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Month: May 2016

Probiotics and Prebiotics

May 26, 2016 1:59 pm

Probiotics and Prebiotics are an important part of our overall general and gastrointestinal health. The gastrointestinal (GI) tract is a large, muscular tube that allows the digestion of food. The intestinal lining of the tract plays a role in absorbing vital nutrients and acts as a barrier for the macromolecules and microorganism from circulation. Our GI system is exposed to many bacterial agents that undergo fermentation in the mucosa. The type of fermentation carried out in the gut is greatly influenced by the types of bacteria found in the lumen.

The GI microflora is an elaborate ecosystem consisting of neutral and beneficial bacteria whose balance impacts overall health. This microenvironment consists of about 400 different bacterial species that make up approximately 100 billion organisms in the gut. The flora functions in nutrient consumption, vitamin production, detoxification, hormone activity, and other regulatory processes. Abnormal microbial balance or colonization results in dysbiosis, where the deviant nature of bacteria may become pathological (7). Dysbiosis is a contributing factor to many degenerative and chronic diseases.

Effect of dysbiosis on the body.
Effect of dysbiosis on the body. Source: Qsota Medical, Gastroenterology.

Benefits of Probiotics and Prebiotics:

Our bodies are full of both good and bad bacteria. Probiotics contain live bacteria and yeasts, whose activity is beneficial when present in appropriate amounts (11,12). These helpful microorganisms regulate the body’s systems in several ways:

  • Gastrointestinal: Probiotics work to reduce infectious diarrhea, specifically types identified by antibiotic use (1). Certain strains enhance stool consistency and bowel movement frequency. Probiotics have also proven effective in alleviating bloating and gas found in irritable bowel syndrome (9). Further studies suggest that specialized strains aid in milder forms of ulcerative colitis, an inflammatory bowel disease. A recent Russian study suggested eradication of SIBO and IBS using a combination of Bifidobacterium bifidum, Bifidobacterium longum, Bifidobacterium infantis and Lactobacillus rhamnosus, called Florasan-D available in Russia. These findings were presented at the 2015 Gut Microbiota for Health World Summit in Barcelona, Spain by Elena Polouektova, MD, a researcher at I.M. Sechenov First Moscow State Medical University.


  • Weight Loss: A clinical study (8) revealed reduced body fat in patients who consumed yogurt (probiotic source), although there were no observed changes in weight. Another study, published in the 2011 European Journal of Clinical Nutrition (6), found that subjects who consumed fermented milk that contained a specific bacterial strain observed abdominal fat and weight loss, when compared to subjects drinking a control.


  • Immunity: Although the clinical implications of this evidence are still being studied, it has been found that immune response strength is greatly improved through certain strains of probiotics (2,4). They have also been shown to lighten hypersensitivity reactions and normalize added mucosal dysfunction.


  • Other Uses: Bacteria also reside in the mouth. Probiotics play an essential role in oral health, where they reduce throat infection, bad breath and periodontal disease, a gum infection (5). There have been claims that probiotics lower the effects of some skin conditions, prevent colon cancer, lower blood pressure and cholesterol, and alleviate anxiety and depression (3). Future studies are working towards the consistency of these claims.

Probiotics regulate the movement of food through the digestive system. They help replace unwanted bacteria and maintain the mucosal microenvironment to avoid dysfunction. Prebiotics are fiber compounds that move through the GI tract undigested. Prebiotics are important in stimulating probiotic growth and maintaining a stable environment for their optimal activity (13). The best way to get all the powerful benefits of probiotics is through consuming foods that are prepared by bacterial fermentation. Supplements are also available. Previous blog regarding probiotic supplements here. Previous blog regarding probiotics, C.Diff and Hyperoxaluria here.

Prebiotic and probiotic-rich food sources. Source:
Prebiotic and probiotic-rich food sources.


Written by: Mariam Michelle Gyulnazaryan & Dr. Ara Keshishian


  1. Bowen, J. M., Stringer, A. M., Gibson, R. J., Yeoh, A. S., Hannam, S., & Keefe, D. M. (2007). VSL# 3 probiotic treatment reduces chemotherapy-induced diarrhoea and weight loss. Cancer biology & therapy, 6(9), 1445-1450.


  1. Chiang, B. L., Sheih, Y. H., Wang, L. H., Liao, C. K., & Gill, H. S. (2000). Enhancing immunity by dietary consumption of a probiotic lactic acid bacterium (Bifidobacterium lactis HN019): optimization and definition of cellular immune responses. European journal of clinical nutrition, 54(11), 849-855.


