Increased rates of Alcoholism is seen in Gastric bypass patients
December 26, 2011 9:26 pm
Why am I hungry? A look at how hormones regulate our appetite?
November 17, 2011 9:21 pm
One of the main reasons why humans become hungry is because of the hormone ghrelin. Ghrelin is primarily secreted by the stomach, which responds to hunger and starvation. Once ghrelin gets into the blood, it circulates the body until it reaches the Vagus nerve, which sends a signal to your brain that tells you “I am hungry!” Actually, for people who have had their Vagus nerve divided (a Vagotomy), ghrelin no longer has a significant impact on hunger. This finding suggests that the Vagus nerve and ghrelin are needed for maximum stimulation of hunger. Also, ghrelin containing neurons are found in the arcuate nucleus, a region of the brain that regulates appetite. In order to stimulate hunger, these neurons send signals to other neurons that contain neuropeptide Y (NPY), which stimulates hunger. However, if the body wants to suppress hunger, it will send signals to neurons containing proopiomelanocortin (POMC). (i)
Now that we know a little about how ghrelin makes us hungry, lets see how the hormone leptin makes us full. Leptin is made in the fat cells (adipose tissue) of our body. The way leptin regulates hunger is by stimulating or not stimulating nerves in the brain. Just like ghrelin, leptin acts on the arcuate nucleus. When leptin is not present, NPY causes us to be hungry. When leptin levels are high, they block NPY and stimulate POMC nerves in the brain that make us full. However, one might ask, if we have more fat cells that produce leptin, why are we still hungry? The answer is that many obese individuals have genetic defects that block the function of leptin. The other is that too much leptin can cause negative feedback to fat cells, which tell the body “hey we have too much leptin, stop making it.” (ii)
Although the exact mechanisms of how ghrelin and leptin work are extremely complex, we see that the three main responses that are contributed to the presence of ghrelin (iii) (iv) are:
- Stimulation of appetite
- Reduction of metabolism
- Reduction of fat catabolism (fat breakdown)
In contrast to ghrelin, leptin’s main responses are:
- Suppression of appetite
- Increase in metabolism
- Increase immune function
The following table summarizes the information on ghrelin and leptin, its relationship with other GI hormones, and its levels after Sleeve Gastrectomy. (v)
| Hormone | Source | Mechanism of action in Obesity | Effect on Weight regulation | Levels after Sleeve Gastrectomy |
| Ghrelin | Stomach Fundus (mainly), Pancreas, small intestine (vi) | Stimulates Growth Hormone release, stimulate NPY, inhibits POMC, and opposes Leptin action | Stimulates Appetite, Reduces metabolic rate, and reduces fat catabolism (breakdown) | Reduced |
| PYY (peptide tyrosin tyrosine) | Is released by endocrine cells of distal ileum, colon, and rectum(vii) | Binds to NPY receptors, inhibits gastric motility, increases water and electrolyte absorption in the colon (vii) | Reduced appetite | Increased |
| Leptin | Fat cells (adipose tissue) | Inhibit NPY and activates POMC | Suppress Appetite | Reduced |
By: Chris Tashjian BS – Ara Keshishian MD, FACS, FASMBS
(i) Sato T, Nakamura Y, et al. Structure, regulation, and function of Ghrelin. Journal of Biochemistry. Oct 31, 2011.
(ii) Friedman JM, Halaas JL. Leptin and the regulation of body weight in mammals. Nature. 1998 Oct 22; 395 (6704): 763-70
(iii) Le Roux CW, Aylwin SJ, Batterham RL, et al. Gut Hormone profiles following baraitric surgery favor an anorectic state, facilitate weight loss, and improve metabolic parameters. Ann Surg. 2006; 243:108-114.
(iv) Hansen TK, Dall R, Hosoda H. et al. Weight loss increases circulating levels of ghrelin in human obesity. Clin. Endocrinology 2002; 56:203-206
(v) Melissa Gianos, et al. Understanding The Mechanisms of Action of Sleeve Gastrectomy on Obesity. Bariatric Times 8;5: S4-S6 (Supplement)
(vi) Ariyasu H, Takaya K et al. Stomach is a major source of circulating ghrelin, and feeding state determines plasma ghrelin-like immunoreactivity levels in humans. J Clin Endrocrinology Metabolism. 20001;86:4753-4758
(vii) Liu CD, Aloia T, et al. Peptide YY: a potential proabsorptive hormone for the treatment of malabsorptive disorders. American Journal of Surgery. 1996 Mar; 62(3) 232-6.
