Bile reflux gastritis is not a the result of the cholecystectomy but may be seen in a subset of patient with other confounding conditions. Bile is produced in the liver and stored in the gallbladder. In response to high fat and protein in the stomach, the gallbladder contracts to ” squeeze” the bile stored in the gallbladder into the small bowel to help absorb the fat and protein.
With the gallbladder removed, the bile produced by the liver cannot be stored and goes directly to the small bowel via the biliary tree.
It is possible and likely that some of the bile will find its way back to the stomach. In some patients, due to compounding circumstances, the bile may collect and cause gastritis. We need to dissect this a little for it to make sense.
Not every patient after cholecystectomy will have bile in their stomach.
Not every patient with bile in the stomach has gastritis.
To appreciate this, let’s remember that for bile to get from the small bowel to the stomach, it needs to:
Go upstream, against the peristalsis of the small bowel, and do not be washed down by the flow of the gastric
juices coming out of the stomach.
Go through the pyloric valve.
If it reaches the stomach, the acid in the stomach does not neutralize it, causing gastritis.
As I’m sure we all appreciate, other contributing factors besides cholecystectomy may cause bile reflux and bile reflux gastritis. This is why it’s also emphasized that bile in the stomach alone does not confirm biliary reflux gastritis. It is also why we always state that bile reflux gastritis is a disease of exclusion, where other conditions such as gastroparesis, acid reflux, and hiatal hernia (regardless of size, as some patients are unfortunately told that since the hernia is small it does not need to be fixed, which is incorrect) must be considered. Further information on Bile Reflux.
Billary Diversion is the only definitive surgical procedure for Bile Reflux Gastritis.
Endoscopic sleeve gastroplasty (ESG) differs from Laparoscopic sleeve gastrectomy (LSG).
ESG (Endoscopic Sleeve Gastroplasty) is promoted and advocated as a low-risk, equal alternative to the Laparoscopic Sleeve Gastrectomy, but it is not.
Anatomically speaking:
Endoscopic Sleeve Gastroplasty is an endoscopic procedure performed under general anesthesia. During this procedure, a specialized endoscope is inserted through the mouth into the stomach. Multiple plastic “H”-type anchors are used to create a fold in the stomach, thereby reducing its size. No part of the stomach is removed. Initial limited weight loss occurs as the patient feels full after consuming small volumes of food. This effect resembles what happens with the lap band and gastric balloon, and we know how the story ends with those.
LSG is performed laparoscopically with incisions on the abdomen under general anesthesia. Seventy-five to eighty-five percent of the stomach, along its greater curvature, is removed, eliminating the part of the stomach that produces the Ghrelin hormone, which controls and modulates hunger. This is why patients feel fuller with a smaller volume of food and experience significantly reduced hunger.
Results:
Please read the fine print
The summary results indicate
“Our results suggest that ESG is safe and effective for the treatment of obesity, with durable
long-term results for at least up to 5 years after the procedure. “
When you look at the details of the results, however, it states:
“At 5 years, mean TBWL was 15.9% (95% CI, 11.7-20.5, p < .001) and 90 and 61% of
patients maintained 5 and 10% TBWL, respectively.”
This means that five years after ESG, 90% of the patients have only lost 10% of their TBWL (total body weight loss), and 61% would have lost 10% of their TBW (Total Body Weight).
This serves as an illustration of how actual outcomes are obscured within the fine print, resulting in a lack of attention from individuals seeking the optimal outcome devoid of perceived risk. The same principle applies to the ongoing discourse regarding GLP-1 medications. The genuine risk associated with ESG and PLG-1 is that patients have undergone alterations to their anatomy and physiology without demonstrable results. Several years into contemplating a treatment promising sustained outcomes, we find that the alterations have increased the overall risk.
As a surgeon, I encourage people to always ask questions and demand that scientific proof be provided. I am not opposed to progress; considering the nature of our practice, we have witnessed and have unrgone significant evolution over the past 30 years, transitioning from performing open cases necessitating a hospitalization period of 4 to 6 days to performing the same cases laparoscopically and robotically in some cases outpatient procedures.
In 1986, GLP-1 was identified (Mojsov et al., 1986). In 2005, the FDA approved a compound similar to GLP-1 (exenatide) for diabetes. It took nearly three decades of technological advancement in genetic research, tissue culturing (Saccharomyces cerevisiae), genetic sequencing, purification, and stabilization of the product for GLP-1 to become commercially available.
