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).
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.
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Review & Update Giveaway!
August 31, 2016 6:27 pm
The Prize winners are Jo and Kimberly! Congratulations ladies and enjoy the Obesity Help National Conference! Thank you to all that participated in the Giveaway!
We are holding a review and update giveaway for two different prizes! Thank you for your
participation!
One Prize and One Grand Prize
Prize: two tickets to Obestiy Help National Conference Sept. 30-Oct 1, 2016
Grand Prize: two tickets to Obesity Help National Conference and one night
hotel stay October 1, 2016
Conference: 11999 Harbor Boulevard Garden Grove, California 92840 Event link here
Hotel Prize: SHERATON GARDEN GROVE – ANAHEIM SOUTH HOTEL
12221 Harbor Boulevard
Garden Grove, California
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 5 entries per person.
- Write a review of Dr. Ara Keshishian on one or all of the sites below or do an update on your profile on Obesity Help between now and Sept. 8, 2016 at 5:00 PM
2. Take a screen shot of the review or update with your username and date.
3. E-mail the screenshot to [email protected] 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 1, 2016 and ends September 8, 2016 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 72 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.
Ulcer and Stricture
August 29, 2016 5:21 am
A patient was referred to us for second opinion who was experiencing nausea, vomiting, GERD. The patient had Duodenal Switch procedure many years ago but more recently had developed significant nausea, worsening reflux and solid intolerance. The patient had an endoscopy a few months ago and was only found to have a stricture within the Duodenum, no definitive treatment was offered at the time to the patient. On second examination of this patient with a second EGD the result was development of diffuse Duodenal ulcers and stricture.
Note that these images are nearly identical positioning showing the stricture at 9 position. The image on the right also shows patchy ulcers.
Any changes in GERD, nausea, vomiting, gastric pain or discomfort after weight loss surgery should always be evaluated, treated, and followed. In a previous blog, the effects of GERD have been described.
Duodenal Switch
August 24, 2016 5:45 am
Buyer Beware ! There are a lot of look alike and counterfeit “Duodenal Switch” procedure being performed. A recent online chat discussion clearly demonstrates the point that just because a patient is told that they had the duodenal switch operation this is not necessarily the case.
In our practice, we always warn our patients of not comparing notes and their outcome to others. I perform the Duodenal Switch procedure the way it was described by Dr. Hess, making the common and alimentary lengths as a percentage of the total length of small bowel. This is why our patient population has very little nutritional, and gastrointestinal issues compared to others. Unfortunately when a patient is given a disproportionately long Common channel and/or Alimentary channel the patient will have inadequate weight loss. Alternatively, when patients are given a shorter alimentary channel in proportion to the total bowel length, significant nutritional deficiencies can arise. In a shorter alimentary channel situation patients have to consume higher doses of vitamins and nutrients to keep their laboratory values normal.
I have repeatedly raised the issues to clearly distinguish the single anastomosis procedures from Duodenal Switch operation.
One of the unfortunate problems is the lack of clear guidance given to the patients. It is not uncommon, when I do second opinion consultation with patient who were given generic gastric bypass post op protocol and instructions after their duodenal switch operation. This clearly shows lack of fundamental understanding of the practice performing these procedures and it is carried onto the patient.
Let’s Chat
August 22, 2016 8:46 pm
We are planning on using this blog post to hold routine sessions called “Let’s Chat!” where Dr. Keshishian is available to answer questions online.
This will be more private than some of the social media sites and give more people an opportunity to ask questions. We will announce when we are going to hold these Let’s Chat sessions on social media, however, the actual chat will take place here on the blog. You will just need to post your comment or question, provide a name (can be initials if you require more privacy) and an e-mail (which is not posted with your question to provide more privacy). If you scroll to the bottom of this page there is a reply box. Type in your question or comment, enter the other information and click the post comment icon. Your post will not be visible until it is approved by the host.
The Let’s Chat session will be similar to our FaceBook chats. Here is an example of one of our FaceBook chats.
Exercise Benefits & Events
August 09, 2016 2:25 pm
Exercise and it’s benefits for body, mind and weight loss can’t be over emphasized. Everyone can benefit from some form of exercise whether it be a brisk walk, chair exercises, exercise bands, aquatics, running, hiking or biking. As a family we try to exercise often and attempt to participate in at least one event a month or so. These types of events tend to keep us more accountable and motivated. The group atmosphere, energy and vibe only add to the experience. Listed below are some of our favorite exercise events. We will update this list and add to it.
Physical Benefits:
- Weight loss and maintenance can be a benefit of exercise. It also improves muscle function and strength.
