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

Blog

Lymphatic Channels

May 22, 2018 8:21 am

We are all aware of the arterial and venous systems. Arteries take the oxygenated blood from the heart to the organs and the veins take the blood back to the lungs to unload the carbon dioxide and reload oxygen to be taken back to the organs. In addition to the arterial and venous vascular systems, we also have the lymphatic channels that flow into the lymphatic system.

The Lymphatic channels and system may be new to some, however, it is the third vascular network that is much less defined. The Lymphatic system collects fluids that has left the artierial/venous vascular system along their travel outlined above and take it back to the venous system. The lymphatic vessels transport this fluid to the lymph nodes throughout the body where the nodes filter the fluid of bacteria and harmful substances.  Eventually, the fluid makes it way back to the venous system via the Superior Vena Cava. Additionally, Lymphatics collect the lipids within the GI tract and transport them to the venous system for metabolism. Most of the time these serosal lymphatic vessels are very small and hard to notice on the bowel.

Example of Lymphatic channels

The following image is in a patient who had small bowel obstruction. The obstruction had resulted in vascular congestion at the base of the mesentery. The congestion had effected the low pressure system of the veins and the lymphatics disproportionately more that the arterial system. The white-milky tubular structures  are the lymphatic channels filled with lipids.

lymphatic channels
Visible white lymphatic channels

There are three layers to the small intestinal lymphatic system, in the villi, submucosal and serosal layers and has the unique ability to transport absorbed intra-lumenal nutrients. There is a need for further research in the areas of health, obesity and disease in regards to the lymphatic system.

Liver Injury and Obesity

April 30, 2018 11:36 am

Liver is a vital organ. It has many roles in the physiologic pathways including protein productions, clotting function, iron metabolism, production of bile and cholesterol, etc. as well as metabolism and filtering of waste products. We should think of it as a refinery, for conversion of raw material from food to energy used by our body, in addition to a processing and distribution center for mineral, and nutrients. Liver injury can have devistating effects and long term ramifications if unchecked.

Liver is also very resilient and forgiving to stressors and injury. The liver will tolerate repeated insults caused by Medication (both prescription and over the counter) , obesity, Diabetes, alcohol, and herbal supplements, to name a few, but only if care is taken and the offending stressor is removed. During the injury phase, however, the liver may have a difficult time keeping up with bodily function needs due to loss of fully function cells.

The anatomy of liver can change from normal (both visually to the naked eye and under microscope) to mild inflammation and reverse back to normal if the underlying causes of injury are removed. IF, however, the anatomy of the liver changes with fibrosis, it crosses to an irreversible range where it can only be prevented from progressing rather than reversing.

 

Stages of Liver Injury and Fibrosis

A normal liver is soft, smooth, shinny with well defined edges. As liver injury sets in, it develops “cobble stone” characteristics with loss of well defined edges and becomes hard. Obesity is a risk factor for this type of liver injury. So are some of the medications that patients take for diabetes, high cholesterol and triglyceride, pain medications.

example of liver fibrosis
example of liver fibrosis

In the obese population, Non-alcoholic Fatty Liver Disease (NAFLD) causes inflammation and a slow diminishing functionality of the liver. NAFLD is the leading cause of liver disease in the U.S. Unchecked or untreated NAFLD can progress to NASH (Non-Alcoholic Steatohepatitis. NAFLD or “fatty” liver disease is an accumulation of fat within the liver. NASH is a progression that can lead to inflammation of the liver cells or advance to fibrosis and cirrhosis. In addition to liver injury, there is some evidence that NAFLD also correlates with cardiovascular disease.

Causes of NAFLD:

  • Obesity
  • Type 2 Diabetes Mellitus
  • Hypertension
  • High cholesterol
  • Sedentary lifestyle

Symptoms may include fatigue, right upper quadrant pain, liver enzyme elevation

During bariatric or weight loss surgery we visualize and occasionally biopsy the liver to define the degree of injury, if identified.  Following weight loss surgical procedure a rise in liver function enzymes may be expected due to the processing of waste products following fat mass loss.  However, long term bariatric procedures can significantly improve NAFLD   and NASH.  Bariatric procedure require the adherence to protein and supplement requirements as well as regular physician visits. Past blog of liver disease.

2018 Back on Track

January 28, 2018 11:38 am

back on track 2018 keshishian
2018 Keshishian BOT

Join our 2018 Back on Track challenge and let’s get back on track for 2018! The holidays were wonderful but if you find yourself with a few extra souvenirs don’t feel alone. The average American gains between 1-8 pounds during the holiday season and I am no exception. Let’s get back on track 2018 together.

Time to clear out the kitchen! Disposing of temptations and high trigger foods is the first step to getting back on track. Throw it all away and don’t allow them back in. If foods are difficult to acquired then they are less likely to be consumed.

