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Compounding Pharmacy

March 22, 2017 7:40 pm

We have received notice that the FDA and the compounding pharmacy have changed their regulations for several medications.  Unfortunately, this affects our office and Duodenal Switch patients in regards to injectable Vitamin D and Vitamin A. In the past, we have been able to have injectable Vitamin A and injectable Vitamin D in bulk in our office.  The new regulations require that a patient be assigned to the medication, so we will be unable to have it on hand in our office. This is out of  our hands and control.

We are requesting that if you are anticipating the need for injectable vitamins that you have your laboratory results in our office at least 3 weeks prior to your office visit.  This will give our staff adequate time to order your injectable vitamins to be available at your visit.

Injectable Vitamin D may be needed in some cases of Vitamin D deficiency or inability to increase Vitamin D level with oral supplements. Vitamin D is a fat soluble vitamin. It plays an important role in bone metabolism and structure. It has also been found to affect the immune regulation, control off- inflammatory reactions, and also be involved in a number of broad cellular functions throughout the body.

Research and information regarding Injectable Vitamin D.

Thank you for your understanding in this manner.

Dental Resources

February 24, 2017 10:55 am

You may have heard that I will be giving a lecture at the California Dental Association’s 2017 meeting.   In preparation for the lecture, I have come across some excellent information with the assistance of and dental resources from Dr. Armen Mardirossian of Mardirossian Periodontics and Implants.

The following Dental Resources are part of many of the resources I have used to complete this lecture series for the Dental Association. Periodontal disease can effect every body system and should be addressed to avoid further damage and complications. We can not over emphasize the importance of good dental care. In addition, following weight loss surgery, supplementation of vitamins and minerals is extremely important. Always seek the care of a professional when dealing with dental issues or other physical symptoms.

We are sharing these resources with our patient population in order to shed some light on this topic.  You can also find a previous webinar on the topic of Dental Issues After Weight Loss Surgery here.

Complete Dental Resources here (click on blue links)

dental resources on medical problems

Thank you Dr. Mardirossian for your assistance.

Back on Track 2017 Giveaway

January 10, 2017 10:03 am

Let’s get back on track 2017 after the holiday season! 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 2017 together.

Time to clear out the kitchen! Disposing of temptations and high trigger foods is the first step to getting back on track. If the food isn’t easily acquired then it is 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 and cutting them back 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. 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.

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.

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.  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 2017, 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.  Share your weight loss journey! Don’t be shy, your journey can inspire others and/or motivate yourself. To enter the Back on Track 2017 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 January 31, 2017. You must submit your mailing information to contact@dssurgery.com in order to claim the prize.

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.

Please check with your physician before starting a new supplement and follow laboratory studies for adjustments in supplements. Vitamin information here. Mineral information here.

Weight Gain after Gastric Bypass

January 04, 2017 9:12 am

Weight loss surgical procedures have different long term results and some procedures have more dramatic weight loss than others. Some procedures also result in much more sustained and long term weight loss. Unfortunately, what may be not obvious is that the patient has very little control over the outcome of the surgery in most cases. IT is very easy to blame the patient for weight regain after weight loss surgery. However, it is important to remind ourselves that the long term data reporting outcomes of the surgical procedures in most cases, includes all patient population. All these studies include the most compliant and not so compliant patients. Comparison chart of outcomes of weight loss surgical procedures.

A larger percentage of gastric bypass patients will require revision for weight regain, or other problems. There is no evidence that the size of the pouch or the anastomosis between the pouch and the small bowel changes the weight regain outcomes. Yet, quite frequently I will see patient who have had gastric bypass revision for weight regain, by reducing the size of the pouch or the anastomosis. Here are some publications that support the notion that other than extreme dilation, the size of the pouch and the size anastomosis does not predict the outcome of the surgery. There is some correlation with the site of the pouch, anatsmosis and weight loss, but there is no correlation between the size of the pooch, the opening and the failure rate. This means that patient with smaller pouch do not have better long term outcome that the ones with larger pouch, only that the patient with smaller pouch or anatsmaosis will loose more weight.

“Influence of pouch and stoma size on weight loss after gastric bypass”

“Impact of gastrojejunostomy diameter on long-term weight loss following laparoscopic gastric bypass: a follow-up study”

Weight regain after RNY Gastric Bypass may also be caused by a Gastro-gastric fistula, which is a new connection between the pouch and the remnant stomach. Here is further information on Weight Loss Surgery Revisions.

When considering a primary weight loss surgical procedure, be informed.  Investigate all your options and consider the long term outcomes.  This may mean investigating different weight loss surgical procedures on your own.

Standard Common Channel In Duodenal Switch Will Result In Weight Regain.

December 16, 2016 1:57 pm

Stéfane Lebel, M.D.*, Geneviève Dion, M.D., Simon Marceau, M.D., Simon Biron, M.D., M.Sc., Maud Robert, M.D., Laurent Biertho, M.D. earlier this year released a research article comparing patients undergoing standard common channel of 100cm and standard common channel 200cm. The conclusion of this article was: “In this population, BPD-DS with a 200-cm common channel offered similar remission rate of co-morbidities compared with standard BPD-DS. It was associated with similar weight loss at nadir, followed by a more significant weight regain. It might yield a lower rate of nutritional complications. Long-term randomized data are needed to detect other potential advantages.”

