Obesity Surgery, 14, 1157-1164

Bariatric Surgery Worldwide 2003

Henry Buchwald, MD, PhD, FACS; Stanley E. Williams, PhD
Department of Surgery, University of Minnesota, Minneapolis, MN, USA
Background: There is a world epidemic of overweight, obesity, and morbid obesity, encompassing 1.7 billion people. Bariatric surgery today is the only effective therapy for morbid obesity. Methods: E-mail requests for information were sent to the presidents of the national societies of the 31 International Federation for the Surgery of Obesity (IFSO) nations, or national groupings, plus Sweden. Responses were tabulated; calculation of relative prevalence of specific procedures was done by weighted averages. Results: Responders were 26 of 32 (81%) for the general questions and 24 of 32 (75%) for the question on specific operative percentages. In the year 20022003, 146,301 bariatric surgery operations were performed by 2,839 bariatric surgeons; 103,000 of these operations were performed in USA/Canada by 850 surgeons. The earliest start date for bariatric surgery was 1953 in the USA; IFSO was founded in 1995. In the year 2002-2003, 37.15% of operations were open; 62.85% laparoscopic. The 6 most popular procedures by weighted averages were: laparoscopic gastric bypass, 25.67%; laparoscopic adjustable gastric banding, 24.14%; open gastric bypass, 23.07%; laparoscopic long-limb gastric bypass, 8.9%; open long-limb gastric bypass, 7.45%; and open vertical banded gastroplasty, 4.25%. Pooling open and laparoscopic procedures, relative percentages were: gastric bypass, 65.11%; gastric banding, 24.41%; vertical banded gastroplasty, 5.43%; and biliopancreatic diversion/duodenal switch, 4.85%. Categorizing into restrictive/malabsorptive, purely restrictive, and primarily malabsorptive, the relative distribution of procedures was 65.11%, 29.84%, and 4.85%, respectively. The number of countries performing gastric banding was 23 (95%), gastric bypass 21 (88%), vertical banded gastroplasty 19 (79%), and biliopancreatic
Presented at the 8th World Congress of the International Federation for the Surgery of Obesity (IFSO) in Salamanca, Spain, September 4, 2003. Supported, in part, by Ethicon Endo-Surgery, Inc., Cincinnati, OH, USA. Reprint requests to: Henry Buchwald, MD, PhD, FACS, University of Minnesota, 420 Delaware Street SE, MMC 290, Minneapolis, MN 55455, USA. Fax: 612-625-3206; e-mail: buchw001@umn.edu

diversion/duodenal switch 16 (67%). Purely restrictive procedures were performed in 24 (100%) of the countries, restrictive/malabsorptive in 21 (88%), and primarily malabsorptive in 18 (75%). Conclusions: Bariatric surgery is expanding exponentially to meet the global epidemic of morbid obesity. Operative procedures in bariatric surgery are in flux and specific geographic trends and shifts are evident. Yet, of the patients qualifying for surgery, only about 1% are receiving this therapy the only effective treatment currently available. Key words: Morbid obesity, bariatric surgery, gastric bypass, gastric banding, gastroplasty, biliopancreatic diversion, duodenal switch, laparoscopy

Introduction
There is a world epidemic of overweight (body mass index [BMI] 25) and obesity (BMI 30), estimated to encompass 1.7 billion people.1,2 According to the Worldwatch Institute, the number of overweight people is approximately equal to the number of underweight people.3 Of all the world's nations, the percentage of adult overweight is highest in the United States (about 60%).4-7 However, overweight people are in excess of 50% in Russia, the United Kingdom, and Germany; 20% in Colombia, Brazil, Italy, Austria, and Switzerland; and even 10% in China.8 In Australia, 41% of adult men and 23% of adult women are overweight. In the Federated States of Micronesia, 80% of women 40 to 49 years old are overweight and over 50% are obese.8 Globalization, stated to be an undeniable economic evolution, appears also to be an undeniable weight evolution. Morbid obesity (BMI 40 or BMI 35 in the presence of significant co-morbidities9) is estimated to afflict about 20% of the obese population.4-7 It is in this population that bariatric surgery has come to the
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forefront as the only current mode of therapy that is reasonably successful. Bariatric surgery not only markedly lowers body weight, but reverses or ameliorates the myriad of obesity co-morbidites (e.g., type 2 diabetes, hypertension, hyperlipidemia, heart disease, stroke, asthma, obstructive sleep apnea, back and lower extremity weight-bearing degenerative problems, many forms of cancer, depression, etc.) responsible for >2.5 million deaths per year worldwide.10 The response of the world community of bariatric surgeons to the obesity epidemic was the creation of the International Federation for the Surgery of Obesity (IFSO) in 1995. Since 1999, the annual IFSO congresses have included the International Symposium on Laparoscopic Obesity Surgery (ISLOS), and since 2003, Executive Council membership for Allied Health. The first president of IFSO was Nicola Scopinaro of Genoa, Italy, whose 1997 Presidential Address served as the precursor for this report.11 At present, IFSO has 31 member nations with Sweden as a correspondent nation. The absence of a current international review of bariatric surgery number of cases, number of surgeons, membership in IFSO, and the relative distribution of the standard bariatric operations worldwide and per nation has stimulated this report. These data are based on the compilation and tabulation of responses to an e-mail survey.

