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Month: January 2015

Shared Success Story- Brad P.

January 29, 2015 9:53 pm

Before and after Duodenal Switch
From Fat to Fine – Becoming half the man I used to be!
I started life big – 11lb 13oz to be precise.  From that point, I just grew.
I was the tallest and biggest kid in my class.  I was picked on for my size, but I learned to live with it.  Growing up on a farm, I was active, but never at a loss for a big meal and good food.  Couple that with two war brides as grandmothers, I always cleaned my plate.
I graduated high school well over 350lbs, but at 6’6” I wore it well.  Then before I knew it, I found myself over 450 lbs through most of my 20’s.  I knew this was not sustainable, and albeit I was healthy overall, I tired easily, and wasn’t able to do the things that I used to be able to do.   Everyone told me that I ate too much, and I felt that I was constantly watched whenever I would order food.
I tried everything… I went to the gym five days a week for an hour and a half… lost 12 lbs over 6 months.  Did every diet imaginable- Slimfast, Medifast, Adkins… Even entertained bariatric surgery once in my mid 20’s, but I just saw too many people gain it back afterwards.   During this time my weight fluctuated, and my doctor kept on telling me it was because I ate too much.  Was this the case when I spent six months eating 1200 calories a day?  I think not.
Fast forward to being 495 lbs at 28 years old with a new baby and diabetes on the horizon.  Through researching various options available to me, I learned about the Duodenal Switch.   My wife was interested as well, since she spent most of her life in the same boat as me.  As we researched it, we couldn’t believe that the chances of regain were much less compared to other weight loss surgeries and with the fact that I would be able to partake in the foods that I loved (in moderation of course) post recovery almost confused me.  Could this be real?  You mean I can eat bacon and meat and the normal things that I grew up on in moderation and still be healthy?  This can’t be true! 
 
I met Dr. Keshishian through a local support group.  On his advice, I met with other doctors who performed the same procedure, but I came right back to him.  My wife had her surgery performed June of 2013 (You’ll learn about her soon) I had mine six weeks later on July 22nd.  Eleven months later, I went from a size 54 waist and 5x shirts to XL Shirts and a 38 waist.  But that’s not the most important part.  I’m healthy.  I have the energy to chase my three year old daughter around, and for once in my life, I finally feel like I’m part of the group.  If you are in a position to lose a great deal of weight, the Duodenal Switch is the ONLY way to go.
Surgery Weight: 485
Current Weight: 265
Brad P.
Bakersfield, CA
Congratulations Brad on all your success and weight loss!  You have accomplished a remarkable transformation!

Nearly 16 years Post DS

January 29, 2015 3:24 am

I was recently lucky enough to be able to have dinner with my first private practice Duodenal Switch (DS) patient from almost 16 years ago.  This DS journey has been amazing, enlightening and humbling. I am continually impressed with how people change their lives and go on to exceed their own expectations. It was wonderful to see my rationale for promoting DS as the weight loss surgical procedure with the best long term outcomes and “normal” eating ability perfectly represented. Patient #1 has maintained her weight loss long term, ate the variety of foods served at about 50% of what others around the table ate and has continued to thrive in her life.  Our meal consisted of protein, vegetables, rice and even a bit of dessert. She runs a company with numerous employees and interacts with clients on a daily basis. She has maintained her laboratory studies with consistent daily protein, vitamin and mineral supplementation.  She has not needed iron infusions or any other additional nutritional support. There are many misconceptions out in the bariatric and general community regarding the DS. DS patients do not normally have accidents, have an odor about them, or spend all day in the bathroom unless they have eaten something that does not agree with them. Nor is weight loss surgery an easy way out.  It is a lifetime commitment of protein, vitamin and mineral supplementation with yearly laboratory study surveillance. I have always believed that giving the patient the most “normal” eating ability with long term weight loss success is the best outcome. Dr. Bruce MacPherson was my mentor in Pontiac, Michigan where I learned Hess technique for DS. Dr. MacPherson was personally trained by Dr. Douglas Hess.  My private practice experience with DS started in 1999. I truly believe that Hess technique gives the best overall outcome and lifestyle to the patient. In my opinion,  the Hess technique is comparable to taking normal anatomy and reducing it down to overcome metabolic disruption.  The above is an example of one patient’s outcome.  Each patient’s experience is individualized based on their health history, anatomy, metabolism and surgical outcome.