Yearly lab and medication requests
October 17, 2011 5:28 pm
First, we now have preferred laboratories that have partnered with us. The laboratory results are expected to be sent to us electronically, which should cut down on the time between the blood draw and when the results are available to us. The information on the preferred labs is located at: https://www.dssurgery.com/lab. Needless to say, there are no financial incentives for us. You should also check with one of the labs, as well as with your insurance company, to make sure that they are a contracted facility and that the order is covered under your policy. It is your responsibility to make sure that your insurance company will pay for the labs ordered. We are in no way responsible for the verification of benefits for the laboratory services that we order.
Second, we have had to change the way we order our yearly lab work. As most of you are aware, it is critical that weight loss surgical patients have continuous yearly follow-up care and monitoring. It is critical that the patients continue to receive yearly follow-up care, not only by doing their scheduled laboratory studies, but also by a yearly follow up in office exam. We provide a comprehensive follow-up plan to the patients who have had the the Duodenal Switch or Revision from other failed weight loss surgical procedures. This includes ordering the laboratory studies, review and interpretation of the results, as well as office visits as frequently as required or deemed necessary.
Vitamin D supplements
August 01, 2011 1:12 am
Is my weight loss surgery reversible?
May 23, 2011 2:39 am
“The LAP-BAND® System is reversible and, if necessary, can be removed — with the stomach usually returning to its original shape.”
This is a direct quotation from the manufacture’s website. It is a statement of its reversible state that is usually used to promote the adjustable gastric banding procedure compared to other surgical alternatives. In my practice I am a very strong advocate of the Duodenal Switch operation and as a distant second, I offer Sleeve Gastrectomy. I do not offer or recommend the Gastric Bypass (RNY, proximal or distal) procedures because of their well known complications of dumping syndrome, weight regain, inadequate weight loss, as well as anatomical complication of stricture or marginal ulcerations that are seen.
I would only assume that the reversibility issue is to be discussed if the procedure is expected to fail frequently . As a surgeon who performs the duodenal switch operation as a primary weight loss surgical procedure, I have rarely had to reverse the procedure. In my opinion, the physiologic reversal of the duodenal switch operation is by far the easiest of all surgical procedures. It involves creation of a side-to-side anastomosis between the alimentary and the biliopancreatic limbs.
The following are images of a Lap-Band® being removed because the patient kept suffering from persistent nausea and vomiting. The operation was performed laparoscopically. The operative finding identified a significant amount of reactive tissue (scar formation) that represented substantial difficulty in the operating room from a technical point of view. The long term damage done to organs by the Lap-Band makes it not easily reversible.
My recommendations for any individual considering a weight loss surgery is not to focus on the ease of reversibility of the procedure, but rather its long-term outcome data as the basis for choosing an operation.
Does duodenal switch correct dumping syndrome and the hypoglycemic complication of The RNY-gastric bypass, and it variations? A patient’s story
May 20, 2011 7:13 pm
On 10/28/2009 I had a variation of the RNY gastric bypass known as the Fobi pouch. I lost over 270 pounds, but I had debilitating complications of dumping syndrome, reactive hypoglycemia, acid reflux and vomiting.
My entire day was pretty much controlled by dumping syndrome. Due to the hypoglycemic episodes that resulted from dumping syndrome, I was constantly in a binge cycle, because I constantly needed to stabilize my blood sugar. I would eat breakfast and need to lay down. Once I started having hypoglycemia, I would get up and splurge on carbohydrates.
Note that my dumping syndrome was not caused by poor food choices. I only splurged off carbohydrates in a desperate attempt to quickly get my glucose levels up. This did work, but it lead me to dumping syndrome again. I then had another episode of hypoglycemia, which lead to more binging which resulted in more dumping, more binging and weight gain. Here is a diagram of the cycle I was constantly in:
Eat –> dump –>hypoglycemia –> binge –>redump –> more hypoglycemia –> binge –> dump
This was a constant cycle I was in, and as you can see here, my entire life became controlled by dumping syndrome, and it eventually caused me to become disabled. I am a full time student and was not able to go to school in this state. I would eat lunch and then go to class only to start dumping ten minutes into lecture, and I ended up dropping my classes for the semester.
I went to my bypass surgeon and told him of the problems I was having, and he told me that I was anorexic. I was also told that it was “…all in my head.”