Our Experience:

One of the most dreaded outcomes of any weight loss surgical procedure is weight regain. This is assuming that initial adequate weight was lost to result in resolution of the co-morbidities in the first place.  As the weight loss surgical field has changed over the years so has been the cases of regain that we have seen.

There was a time when Lap bands were being revised for inadequate weight loss and weight regain. Not to mention the complications of reflux, difficulty swallowing and persistent Nausea and vomiting. Then as more Gastric bypass procedures “aged” the number of patients that started looking for revision for weight regain increased. The latest fad is the Vertical Sleeve Gastrectomy that are done with false sense of expectation and results. The long term outcome of Vertical Sleeve Gastrectomy is no where close to that of the Duodenal Switch, independent of the size of the sleeve. In fact, more surgeons are trying to get a little more weight loss by making the sleeve too tight. All they are doing is creating a significant and debilitating set of problems such as reflux, nausea, and solid intolerance.

The ideal revisional procedure for these patients should be the Duodenal Switch. Some surgeons, however, have started advocating “single anastomosis” knock off the duodenal switch. Others do “standard length common channel” rather than a Hess method Duodenal Switch. I have always performed a traditional Hess method Duodenal Switch.  The Hess method Duodenal Switch has held the largest and longest excess weight loss maintenance for 28 years, going into 29 years.  Here is a past blog regarding small bowel length.

The predetermined standard common channel results in weight regain. Study

 

Causes and Perception of Obesity

December 12, 2016 7:34 am

Introduction

Society has long ignored the scientific causes of obesity and formed their perceptions based on personal attitudes. There are a number of  factors that have been identified that contribute to the epidemic of obesity. Unfortunately, there continues to be a public perception of obesity being a “personality” disorder. Quite frequently patients are told “…just eat right and exercise, and everything will be fine.” We all know that is not the case. One of the poster presentations during the 2016 Obesity Week was on the subject of causes and perception of obesity. This topic is always an important talking point at these meetings and there seems to be some changes in viewpoint of the general population.

title

This was a large study conducted over a long time frame with a relatively decent population size.

study-sample

The study showed a slow but steady improvement in the perception by the general population in recognizing the multifactorial nature of obesity with less personal blame on the patient. The pace of change in perception has been positive, however, there is a still large gap for improvement. There is hope for the future of a correlation of causes and perceptions of obesity.

blame-bad-choices
obesity-narrative-trends Causes of Obesity

blame-patient

 

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Summary

We, as a healthcare providers and society, are making improvements in educating, awareness, and perception of obesity but we still have work to do.  In this changing healthcare environment, we can not let these gains in perception slip back to old patterns and biases. We need to maintain our diligence, education and our forward thinking to continue the positive and factual perception of obesity.

Waiting on Pregnancy after Bariatric Surgery

October 27, 2016 11:47 am

Screen Shot 2015-04-04 at 11.29.35 AM

Following Bariatric Surgery women should wait to conceive until they are at least 2 yrs post surgery, their weight has been stable for several months and their laboratory studies of vitamin, minerals and electrolytes levels are normal.  After weight has stabilized and blood work is normalized pregnancy after Bariatric Surgery can be achieved in a health manner for both mother and infant if monitoring is provided in relation to the surgery. We have discusses previously the importance of these issues in the following blogs here.

The following article by Lisa Rapaport re-emphasises this:
(Reuters Health) – Babies born less than two years after their mothers have weight loss surgery may face a higher risk of serious complications than infants delivered after more time has passed, a U.S. study suggests.

Because obesity is linked to fertility issues, undergoing so-called bariatric surgery to shed excess weight can make it easier for some women to get pregnant. But when these women do conceive, they are more likely to have premature or small infants that require intensive care than women in the general population. The remainder of the article can be found here.

Gut Biome and Body Fat

October 06, 2016 7:02 am

The Gut Biome and body fat link continues to be an interesting and new front in the science of obesity.  Although we know more factors in obesity it has remained an elusive multi-factorial process. The following article is yet another piece of the puzzle.

Study finds link between faecal bacteria and body fat

gut-biome
www.connersclinic.com

“Researchers at King’s College London have found a new link between the diversity of bacteria in human poo – known as the human faecal microbiome – and levels of abdominal body fat.
The research, published today in Genome Biology, also provides further evidence of possible genetic influences on obesity, through heritable bacteria found in the faecal microbiome.”

View the rest of the article here. The research paper here.

Our past posts on gut biome and probiotics here

Small Intestine

September 25, 2016 10:27 am

The small intestine is a long tubular organ that is approximately 460-1000cm in adults. It is divided into three sections, Duodenum, Jejunum, and Ileum. The surface area is greater than one might think due to the folds, villi, and microvilli. The surface area is approximately 30 square meters. Most of human digestion and absorption takes place within these three sections of small intestine.