4. When did your country join IFSO? The questionnaire also requested the relative percentage of open and laparoscopic operations, and the relative percentage of the following specific bariatric procedures performed: Open adjustable gastric banding Laparoscopic adjustable gastric banding Open gastric bypass Laparoscopic gastric bypass Open long-limb gastric bypass Laparoscopic long-limb gastric bypass Open vertical banded gastroplasty Laparoscopic vertical banded gastroplasty Open biliopancreatic diversion Laparoscopic biliopancreatic diversion Open duodenal switch Laparoscopic duodenal switch Other (specify)

Data Analysis
For the tabulation of findings, the supplied data are presented. For the calculation of relative prevalence of specific procedures, weighted averages are used to compensate for the wide ranges of the number of procedures performed: % Variable x Number of Variable ______________________________ Number of Variable

Materials and Methods Questionnaire

E-mail requests for information were sent to the presidents of an IFSO nations society for bariatric surgery and other national bariatric surgery leaders (see Acknowledgements). These requests were followed, if necessary, by second e-mail requests and communications seeking clarification. The e-mail survey consisted of 4 general questions: 1. Approximately how many bariatric surgery operations were being done in your country yearly? 2. Approximately how many surgeons practise bariatric surgery in your country? 3. When did bariatric surgery start in your country?
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Results Response Rate

Of the 31 IFSO nations (or national groupings) plus Sweden (n=32), 26 responded for a response rate of 81%. New Zealand data are included with those of Australia and Luxembourg data with those of Belgium. For Brazil and Panama, only incomplete information was available on the specific bariatric procedures performed; thus, those calculations are based on 24 responders for a response rate of 75%.

First General Question

The 26 responders performed a total of 146,301 operations annually (year 2002-2003 data) (Table 1). USA/Canada performed the most procedures at

Bariatric Surgery Worldwide 2003

Table 1. Question 1 - Approximately how many bariatric surgery operations are being done in your country yearly? Argentina - 200 Australia (New Zealand) - 2,750 Austria - 1,396 Belgium (Luxembourg) - 6,000 Brazil - 4,000 Czech Republic - 400 Egypt - 2,750 France - 12,000 Germany - 1,100 Greece - 500 Hungary - 30 Israel - 1,000 Italy - 3,000 Japan - 20 Mexico - 2,500 Netherlands - 800 Panama - 60 Poland - 145 Russia - 350 Spain - 2,000 Sweden - 600 Switzerland - 800 Turkey - 150 Ukraine - 150 United Kingdom - 600 USA/Canada 103,000 Table 2. Question 2 - Approximately how many surgeons practise bariatric surgery in your country? Argentina - 30 Australia (New Zealand) 68 Austria - 38 Belgium (Luxembourg) - 200 Brazil - 510 Czech Republic - 6 Egypt - 12 France - 200 Germany - 54 Greece - 8 Hungary - 1 Israel - 50 Italy - 200 Japan - 20 Mexico - 200 Netherlands - 40 Panama - 5 Poland - 14 Russia - 35 Spain - 160 Sweden - 20 Switzerland - 90 Turkey - 5 Ukraine - 10 United Kingdom - 13 USA/Canada - 850