  1. Foster, J. A., & Neufeld, K. A. M. (2013). Gut–brain axis: how the microbiome influences anxiety and depression. Trends in neurosciences, 36(5), 305-312.


  1. Isolauri, E., Sütas, Y., Kankaanpää, P., Arvilommi, H., & Salminen, S. (2001). Probiotics: effects on immunity. The American journal of clinical nutrition, 73(2), 444s-450s.


  1. Krasse, P., Carlsson, B., Dahl, C., Paulsson, A., Nilsson, A., & Sinkiewicz, G. (2005). Decreased gum bleeding and reduced gingivitis by the probiotic Lactobacillus reuteri. Swedish dental journal, 30(2), 55-60.


  1. Merenstein, D., Murphy, M., Fokar, A., Hernandez, R. K., Park, H., Nsouli, H., … & Shara, N. M. (2010). Use of a fermented dairy probiotic drink containing Lactobacillus casei (DN-114 001) to decrease the rate of illness in kids: the DRINK study A patient-oriented, double-blind, cluster-randomized, placebo-controlled, clinical trial. European journal of clinical nutrition, 64(7), 669-677.


  1. Myers, S. P. (2004). The causes of intestinal dysbiosis: a review. Altern Med Rev, 9(2), 180-197.


  1. Omar, J. M., Chan, Y. M., Jones, M. L., Prakash, S., & Jones, P. J. (2013). Lactobacillus fermentum and Lactobacillus amylovorus as probiotics alter body adiposity and gut microflora in healthy persons. Journal of functional foods, 5(1), 116-123.


  1. Prantera, C., & Scribano, M. L. (2009). Antibiotics and probiotics in inflammatory bowel disease: why, when, and how. Current opinion in gastroenterology, 25(4), 329-333.


  1. Reid, G., Jass, J., Sebulsky, M. T., & McCormick, J. K. (2003). Potential uses of probiotics in clinical practice. CLINICAL microbiology Reviews, 16(4), 658-672.



  1. Rolfe, R. D. (2000). The role of probiotic cultures in the control of gastrointestinal health. The Journal of nutrition, 130(2), 396S-402S.


  1. Sanders, M. E. (2008). Probiotics: definition, sources, selection, and uses. Clinical Infectious Diseases, 46(Supplement 2), S58-S61.


  1. Schrezenmeir, J., & de Vrese, M. (2001). Probiotics, prebiotics, and synbiotics—approaching a definition. The American journal of clinical nutrition, 73(2), 361s-364s.

Weight loss Surgery for Treatment of Diabetes

May 25, 2016 7:21 am

New guidelines and recommendation are coming out of the second Diabetes Surgery Summit in the Fall of 2015. One major change is Metabolic or Weight Loss Surgery for the treatment of Diabetes. With all the advances made in newer classes of medication for treatment of diabetes, the majority of patients who are being treated fail to get to achieve the desired results of lowered blood glucose level. This is in contrast where weight loss surgical procedures such as Duodenal Switch can results in >95% cure rate of type II diabetes.

The American Diabetes Association has made the recommendation for weight loss surgical procedures be considered as a treatment option for type II diabetes.

Summarizing their criteria “According to the new Guidelines, metabolic surgery should be recommended to treat type 2 diabetes in patients with Class III obesity (BMI greater than or equal to 40 kg/m2), as well as in those with Class II obesity (BMI between 35 and 39.9 kg/m2) when hyperglycemia is inadequately controlled by lifestyle and medical therapy. It should also be considered for patients with type 2 diabetes who have a BMI between 30 and 34.9 kg/m2 if hyperglycemia is inadequately controlled, the authors agreed. The Consensus S

diabeties control post WLS
Diabetes controls post weight loss surgery

tatement also recognizes that BMI thresholds in Asian patients, who develop type 2 diabetes at lower BMI than other populations, should be lowered 2.5 kg/m2 for each of these categories. ”

This is a remarkable change in thought and policy on diabetic treatment and long term strategies that can only improve patient outcomes.  Stabilization and blood glucose hemostasis can only improve patient health, health care utilization and health care costs.

Inadequate Weight loss and Weight Regain

May 24, 2016 7:56 am

There were numerous causes for the inadequate weight loss and or weight regain after weight loss surgery.

These factors may include:
1-Type of the surgery: Duodenal Switch, RNY, Adjustable Gastric Banding, Intragastric Balloon, etc.
2-Patients metabolic state (age, activity level, hormones state etc)
4-Patient compliance

Each and every one of these may be an independent factor or may be a contributing cause.