Stock up on high protein and whole, unprocessed foods that are low carbohydrate and nutrient dense. When quality foods are easily available we are more likely to stay on track with the types of foods we should be eating. Simple sugars/carbohydrates are the biggest culprit of holiday weight gain. We need to go back to the basics of hydration, high protein, low carbohydrate/sugar, vitamin/mineral supplements and exercise. Simple sugars and carbohydrates are easy for our bodies to use and absorb. Cutting them out can jump start your weight loss. Each individual needs to identify the daily carbohydrate intake that works for them. Some people stay under 50 grams of carbohydrates daily and some can tolerate more daily grams. You may also need to look at your protein and fat intake. All excess nutrients absorbed have the potential to turn into fat mass and inhibit weight loss. Metabolism video.

Hydration is an important ways to start getting back on track. Water is essential to life functions. The brain is 85% water, blood is 80% and muscle is about 70% water. Hydration aids in digestion, eliminating waste, byproducts and toxins. It also can decrease the feeling of hunger. Lack of hydration can increase fatigue which can lead to craving high carbohydrate foods to increase energy.

Protein’s importance in almost every bodily function and muscle mass can not be ignored. High quality complete Protein sustains muscle mass during weight loss, aids immunity, antioxidant function, and enhances leptin and insulin function. Filling up on protein first will help with carbohydrate carvings and give a sustained satisfied feeling. A prior blog post gives additional information on the importance of protein and the effects of protein malnutrition. WLS makes daily protein intake important but especially after Duodenal Switch, protein is a necessity of daily life.

Vitamins, minerals and supplements will ensure the body has the nutrients it needs to function adequately and can keep cravings at bay. Deficiencies in vitamins and minerals can cause cravings for foods. Vitamin and minerals are essential to muscle function, red blood cell production, bone health, and numerous other physiologic functions. We may all slack off on our supplements occasionally but now is the time to get back into the habit of daily vitamins and mineral supplements. A daily vitamin, mineral, and supplement routine is a lifetime commitment after Duodenal Switch or any WLS. Here is a list of commonly used supplements. If you haven’t kept up with your minimum yearly laboratory studies, now is the time to be seen and have your labs done.

Exercise can increase weight loss, overall well being, mental well being, mood, alertness, improve digestion, improve sleep, and increases energy levels. Exercise does not have to be a daunting task. Simply adding 15-30 minutes of activity can give added benefits. Yoga, walking, dancing, lifting weights, hiking, and sports activities can be included or added to more traditional forms of exercise. There are many free online videos for all types of exercise available. This year we are teamed up with The Kinesis Centre to offer a 4 week training program that can be accessed from anywhere. A 4 week training program will be included in our 2018 Back On Track Grand prize.

Finding a new hobby can keep both your hands and mind busy, curbing the unconscious eating of foods that are high in sugar and carbohydrates. Adult coloring books, drawing, painting, knitting, crocheting, sewing, dance lessons, gardening, learning to play an instrument and many others are great ways to use your time and expand your quality of life and brain function. New hobbies can also help establish new coping skills. Our previous post on Coping Skills After Bariatric Surgery can be found here. There are a whole host of online videos for “how to” on new hobbies.

Teaming up with others can also help increase weight loss and compliance. Support from friends, family and other groups will assist you. There is a whole gamut of support group online and in person. If you have fallen out of the habit of attending our support group or webinars get back to them. You can find our schedule and announcements regarding webinars here. Our Central Valley Bariatric Facebook page also gives daily inspirational messages, protein recipes and articles and any new information or research available. There is also our Duodenal Switch Facebook Group. Anything that increases accountability is a benefit and motivates us to stay on track.

Experiment with new recipes and flavors that are bariatric friendly and within your dietary needs. There are so many options for quick and easy meals that are whole foods, high protein, and low carbohydrate. We have several recipes on our page for all stages following weight loss surgery and Duodenal Switch. However, there are endless option on the internet in Paleo, low carb, and high protein type recipes.

In the spirit of new starts and getting back on track 2018, we are having a giveaway with the basics to get back into the swing of things. This year we are looking for before and after weight loss surgical journeys for our Grand Prize. Share your weight loss journey! Don’t be shy, your journey can inspire others and/or motivate yourself. To enter the Back on Track 2018 Giveaway, please submit your weight loss surgical journey with before and after pictures to contact@dssurgery.com or you can also post your before and after pictures on our Facebook page. You will also need to sign a release for the use of your story on our website. We will draw 2 names from those that enter by announcing it on our FaceBook page or by e-mail on February 14, 2018. You must submit your mailing information to contact@dssurgery.com in order to claim the prize. You must be a verifiable patient of Dr. Ara Keshishian.

