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Month: June 2016

Intestinal Peristalsis

June 24, 2016 6:32 pm

The following video is an example of intestinal peristalsis, the rthymic contraction and relaxation of the intestinal muscles to propel digested food through the intestinal tract. This process starts after food product is swallowed into the esophagus. It continues once the food is emptied through the pyloric valve into the small intestine. This motion allows for absorption of nutrients from the food product. Peristalsis continues throughout the small intestine and into the colon (large intestine) until defecation.

Click the following to view the Video of Intestinal Peristalsis

Peristalsis also happens within the tubes connecting the kidneys and bladder and also the tubes between the gallbladder and duodenum

Don’t lose your Pyloric Valve over a Failed Gastric Sleeve

June 22, 2016 9:32 am

Diagram of Duodenal Switch

In my opinion, there are very few reasons to lose your Pyloric Valve after sleeve gastrectomy. Recently, I am hearing of people who have had regain due to a failed Sleeve Gastrectomy being revised to Gastric Bypass RNY and then seeking a Duodenal Switch due to regain from Gastric Bypass RNY.  A better option is to go from Sleeve Gastrectomy to Duodenal Switch, due to the long term excess weight loss maintenance of Duodenal Switch. The benefit of the pyloric valve can not be taken lightly.

Let’s start by reminding ourselves as to how the Sleeve Gastrectomy has gained popularity.   In the quest for a simple solution to the complex problem of obesity, adjustable gastric banding gained popularity only fail to deliver anything close with the results that were promoted and heavily marketed.   The focus was then changed to another seemingly simple procedure, laparoscopic sleeve gastrectomy.  For some surgeons this is a new procedure.  Surgeons that had been doing the duodenal switch operation for decades,  sleeve gastrectomy has not been a new procedure.  Surgeons that just started doing sleeve gastrectomy as a stand alone procedure started experiencing complications of the sleeve gastrectomy, such as regain and are now looking for another option for these patients.  This complication are even more frequent when they’re done following a failed adjustable gastric band procedures due to the metabolic issues after revising one weight loss surgery to another. A similar short sighted  approach is also being promoted with SIPS/SADI procedures,  which is significantly simpler to perform than the duodenal switch operation.

Laparoscopic sleeve gastrectomy  has a predictable profile for weight loss.  It will not have as good on the long-term success rate as a duodenal switch operation. Complications of the sleeve gastrectomy including reflux, stricture, fistula, inadequate weight loss which may warrant  evaluation and possible intervention.  In my opinion, as a surgeon who does the duodenal switch operation routinely, a sleeve gastrectomy requiring revision should almost never be revised to a gastric bypass.  I have seen number of patient’s who have had an adjustable gastric banding which was revised to the sleeve gastrectomy then to a gastric bypass.  We are contacted for a possible revision to Duodenal Switch operation because of the weight regain.  One can argue that the patient should not have had the sleeve gastrectomy or gastric bypass.  It is critical that the complexity of the disease of the obesity is clearly appreciated that it purely restrictive procedure will not yield  the desirable outcome long-term.

Benefits of the Pyloric Valve:

Structures of the Stomach
Structures of the Stomach

The pylorus is the valve located at the end of the stomach. It controls the release of the liquid mixture of food from the stomach into the small intestine.

The body naturally regulates the passage of food, so food will stay in the stomach for a certain period of time. We believe it is very important to continue that feeling of fullness in between meals. As a result, one of the principle functions of the pyloric valve is to regulate the amount of food products released into the small intestine where they are absorbed. This helps prevent  dumping syndrome and ulceration.

The bodies natural diameter of stomach, pyloric valve and small intestine is left intact.  This elevates stretching of the stomas created by RNY Gastric Bypass.


These failed Sleeve Gastrectomies should be revised to Duodenal Switch unless there are overwhelming health issues that would require another option.  I always suggest several opinions from different Bariatric Surgeon’s who do a variety of Weight Loss Surgeries before deciding which type of revision to proceed with.

Is Weight Loss Important Before Weight loss Surgery?