Total (Responders) 2,839 Table 3. Question 3 - When did bariatric surgery start in your country? Argentina - 1988 Australia (New Zealand) - 1960 Austria - 1973 Belgium (Luxembourg) - 1970 Brazil - 1973 Czech Republic - 1983 Egypt - 1996 France - 1984 Germany - 1975 Greece - 1978 Hungary - 1999 Israel - 1978 Italy - 1973 Japan - 1982 Mexico - 1971 Netherlands - 1973 Panama - 1989 Poland - 1974 Russia - 1969 Spain - 1977 Sweden - 1970 Switzerland - 1970 Turkey - 1990 Ukraine - 1978 United Kingdom - 1955 USA/Canada - 1953

Total (Responders) 146,301

103,000. Nations performing 2,000 operations or more annually were France, 12,000; Belgium, 6,000; Brazil, 4,000; Italy, 3,000; Australia (New Zealand), 2,750; Egypt, 2,750; Mexico, 2,500; and Spain, 2,000.

Second General Question

The 26 responders reported a total of 2,839 bariatric surgeons: 850 in USA/Canada, 510 in Brazil, 200 in Belgium, 200 in France, 200 in Italy, 200 in Mexico, 160 in Spain and less than 150 for the rest of the responders (Table 2).

Earliest Start Date 1953 USA Latest Start Date 2002 Panama

Third General Question

The earliest start date for bariatric surgery was 1953 in the USA; the most recent start date among the 26 responder nations was 2002 in Panama. All of the specific start dates for the responders are given in Table 3. The cumulative numbers of nations performing bariatric surgery, by the decade they started, are shown in Figure 1.

They were joined in 1996 in Prague by Austria, Belgium (Luxembourg), Brazil, Germany, Greece, and the Netherlands, and in 1997 in Cancun by France, Israel, Paraguay, and Spain (Table 4, Figure 2).

Open vs Laparoscopic
Of the 26 responder nations (or national groupings), the relative percentages of open procedures vs laparoscopic were 37.15% to 62.85%. Thus, today, nearly two-thirds of the world's bariatric surgery is performed laparoscopically.
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Fourth General Question

IFSO was founded in 1995 in Stockholm by the following nations: USA/Canada, Australia (New Zealand), Italy, Mexico, and the Czech Republic.

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30 27 25 25 22
No. of Nations

35 30 30 25 20 20 15 15 10 8 17 20 24 25 31

No. of Nations

20 15 10 5 0 1950 1960 4 2

17

5 0 1995 1996 1997 1998 1999 2000 2001 2002 2003

1970

1980

1990

2000

Decade since 1950 Decade since 1950

Figure 2. Cumulative number of nations (or national groupings) joining IFSO by year.

Figure 1. Cumulative number of nations (or national groupings) starting bariatric surgery by decade since 1950.

Procedures Performed Worldwide

For the 24 responder nations (or national groupings) information on specific bariatric procedures, using weighted averages, is listed in Table 5. Subsequent to the initial tabulation of the data, the other category of the questionnaire was replaced by laparoscopic nonadjustable gastric banding and open jejunoileal bypass. The 3 leading procedures, each comprising over 20% of the total, were laparoscopic gastric bypass (25.67%), laparoscopic adjustable gastric banding (24.16%), and open gastric bypass (23.07%). The 6 most commonly performed procedures in this 24-nation subset and their weighted averages are shown in Figure 3. The distribution per nation (or national groupings) of the 15 bariatric surgery procedures cataloged is
Table 4. Question 4 - When did your country join IFSO? Argentina - 2000 Australia (New Zealand) 1995 Austria - 1996 Belgium (Luxembourg) - 1996 Brazil - 1996 Czech Republic - 1995 Egypt - 1997 France - 1997 Germany - 1996 Greece - 1996 Hungary - 2002 Israel - 1997 Italy - 1995 Japan - 1998 Mexico - 1995 Netherlands - 1995 Panama - 2002 Poland - 2002 Russia - 2000 Spain - 1997 Switzerland - 1999 Turkey - 1998 Ukraine - 2000 United Kingdom - 2000 USA/Canada - 1995

given in Table 6. The number of nations (or national groupings) performing specific bariatric procedures and the relative percentages for this 24-nation subset is given in Table 7.

