, AZ 85741
Phone: (520) 219-8690

Dr. Kuldeep Singh, M.D.
7625 Maple Lawn Boulevard, Suite 145
Fulton, MD 20759
Ph: 301-490-2193

Comprehensive Bariatric Surgery Center, Baylor
Dr. Vadim Sherman
6620 Main Street
Houston, TX 77030
(713) 798-5662

Mickey Seger, MD, FACS, FASMBS
9910 Huebner Rd, Ste 250
San Antonio, TX 78240
Phone: (210) 615-8500

Toby Broussard, M.D.
1800 S. Renaissance Blvd
Edmond, OK 73013
Phone: (405) 359-2473
Guillermo Alvarez M.D.
www.EndoBariatric.com
112 Rodrigo Andalon St. Suite A
Piedras Negras, Mexico


Appendix B

Example Bariatric Revision Policies

Example 1 – Aetna Bariatric Revision Policy

Aetna considers repeat bariatric surgery medically necessary for members whose initial bariatric surgery was medically necessary (i.e., who met medical necessity criteria for their initial bariatric surgery), and who meet either of the following medical necessity criteria:
· Conversion to a RYGB or BPD/DS may be considered medically necessary for members who have not had adequate success (defined as loss of more than 50 percent of excess body weight) two years following the primary bariatric surgery procedure and the member has been compliant with a prescribed nutrition and exercise program following the procedure; OR
· Revision of a primary bariatric surgery procedure that has failed due to dilation of the gastric pouch is considered medically necessary if the primary procedure was successful in inducing weight loss prior to the pouch dilation, and the member has been compliant with a prescribed nutrition and exercise program following the procedure.

Example 2 – United Healthcare

Revisional surgeries are covered for patients who have had previous surgical treatment for morbid obesity if the patient had previously met the medical necessity indications at the time of the initial surgery.

Example 3 – ODS Healthplan

Reoperation and Surgical Revision:
Surgical revision may be considered medically necessary when a patient develops complications
from the original surgery (i.e. stricture or obstruction). Medical and surgical complications may
be covered if determined to be medically necessary even if the original surgery was not a covered
benefit.

Example 4 – University of Pittsburgh Medical Center

Repeat or revision bariatric surgery is considered medically necessary for any of the following:
1. To correct complications from surgery such as obstructions or strictures, OR
2. When the primary procedure has failed due to dilation of the gastric pouch, AND
If the primary procedure was successful in inducing weight loss prior to the pouch
dilation, AND The member has been compliant with the prescribed nutrition and exercise
Program.

Example 5 – Blue Care of Michigan

Previous gastric restrictive procedures that have failed for anatomic or technical reasons (for example, obstruction, staple dehiscence, etc.) are determined to be medically appropriate for revision without consideration of the criteria outlined here [ed. note: referring to weight criteria].

Example 6 – WellCare Health Plans

Repeat bariatric surgery is considered medically necessary under the following condition ONLY:
1. A complication has occurred associated with the original procedure

Example 7 – BCBS of Tennessee

Bariatric surgery, for the treatment of morbidly obese individuals 18 years or older, is considered medically appropriate if ANY ONE of the following criteria are met:

An individual who has had a prior bariatric surgical procedure and is requesting / requiring a revision, alteration or reversal must have a related medical or surgical complication of that procedure that is documented by the physician.

Bibliography
[i] Long-Term Results of Bariatric Restrictive Procedures: A Prospective Study
Schouten R, Wiryasaputra DC, van Dielen FM, van Gemert WG, Greve JW.
Obesity Surgery, 2008

[ii] Analysis of poor outcomes after laparoscopic adjustable gastric banding.
Kasza J, Brody F, Vaziri K, Scheffey C, McMullan S, Wallace B, Khambaty F.
Surg Endosc. 2010 Jun 30.