June 21, 2016 7:52 am

The question of “Is a pre operative diet and weight loss important?” No.  This is the short answer.  In a previous blog, “Weight Loss Before Weight Loss Surgery?” I have gone into further detail about why I don’t require a pre operative diet and weight loss program.

More recently there has been a concerted effort by a number of major health plans to require  3-6 months documented pre operative diet attempt prior to authorization for weight loss surgery.  Furthermore, there are surgeons who would mandate a 10% weight loss  as a precondition for the patient to have a weight loss surgery, laparoscopic sleeve gastrectomy for example.  The overwhelming scientific literature fails to support any direct correlation between preoperative weight loss and the outcome of the weight loss surgery.

Some surgeons  require preoperative weight loss as a way to reduce the size of the liver.  I’ve personally have never met a liver I couldn’t work around unless it was severely diseased.

Diagram of liver and adjacent organs.
Diagram of liver and adjacent organs.

There is some literature to support this position.  However, one has to critically look at all the studies. Almost all the studies have very specific population and procedures that are being looked at. Most often the recommendations had been made for adjustable gastric banding procedures. There are also some that are recommending the same for Lap Sleeve cases only siting the reduction of the liver size as a reason for the Very Low Energy Diet as a precondition to surgery. It is, however, important to remind ourselves that there is no long term studies whatsoever that show any relationship between the preoperative weight loss and the outcome of any weight loss surgery.

Why “Diets do not Work?

June 17, 2016 6:24 am

We have all heard” diets do not work”. In the medical literature, there is a significant amount of information available that explains this observation.  However it has only been recently after publication of an article in the New York Times article “After ‘The Biggest Loser’; Their Bodies Fought to Regain Weight” that this message has  gained traction in the mass media.
Metabolic Rate and diet
Metabolic rate slows as the weight is regained
It is interesting to note that, with one exception, the other contestants gained weight. However that one exception’s metabolic rate has slowed down.  This is an observation which explains why it is moderately easy to lose the first few pounds rather than last few pounds of an excess weight.  As the patient goes on a diet, the patient’s basal metabolic rate slowed down in order to maintain and preserve energy.

Causes of Obesity

We have said and research has repeatedly shown, “obesity is not a disease of over eating and lack of exercise.”   Obesity is a multi-factorial process that may involve all or part of the following:
  • genetics
  • metabolic syndrome
  • metabolism
  • medical history
  • past diet history
  • gut microbiome
  • environmental exposure
  • dietary choice
  • physical activity level
  • age
This is not to discount  the significance of healthier dietary choices and increased activity.  However to tell the patient to “just eat right and exercise,  everything would be fine” is not only not supported by the scientific literature it is also responsible. Diets do not work. Weight loss Surgery, specifically Duodenal Switch, has had the best long term success for maintaining excess weight loss and a 95% cure rate for Type II Diabetes. Weight loss surgery should be more readily available to people who are morbidly obese as a long term tool to maintain excess weight loss and combat regain.  The American Diabetic Association just changed their recommendations and guidelines that Bariatric Surgery should be considered an option for Type II Diabetic patients.    

Diet Soda, Diabetes and Weight Loss Surgery

June 14, 2016 7:02 pm

Our practice has long discouraged the consumption of diet soda and carbonated sugary beverages for anyone, but especially our weight loss surgical patients. These products’ detrimental effects on bone health, gut microbiome, increase appetite, diarrhea, inhibited weight loss and regain shouldn’t be ignored.  In addition, in the situation of limited space post Bariatric surgery, a WLS patient needs nutrient rich, protein foods.  These beverages provide no nutritional value.

soda cans

In addition, these products are also not recommended for non-WLS patients.  Oral health, peak in insulin levels, increase weight gain, increased Type 2 DM, and diarrhea are also issues that can effect patients  in addition to the above issues.

Our practice, as well as a recent article on Medical News Today  Written by Jon Johnson, encourages people to:

“Saying goodbye to diet soda

Soda, whether regular or diet, is a dietary waste. Sodas have little nutrients, and have a long list of side effects. For people with diabetes, diet soda has been associated with weight gain and symptoms of metabolic syndrome. Some sweeteners in diet soda even cause sugar and insulin spikes in the blood.”