Derivative Data
When the open and laparoscopic procedures are pooled in the 24 nations cohort, with biliopancreatic diversion/duodenal switch considered a single category, gastric bypass took a commanding world lead (65.11%), followed by gastric banding (24.41%), vertical banded gastroplasty (5.43%), and biliopancreatic diversion/duodenal switch (4.85%) (Figure 4). Categorizing the procedures by weighted averages
Table 5. Bariatric surgery procedures worldwide % Laparoscopic gastric bypass Laparoscopic adjustable gastric banding Open gastric bypass Laparoscopic long-limb gastric bypass Open long-limb gastric bypass Open vertical banded gastroplasty Open duodenal switch Laparoscopic vertical banded gastroplasty Laparoscopic biliopancreatic diversion Open biliopancreatic diversion Laparoscopic duodenal switch Open adjustable gastric banding Laparoscopic gastric pacing Laparoscopic nonadjustable gastric banding Open jejunoileal bypass 25.67 24.16 23.07 8.92 7.45 4.25 2.03 1.18 1.09 0.87 0.85 0.17 0.15 0.08 0.07

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Bariatric Surgery Worldwide 2003

30% 25.67% 24.16% 25% 23.07%

20%

15%

8.92% 10% 7.45% 4.25% 5%

0% Lap. Gastric BypassLap. Adjustable Gastric Banding Open Gastric Bypass Lap. Long-Limb Open Long-Limb Gastric Bypass Gastric Bypass Open Vertical Banded Gastroplasty

Figure 3. Six most commonly performed procedures by weighted averages.

into the functional categories of restrictive/malabsorptive (gastric bypass standard and long-limb), purely restrictive (gastric banding, vertical banded gastroplasty), and primarily malabsorptive (biliopancreatic diversion, duodenal switch), their relative distribution is 65.11%, 29.84%, and 4.85%, respectively. Looking at the popularity of procedures worldwide, i.e. the number of nations (or national groupings) performing certain procedures, 23 of the 24 (96%) perform gastric banding; 21 (88%), gastric bypass (standard and long-limb); 19 (79%), vertical banded gastroplasty; and 16 (67%), biliopancreatic diversion/duodenal switch. Thus, in the year 20022003, gastric banding was performed in all but 1 of the 24 responding nations (or national groupings). Within functional categories, purely restrictive procedures (gastric banding and vertical banded gastroplasty) were performed in 24 of the 24 nations (100%), restrictive/malabsorptive (gastric bypass, standard and long-limb) in 21 (88%), and primarily malabsorptive (biliopancreatic diversion and duodenal switch) in 18 (75%) (Figure 5).

Discussion
This tabulation and analysis of bariatric surgery worldwide is the first major attempt to perform such a function since the paper by Scopinaro in 1998, over 5 years ago.11 During this time interval, the number of annual bariatric surgery operations has increased from 40,000 to 146,301 worldwide an

increase of 266%. The number of IFSO societies has increased from 14 to 31 an increase of 121%. The data in this paper are limited by certain factors: not all nations performing bariatric surgery belong to IFSO, the response rate from the IFSO member nations (or national groupings) was less than 100%, and within each nation delineation of the number of procedures and the number of bariatric surgeons, more than likely, was not precise. Furthermore, for the relative prevalence of specific procedures, the available numbers were even less precise; an exception was the information obtained from Italy, which has a functioning and inclusive bariatric surgery registry.12 Finally, there were several discrepancies in the data supplied by some of the responders, which we corrected to the best of our knowledge. Nevertheless, the information in this study gives a fairly accurate overview of this field and provides data for a contemplation of trends. Certain conclusions can be drawn from these findings. As in all other surgical fields, operative procedures are always in flux. There is no gold-standard bariatric procedure and, probably, never will be. It was just a number of years ago that vertical banded gastroplasty was not only the primary purely restrictive operation performed but in the USA the most commonly performed bariatric procedure.13 Today, vertical banded gastroplasty in the USA/Canada comprises only 1.4% of bariatric procedures. Again, in the USA/Canada before 2002, laparoscopic adjustable gastric banding was not performed at all outside of trials sanctioned by the Food and Drug Administration (FDA).13 Currently, 9% of bariatric procedures in the USA/Canada are laparoscopic adjustable gastric banding operations. Worldwide, the percentage of biliopancreatic diversion/duodenal switch procedures is growing. New operations (e.g., gastric pacing) are being introduced and may well become popular. Definite geographic trends and shifts are observable in the specific bariatric procedures being performed. Biliopancreatic diversion started in Genoa, Italy; it was converted to the duodenal switch in the USA/Canada;14 and now these two operations are both becoming more widely employed in Europe. Certainly, laparoscopic adjustable gastric banding was a European, Australian, and South American procedure until recently and its introduction into the USA/Canada. In return, Europe and nations outside
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Weighted % of Bariatric Operations % of Bariatric Operations