[iii] Long-Term Results and Complications Following Adjustable Gastric Banding.
Lanthaler M, Aigner F, Kinzl J, Sieb M, Cakar-Beck F, Nehoda H.
The Journal of Metabolic Surgery and Allied Care, 2010

[iv] A 10-year experience with laparoscopic gastric banding for morbid obesity: high long-term complication and failure rates
Suter M, Calmes JM, Paroz A, Giusti V.
Obesity Surgery, 2006

[v] Weight Loss and Quality of Life After Gastric Band Removal or Deflation
Lanthaler M, Strasser S, Aigner F, Margreiter R, Nehoda H.
Obesity Surgery, 2009

[vi] Laparoscopic Sleeve Gastrectomy as Revisional Procedure for Failed Gastric Banding and Vertical Banded Gastroplasty
Iannelli A, Schneck AS, Ragot E, Liagre A, Anduze Y, Msika S, Gugenheim J.
Obesity Surgery, 2009

[vii] Laparoscopic sleeve gastrectomy: a retrospective review of 1- and 2-year results
Jacobs, Bisland, Gomez, Plasencia, Mederos, Celaya and Fogel
Surgical Endoscopy, 2009

[viii] Laparoscopic Sleeve Gastrectomy as a Single-Stage Bariatric Procedure
Tarik Sammour, Andrew G. Hill, Parry Singh, Anudini Ranasinghe, Richard Babor and Habib Rahman
Obesity Surgery, 2010

[ix] Laparoscopic sleeve gastrectomy as first stage or definitive intent in 300 consecutive cases
N. Basso, G. Casella, M. Rizzello, F. Abbatini, E. Soricelli, G. Alessandri, C. Maglio and A. Fantini
Surgical Endoscopy, 2010

[x] Sleeve Gastrectomy as Sole and Definitive Bariatric Procedure: 5-Year Results for Weight Loss and Ghrelin
Arthur Bohdjalian, Felix B. Langer, Soheila Shakeri-Leidenmühler, Lisa Gfrerer, Bernhard Ludvik, Johannes Zacherl and Gerhard Prager
Obesity Surgery, 2010

[xi] Short- and mid-term outcomes of sleeve gastrectomy for morbid obesity: the experience of the Spanish National Registry.
Sánchez-Santos R, Masdevall C, Baltasar A, Martínez-Blázquez C, García Ruiz de Gordejuela A, Ponsi E, Sánchez-Pernaute A, Vesperinas G, Del Castillo D, Bombuy E, Durán-Escribano C, Ortega L, Ruiz de Adana JC, Baltar J, Maruri I, García-Blázquez E, Torres A.
Obesity Surgery, 2009

[xii] A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years.
Himpens J, Dapri G, Cadière GB.
Obesity Surgery, 2006

[xiii] Weight loss over time for adjustable gastric bands, Roux-en-Y gastric bpasses, and sleeve gastrectomies: A comparative analysis"
Snyder B et al
ASMBS 2010; Abstract PL-311.

[xiv] Laparoscopic Sleeve Gastrectomy
Ismael Court, MD; Omar Bellorin, MD; Fernando Dip, MD; Christopher DuCoin, MD; Samuel Szomstein, MD, FACS; and Raul J. Rosenthal, MD, FACS
Surgical Perspective, Bariatric Times, 2009

[xv] Two-Year Results on Morbidity, Weight Loss and Quality of Life of Sleeve Gastrectomy as First Procedure, Sleeve Gastrectomy After Failure of Gastric Banding and Gastric Banding
Sabbagh, Verhaeghe, Dhahri, Brehant, Fuks, Badaoui and Regimbeau
Obesity Surgery, 2010

[xvi] Feasibility of Laparoscopic Sleeve Gastrectomy as a Revision Procedure for Prior Laparoscopic Gastric Banding
P Bernante, M Foletto, L Busetto, F Pomerri, F Francini Pesenti, MR Pelizzo and D Nitti
Obesity Surgery, 2006

[xvii] Feasibility and technique of laparoscopic conversion of adjustable gastric banding to sleeve gastrectomy.
Dapri G, Cadière GB, Himpens J.
Presented as an oral presentation at the 25th Annual Meeting of the American Society for Metabolic and Bariatric Surgery, Washington, DC, June 15–20, 2008

[xviii] Safety and short-term outcomes of laparoscopic sleeve gastrectomy as a revisional approach for failed laparoscopic adjustable gastric banding in the treatment of morbid obesity.
Acholonu E, McBean E, Court I, Bellorin O, Szomstein S, Rosenthal RJ.
Obesity Surgery, 2009