Office Hours: Monday - Friday 8:00am - 5:00pm

Month: August 2015

Revision of a Sleeve Gastrectomy or RNY

August 31, 2015 6:32 am

These are examples of two types of patients referred to us for revision surgery. The first example is a  gastric bypass that we revise to the duodenal switch operation. The upper GI series after the revision, shows a “banana shaped” stomach, the pyloric valve and the duodo-ilesotomy anatomosis component of the duodenal switch.
Normal DS
post op RNY to DS revision Upper GI film
  The second example, images noted below,  is that of a sleeve revised to the duodenal switch – both operations done at different institution. Note how the stomach is not a “banana shaped” and more like a funnel with a narrowing at the bottom of the stomach- a stricture.
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Funnel Sleeve Gastrectomy with stricture
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Red overlay showing the desired Sleeve shape

Shared Success: Kriston & Shirden

August 27, 2015 5:27 am

Before Duodenal Switch

My wife, Kriston, and I have struggled with our weights for most of our lives. Over the years we have tried dieting, exercise, medications, and so on….with no luck. A few years ago she started to bring up the idea of weight loss surgery as a possibility. This was an idea that I was dead set against partly for fear of having major surgery and partly because it felt like cheating to me. In my mind, I believed that I should have been able to lose the weight if I really wanted to do so. Kriston continued to bring up the subject. She talked about friends who had had the surgery and how well they were doing with their weight loss. I still resisted the idea until she made the argument that if we didn’t do something about our weight then we might not live to see our daughter grow up and have children of her own someday. That was when I realized that I had to investigate the surgery and what it entailed.

After Duodenal Switch

We made an appointment to meet with Dr. Keshishian for an orientation and listened to him as he talked about the problems many people have with weight loss, obesity, genetics, metabolism, what surgeries were available, and the pros and cons of each of them. After meeting him and learning about the surgeries and obesity,  I felt very confident that this was the man that could help us with our weight loss struggles. We decided to go with the Duodenal Switch and I scheduled my surgery for June of 2013 and Kriston scheduled hers for November of that same year. We felt this would allow me time to heal and then I would be able to help Kriston after her surgery. I won’t go in to all the details of the surgeries except to say that they both went very well. My recovery was a bit rocky, my wife will say that I was a big baby, but I did recover.  I will admit that she was a much better patient than I. Fast forward two years and we are both doing very well. I have lost 180 lbs and Kriston has lost a little over 100 lbs. We look and feel great and we enjoy a much happier and active life style, we even went ocean kayaking last week which is something I could have never done at 370 lbs. This surgery has changed our lives and we could not be happier. We will be forever grateful to Dr. Keshishian, and his incredible staff, for all that they have done to help us become the healthy and happy people we are today.

Sea Kayaking

Hypertrophy of Small Bowel and Weight Gain Years After Duodenal Switch

August 21, 2015 7:53 pm

Duodenal switch (DS) operation results in the highest success rate of all weight loss surgical procedures. Patients, over time, will  experience some weight gain many years after DS procedure. There are a number of  suspected mechanisms that may be responsible for the weight gain:

1-Ageing may slow the metabolism and the activity down.

2-Over time patients may not be as adherent to healthy dietary and lifestyle changes as they may have been immediately after surgery.

3- Hypertrophy of the alimentary  and common channels  over time increases in surface area f allowing greater caloric absorption leading to increased weight gain.

It has been demonstrated in bowel resection studies, as well as rat studies, that the nutrient stimulated regions of small intestine increase villus height and total weight, crypt depth and proliferation as well as wall thickness, as an adaptation to compensate for the loss of absorptive capacity in the resected bowel. This observation may be applied to DS procedure as seen in histological slides from a patient who had to have an operation done requiring bowel resection. The segment of the bowel resected included the junction of the biliopancreatic, common and alimentary limbs.

The histologic slides are the same size of tissue, photograph and magnifications.

It is significant that the Muscular and the mucosa of the alimentary limb over time have hypertrophied (thickened) and this represents more surface area, increased blood flow to and from the mucosa and the resultant incased absorption be partly responsible for weight gain.

