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Blog

Dr. Facebook

March 22, 2019 8:24 am

We have become reliant on the information that we obtain from the internet, specifically platforms such as Facebook. In our practice we have to continuously correct information that patients have obtained from other patients, unmonitored sites, blogs, and postings. Most of this information is based on individual experiences that has become gospel. “Fat is good for you” is one of them. To clarify, some health fat (olive oil, avocado, Omega 3) is healthy and needed for all patients. We do not recommend “fat bombs” as a part of ones daily dietary intake.

The following article was written on the accuracy of nutritional posts in support groups on Facebook.

Koalall et. all  in  SAORD, December 2018  Volume 14, Issue 12, Pages 1897–1902 published
“Content and accuracy of nutrition-related posts in bariatric surgery Facebook support groups”

The conclusion, as suspected, that “Over half of the posts contained inaccurate content or information that was too ambiguous to determine accuracy..:”

pilot
Pilot by Dr. Ara Keshishian

It is our recommendation before any dietary recommendations are taken from facebook and the like, the source of the information should be verified.  As I have stated in the past, a frequent flier passenger is probably not qualified to fly a

commercial airplane, any more than a previous weight loss surgical patient providing medical and nutritional advice. We realize that there is significant value to the forum for exchange of information and sharing of experiences with other weight loss surgical patients as long as the information is well sourced and verified.

Previous blog with artwork.

by Rina Piccolo https://www.rinapiccolo.com/piccolo-cartoons

Gastric Balloon

March 12, 2019 9:10 am

Here we go again…. There is a new cure for obesity, Gastric Balloon, with minimal to no risk, is an outpatient procedure and/or can be done in the surgeons office with no anesthesia. Have we not similar claimed like this before (Adjustable gastric band) ?

Randomized sham-controlled trial of the 6-month swallowable gas-filled intragastric balloon system for weight loss published  in Surgery for Obesity and Related Diseases 14 (2018) 1876–1889, by Sullivan et. al  reports

“Conclusions: Treatment with lifestyle therapy and the 6-month swallowable gas-filled intragastric balloon system was safe and resulted in twice as much weight loss compared with a sham control, with high weight loss maintenance at 48 weeks.”

This sound very promising, however is very vague and leaves out significant, critical, and pertinent information.

The outcome of weight loss at 24 weeks was reported in Total Body weight loss % (TBWL%), Excess weight % (EWL), weight loss, and BMI change. Of those, the last three were statistically significant changes.

The outcome the weight loss was reported to be at 7% TBWL% at 24 weeks with some weight regain, with the patient employing post REMOVAL life style changes.

It is stated that the Gastric Balloon is temporary device that needs to be removed in 6 months and should  be considered in low BMI patients (<35kg/m2).  It is is important for those patients who are considering this temporary expensive measure for minimal weight loss to entertain the alternative of the same temporary results that may be obtained by lifestyle changes. These results may be maintained by a healthy lifestyle, exercise, and eating without the need for a device.

Adhesions, Internal Hernia And Bowel Obstruction

December 15, 2018 2:35 pm

Adhesions are fibrous bands of scar tissue that form during the healing process. Following surgery, many people live normally with this scar tissue. However, they are also the cause of bowel obstruction when the adhesions form in such a way that causes a segment of the bowel to either get trapped, or form a “knot”. In both of those cases, the end result is a partial narrowing or a complete blockage of the intestines. This is called bowel obstruction.

Without treatment, the blocked parts of the intestine can die, leading to serious issues. However, with prompt medical care, intestinal obstruction often can be successfully treated.

Other causes of bowel obstruction:

  • In children, the most common cause of intestinal obstruction is telescoping of the intestine (intussusception).
  • Intussusception telescoping of the interstine
  • Hernias — portions of intestine that protrude into another part of your body
  • Inflammatory bowel diseases, such as Crohn’s disease
  • Diverticulitis — a condition in which small, bulging pouches (diverticula) in the digestive tract become inflamed or infected
  • Twisting of the colon (volvulus)
  • Impacted feces
  • Colon Cancer
Adhesion band with trapped bowel

 

Internal Hernia

In patients who haven’t Bariatric / weight loss surgery or an untouched GI track, bowel obstruction may manifest itself by symptoms of loss of appetite, constipation, nausea, vomiting, enlarged abdomen, abdominal pain, cramping, with no passage of gas or bowel movements.