We encourage the use of Stevia, which is a natural sweetener, instead of other artificial sweeteners. Stevia is a herb type plant with leave that can be used for sweetening.  It has been used for many years in other countries and cultures. It contains Magnesium, Potassium, zinc, Vitamins A, B3 and C as well as fiber.

A past blog post on Carbonated Beverages and Weight loss Surgery .

Crohn’s Disease and Ulcerative Colitis

June 07, 2016 6:33 am

Crohn’s Disease and Ulcerative Colitis are two disease processes that effect the large intestine to varying degrees and in the case of Crohn’s possibly part of the small intestines. Both fall under the category of Inflammatory Bowel Disease however there are differences between Crohn’s Disease and Ulcerative Colitis even though they may share some symptomatology.
Inflammation in CD & UC
Inflammation in CD & UC
Crohn’s Disease (CD) is an inflammatory bowel disease (IBD) that causes deep tissue inflammation of the digestive lining tract. It affects the gastrointestinal (GI) tract, extending from the mouth to the rectum. CD has an asymmetrical progression, where it does not affect the entire tract uniformly (1). It is commonly found at the end of the small bowel (ileum) to the start of the large bowel (colon). Complex interactions between three factors contribute to the occurrence of CD:
  1. Immune Response: Foreign environmental substances may elicit an overactive immune response. T-cell mediated immune response identifies threatening affluences and works to protect the body. This stimulates inflammation, often times without control, in the body as the body’s natural defense mechanism (2,3).
  2. Inherited Genes: Variation in genes that produce proteins involved in immune function may disrupt intestinal cell’s ability to respond normally to bacteria. Studies also show genetic deviation in chromosomes 5 and 10, which contain IBD loci. Alterations at this locus may lead to the increased risk of CD.
  3. Environmental Factors: Factors such as smoking, those between the ages of 10-40 yrs. (commonly diagnosed before 30 yrs.), diets high in sugar/sweeteners, fats/oils, and total fat may lead to the increased risk of developing CD.
Common symptoms of CD include frequent diarrhea, rectal bleeding, fatigue, fever, weight loss, reduced appetite, abdominal pain/cramps, and fever. Inflammation in CD is unevenly widespread throughout the GI tract. Inflammation in the mouth, esophagus, and stomach can lead to ulcers. However, they are rather uncommon. Inflammation in the small intestine, colon, and rectum may lead to ulcers as the severity increases (5). The complications in CD are due to chronic inflammation, which may lead to:
  1. Intestinal narrowing (stricture)
  2. Abscess: collection of pus
  3. Fistula: abnormal connection or tract
  4. Colon Cancer
  5. Other disorders such as anemia, osteoporosis, gallbladder/liver disease, etc.
Antibiotics, anti-inflammatories, corticosteroids, and immunomodulators have been proven to regulate the mechanisms of CD. Surgical treatment may also benefit the patient. There are several surgical options that may be performed depending on the symptoms and findings.
  1. Strictureplasty
  2. Resection
  3. Proctocolectomy or Colectomy
There is no known cure for Crohn’s Disease; however these treatment options may control it. Ulcerative Colitis (UC) is an inflammatory bowel disease (IBD), which results in damaging inflammation of the colon and rectum. It effects 700,000 men and women in the United States. As opposed to Crohn’s Disease, UC spreads evenly throughout the colon and rectum only (9). It does not affect the entire GI tract. Like CD, Ulcerative Colitis occurs through a complex interaction of three factors:
  1. Immune Response: T cells (lymphocyte) mature and function in identifying foreign substances to then defend the body against infection.
  2. Inherited Genes: Variation in genes that protect intestinal function are more likely to respond abnormally to bacteria. Studies show genetic deviation in chromosomes 1 and 12 (11).
  3. Environmental Factors: Factors such as those between the ages of 1-30 yrs. or exposure to isotrentinoin (vitamin A derivative) may be at risk for UC.
Common symptoms of UC include bloody diarrhea, abdominal pain, weight loss, reduced appetite, fatigue, and fever. Inflammation in UC is evenly spread, yet restricted between the colon and rectum (10). Inflammation in the right (ascending), transverse, left (descending), sigmoid colons, and rectum can lead to ulcers that vary in size and depth (red, bloody, swollen). The complications of UC are due to prolonged inflammation, which can lead to:
  1. Increased risk of blood clots
  2. Colon Cancer
  3. Other disorders such as osteoporosis, liver disease, etc.
Antibiotics, anti-inflammatories, corticosteroids, and immunomodulators have been proven to normalize the mechanisms of UC. There is no cure for Ulcerative Colitis, but these treatment options may help regulate it.  
Differences in Crohn's Disease and Ulcerative Colitis
Key Differences in Crohn’s Disease and Ulcerative Colitis
It is important to have a coordinated team of medical professionals to develop an ongoing and dynamic treatment plan as well as surveillance for side effects of CD and UC.  Patients can lead a productive life regardless of the challenges of CD and UC with appropriate medical treatment. References
  1. Westall, F. C. (2006). Integrating theories of the etiology of Crohn’s disease on the etiology of Crohn’s disease: questioning the hypotheses. William M. Chamberlin, Saleh A. Naser Med Sci Monit, 2006; 12 (2): RA27-33. Medical Science Monitor, 12(5), LE5-LE6.
  2. Folwaczny, C., Glas, J., & Török, H. P. (2003). Crohn’s disease: an immunodeficiency?. European journal of gastroenterology & hepatology, 15(6), 621-626.
  3. Braat, H., Peppelenbosch, M. P., & Hommes, D. W. (2006). Immunology of Crohn’s disease. Annals of the New York Academy of Sciences, 1072(1), 135-154.
  4. Canavan, C., Abrams, K. R., Hawthorne, B., Drossman, D., & Mayberry, J. F. (2006). Long‐term prognosis in Crohn’s disease: factors that affect quality of life. Alimentary pharmacology & therapeutics, 23(3), 377-385.
  5. Talbot, R. W., Heppell, J., Dozois, R. R., & Beart, R. W. (1986, February). Vascular complications of inflammatory bowel disease. In Mayo Clinic Proceedings (Vol. 61, No. 2, pp. 140-145). Elsevier.
  6. Eaden, J. A., Abrams, K. R., & Mayberry, J. F. (2001). The risk of colorectal cancer in ulcerative colitis: a meta-analysis. Gut, 48(4), 526-535.
  7. Colitis–Pathophysiology, U. (2003). Inflammatory bowel disease part I: ulcerative colitis–pathophysiology and conventional and alternative treatment options. Alternative medicine review, 8(3), 247-283.
  8. Greenstein, A. J., Janowitz, H. D., & Sachar, D. B. (1976). The extra-intestinal complications of Crohn’s disease and ulcerative colitis: a study of 700 patients. Medicine, 55(5), 401-412.
  9. Lennard-Jones, J. E. (1989). Classification of inflammatory bowel disease. Scandinavian Journal of Gastroenterology, 24(sup170), 2-6.
  10. Gillen, C. D., Walmsley, R. S., Prior, P., Andrews, H. A., & Allan, R. N. (1994). Ulcerative colitis and Crohn’s disease: a comparison of the colorectal cancer risk in extensive colitis. Gut, 35(11), 1590-1592.
  11. Silverberg, M. S., Cho, J. H., Rioux, J. D., McGovern, D. P., Wu, J., Annese, V., … & Barmada, M. M. (2009). Ulcerative colitis–risk loci on chromosomes 1p36 and 12q15 found by genome-wide association study. Nature genetics, 41(2), 216-220.