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Table 6. Countries performing specific procedures of 24 responders Procedures (%)
Nations LRGB LAGB ORGB LLLLOVBG ODS LVBG LBPD LRGB ORGB OBPD LDS OAGB LGP LNAGB OJIB

Argentina Australia (New Zealand) Austria Belgium (Luxembourg) Czech Republic Egypt France Germany Greece Hungary Israel Italy Japan Mexico Netherlands Poland Russia Spain Sweden Switzerland Turkey Ukraine United Kingdom USA/Canada

5 4 1.5

80 80 98 70

5 4 7

1 1

1 1

1 1

1 1 0.5

6 1

0.5

1.5 15

5 10 5 2 1

80 25 80 90 15 95 90 5 1 70 0.5 25 10 10 40 15 6 37 4 5 14 30 17 5 38 10 1 23 5 2 2 3 20 3 5 8 2 3 20 1 4 3 1 4 1 1 4 10 26 3 4 6 5 10 25 10 30 12 10 5 8 1.1 20 1 2.5 0.3 1 20 2 1 20 2 0.1 3 5 1.4 13 20 7 14 1 10 1 10 0.3 0.2 1 0.8 0.02 5

41

10 4

60 75 10 40

10 5 8 7 34

1 1

32 15

16 22 20

6 10 45 90 10

2 33

75 9

KEY: LRGB=laparoscopic Roux gastric bypass; LABG=laparoscopic adjustable gastric banding; ORGB=open Roux gastric bypass; LLLRGB-long-limb laparoscopic Roux gastric bypass; LL-ORGB=long-limb open Roux gastric bypass; OVBG=open vertical banded gastroplasty; ODS=open duodenal switch; LVBG= laparoscopic vertical banded gastroplasty; LBPD=laparoscopic biliopancreatic diversion; OPBD=open biliopancreatic diversion; LDS=laparoscopic duodenal switch; OAGB=open adjustable gastric banding; LGP=laparoscopic gastric pacing; LNAGB=laparoscopic nonadjustable gastric banding; OJIB=open jejunoileal bypass. NOTE: Specific breakdown of procedures is not available for Brazil or Panama, although 96% of the procedures in Brazil are LRGB and LAGB.

of the USA/Canada have become more receptive to laparoscopic gastric bypass. The annual IFSO meetings, throughout the world, have had a major role in this cross-fertilization process. Bariatric surgery is expanding exponentially to address the global epidemic of morbid obesity. The success of bariatric surgery will stimulate research into the origins of obesity and into biochemical
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ways to ameliorate this disease. Eventually, pharmaceutical agents will assume part of the therapeutic burden and may, indeed, work in concert with bariatric surgery a synergistic or hybrid approach to therapy. In the USA, bariatric surgery is currently used to treat 1% to 2% of the morbidly obese population qualifying for operative therapy by the outdated cri-

Bariatric Surgery Worldwide 2003

Table 7. Number of nations (or national groupings) (%) performing specific procedures 23 (96%) Laparoscopic Adjustable Banding Open Vertical Banded Gastroplasty 19 (79%) Open Roux Gastric Bypass 17 (71%) Laparoscopic Roux Gastric Bypass 16 (67%) 15 (63%) Open Biliopancreatic Diversion Open Duodenal Switch 11 (46%) Laparoscopic Vertical Banded Gastroplasty 10 (42%) Open Long-Limb Gastric Bypass 9 (38%) Open Adjustable Gastric Banding 8 (33%) Laparoscopic Biliopancreatic Diversion 7 (29%) Laparoscopic Duodenal Switch 6 (25%) Gastric Pacing 5 (21%) Laparoscopic Nonadjustable Gastric Banding 4 (17%) Laparoscopic Long-Limb Gastric Bypass 3 (13%) Open Jejunoileal Bypass 2 (8%)
120% 100% 80% 60% 40% 20% 0%
Purely Restrictive Restrictive/ Malabsorptive
(Gastric BypassStandard and Long Limb)

% of Nations Performing Procedures

100% 88% 75%

Primarily Malabsorptive
(Biliopancreatic Diversion/ Duodenal Switch)