In our experience, patients non-compliance is not as common as others believe. Frequently, we see patients in our office where they have been told that the poor outcome of the surgery is “their fault”
We see this with RNY, and Band patients as well as some of the duodenal switch patients who are seeking advice for weight regain or inadequate weight loss.

I would like to talk about the issues of inadequate weight loss or regain post Duodenal Switch specifically. Duodenal switch operation as described by Dr. Hess, outlined the division of the small bowel lengths to be proportional to each and every patients own total bowel lengths. This meant that two patients with the same BMI and weight will end up with two different lengths for common and alimentary limbs if there total length of the bowel is different. Unfortunately, too often patients are given a “standard”  or “set” ( not clear what that word means, since there is no established standard in the literature) length for common channels and alimentary  channels regardless of the total small bowel length. In some patients, those lengths may result in acceptable weight loss. However, quite frequently a patient with a preselected length for the common and alimentary limbs will end up either loosing too much weight and have nutritional problems or not loose adequate weight. As with all practices, we have over the years had patients who have had nutritional deficiencies and excessive weight loss or have had inadequate weight loss. Looking at the raw numbers however, we have had more patient from other practices that have come to us for revisions and corrections of lengths of the bowel lengths from other practices that our own patients have required.

Another level of the confusion is the improper interchanging of the “SIPS and SADI” procedures with the duodenal switch operation. As I have said in the past repeatedly, SIPS and SAID are not the same as the duodenal switch- and attempt to call these different procedures the same is misleading to say the least.

The other category of weight regain or inadequate weight loss includes medications and new health issues.  Discussed in a previous blog, there are many medications that can influence weight gain.  It is important to work with your health care provider to find medications that have a positive effect on symptoms without added side effects whenever possible.

In summary, weight re-gain or inadequate weight loss can have many facets.  However, surgical technique can provide an advantage.  Each aspect should be addressed and identified.

Fat, Protein – Post Duodenal Switch Diet

May 23, 2016 6:43 am

Fat and Protein after weight loss surgery…. This is a subject that seems to come up all the time.

What I recommend is “…Water, protein, vitamins, supplements and every thing else….”

Dehydration can cause a lot of problems, stay hydrated.

Weight Loss Surgery (WLS) is a surgically imposed catabolic state (surgical induced starvation).  The weight is lost by not allowing enough caloric intake/absorption and forcing the body rely on stored sources of energy, mostly fat mass.  The rationale for the high protein intake is to minimize net muscle mass loss during the catabolic state.   Low carbs and low fat further push the body into catabolizing the fat mass, and reducing the net loss of protein content. As the fat mass is broken down it will release hormones and other byproducts that the body will eliminate. Hydration is crucial to every bodily function and even more so in the weight loss phase to allow for elimination of some of these byproducts.

The mechanism by which Duodenal Switch works during the weight loss phase is by limiting the caloric intake.  Long term  Duodenal Switch keeps the weight off due to the malabsorptive component as the caloric intake increases. Protein intake, Vitamin/Mineral supplementation and diligence in surveillance of vitamin/mineral levels is imperative and a life long commitment after WLS.

There are a number of different types of  Fatty Acids.  Our bodies naturally produce, from other components,  all but 2 essential fatty acids: Omega 3 and Omega 6.  Most fatty acids require bile salts to be absorbed within the small intestines.  Those are the fatty acids that are absorbed to a lesser degree after Duodenal Switch.  Medium chained fatty acids do not require bile salts and can be absorbed into the blood stream from the small intestines. Medium chained fatty acids are used for energy as they are processed in the liver. Medium chained fatty acids are actually given to patients with Short Bowel Syndrome to decrease fatty stool and increase their body weight.  This is also a possible reason some fats cause DS patients more loose stools and others do not (medium chained fatty acids). Adding fats is a purely individualized process.  Each person has a different length of small bowel, alimentary limb, common channel, percentage of excess weight to lose and metabolism. Patient’s tolerance for fat in regards to vitamin/mineral levels, stool consistency and frequency is completely individualized.

Fats and Fatty acids can be divided according to their structure in groups:

A) Saturated  Fat (animal fats, butter, lard- solid in room temperature)

B) Unsaturated Fat (liquid in room temperature)

           1-PolyUnsaturated Fats
                    a)Omega 3-fattty acids (fish, shellfish, soybean, walnut, flaxseed)
                    b)Omega 6-fatty acids (corn oil, sunflower oil)
            2-Monounsaturated fats
                    a)Omega 9-fatty acids (olive oil, avocados, peanuts, almond

The main focus in the weight loss phase should be hydration, hydration, hydration, protein, low carb, low fat and vitamin/mineral supplementation (page 22).  Rest is key in the early post op phase but gradually adding exercise is also important in ensuring the body does not breakdown muscle mass.  Adequate intake of protein and use of muscles diminishes the bodies natural response of breaking down muscle mass in a low caloric intake state.

