Grandfather’s Obesity May Affect Grandchild’s Health
July 21, 2016 2:36 pm
A father’s metabolic health can be passed from generation to generation, affecting not only his children but more importantly his grandchildren, suggests a study. According to the study published in the journal Molecular Metabolism, parental obesity can have harmful effects on future generations. “A baby’s health has long been considered the mother’s responsibility as soon as she falls pregnant. Now, we’ve found powerful evidence, in a mouse model, that father’s nutrition and metabolic health can influence his sons and even his grandsons,” said Catherine Suter, Associate Professor, Victor Chang Institute. Read more…
Original research article here.
Less Invasive, Easier?
July 20, 2016 11:02 am
There is a continuous desire for a “less invasive”, “easier” procedure for the treatment of obesity and its associated co-morbidities. We have been very clear when discussing the benefits and long term outcome of the procedures. Let’s remind ourselves that “less invasive” does not mean a better option. In almost all cases a less invasive weight loss surgery means less weight loss, lower incidence of resolution of co-morbidities, and in some cases higher complications rate. Have we forgotten the adjustable gastric banding that was advocated to be the cure all for all obesity? All we hear now are the complications, the long term sequel of the reflux, hiatal hernia, irreversible esophageal injury, in addition to inadequate weight loss or weight regain.
Unfortunately, the same is to be said about the Sleeve Gastrectomy. We have said, as supported by the scientific literature, that the long term outcome of the sleeve gastrectomy is not as good as that of the Duodenal Switch procedure. This is true for the amount of weight loss as well as the resolution of the co-morbidities. We see quite a few patients who have gained their weight back after sleeve, never lost enough weight, and/or did not achieve resolution of their co-morbidities, such as diabetes, and are having their procedure revised to Duodenal Switch procedure.
Here is a recent publication that discusses this.
Along with the same argument, this is why I caution patients when having the SIPS or SADI procedures. There is a chance that when the long term data for SIPS/SADI is available there may be some benefits procedure. However, as it stands at this point in time, these procedures are not the same as the Duodenal Switch procedure. So in short, less invasive, easier isn’t better.
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July 07, 2016 2:22 pm
Intestinal Peristalsis
June 24, 2016 6:32 pm
The following video is an example of intestinal peristalsis, the rthymic contraction and relaxation of the intestinal muscles to propel digested food through the intestinal tract. This process starts after food product is swallowed into the esophagus. It continues once the food is emptied through the pyloric valve into the small intestine. This motion allows for absorption of nutrients from the food product. Peristalsis continues throughout the small intestine and into the colon (large intestine) until defecation.
Click the following to view the Video of Intestinal Peristalsis
Peristalsis also happens within the tubes connecting the kidneys and bladder and also the tubes between the gallbladder and duodenum
Don’t lose your Pyloric Valve over a Failed Gastric Sleeve
June 22, 2016 9:32 am
In my opinion, there are very few reasons to lose your Pyloric Valve after sleeve gastrectomy. Recently, I am hearing of people who have had regain due to a failed Sleeve Gastrectomy being revised to Gastric Bypass RNY and then seeking a Duodenal Switch due to regain from Gastric Bypass RNY. A better option is to go from Sleeve Gastrectomy to Duodenal Switch, due to the long term excess weight loss maintenance of Duodenal Switch. The benefit of the pyloric valve can not be taken lightly.
Let’s start by reminding ourselves as to how the Sleeve Gastrectomy has gained popularity. In the quest for a simple solution to the complex problem of obesity, adjustable gastric banding gained popularity only fail to deliver anything close with the results that were promoted and heavily marketed. The focus was then changed to another seemingly simple procedure, laparoscopic sleeve gastrectomy. For some surgeons this is a new procedure. Surgeons that had been doing the duodenal switch operation for decades, sleeve gastrectomy has not been a new procedure. Surgeons that just started doing sleeve gastrectomy as a stand alone procedure started experiencing complications of the sleeve gastrectomy, such as regain and are now looking for another option for these patients. This complication are even more frequent when they’re done following a failed adjustable gastric band procedures due to the metabolic issues after revising one weight loss surgery to another. A similar short sighted approach is also being promoted with SIPS/SADI procedures, which is significantly simpler to perform than the duodenal switch operation.