We are also doing 3 prizes of a 4 week training with the Kinesis Centre if you share an achievement picture on our FaceBook page . This achievement picture can be a milestone in your journey, something you’ve haven’t done before, a non-scale victory, a goal that you reached, anything that you are proud of achieving. Let’s do this 2018 Back on Track challenge!

Please remember that medications, health status, age, bowel motility, genetics, and diet all play a role in weight and weight maintenance. Please have a physician review your health history and medications.

*NOTE: Giveaway items may or may not be identical to the pictured items.
We are not affiliated with any of the products nor do we endorse any one type of product. There is no cash value to the prizes.

Compounding Pharmacies

January 22, 2018 2:38 pm

New FDA regulations for compounding pharmacies has spurred changes in our pricing and ability to provide injectable Vitamin A and Vitamin D.  The compounding pharmacies are no longer compounding injectable Vitamin A and there is a nationwide shortage of the national brand of injectable Vitamin A.  We have a tentative date of February 2018 when we may be able to obtain injectable Vitamin A. We won’t be able to quote pricing on Vitamin A injections until we are able to orders.

We are able to obtain and supply our patients with injectable Vitamin D but with a price increase.

The following is the letter we received from our compounding pharmacy.

“The healthcare industry has continuously undergone changes in regulations and legislation. The compounding industry is no exception and has faced rigorous regulatory requirements this past year such as new testing specifications and compliance standards.

We are set on facing these demanding challenges by meeting and exceeding these new regulatory requirements. We want to assure you we will continue to provide the best products on the market for you and your patients. Quality and safety remain a top priority. We understand that our pharmacy plays a vital role in providing care to your patients. The increase in pricing is a reflection of the additional cost in producing and testing the product based on regulatory specifications.”

Revision from failed AGB to Duodenal Switch

January 10, 2018 2:10 pm

A few times a month during consultation for weight loss surgery , I’m ask as to why I do not offer the adjustable gastric banding as an alternative to the patients. As I have said over the years when a patient considers an weight loss surgery the totality of the risk should be considered. This includes the operative, immediate postoperative course, the maintenance and the follow-ups needed. The potential complications of the procedure in addition to the long-term success off each operation should also be taken into account.

Unfortunately, some patients are led to believe that any perceived benefit in the short operative time and the ease of the adjustable gastric banding also translates to a better outcome. This is in fact the opposite of what the published data have shown, a recent study published in April 2017 by Vinzes et.al, shows that 71% of patient lost their band by 10 years out.

 

What is also interesting that more patients underwent revision from failed AGB to the duodenal switch than the sleeve gastrectomy (Fig 1.). This is what I also recommend.

Fig 1

 

More importantly, The patients who underwent a revision from failed AGB to the duodenal switch operation had the best long term results of all patients (Fig 2.) note the “rBPD” line that is the highest of %EBMIL.

Fig 2

Complication’s were broad and frequent (Table 3.)

Table 3

 

Further information on revision from failed AGB to Duodenal Switch or other failed weight loss surgeries can be found here. 

Bile Reflux Gastritis

January 10, 2018 1:45 pm

Bile reflux gastritis has been recognized as a significant cause of dyspepsia in a subset of patients. This patient group set does not respond to the standard treatment (not expected to) and some get improvement with the treatment of H.Pylori infection if one is diagnosed at the time of upper endoscopy and biopsy. Inflammation and Foveolar hyperplasia are some of the findings that can be seen endoscopically. This and other findings have all been documented in the literature. An article published in 2005, reported over 40% incidence of  Foveolar hyperplasia in patient with bile relax. It is been noted that bile causes the thickening of the mucosa lining of the GI track. This is called Foveolar hyperplasia when the mucosa of the stomach is noted to be thicker with more numerous and deeper folds.
Foveolar Hyperplasia- Bile Reflux Gastritis
The treatment for this is reduction and prevention of bile reflux to the stomach, in some cases this can only achieved by surgical diversion of the bile from the stomach. Additional information on Bile Reflux and the surgical treatment can be found here.

Vitamin A injections

October 25, 2017 10:31 am

Unfortunately, we have been informed that the company we order our Vitamin A injectionsVitamin A injections from will no longer have Vitamin A available.  We have contacted several other companies and they also do not have it available.  The manufacturer of Vitamin A states that there is a nationwide shortage of injectable Vitamin A and it may be available next year.

Our office has a few vials left and we are hoping that we can get to as many people as possible before we are completely out.  We will continue to look for a source of Vitamin A injections. We will let you know when it is no longer available and when we receive a new shipment.   Thank you for your understanding and we apologize for this issue.
Information on Vitamin A deficiency here.
You can find our list of recommended supplements here.