Post Surgical Needs for the first 90 days in order of importance:
This is to allow healing to take place before adding additional stress on the body and surgical sites.
Minimum of 64 ounces of fluids daily
Minimum 80-100 grams of protein daily (protein requirements are based on ideal body weight)
30 gms by 30 days post-op
60 gms by 60 days post-op
90 gms by 90 days post-op
Vitamin/Mineral Supplements
Low carb
Low fat
Rest (early Post-op)

Proteins are important, not only for structure (muscle) but for functions. We know that proteins and amino acids are involved in all aspects of our body’s function. This is even more critical during the rapid weight loss phase. Protein needs may increase and change based on health status, pregnancy, surgeries, healing, etc.

When it comes to fat, I do not recommend patients consuming excessive amounts of fat- At the same time I do not recommend patients go on a low fat diet.  There is this misconception that since DS is causing fat and fat soluble vitamin malabsorption, then taking more fat (in excessive amounts) can solve the problem of vitamin deficiency. How about the possibility that some patients are causing their own vitamin deficiency by taking large volumes of fat which may results in more frequent bowel movements and decreased vitamin absorption.

It is not to be forgotten that each patient will respond differently with dietary changes after duodenal switch. Some patients may tolerate more and some less fat in their diet.  After the initial 90 day post op phase I recommend that patients go slowly in adding new food items by giving it several days before adding another food item. i.e.; add carrots for 3-5 days to see how your body handles it before attempting to add another new item.  The above is not the entire weight loss process or education and is only a small portion of the education needed before undergoing any WLS procedure. These recommendation are my recommendations for my patients with the Hess technique for Duodenal Switch.

Curved Adjustable Gastric Band Discontinued

May 19, 2016 11:19 am

The Curved Adjustable Gastric Band will be discontinued. Johnson and Johnson, the parent company of the Ethicon, is removing the Curved adjustable Gastric Band from its’ product line. This particular band is known as the Realize Band launched by Johnson & Johnson and did not gain much traction. The number of Adjustable gastric band placements have gone down significantly as the data have shown poor outcome over long term and a high complication and re-operative rates.

Adjustable Gastric Band

The following link is a copy of the letter from Ethicon Johnson and Johnson regarding the Curved Adjustable Gastric Bands Discontinuation: Realize Band removed from the Market.

Minimally Invasive Weight Loss Surgery

May 17, 2016 9:02 am

Minimally Invasive does not mean better, easier, proven outcomes or good excess weight loss. Weight loss surgical patients  should be careful of catch phrases such as “less invasive”, “simpler”, “shorter recovery”, “outpatient” and many others that had been used to  described procedures with less than optimal outcome.  We should not forget the lessons learned from adjustable gastric banding which was also promoted as  ” less invasive, simpler to perform, and be done as an outpatient with a short recovery “.  We all know how that story has panned out. The overwhelming majority of patients who had an adjustable gastric banding  have undergone revision, had it removed or had additional surgeries following the complications  which were associated with this simple procedure.

When evaluating outcome data for weight loss surgical procedures, it is important to bear in mind that the long-term success of these procedures will take years to document.  More often than not the early weight loss is significantly better than the long-term stable weight loss. This has been clearly documented in the case of the adjustable gastric banding and the gastric bypass and laparoscopic sleeve gastrectomy operation. Duodenal switch , as described by Dr. Hess using the percentage based technique, has the best long-term documented success of all of the weight loss surgical procedures.   The scientific data reports 20+ years of  successful excess weight loss with a Hess Duodenal Switch procedure.   There has been an alternative proposed to Duodenal Switch recently, the SIPS and SADI  procedures.  As I have already stated in the past, these are not the same as the duodenal switch operation.  Any suggestion or innuendos that SIPS/SADI is the same as the Duodenal Switch is deceptive and misleading.    We have also seen attempts to use the same catch phrases as described above to promote these unproven procedures. The published data that’s been reported with SIPS/SADI is mostly short-term in small population studies.  There are no long-term studies that have documented the efficacy of the SIPS/SADI procedure and “simpler” or minimally invasive does not mean better.

Does Your Sleeve Look Like this?