After doing much research, I consulted with Dr. Keshishian. I handed him a list with the problems I was having and asked if revision to the duodenal switch would resolve these problems. Dr. Keshishian drew out a diagram of the anatomy of my surgery and showed me exactly why I was having these complications. I remember him saying, “There is a physiological explanation for why you are having these problems. It is not in your head. Yes, revision will resolve these complications.”
I had my revision on 4/11/2011, and all the complications I had with my bypass have been resolved, and I have had no complications with my duodenal switch. Now that my pylorus is working again, I can eat without becoming ill. I have now gone back to school, work, and have resumed back to a normal life.
YG
Vitamin A
May 17, 2011 7:20 pm
Vitamin A occurs in animal tissue as retinol. There are a number of different provitamins in food of vegetable origin. Disorder yellow and red carotenoid pigments can be changed to vitamin A in the liver.
A number of functions for vitamin A have been found, including defense mechanisms, maintenance of healthy epithelial tissues, and most importantly, a function in the visual system. A deficiency may manifest itself by: 1.) A scale-like appearance in the skin and occasional acne, 2.) A failure of growth in young animals, including C. station of skeletal growth, and 3.) A failure of reproduction associated with atrophy of the epithelial cells of the testes and interruption of the female sexual cycle. A deficiency may also represent a decreased visual acuity, and more specifically, night blindness. This was found in a patient who complained that they were unable to read a particular sign at night while driving, but was able to read it during the day
Vitamin A Deficiency Treatment
When a patient is diagnosed with a deficiency, the treatment will require aggressive oral supplementation. For cases in which vitamin A levels do not respond to “Dry” Vitamin A oral supplementation, intramuscular injections may be required. The usual injected dosage is between 25,000-50,000 international units. Repeated injections in a 3-month interval have been required in some patients to normalize their level, as well as resolving the symptom of night blindness.
Psychiatric Medications and Weight Gain
April 07, 2011 9:11 pm
One of the most common and frequent questions asked by patients is the relationship between psychiatric medications and their effect on weight loss after surgery. This is a summary of an article that was published in March 2011 issue of Bariatric Times magazine. The incidence of major depressive disorder is between 2-9% in general population. The World Health Organization reports increasing incidence of depression and other psychiatric illnesses.
There is a complex relationship that exists between depression and obesity. This relationship is even more complicated when one considers the sex of the patient. An example is that men with obesity are less likely to suffer from depressive disorders than normal weight men. Underweight men however are more likely to suffer from depressive disorders and suicidal ideation. This data comes from a study that included 40,000 individuals.
There are a number of different classes of psychiatric medications. These include tricyclic antidepressants (TCA), the newer selective serotonin reuptake inhibitors (SSRI), serotonin norepinephrine reuptake inhibitors (SNRI) and dopamine and norepinephrine reuptake inhibitors (DNRI). And then there are a few, such as Wellbutrin, that do not belong to any of those groups noted.
In general weight gain is more common with TCA medications. There are some in which some weight loss is also noted. The table below outlines a summary of weight neutrality, relative weight gain or weight loss for a number medication. The mechanism by which the weight gain or weight loss occurs is not clear for all medications.
The relationship between antidepressants, mood stabilizers, antipsychotic and weight gain is an example of how important it is for all health care providers to be aware off a patient’s medications and it’s possible side effect on weight gain.
| Medication | Effect on Weight |
| Antidepressants | |
| Elavil | Gain |
| Wellbutrin | Loss |
| Celexa | Neutral |
| Pristiq | Neutral |
| Cymbalta | Neutral |
| Prozac | Loss |
| Luvox | Neutral |
| Paxil | Gain |
| Zoloft | Mild Gain |
| Effexor | Possible Gain / Neutral |
| Antipsychotics | |
| Abilify | Neutral |
| Thorazine | Neutral |
| Clozaril | Significant Gain |
| Haldol | Neutral |
| Zypreza | Significant Gain |
| Seroquil | Gain |
| Risperidal | Gain |
| Geodon | Significant Gain |
| Mood Stablizer | |
| Lamictal | Neutral |
| Lithium | Gain |
| Topomax | Loss |
| Depakote | Significant Gain |
Note: Individual results may vary and this is not meant to be an inclusive list of medications
“Gas problem”
March 25, 2011 3:15 am
“Common bile duct is dilated”
March 10, 2011 8:16 am