Just as a reminder, we have no financial interest in any of the vendors that are recommended on our website. Also, please note that this is not in ANY form or fashion a substitute for the evaluation by your surgeon or primary care physician.  This is informational only and is not to be taken as a recommendation for any patients’ condition.  

Long Term Complications of Adjustable Gastric Banding

October 17, 2017 6:35 am

It is interesting to encounter patients who are still being recommended for Lap Band placement to treat morbid obesity. There is a vast body of scientific evidence supporting that Lap Band not only does not result in a sustained weight loss for majority of the patients, but that it results in significant long term complications for some. One of the complications is a significant stricture (narrowing) where the band is located even when it is completely empty. This is cause by: 1- either scarring of the tissue around that band causing a “belt” effect around the stomach, or  
Stricture of a deflated AP-10cc band
2-Slipped band.
Partially slipped band
There are numerous other complications that are associated with Adjustable Gastric Bands that encompass a wide range of areas that are not discussed in this blog. This recent article  (yes another one) outlines the dismal long term outcome of the Adjustable Gastric banding- Buyer Beware. https://www.dsfacts.com/pdf/agb-long-term-results-1506834076.pdf  

Enter to Win!

September 08, 2017 9:41 am

Keshishian Obesity Help Contest

We are holding a giveaway for tickets to the Obesity Help National Conference Oct 27 & 28, 2017 in Long Beach, CA. Enter to Win!

Dr. Ara Keshishian is on the Q&A panel.

Support and see two of our own, Jo Diniz and Heidi Brown, at the conference

Jo contest piccontest Heidi pic

Conference Location:

Hilton Long Beach

701 W Ocean Blvd.
Long Beach, CA 90831

Event link: www.obesityhelp.com/events

Official Rules:

How to Enter and eligibility: All entrants and winners must be 18 years of age or older at the time of entry. Up to 4 entries per person.

  1. Share a picture of an achievement, non-scale victory or positive experience on our FaceBook page   The picture must be visible to the public. Your sharing is acknowledgement of use for contest purposes and visibility to the public.

2. Take a screen shot of the review or update with your username and date.

3. E-mail the screenshot to contact@dssurgery.com with your contact information (name, phone number, e-mail, and mailing address )

4. Entries must be a verifiable patient of Dr. Ara Keshishian in Glendale, CA.

Promotion Timing:

The Review & Update Giveaway begins September 8, 2017 and ends September 14, 2017 at 5:00pm PST

How Winners are Chosen:

Winners will be chosen by random draw.  Odds of winning vary upon the number of entries received for the giveaway.

Winner Notification and the Claiming of Prizes:

Winners will be notified via the email provided at time of entry and also published on our blog comments www.dssurgery.com/blog and on our FaceBook page. The winner will have 24 hours to respond to the winning notification email or the prize will be forfeited.  The prizes have no cash value. The prizes are non-transferable and must be accepted as awarded. No changes may be made to the prizes. There is no cash value for the prizes.

General Conditions:

By entering the Giveaway, entrants agree to abide by and be bound by these Official Rules and the decisions of the Sponsor, which are final and binding in all matters relating to the Giveaway, and release and hold harmless Sponsor and its affiliates, directors, officers, employees and assigns from and against any liability, claims, lawsuits, judgments, losses, damages of any kind, injuries, death, property damage, costs and expenses, arising from, resulting from or in connection with the Giveaway, the participation in the Giveaway, or the receipt, possession, use or misuse of any prize. Sponsor is not responsible for lost, late, incomplete, inaccurate, stolen, delayed, misdirected, undelivered or illegible entries or for lost or stolen entry boxes or other errors or difficulties of any kind whether human, mechanical, electronic, typographical, printing or otherwise relating to or in connection with the Giveaway, including, without limitation, errors or difficulties which may occur in connection with the administration of the Giveaway, the processing of entries, the announcement of the prizes, or in any Giveaway-related materials. Sponsor is not responsible for technical, hardware, software or telephone malfunctions of any kind, lost or unavailable network connections, or failed, incorrect, incomplete, inaccurate, garbled or delayed electronic communications caused by the user or by any of the equipment or programming associated with or utilized in the Giveaway. Persons who tamper with or abuse any aspect of the Giveaway or who are in violation of these Official Rules, as solely determined by Sponsor, will be disqualified and all associated entries will be void. The Sponsor reserves the right, at its sole discretion, to cancel, terminate, modify or suspend the Giveaway if, in Sponsor’s opinion, it is not capable of running as planned, including, but not limited to, due to tampering, unauthorized intervention, fraud, technical or phone line failures or any other problems beyond the control of the Sponsor, and select the winners for affected drawing(s) from among all eligible entries timely received for such affected drawing(s) prior to cancellation.