Keshishian master-normal-anatomy-with-text

The diagram of normal anatomy absorption in the small intestine is pictured to the right.  It is color coded based on the area of the digestive tract the absorption takes place. You may also view here: master-normal-anatomy-with-text

Overview

Length: 22 ft. (6.7 m)

Width: 1 inch

pH: neutral or slightly alkaline (5-7)

  • Steps:
    1. Neutralization in stomach, where enzymes act to breakdown food
    2. Digestion through greater breakdown with help of bile and pancreatic juices
    3. Absorption through assimilation of digested food, vitamins, and salts. Nutrients are taken into the bloodstream via specialized epithelial cells to the liver through the hepatic portal vein.

Duodenum

Length: 1 ft. (0.30 m)

pH~ 5

  • Main site of breakdown
  • C shaped turn with 4 parts: superior, descending, inferior, ascending
  • Mixes food (now in form of chyme) with bile and other digestive juices
  • Passes chyme through duodenojejunal flexure which contains suspensory muscle to widen the duodenal angle and increase movement.

Jejunum

Length: 8.2 ft. (2.5 m)

pH~ 6

  • Coiled, vascular tube that contains a thick intestinal wall
  • The wall contains epithelial projections called intestinal villi
    • Smaller projections in the villi, called microvilli work to:
  1. project specialized transport cells called enterocytes
  2. increase surface area
  3. allow more absorption

Ileum

Length: 11.5 ft. (3.5 m)

pH~ 7

  • Less vascularized and thinner intestinal wall
  • Absorbs nutrients that preceding sections of the gut did not
    • particularly works with vitamin B12 and bile salt absorption
  • Connects to the colon through the ileocecal valve for further breakdown.

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  Absorption Duodenal Switch Anatomy (1.2 MiB, 13 hits)
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References:

  1. Campbell NA, Reece JB, Mitchell LG. Biology. 5th ed. Benjamin-Cummings Pub Co. 1999-2002; 802-805.
  2. Ovesen L, Bendtsen F, Tage-Jensen U, Pedersen NT, Gram BR, Rube SJ. Intraluminal pH in the stomach, duodenum, and proximal jejunum in normal subjects and patients with exocrine pancreatic insufficiency. Gastroenterology. 1986; 90(4): 958-62.
  3. Stevens C. E., and Hume, I. D. 1995.Comparative Physiology of the Vertebrate Digestive System. 2nd ed. New York: Cambridge University Press.
  4. Schmidler C. Anatomy and Function of the Digestive System. Healthpages.org. 2016.

Seroma

September 21, 2016 12:06 pm

A seroma is a collection of a serum that builds up under the skin or between tissue layers, usually at surgical sites or where tissues has been removed. The development of a seroma usually doesn’t appear for a week or so after surgery or drains are removed.

The best way to understand a seroma formation at an abdominal site is to know the anatomy of the abdominal wall. The abdominal wall has a number of distinct layers. Starting from outside to inside they are: the skin, adipose (fatty layer), muscle and then the peritoneal. I should mention that this is over simplification since depending on what part of the body we are specifically looking at the thickness of each layer may be different. Additionally, there may be other fascia or muscle layers that overlap at certain places that do not for example in the midline.

 

The skin is self explanatory, it is a protective layer.

The fatty layer, underneath the skin layer, is where energy is stored. The key with this layer is that there are very few blood vessel and lymphatic channels located in this layer. From a metabolic standpoint, fat is not very active so there is no need for it to have significant amount of circulation, unlike a skeletal muscle that may be involved with movement of large bones for example.

The muscle layer is well drained by lymphatic system and has excellent venous and arterial supply and drainage.

The peritoneal cavity is where the organs are encased with in the peritoneum (thick membrane).

keshishian-abdominal-layers

When an incision is made, it traverses thru all the planes of the abdomen, from the skin all the way down to peritoneal. The fatty layer, as mentioned above lack lymphatic channels and drainage. Its’ blood supply, arteries and veins are sporadic. This results in an environment with poor drainage properties. Any small amount of fluid either left behind from irrigation, or any fluid that collects in the tissue, caused by the swelling , inflammation which results from the injury of the surgery, can potentially collect.

There are a number of ways to help prevent seroma formation, however, depending on the individual, their health status, inflammatory response, healing process, medications, etc. they may still form. In order to provide for a way for the fluid to drain a number of things can be done. Sometimes different drains are placed within the fatty layer allowing the fluid to drain out or collect in the drain. Another technique is to close the incision with skin staples far apart, allowing the fluid to drain between the staples. I close the incisions with the absorbable stiches, but leave the top and the bottom of the incision open by 1cm (1/4”).  These openings in the incision allow for natural drainage of fluids out of the abdominal space, which we want.  These openings also allow me to gently place a sterile q-tip in the office to make sure there is no fluid collection and to drain if any has formed. Wearing compression binders or garments can help to reduce swelling and risk of seroma formation.

As healing takes place seromas may reoccur and need draining. Although they are bothersome seromas are rarely serious and will eventually resolve with healing and if needed draining. The fluid draining from an incision should be thin and clear, yellowish clear or pink clear. It should not be milky, thick, purulent, or green. If you are experiencing anything out of the ordinary, please do not hesitate to call your surgeon.

keshishian-seroma