Laparoscopic sleeve gastrectomy has a predictable profile for weight loss. It will not have as good on the long-term success rate as a duodenal switch operation. Complications of the sleeve gastrectomy including reflux, stricture, fistula, inadequate weight loss which may warrant evaluation and possible intervention. In my opinion, as a surgeon who does the duodenal switch operation routinely, a sleeve gastrectomy requiring revision should almost never be revised to a gastric bypass. I have seen number of patient’s who have had an adjustable gastric banding which was revised to the sleeve gastrectomy then to a gastric bypass. We are contacted for a possible revision to Duodenal Switch operation because of the weight regain. One can argue that the patient should not have had the sleeve gastrectomy or gastric bypass. It is critical that the complexity of the disease of the obesity is clearly appreciated that it purely restrictive procedure will not yield the desirable outcome long-term.
Benefits of the Pyloric Valve:
The pylorus is the valve located at the end of the stomach. It controls the release of the liquid mixture of food from the stomach into the small intestine.
The body naturally regulates the passage of food, so food will stay in the stomach for a certain period of time. We believe it is very important to continue that feeling of fullness in between meals. As a result, one of the principle functions of the pyloric valve is to regulate the amount of food products released into the small intestine where they are absorbed. This helps prevent dumping syndrome and ulceration.
The bodies natural diameter of stomach, pyloric valve and small intestine is left intact. This elevates stretching of the stomas created by RNY Gastric Bypass.
Summary
These failed Sleeve Gastrectomies should be revised to Duodenal Switch unless there are overwhelming health issues that would require another option. I always suggest several opinions from different Bariatric Surgeon’s who do a variety of Weight Loss Surgeries before deciding which type of revision to proceed with.
Is Weight Loss Important Before Weight loss Surgery?
June 21, 2016 7:52 am
The question of “Is a pre operative diet and weight loss important?” No. This is the short answer. In a previous blog, “Weight Loss Before Weight Loss Surgery?” I have gone into further detail about why I don’t require a pre operative diet and weight loss program.
More recently there has been a concerted effort by a number of major health plans to require 3-6 months documented pre operative diet attempt prior to authorization for weight loss surgery. Furthermore, there are surgeons who would mandate a 10% weight loss as a precondition for the patient to have a weight loss surgery, laparoscopic sleeve gastrectomy for example. The overwhelming scientific literature fails to support any direct correlation between preoperative weight loss and the outcome of the weight loss surgery.
Some surgeons require preoperative weight loss as a way to reduce the size of the liver. I’ve personally have never met a liver I couldn’t work around unless it was severely diseased.
There is some literature to support this position. However, one has to critically look at all the studies. Almost all the studies have very specific population and procedures that are being looked at. Most often the recommendations had been made for adjustable gastric banding procedures. There are also some that are recommending the same for Lap Sleeve cases only siting the reduction of the liver size as a reason for the Very Low Energy Diet as a precondition to surgery. It is, however, important to remind ourselves that there is no long term studies whatsoever that show any relationship between the preoperative weight loss and the outcome of any weight loss surgery.
Why “Diets do not Work?
June 17, 2016 6:24 am
The question of “Is a pre operative diet and weight loss important?” No. This is the short answer. In a previous blog, “Weight Loss Before Weight Loss Surgery?” I have gone into further detail about why I don’t require a pre operative diet and weight loss program.
More recently there has been a concerted effort by a number of major health plans to require 3-6 months documented pre operative diet attempt prior to authorization for weight loss surgery. Furthermore, there are surgeons who would mandate a 10% weight loss as a precondition for the patient to have a weight loss surgery, laparoscopic sleeve gastrectomy for example. The overwhelming scientific literature fails to support any direct correlation between preoperative weight loss and the outcome of the weight loss surgery.
Some surgeons require preoperative weight loss as a way to reduce the size of the liver. I’ve personally have never met a liver I couldn’t work around unless it was severely diseased.
There is some literature to support this position. However, one has to critically look at all the studies. Almost all the studies have very specific population and procedures that are being looked at. Most often the recommendations had been made for adjustable gastric banding procedures. There are also some that are recommending the same for Lap Sleeve cases only siting the reduction of the liver size as a reason for the Very Low Energy Diet as a precondition to surgery. It is, however, important to remind ourselves that there is no long term studies whatsoever that show any relationship between the preoperative weight loss and the outcome of any weight loss surgery.