(Gastric Banding and Vertical Banded Gastroplasty)

Figure 5. Nations (or national groupigs) performing procedures (%).

teria of the 1991 National Institutes of Health (NIH) Consensus Conference.9 Elsewhere in the world, the percentage of qualifying individuals who actually undergo bariatric surgery is even less. The ratio of the number of patients with the disease of morbid obesity to the number being treated by the only currently effective therapy bariatric surgery would not be tolerated by healthcare organizations or the public, if the disease were any other than morbid obesity and if the therapy were any other than surgical. The next few years, or decade, will be critical in the growth, maturation, and assessment of bariatric surgery worldwide. We plan to update this study, if feasible, on a periodic basis.

We wish to thank Dr. Nicola Scopinaro for his original assessment of bariatric surgery worldwide and his help in reviewing some of these data. We also thank Dr. Mervyn Deitel for providing facts, insights, and time. We are grateful to the international contributors of information, the responders to our e-mail survey, that made this effort possible: Argentina - Dr. Carlos A. Casalnuovo; Australia (New Zealand) - Dr. Paul E. O'Brien and Dr. Andrew C. Jamieson; Austria - Dr. Karl A. Miller; Belgium (Luxembourg) - Dr. Luc Lemmens; Brazil - Dr. Fernando Barosso; Czech Republic - Dr. Martin Fried; Egypt - Dr. Essam Abd-El Galil; France - Dr. Jerme Dargent; Germany - Dr. Rudolf Weiner; Greece - Dr. John Melissas; Hungary - Dr. Jnos Bende; Israel Dr. Ilan Charuzi; Italy - Dr. Nicola Scopinaro; Japan - Dr. Isao Kawamura; Mexico - Dr. Ariel Ortiz Lagardere and Dr. Rafael Alvarez-Cordero; Netherlands - Dr. Jan Greve; Panama - Dr. Csar A. De Len Poblete; Poland - Dr. Marian Pardela; Russia Dr.Yury I.Yashkov; Spain - Dr. Aniceto Baltasar; Sweden - Dr. Erik Nslund; Switzerland - Dr. Andreas Glattli; Turkey - Dr. Mustafa Taskin; Ukraine - Dr. Andriy S. Lavryk; United Kingdom - Dr. John N. Baxter; and USA/Canada - Ms. Georgeann Mallory.

References
70% 65.11%

Weighted % of Bariatric Operations

60%

50%

40%

30%

24.41%

20% 5.43% 4.85%

10%

0% Gastric Bypass (Standard and LongLimb) Gastric Banding Vertical banded Gastroplasty Biliopancreatic Diversion/Duodenal Switch

Figure 4. Weighted percentages (open and laparoscopic pooled).

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Buchwald et al lence and trends, 1960-1994. Int J Obes 1998; 22: 3947. Mokdad AH, Serdula MK, Dietz WH et al. The spread of the obesity epidemic in the United States, 19911998. JAMA 1999; 282: 1519-22. Monteforte MJ, Torkelson CM. Bariatric surgery for morbid obesity. Obes Surg 2000; 10: 391-401. The National Center for Health Statistics NHANES IV Report. Available at: http://www.cdc.gov/nchs/product/pubs/pubd/hestats/obes/obese99.htm2002. Accessed September 9, 2002. World Health Organization Reports. [online] 2002. Available at: http://www.who.ch/ Accessed September 9, 2002. Gastrointestinal surgery for severe obesity. National Institutes of Health Consensus Development Conference Draft Statement. Obes Surg 1991; 1: 25766. 10.World Health Report 2002. Available at: www.iotf.org www.who.int/peh/burden/globalestim.htm. Accessed January 13, 2004. 11.Scopinaro N. The IFSO and obesity surgery throughout the world. Obes Surg 1998; 8: 3-8. 12.Angrisani L, Alkilani M, Basso N et al. Laparoscopic Italian experience with the Lap-Band. Obes Surg 2001; 11: 307-10. 13.Buchwald H. Mainstreaming bariatric surgery. Presidential Address, ASBS. Obes Surg 1999; 9: 46270. 14.Buchwald H, Buchwald JN. Evolution of operative procedures for the management of morbid obesity 1950-2000. Obes Surg 2002; 12: 705-17. (Received July 21, 2004; accepted August 5, 2004)

5.

6. 7.

8.

9.

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