However, patients who have had a weight loss surgery (Duodenal Switch, or the Gastric Bypass) because of the parallel limbs of the small bowel, the symptoms outlined above may not present. The diagnosis of a bowel obstruction, when suspected, should be identified with CT scan of the abdomen and pelvis with Oral and IV contrast. A CT scan with no oral contrast or water instead of oral contrast is inadequate and may lead to a delay in diagnosis and surgical intervention. Examples of Bowel Obstruction CT findings were discussed previously.

The treatment for an internal hernia and adhesions causing a bowel obstruction depending on the severity may range from observation to  surgical intervention in order to release the small bowel from the constraints of the adhesions.

GI Bleed following Weight Loss Surgery

September 17, 2018 10:28 am

Gastrointestinal (GI) Bleed following weight loss surgery is rare but does require knowledge of the particular bariatric surgical procedure the patients has and how to proceed with diagnostics to fully evaluate the situation. Acute or chronic gastrointestinal bleeding can cause anemia in patients. However, Anemia may also be caused by nutritional deficiencies (iron, vitamin , minerals), Kidney disease, bone marrow disease and others. The work-up for anemia following weight loss surgery follows a routine protocol. If there is an evidence of bleeding from intestine (bloody emesis, bloody bowel movement, “tar” like black bowel movements) then the diagnostic work up would include an upper and lower endoscopy.

Endoscopic Procedures:

Upper endoscopy Esophagogastroduodenoscopy (EGD): evaluates the esophagus, stomach and a limited area of the duodenum past pyloric valve.

Normal Anatomy
Normal Anatomy

Lower endoscopy Colonoscopy or coloscopy: evaluates the rectus and the entire colon.

Between these two tests, there is still a considerable amount of the small bowel that is not accessible or visualized with endoscopic procedures. For the small bowel, examination Capsule endoscopy is an option in an intact GI tract. Patients who have had Gastric bypass RNY or the Duodenal Switch, the large segments of the small bowel can not be visualized or examined with capsule endoscopy.

RNY Gastric Bypass
RNY Gastric Bypass
Duodenal Switch Two Anastomosis
Duodenal Switch Two Anastomosis
SADI-S Single Anastomosis Duodeno-ileal - Sleeve
SADI-S Single Anastomosis Duodeno-ileal - Sleeve

Patients who have had Duodenal Switch, Gastric Bypass and SADI – S would need a tagged red cell scan or CT angiography if GI bleed is suspected in areas of the small intestine that are inaccessible by endoscopic procedures.

Cholecystectomy-Gallbladder Removal

September 10, 2018 9:44 am

There are differing opinions, based on a broad set of scientific publication, wether or not gallbladder should be removed at the time of weight loss surgery. Obviously, Cholecystectomy is a stand alone general surgical procedure that is often performed due to gallstones and/or gallbladder disease with a variety of symptoms. However, the focus of this blog will deal with Bariatric Surgery and Cholecystectomy.

Rapid weight loss can increase a patients chance of forming gallstones. This rapid weight loss can be as little as 3-5 pounds per week. Weight loss surgery can increase your risk for gallstone formation. Several of the common thought processes the mechanism of this is, obesity may be linked to higher cholesterol in the bile, larger gallbladders, high fat diet and larger abdominal girth.

Gallbladder, Duct and Duodenum
Gallbladder, Duct and Duodenum

When a patient is having the Duodenal Switch (DS) Bariatric operation, or having a revision of a failed gastric bypass to the DS, I always remove the gallbladder. This is because there isn’t an anatomical route to utilize endoscopic procedure for an ERCP should the need rise.