First Step
June 15, 2016 2:17 pm
First Step
Diet Soda, Diabetes and Weight Loss Surgery
June 14, 2016 7:02 pm
Our practice has long discouraged the consumption of diet soda and carbonated sugary beverages for anyone, but especially our weight loss surgical patients. These products’ detrimental effects on bone health, gut microbiome, increase appetite, diarrhea, inhibited weight loss and regain shouldn’t be ignored. In addition, in the situation of limited space post Bariatric surgery, a WLS patient needs nutrient rich, protein foods. These beverages provide no nutritional value.
In addition, these products are also not recommended for non-WLS patients. Oral health, peak in insulin levels, increase weight gain, increased Type 2 DM, and diarrhea are also issues that can effect patients in addition to the above issues.
Our practice, as well as a recent article on Medical News Today Written by Jon Johnson, encourages people to:
“Saying goodbye to diet soda
Soda, whether regular or diet, is a dietary waste. Sodas have little nutrients, and have a long list of side effects. For people with diabetes, diet soda has been associated with weight gain and symptoms of metabolic syndrome. Some sweeteners in diet soda even cause sugar and insulin spikes in the blood.”
We encourage the use of Stevia, which is a natural sweetener, instead of other artificial sweeteners. Stevia is a herb type plant with leave that can be used for sweetening. It has been used for many years in other countries and cultures. It contains Magnesium, Potassium, zinc, Vitamins A, B3 and C as well as fiber.
A past blog post on Carbonated Beverages and Weight loss Surgery .
Crohn’s Disease and Ulcerative Colitis
June 07, 2016 6:33 am
Crohn’s Disease and Ulcerative Colitis are two disease processes that effect the large intestine to varying degrees and in the case of Crohn’s possibly part of the small intestines. Both fall under the category of Inflammatory Bowel Disease however there are differences between Crohn’s Disease and Ulcerative Colitis even though they may share some symptomatology.
Crohn’s Disease (CD) is an inflammatory bowel disease (IBD) that causes deep tissue inflammation of the digestive lining tract. It affects the gastrointestinal (GI) tract, extending from the mouth to the rectum. CD has an asymmetrical progression, where it does not affect the entire tract uniformly (1). It is commonly found at the end of the small bowel (ileum) to the start of the large bowel (colon).
Complex interactions between three factors contribute to the occurrence of CD:
- Immune Response: Foreign environmental substances may elicit an overactive immune response. T-cell mediated immune response identifies threatening affluences and works to protect the body. This stimulates inflammation, often times without control, in the body as the body’s natural defense mechanism (2,3).
- Inherited Genes: Variation in genes that produce proteins involved in immune function may disrupt intestinal cell’s ability to respond normally to bacteria. Studies also show genetic deviation in chromosomes 5 and 10, which contain IBD loci. Alterations at this locus may lead to the increased risk of CD.
- Environmental Factors: Factors such as smoking, those between the ages of 10-40 yrs. (commonly diagnosed before 30 yrs.), diets high in sugar/sweeteners, fats/oils, and total fat may lead to the increased risk of developing CD.
Common symptoms of CD include frequent diarrhea, rectal bleeding, fatigue, fever, weight loss, reduced appetite, abdominal pain/cramps, and fever. Inflammation in CD is unevenly widespread throughout the GI tract. Inflammation in the mouth, esophagus, and stomach can lead to ulcers. However, they are rather uncommon. Inflammation in the small intestine, colon, and rectum may lead to ulcers as the severity increases (5). The complications in CD are due to chronic inflammation, which may lead to:
- Intestinal narrowing (stricture)
- Abscess: collection of pus
- Fistula: abnormal connection or tract
- Colon Cancer
- Other disorders such as anemia, osteoporosis, gallbladder/liver disease, etc.
Antibiotics, anti-inflammatories, corticosteroids, and immunomodulators have been proven to regulate the mechanisms of CD. Surgical treatment may also benefit the patient. There are several surgical options that may be performed depending on the symptoms and findings.
- Strictureplasty
- Resection
- Proctocolectomy or Colectomy
There is no known cure for Crohn’s Disease; however these treatment options may control it.
