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Health Insurances Working Against You

July 09, 2018 12:01 pm

Are Health Insurances working against you? Especially in people who have the disease of obesity? Insurance companies continue to lengthen the pre-operative period. The time that is required to lapse has now in some cases been extended between 6-12 months for some commercial health plans. There are yet again studies that have shown no benefit to the patient with this mandated waiting periods imposed on the patients. Unfortunately, the patients need to challenge the health care insurance companies by the means of all options that may be available to them. This may include internal appeal to external evaluation by some state agency. There are numerous studies that show pre-operative dieting does not equal better weight loss or compliance.

Insurance-1Insurance-2

 

 

Parathyroid Scan

July 09, 2018 11:48 am

A Parathyroid scan or Sestamibi scan may be needed if the typical weight loss surgical reasons for elevated PTH levels have been addressed. Sestamibi is a small protein which is labeled with the radio-pharmaceutical technetium-99. This very mild and safe radioactive agent is injected into the veins of a patient with overactive parathyroid and is absorbed by the overactive parathyroid gland. If the parathyroid is normal it will not absorb the agent. The scan below shows the uptake of the agent.

Calcium, Vitamin D and Parathyroid hormone are routinely measured on yearly follow up for most post weight loss surgical (WLS) patients. Elevated parathyroid hormone (PTH) may be caused by Vitamin D deficiency or calcium deficiency (most common in post WLS) or by over active parathyroid gland(s). In the latter case, if one of the four glands  is overactive then this is knows as a parathyroid Adenoma. If all 4 are over active and are secreting too much PTH, this is known as hyperplasia. Ultrasound of the neck, may identify an enraged parathyroid gland (adenoma) which is located behind the thyroid gland. Given the large area where the parathyroid gland may be located, additional tests are needed to not only identify the location of the gland(s) but also to distinguish between single gland (adenoma) or multiple glands (hyperplasia) cause for the elevated PTH. It is important to investigate all avenues and testing in parathyroid hormone elevation and in some cases, not to rely on one test for your diagnosis.  It is also imperative that weight loss surgical patients take their supplements routinely and consistently and have their laboratory studies followed at least yearly.

Informative Video on Vitamin D: here

 

Candy Cane Gastric Bypass – RNY

June 21, 2018 1:05 pm

One of the findings following Gastric Bypass is a Candy Cane Gastric Bypass. Nausea and vomiting , upper abdominal pain is a common complaint of patient who have had the Gastric Bypass RNY operation. This is in addition to the high incidence of patients who experience the complications of weight regain and or dumping syndrome.

Quite frequently the symptoms of  nausea, vomiting and upper abdominal pain of a patient with history of gastric bypass is evaluated by a primary care, referred to a gastroenterologist. The “routine” work up recommended is X-ray of the abdomen, maybe contrast study (Ct scan or upper GI) and for sure and upper endoscopy. The result quite frequently reported as “…nothing wrong”.

A typical upper GI in a Candy Cane Gastric Bypass situation may look like this:

Upper GI

A common and underreported problem may be a Candy Cane finding.  The “blind” end of the small bowel anastomosis is too long and this results in food settling in the hook of the candy cane. The symptoms of the nausea, vomiting and upper abdominal pain may be from the residual food and liquids that do not drain from this area.

Flow of oral Intake

 

Candy Cane Gastric Bypass finding

Candy Cane

Candy Cane Gastric Bypass cases will require surgical intervention to shorten the length of the blind segment of the small bowel to improve symptoms.

It is my recommendations that any patient with history of weight loss surgery who is having any persistent gastrointestinal symptoms be evaluated by weight loss surgeon.

 

Calcium Lab Results

June 05, 2018 3:26 pm

Calcium is measured to evaluate function and adequacy of a physiologic processes. Calcium plays a critical role in several body functions such as, coagulation pathways, bone health, nerve conduction, and other functions. It is important whenever you are evaluating laboratory results that you look at the whole picture of the person, including medications, other laboratory studies and health history.  One value is not a stand alone result.  There are many factors that effect calcium results.

Factors that effect calcium results: (not an all inclusive list)

pH

Albumin

Lactate

Heparin

Vitamin D deficiency

Magnesium depletion

Anticonvulsants

Renal Disease

Pancreatitis

Parathyroid

Thyroid

The two most common issues following Weight loss Surgery  or Duodenal Switch may be albumin level and Vitamin D level.  Please see past blogs on Vitamin D. Magnesium may also play a role in a Duodenal Switch patient.

The most common calcium result drawn is the total calcium level. Laboratory results may not explicitly label it as such, however, it measures the calcium that is bound to protein. Ionized calcium is the free calcium that is representative of the true total calcium. Ionized Calcium can be measured by ordering specific lab. Alternatively, the Ionized calcium can be calculated by the following formula: Corrected calcium mg/dL = (0.8 * (Normal Albumin – Pt’s Albumin)) + Serum Ca  ) or use the calculator at the bottom of this post.

 

The low Albumin level accounts for the low calcium level. This may be the reason for a patient with a low albumin/protein level, also having their calcium level reported as low. However, when adjusted for the protein deficiency the corrected calcium comes into normal range. Video of Trouseau’s sign of a patient with calcium deficiency. Calcium bound to albumin Keshishian

The first step in a patient who has low calcium reported, is to make sure their protein and albumin levels are normal, along with Vitamin D.

Calcium levels are managed by two processes major regularly hormones and  influencing hormones. Controlling or major regulatory hormones include PTH, calcitonin, and vitamin D. In the kidney, vitamin D and PTH stimulate the activity of the epithelial calcium channel and the calcium-binding protein (ie, calbindin) to increase calcium absorption. Influencing hormones include thyroid hormones, growth hormone, and adrenal and gonadal steroids.

Further information on protein.

Further information on calcium. 

Videos/Webinars on several of the above topics.

calcium metabolism
Duodenal Calcium Metabolism

Corrected calcium = 0.8 * (4.0 – serum albumin) + serum calcium

Corrected Calcium Level Calculator

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.