Weight loss Surgery Coverage Changes

January 20, 2015 10:30 pm

Weight loss surgical procedures have been proven to be the only viable option for sustained weight loss when compared to all other modalities, including diet, exercise, behaviors modifications, appetite suppressant, and other less scientific approaches. Different weight loss procedures have had varying degree of success as measured with resolution of the co-morbidities and long term weight loss.
 
 
In December of 2014, Blue Cross of California notified the providers of a number of changes in their coverage will be taking place. 
 
 
One such specific modification in policy involves primary and revision weight loss surgery.
 
 
These policy changes have significant practical implications for those seeking surgical treatment for morbid obesity and associated co-morbidities.
 
 
First of all, they create a road block for those patients who are not able to provide documentation for the “…6 continuous months, in the 2 years prior to surgery, to enable both behavioral changes and adequate assessment of anticipated postoperative dietary maintenance.”  It also places the responsibility on the surgeon by requiring that compliance with these requiremens are “…. fully appraised and documented by the physician requesting authorization for surgery.”  
 
The practical implication of this is much longer wait between the first office visit with a surgeon and the ability to obtain authorization unless a patient comes in with 6 months’ worth of documentation. The impropriety of such medically unsubstantiated requirements, including the unacceptable and harmful effect of delay or denial on access to medically necessary treatment, was addressed by the ASMBS in the March 2011 position statement on Preoperative Supervised Weight Loss Requirements (http://asmbs.org/resources/preoperative-supervised-weight-loss-requirements).  These new requirements are inconsistent with the ASMBS Position Statement and should be vigorously opposed.
 
The second and in my opinion more restrictive and significant change is for  revision procedures. It indicates that any patients in need of a medically necessary revision surgery, must meet the criteria for initial weight loss surgery. This can dramatically limit access to revision surgery for those who are having complications, e.g., of the Adjustable Gastric banding procedures (because they are unable to eat, having constant nausea and vomiting, abdominal pain etc.) or gastric bypass (dumping syndrome, solid intolerance, etc.) but who do not meet the weight criteria or have documentation for 6 months of “ … participation in a non -surgical weight loss …” since they were not trying to lose weight.
 
This should also concern those who have or perform the duodenal switch as a staged procedure, where the sleeve is done as the first step, to be followed by the completion of duodenal switch operation at a later time. Although  I am generally against a staged approach to the duodenal switch operation, this policy change introduces unnecessary and even insurmountable hurdles for those patients for whom this approach is deemed medically necessary. 
 
For all those who are not in California, please note that a lot of policies do start here and propagate to the rest of the country. I would propose that  everyone take time to contact their state health insurance providers regulatory agency and voice their opposition to the proposed changes. The state regulatory agencies are located here. (http://www.dsfacts.com/image-files-new/agencies-by-state.pdf)

Hiatal Hernia Repair- Reflux and Adjustable Gastric Band Revision

January 14, 2015 3:47 pm

Hiatal Hernia is an anatomical weakening or enlargement of the opening in the diaphragm where the esophagus meets the stomach. The defect can allow a section of stomach to slide or roll into the chest cavity. This causes the reflux of stomach content back to the esophagus. Esophageal Reflux may also be occur without the presences of a Hiatal hernia. It is reported that approximately 60% of people over 50 have a Hiatal hernia with about 9% being symptomatic. However, over the years we have also noticed a significant increase in reflux disease in patients who have had adjustable gastric band placed.  Quite frequently the reflux symptoms after the band is ” blamed” on the patient’s eating habit. Most of the time all studies are reported as “normal” and the  complaints are discounted. Other symptoms of Hiatal hernia may or may not include shortness of breath, heart palpitations, or a feeling of food being stuck. It is important to confirm the presence or absence of a hiatal hernia when considering revision from an  adjustable gastric band procedure.   Any hiatal hernia identified either before surgery or at the time of the operation will need to be repaired surgically.
 
With a hiatal hernia repair, the opening is made smaller, and the esophagus, stomach and the junction between them is returned to the proper location to minimize-eliminate reflux.