GLP-1 is a potent stimulator of insulin release (lowers blood sugar) while decreasing Glucagon secretion (think of it as anti-insulin). GLP-1 also slows GI motility and stomach emptying. It reduces the appetite at the brain level. GLP-1 medication stimulates insulin release from the Beta cell, which produces insulin in the pancreas. GLP-1 intercepts signals in the Vagus nerve to slow gastric emptying.
There are built-in safety mechanisms to prevent the human body from self-destructive, runaway chemical imbalances. For example, osteoclasts and osteoblasts are cells that break down and build bones, as we read in this blog. This balance is closely regulated against outside interferences to prevent osteoporosis or bone thickening (low vitamin D, menopause, or growth hormone injections).
When a patient takes thyroid medication, the TSH goes down because it senses enough thyroid in the bloodstream to stop ordering thyroid gland from secreting (even though none was being secreted as to why the thyroid medication was started)
These are all examples of where I am going with this: What is not adequately explained and discussed is that other chemical pathways are being affected in ways that we do not recognize. We already know it can cause pancreatitis because GLP-1 can overstimulate the beta cells. We also know that it can cause certain rare types of thyroid cancer.
Yes, I am a surgeon, but I could help my patients. I would have started prescribing these medications long ago before we started seeing a patient who is now coming to have surgery after trying GLP-1 medications and gaining weight back after they stopped because they had significant complications and side effects, or they could not afford it. The complication profile and the side effects cause significant portion of the medication discontinuation.
I have already stated before that GLP-1 medications offer no off-ramp for the patients. Once you start it, you must stay on it for a long time. The published data provides dismal long-term outcomes for patients who stop the medication.
Imaging technology has evolved dramatically since Dr. Roentgen’s first X-ray was taken in December 1895. Our understanding of the science of radiation has changed exponentially. However, there is significant evidence that overutilizing radiation-related diagnostic studies is unnecessary. Several factors, including medico-legal and financial concerns, likely drive this.
There is a new publication that has documented the increased risk of cancer associated with excessive radiation caused by diagnostic testing.
We should all ask the question before ordering and submitting to a diagnostic examination that involves radiation:
What information am I trying to get?
Have I had a similar test done? And if so, do I have access to the records and images?
This is why I always recommend that patients maintain the report, the images, and all the radiologic studies they get done so they are readily available to them and their healthcare providers. This helps to reduce the amount of imaging radiation a patient may be exposed to.
A volvulus is when a loop of intestine twists around itself and the mesentery that supports it, resulting in a bowel obstruction that can compromise intestinal blood flow. For this reason, it tends to be a surgical emergency which requires prompt attention; failure to recognize the signs and symptoms of intestinal volvulus may lead to bowel ischemia and perforation. A volvulus can develop anywhere along the intestine, however for this blog we will discuss types of Colonic Volvulus.
Sigmoid Volvulus where the bowel is twisted on top of each other (dashed segment)
The most common forms of volvulus in the gastrointestinal tract are sigmoid and cecal volvulus, both colonic volvulus. Sigmoid volvulus is responsible for 80% of intestinal obstructions.
Volvulus can occur anywhere in the large and small GI tract. This is caused by a bowel twist around an anchor position, which may be the mesentery. Think about how the loose skin hangs lower with weight loss. We see the mesentery fat thinning, which causes the bowel to twist around it. A very high degree of suspicion is needed to make the diagnosis.
Sigmoid Volvulus where the bowel is twisted on top of each other (dashed segment)
High-fiber diets and chronic constipation are common risk factors because they cause increased gas and sigmoid colon elongation. Worldwide, the incidence of men is much higher than in women, which may be explained by the mesenteric shape, which tends to be longer and has a narrower base. In weight loss surgical patients specifically, such as Duodenal Switch, increased gas and diarrhea are shared in patients with carbohydrate and fiber-rich diets. In some cases, they are recommended to have a high fiber diet by other providers who may not be aware that this may only complicate the problem and exacerbate the symptoms. The solution would not include adding fiber but eliminating the underlying food items causing the increased gas and diarrhea.
The presentation of volvulus is much the same, regardless of its anatomic site; Cramping abdominal pain, distention and constipation are present. With progressive obstruction, nausea and vomiting will occur.