Shared Success Story Update- Cyndi RNY to Duodenal Switch

June 06, 2016 6:37 am

Three Years Out Cyndi E … RNY to Duodenal Switch Revision

The Journey to get to the three year mark, has been amazing! And truly, The JOY is in the JOURNEY.

I am a JOYFUL “Third Time’s the Charm Revisionista”…. This is my new title…. And I say this proudly!!


For too many years (like 45! at least) I carried the shame and blame of being overweight and beat myself up on the inside. I tried everything, from age 13. I tried every diet, every program, and yes, I will say it, I have had THREE, yes THREE surgeries. And then, I let others convince me, and I bought into this, that I was a failure… BUT, I am not a failure. Surgery fails. For a long time, I could not say that, again with the SHAME word. BUT, I am done with shame, and I am done with blame. I no longer blame myself and I no longer shame myself or my body, because now, she and I, my body and I, are friends, and we are nice to each other.

Thankfully for me, I was in the right place at the right time, and met Dr. Ara Keshishian… My story with Dr. Keshishian, is simple. Dr. K was the first Doctor that did not blame me for my weight. He explained that each weight loss surgery has different measures of success, and percentages by weight loss surgery and outcomes. He educated me. He did not blame or shame me, he encouraged me. He also did an Endoscopy and found that I has a Gastro-Gastric Fistula.  Simply put, this was an abnormal connection between the bypassed stomach and the small pouch created by the RNY Gastric Bypass surgery. Food could travel two ways, thus rendering the Gastric Bypass ineffective causing weight gain.

Dr. Keshishian performed my revision from RNY to Duodenal Switch on May 31, 2013. The procedure corrected my anatomy, enabling me to lose weight and regain my health. I have no complications, no issues post surgery.


Today, being a “Three Year Old” RNY to Duodenal Switch revisionista, I have a better perspective as a relative “newbie”. I am not a prisoner of my weight. I have lost 125-130 pounds, I am 5’12” (6 feet lol) 61 years old and for the first time in my life at a NORMAL WEIGHT! I do not fear, any longer, that I will gain my weight back. I am, however, mindful that I am consistent in my new habits and patterns that I have put in place, that keep me on track. I am also accountable. To myself, also to my Weight Loss Support Group, here in Paso Robles, to some fellow DS girlfriends that


I talk with about challenges, and with Dr. Keshishian. I am not held captive by my limitations, or my weight, and now I live with the possibilities each day brings and the fun challenges I put in front of me to conquer.

To the “newbies” I say, please take your time, treat yourself kindly, with your inner voice. This is not a race, this is a journey. Don’t rush, it’s ok to take it slow, listen to your body. And do not compare your journey to anyone else. You are you! You do you! You can do this well, one day at a time. Listen to the sage advice of those who went before you. We too have learned by trial and error. Be willing to sacrifice in the short term, for the gift of the long term life. Your DS is forgiving, you be forgiving as well!!!


With JOY, Cyndi

Cyndi’s first Shared Success Story here.

Shared Success Story- Heidi

June 02, 2016 7:59 am

My name is Heidi and this is my weight loss journey. I had been struggling with my weight for years and was actively researching different surgical procedures available. I was also trying everything to lose the weight on my own. My wake up call to take action was one night when my husband said,  “I’m worried about you and want you around for a long time.” I knew I had to do something. If someone loved me that much I needed to love myself enough to change.

before image back
Before Duodenal Switch
before image side
Before Duodenal Switch

So the very next day I made an appointment with my Primary Care Physician who recommended Dr. Ara Keshishian. That afternoon I called Dr. Keshishian’ office, scheduled a consultation and began what was about to be one of the greatest journeys of my life. I was approved within a month and ready to go.

After Duodenal Switch Imaga
After Duodenal Switch with my beautiful son

In 2012, I had my Duodenal Switch with the great Dr. Keshishian. I was hopeful post op and determined to succeed. I knew with my husband’s and family’s love and support I could do it. I wanted to lose the weight for me, my husband and our future children so they had the healthy, happy mom they deserved. My Surgery weight was 220 ( Started at 230) I reached my goal at 10 months post op at 125lbs. Since having my DS I have had 1 (almost 2) amazing son’s. Duodenal Switch made this possible. I have my older son and I am currently 8 months pregnant with my 2nd son. Duodenal Switch did not just allow me to lose the weight that kept me from living life but it allowed me to get healthy and live life to the fullest. I am grateful everyday for my DS, my amazing husband, my boys, and Dr. Keshishian.

I am simply blessed. Would I do it again? In a heart beat.
Starting weight- 230
Surgery weight- 220
Goal Weight- 125