May 10, 2016 9:03 am

The re-shaping of the stomach for weight loss with a Sleeve Gastrectomy can be a technically challenging procedure. There are complications such as stricture, cork-screw stomach, GERD, nausea and vomiting that can lead to further health issues and possibly nutritional issues.

Upper GI pictures of Sleeved StomachStricture Sleeve gastrectomy

Sleeve Gastrectomy stomach

In the following series of pictures you can visualize that the Sleeve Gastrectomy in the first picture is a hard angled S shape with two stricture points. The second picture points out the two stricture points and the outline the sleeve gastrectomy of a patient referred to our practice for complications of stricture and GERD post sleeve gastrectomy in need of revision. Surgical revision of gastric stricture is highly technical and challenging.  It also takes experience in identifying possible options available to the patient.

The outline in light blue depicts the shape a sleeve gastrectomy should follow.

Sleeve Stomach

Why are strictures bad? What is the problem with having and living with a stricture? Strictures caused by Sleeve gastrectomy or Duodenal Switch, SIPS/SADI procedure can have detrimental effects. The long-term complications may include, irreversible injury to the esophagus and the stomach above the stricture, Teeth and gum damage, aspiration in addition to nutritional deficits because of the inability to tolerate healthy meals. Additional information regarding complications that can arise from stricture, nausea and vomiting here.

Strictures can not be repaired by dilation in most cases since on one side of the narrowed section is formed by the sample line. These should be addressed surgical by an experienced surgeon. Ideally a a stricture would be avoided at all cost by assuring that the sleeves are not done too tight and narrowed and that there are no sharp angles created when the stomach is divided during these procedures. The repair of these strictures of the stomach in the duodenal switch, sleeve and the SADI/SIPS procedures are complicated since the remnant stomach is removed and the options are limited.  Additional information regarding stricture complications and pictures of other stricture types here.

Stricture after Sleeve Gastrectomy Duodenal Switch

May 01, 2016 9:45 pm

According to the American Society of Metabolic and Bariatric Surgery sleeve gastrectomy has become the most commonly performed operations in 2012.  Sleeve gastrectomy became popular because of the high failure rate of the adjustable gastric banding and the issues with RNY pouch. The Sleeve Gastrectomy was performed many years prior to 2012 as a part of the Duodenal Switch procedure. Stricture is a complication occurring post Sleeve Gastrectomy and Duodenal Switch.

Screen Shot 2015-08-26 at 7.51.43 PM
Sleeve Gastrectomy with stricture


Sleeve gastrectomy may appear to be a simple procedure under the surface; however, it is fraught with very unique and challenging complications. These may include, but are not limited to, staple line failure resulting in leak,  injury to the spleen,  stricture,  and even a rare and under diagnosed portal vein thrombosis.  Technique is important in avoiding short and long-term complications. Strictures can be caused by making the sleeve stomach too narrow or by stapling in a fashion where the corkscrew stomach.

Screen Shot 2015-08-26 at 7.48.10 PM
X-ray of stricture in a Sleeve Gastrectomy with outline of what a sleeve should look like

Some surgeons create a very narrow sleeved stomach in an attempt to maximize weight loss by increasing restriction.   This can result in significant GERD in patient with  no long-term benefit. Re-sleeving is another incidence were strictures can become an issue. These strictures are debilitating and almost all the time require surgical intervention.  Balloon dilation by an endoscopy method is frequently unsuccessful.  The patient who has a stricture should seek the attention of an experienced revision surgeon for surgical repair.   Strictures are usually a short narrow segment of the stomach.  The reason why sleeve gastrectomy strictures do not respond well to balloon dilatation is because of  the staples line that is present on one side of the  tube of the stomach that cannot be stretched.

An increasingly more complicated problem is when the stricture  is caused by a spiraling of the staple line.  This is quite frequently seen where the stapling of the stomach was started on the  greater curvature of the stomach and rotated anteriorly causing a corkscrew effect of the stomach.  A long segment stricture of the stomach cannot be corrected by balloon angioplasty and would require surgical intervention.

Sleeve Gastrectomy Specimen

I have been involved with numerous repairs of strictures on sleeve gastrectomies and Duodenal Switch  stomach from other institutions.  In  my opinion, repeated endoscopy and balloon dilatation only complicate  further care  by compromising the tenuous tissue of a strictured stomach due to scaring and blood supply.   As above-stated earlier it is critical that a patient who is experiencing significant reflux, changes in nausea and vomiting, suspected stricture or narrowing, or has a corkscrew stomach to be seen by an experienced surgeon for surgical repair.  See the following Blog for health issues that can occur or progress with strictures.

Sleeve Gastrectomy specimen picture.