A definitive diagnosis is made with a CT scan, and the treatment is generally a bowel resection. However, in the case of a sigmoid volvulus, an urgent endoscopic detorsion may be attempted first, only if there are no signs of ischemia. The risk of recurrence following endoscopic detorsion alone is as high as 90% and carries a high risk of mortality up to 35%, therefore definitive elective sigmoid resection is recommended.
The gastrointestinal staplers simultaneously pass six rows of staples and cut in between them to create two secure lines of staples, three rows on each side. The staples come in different thicknesses and lengths for various applications. Staple cartridges that are used for colon surgery are usually thicker tissue staples than those that are used for small bowel stapling.
Different manufacturers have different color coding.
Another question I frequently get asked is, How does a stapler staple and cut at the same time? The stapler needs to be thick enough to not tear through the tissue and provide uniform pressure for control of bleeding and prevent leaks. It can not be too large either.
When stapling on the stomach for sleeve gastrectomy, the stomach wall thickness is different. We use different-sized staples to accommodate the thicker part of the lower stomach toward the thinner part of the stomach where it meets the esophagus.
Stapler and resulting discharged lines of staples.
I have frequently been asking what staples are used in sleeve gastrectomy. A stapling device is used with sleeve gastrectomy. This device comes in different shapes and sizes for different bowel thicknesses and applications. However, they all function the same way. The staple cartridges (the part of the stapler that is replaced after each use with a new one) are selected based on the thickness of the segment of the bowel that needs to be stapled and divided.
The stapling and dividing take place simultaneously. The sampler deploys six rows of staples and cuts between them, leaving three rows on one side and three on the opposite side. With the sleeve gastrectomy, this means that the sleeve stomach that is left has three rows of staples, and the segment of the stomach that is removed also has three rows of staples.
Questions that are frequently asked:
1-Can I have a CT or an MRI done? Yes, The titanium staples are safe for both CT and MRI.
2-What are they made from? The staples are made of titanium and alloys, which are non-reactive and safe.
3-How big are the staples? Different staples are of different sizes, mainly in the mm range; see the tip of the pencil in the image for the relative size.
The surgical changes following the revision of the failed gastric bypass to the duodenal switch or a primary duodenal switch require an evident appreciation and understanding of the anatomy and physiology of placing a feeding tube and managing the nutritional status. There are different places where a feeding tube can be placed.
1-A feeding gastrostomy tube endoscopically cannot be placed because of the transected post-pyloric duodenum (The image viewed on a desktop or a laptop allows the scroller on the image to move)
2-An orogastric or nasogastric tube should only use an elemental feeding formula. This is because the food in the stomach is prevented from mixing with the biliopancreatic juices, which will not be adequately absorbed.
3-A feeding Jejunostomy can only be insured surgical post ligament of traits. This cannot be done endoscopically because duodenal switch transaction post pyloric small bowel to prevent mixing of the biliopancreatic secretion.
Cheers! Let’s take a minute to look at alcohol metabolism. It’s that time of year when it seems we are going from one Holiday or Christmas party to another, and then we get together with the family and have a little more alcohol. The following diagram shows how alcohol metabolism takes place.
Alcohol is a caloric intake, and we all need to keep close tabs on it. Alcohol is very easily metabolized and the calories add up quickly. Every stage of alcohol processing in the liver involves the extraction of calories and free radicals, which are toxins. Excess calories not used in bodily functions can be stored as fat mass. Alcohol can be a roadblock in weight loss. Those drinks add up!
Here is a short video as a reminder while everyone waits to get ready for the next party.
Patients are frequently asked to explain why they take high fat- or water-soluble vitamin doses. They are have often been scared by their well meaning healthcare providers that their higher levels of vitamin supplements will end up with vitamin toxicity.
Let’s clarify one point: there is such a thing as too much vitamin.
However, the point that is often overlooked in teaching within professional schools (medical, nursing, pharmacy, etc.) and drug manufacturers is that recommendations are based on “how much to take” and not how much is needed to keep a patient’s blood level in the normal range.
This table highlights how toxicity is described and what requirements are recommended. Vitamin toxicity is seen rarely in post-weight loss surgical patients who take them proactively in as many doses as needed to get their blood levels in the normal range. I see more patients in the office who suffer from low vitamin levels, such as vitamin D and A levels (duodenal switch and sleeve), than any patient with high or toxic levels of any vitamins.