Layers of the GI Tract (excluding esophagus and rectum)

Mucosa – The inner most layer of the GI tract, which lines the lumen and comes into direct contact with digested food and the secretions. The mucosa itself is Composed of 3 layers:

1-Epithelium (the inner most layer) which is responsible for most of the digestive, absorptive and secretory processes of the GI tract.
2-The lamina propria; a layer of connective tissue.
3-The muscular mucosae, which is a thin layer of smooth muscle that aids in the passing of material through the GI tract.

Muscularis – Muscular layer of the GI tract consisting of an inner circular layer and an outer longitudinal layer. The circular layer prevents back flow of digestive contents whereas the longitudinal layer shortens the GI tract and is responsible for peristalsis.

Serosa – “Seran Wrap” type covering the outside of the GI track (excluding the esophagus and the rectum). It is composed of Smooth muscle membrane formed by two layers of epithelial cells which secrete serous fluid (lubricants).

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Side by Side comparison of Biliopancreatic and the Alimentary limb


Bertoni, Simona, and Giorgia  Gabella. “Hypertrophy of Mucosa and Serosa in the Obstructed Intestine of Rats.” Journal of Anatomy 199.Pt 6 (2001): 725–734. PMC. Web. 19 Aug. 2015.

E, Wallace LE, de Heuvel E, Chelikani PK, Zheng H, et al. (2010) The influence of nutrients, biliary-pancreatic secretions, and systemic trophic hormones on intestinal adaptation in a Roux-en-Y bypass model. J Pediatr Surg 45: 987–995 

Strader AD (2006) Ileal transposition provides insight into the effectiveness of gastric bypass surgery.Physiol Behav 88: 277–282

Ockander L, Hedenbro JL, Rehfeld JF, Sjolund K (2003) Jejunoileal bypass changes the duodenal cholecystokinin and somatostatin cell density. Obes Surg 13: 584–590

DOU, Y. , LU, X. , ZHAO, J. and GREGERSEN, H. (2002), Morphometric and biomechanical remodelling in the intestine after small bowel resection in the rat. Neurogastroenterology & Motility, 14: 43–53.

Internal Hernia And Bowel Obstruction

August 21, 2015 7:49 pm

Whenever there is a bowel resection with anastomosis made there will be a defect in the mesentery (the tissue that holds the blood supply and the nerves etc going to and from the bowel)  that needs to be closed. In this particular case, the stitches that were used to close the defect were intact and yet the tissue had separated from it. The result is an internal hernia. This can cause bowel obstruction, where by a loop of the bowel can go through the defect and kink the bowel causing the blockage. In some cases, the internal hernia may reduce itself with intermittent symptoms of the bowel obstruction and in other cases it may require immediate emergent surgery.  A CAT scan with oral and IV contrast is needed after Duodenal Switch to visualize the alimentary and bioliopancreatic limbs.

Symptoms may include but are not limited to:

  • nausea
  • vomiting
  • abdominal bloating
  • abdominal tenderness
  • cramping abdominal pain
  • diarrhea, constipation
  • feeling of inability to completely empty bowels
  • fever
  • severe abdominal pain.
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Mesentery Defect site of Internal Hernia

Surgical Treatment of Gastric Fistula

August 05, 2015 7:45 pm

Chronic gastric leak or gastric fistula after Sleeve Gastrectomy or Duodenal Switch can be treated with a Roux En Y limb. This does not mean mean conversion to Roux En Y Gastric Bypass but use Roux En Y limb to drain the fistula.  In the case of a Duodenal Switch the Roux En Y limb could be taken from the biliopancreatic limb. The following are links to articles that describe this method of treatment. The early use of Roux limb as surgical treatment for proximal post sleeve gastrectomy leaks 2014 Roux-En-Y Fistulo-Jejunostomy as a salvage procedure in patients with post–sleeve gastrectomy fistula 2014 Use of Roux limb as remedial surgery for sleeve gastrectomy fistulas 2008