In the case of a patient undergoing Vertical Sleeve Gastrectomy, if there are any indications or complaints of abdominal pain then an ultrasound is done. If there are findings of gallstones or other disease of the gallbladder, then a cholecystectomy is performed at the same time as the Sleeve Gastrectomy.

Common_Cystic-Duct
Common_Cystic-Duct
Clipped_Cystic_DuctandArtery
Clipped_Cystic_DuctandArtery

In my opinion, every patient having the Gastric Bypass (RNY) should also have the gallbladder removed because of the anatomical limitations after surgery that prevents the use of ERCP if needed. Some clinicians will place the patient on a long term medications to reduce the chance of gladstone formation after surgery, which themselves have side effects limiting the compliance in most patients.

Further information on Common Bile Duct Dilatation and ERCP

PolyCystic Ovarian Syndrome PCOS

September 04, 2018 9:58 am

PolyCystic Ovarian Syndrome PCOS is a complex condition. The exact cause of PCOS is unknown however, it involves hormones imbalance and multiple ovarian cysts, irregular menses, and infertility. In some cases, PCOS can be compounded by diabetes, hypertension and other metabolic conditions. PCOS has been shown to effect approximately 10% of women of childbearing age with symptoms of menstrual abnormalities, poly cystic ovaries, and excess androgen (male sex hormone). PCOS should be diagnosed by ensuring there are no other underlying endocrine issues. There are several associated disease processes that seem to be related to PCOS. These related disease processes are Type 2 Diabetes, higher depression and anxiety, increased cardiovascular risks, stroke, hyperlipidemia, sleep apnea, overall inflammation, and endometrial cancer.

Anatomically, numerous cysts are found on the ovaries. These are usually diagnosed by ultrasound, blood levels of hormones, and symptoms described above.

Poly Cystic Ovarian Syndrome
Poly Cystic Ovarian Syndrome

Bariatric Surgery and PolyCystic Ovarian Syndrome PCOS

Bariatric Surgery can improve PCOS in those individuals with Type 2 Diabetes Mellitus. Further information on weight loss surgery and its effect on PCOS here.

Laparoscopic Hiatal Hernia Repair

August 21, 2018 10:41 am

A Hiatal Hernia is an abnormal opening or widening of the gastroesophageal junction, which is located at the top of the stomach within the diaphragm. Laparoscopic Hiatal Hernia Surgery is done to tighten the junction between the stomach and esophagus. The most common surgery is done by pulling the stomach back below the diaphragm and wrapping the top of the stomach around the junction between the stomach and esophagus. The stomach is then sewn in place. Surgery is the only way to treat a hiatal hernia that is causing severe symptoms.

Laparoscopic Hiatal Hernia Repair can be performed using Robotic or traditional Laparascopic techniques, both options are minimally invasive.

There is also a technique that can be utilized for hiatal hernia repair post Sleeve Gastrectomy. A Hiatal Hernia Repair can be accomplished post weight loss surgery also. Follow link to see videos: here

Additional information: here

Hiatal Hernia Causes:

  • heavy lifting
  • coughing
  • obesity
  • injury
  • persistent vomiting
  • age related

Symptoms:

  • sour taste
  • reflux
  • heartburn
  • belching
  • chest or abdominal pain
  • difficulty swallowing
  • vomiting
  • no symptoms
Hiatal Hernia Keshishian
Operative finding as soon as liver lifted, exposing the Gastroesophageal junction during Laparoscopic Hiatal Hernia Repair
Laparoscopic Hiatal Hernia Repair
Hiatal Hernia identified with the part of the fundus of the stomach retracted in the chest.
Laparoscopic Hiatal Hernia Repair
Dissected Left and Right Crus (the muscle fibers of the diaphragm) which form the esophageal hiatus.
Close up of the Left and Right Crus
Hiatal Hernia Repair Keshishian
Part of the Laparoscopic Hiatal Hernia repair, approximation of the crus

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-1
Insurance-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.

Parathyroid Scan

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:

Anatomy_1
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-2

Candy Cane Gastric Bypass finding

CandyCane_3
Candy

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.