- Improves Type 2 Diabetes and Metabolic Syndrome
- Reduces some Cancer Risk
- Improved Cardiovascular Health
- Improved “Good” cholesterol
- Strengthens and improves Bone Health
- Living longer
- Improved Sleep
Mental Health Benefits:
- Reduce Stress
- Boosts Endorphins
- Helps with Anxiety
- Improved Self Confidence
- Being in the Great Outdoors and Sunlight (increases Vitamin D)
- Prevent Cognitive Decline
- Sharpen Memory and Cognitive Function
- Help with Addiction
- Increase Relaxation
One important key note is to pay close attention to hydration with exercise, not only with fluids but electrolytes as well. Exercise increases fluid loss due to sweat and increase circulation to muscle. You need to increase fluid intake to compensate for these losses.
Exercise events by the month:
June
The Los Angels River Ride is one of our families favorites. Great ride for a great cause.
August
Luau 5K walk and fun run This is a fun family activity as they have a kids run and lots of activities. It is also in Griffith Park which is a beautiful and treasured location.
September
The Prudential 401K Run is to promote saving for retirement and is a FREE event at the beautiful Rose Bowl
October
The Aloha Run brings a little Hawaiian feel to the fall.
JDRF One Walk fighting Type I Diabetes
November
City of Hope’s Walk for Hope
December
Santa to the Sea (must bring a gift for a child)
Varying months depending on location:
Get your Rear in Gear to fight Colon Cancer
CicLAvia a Los Angeles area quarterly biking event.
Vitamin D status for Infertility Treatment
August 03, 2016 8:02 pm
Many people with obesity face infertility issues and seek infertility treatment or procedures. A recent article linked Vitamin D status to improved success rate of IVF (in-vito fertilization) & ICSI (interacytoplasmic sperm injection) in The Journal of Maternal-Fetal & Neonatal Medicine. It is important to check Vitamin D status for infertility treatment.
Here are the researchers results:
- Of the 252 females that completed the ICSI cycle, 42% became pregnant (n = 108).
- The mean vitamin D status was significantly higher in the pregnant group compared to the non-pregnant group (17.74 ng/ml vs 9 ng/ml, respectively; p = < 0.01).
- Vitamin D status was positively associated with both pregnancy (p = 0.001) and endometrial thickness (p < 0.01).
- Higher vitamin D levels was associated with a 21% increase odds of clinical pregnancy (p < 0.05).
The researchers concluded,
“Deficiency of 25-OHD in females hinders the accomplishment of optimal endometrial thickness required for implantation of embryo after ICSI.”
Following weight loss surgery (WLS) there can be improvement of fertility and for that reason we recommend two forms of birth control methods during the first 18-24 months following WLS or until weight loss has stabilized for several months. This helps to ensure the best outcome and health for the mother and infant.
In our office we continue to stress the importance of Vitamin D3 for bone and dental health, pregnancy, breastfeeding and several auto-immune diseases. Vitamin D has also been shown to reduce pre-term birth Duodenal Switch patients require a dry water miscible form of Vitamin D3 due to the fat malabsorption of the DS procedure. There are several past blog posts on the topic of Vitamin D and it’s associated nutrients.
BMI Threshold for Ventral Hernia Repair
July 21, 2016 2:48 pm
“After Ventral Hernia Repair (VHR), complications are most likely to occur in patients with BMI ≥ 40 kg/m2. This subset of patients also had a significantly higher risk of undergoing surgery for a recurrent hernia, suggesting that this group of patients is likely to experience adverse outcomes after VHR and should be counseled to consider bariatric surgery prior to attempts at VHR.” Information on Bariatric Surgery here.
Read more of the original article here….
A hernia is present when part of an internal organ or tissue bulges through a defect or weak area in the belly wall (fascia). The type of hernia you have depends on where it is and how it occurs. Ventral Hernias are named after the location in the body they occur. A ventral hernia is a bulging of the abdominal wall anteriorly. When the hernia is located at the site of a pervious surgical scar then it is called an incisional hernia. A hernia can occur at any location of the abdominal wall however. Further information regarding incisional hernia here.
A Ventral Hernia can develop due to straining, lifting or increased abdominal pressure and is a weakening of the abdominal wall. Usually fat and internal organs bulge outside the facsia that holds the internal organs within the abdominal cavity. This type of hernia can be asymptomatic or cause pain with pressure or exertion. If left untreated, they can become larger or become incarcerated requiring emergent surgical intervention. Dr. Ara Keshishian performs ventral hernia repairs using a laparoscopic technique that may or may not require mesh repair. Mesh is place behind the defect in the abdomonial wall and extends past the hernia edges. Mesh is used to re-enforce the abdominal wall and allowing the healing tissue to form a sturdy foundation to help prevent reoccurrence of the hernia. Videos of Ventral Hernia Repairs here.