Ulcerative Colitis (UC) is an inflammatory bowel disease (IBD), which results in damaging inflammation of the colon and rectum. It effects 700,000 men and women in the United States. As opposed to Crohn’s Disease, UC spreads evenly throughout the colon and rectum only (9). It does not affect the entire GI tract.
Like CD, Ulcerative Colitis occurs through a complex interaction of three factors:
- Immune Response: T cells (lymphocyte) mature and function in identifying foreign substances to then defend the body against infection.
- Inherited Genes: Variation in genes that protect intestinal function are more likely to respond abnormally to bacteria. Studies show genetic deviation in chromosomes 1 and 12 (11).
- Environmental Factors: Factors such as those between the ages of 1-30 yrs. or exposure to isotrentinoin (vitamin A derivative) may be at risk for UC.
Common symptoms of UC include bloody diarrhea, abdominal pain, weight loss, reduced appetite, fatigue, and fever. Inflammation in UC is evenly spread, yet restricted between the colon and rectum (10). Inflammation in the right (ascending), transverse, left (descending), sigmoid colons, and rectum can lead to ulcers that vary in size and depth (red, bloody, swollen). The complications of UC are due to prolonged inflammation, which can lead to:
- Increased risk of blood clots
- Colon Cancer
- Other disorders such as osteoporosis, liver disease, etc.
Antibiotics, anti-inflammatories, corticosteroids, and immunomodulators have been proven to normalize the mechanisms of UC. There is no cure for Ulcerative Colitis, but these treatment options may help regulate it.
It is important to have a coordinated team of medical professionals to develop an ongoing and dynamic treatment plan as well as surveillance for side effects of CD and UC. Patients can lead a productive life regardless of the challenges of CD and UC with appropriate medical treatment.
References
- Westall, F. C. (2006). Integrating theories of the etiology of Crohn’s disease on the etiology of Crohn’s disease: questioning the hypotheses. William M. Chamberlin, Saleh A. Naser Med Sci Monit, 2006; 12 (2): RA27-33. Medical Science Monitor, 12(5), LE5-LE6.
- Folwaczny, C., Glas, J., & Török, H. P. (2003). Crohn’s disease: an immunodeficiency?. European journal of gastroenterology & hepatology, 15(6), 621-626.
- Braat, H., Peppelenbosch, M. P., & Hommes, D. W. (2006). Immunology of Crohn’s disease. Annals of the New York Academy of Sciences, 1072(1), 135-154.
- Canavan, C., Abrams, K. R., Hawthorne, B., Drossman, D., & Mayberry, J. F. (2006). Long‐term prognosis in Crohn’s disease: factors that affect quality of life. Alimentary pharmacology & therapeutics, 23(3), 377-385.
- Talbot, R. W., Heppell, J., Dozois, R. R., & Beart, R. W. (1986, February). Vascular complications of inflammatory bowel disease. In Mayo Clinic Proceedings (Vol. 61, No. 2, pp. 140-145). Elsevier.
- Eaden, J. A., Abrams, K. R., & Mayberry, J. F. (2001). The risk of colorectal cancer in ulcerative colitis: a meta-analysis. Gut, 48(4), 526-535.
- Colitis–Pathophysiology, U. (2003). Inflammatory bowel disease part I: ulcerative colitis–pathophysiology and conventional and alternative treatment options. Alternative medicine review, 8(3), 247-283.
- Greenstein, A. J., Janowitz, H. D., & Sachar, D. B. (1976). The extra-intestinal complications of Crohn’s disease and ulcerative colitis: a study of 700 patients. Medicine, 55(5), 401-412.
- Lennard-Jones, J. E. (1989). Classification of inflammatory bowel disease. Scandinavian Journal of Gastroenterology, 24(sup170), 2-6.
- Gillen, C. D., Walmsley, R. S., Prior, P., Andrews, H. A., & Allan, R. N. (1994). Ulcerative colitis and Crohn’s disease: a comparison of the colorectal cancer risk in extensive colitis. Gut, 35(11), 1590-1592.
- Silverberg, M. S., Cho, J. H., Rioux, J. D., McGovern, D. P., Wu, J., Annese, V., … & Barmada, M. M. (2009). Ulcerative colitis–risk loci on chromosomes 1p36 and 12q15 found by genome-wide association study. Nature genetics, 41(2), 216-220.