By Charles Bankhead, Staff Writer, MedPage Today
Published: June 26, 2009
Reviewed by Zalman S. Agus, MD; Emeritus Professor University of Pennsylvania School of Medicine and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

DALLAS, June 26 — Patients who undergo gastric bypass surgery often have undiagnosed glucose abnormalities that can lead to bad eating habits and regained weight, a small clinical study suggests.

Almost 80% of the patients had glucose abnormalities, including hyperglycemia, hypoglycemia, or both, Mitchell Roslin, MD, of Lenox Hill Hospital in New York, reported here at the American Society of Metabolic and Bariatric Surgery meeting. Patients were alarmed by the weight regain, but at the same time, they often had a ravenous appetite soon after a meal, accompanied by an almost uncontrollable urge to eat.” Our hypothesis is that . . . patients may have an enhanced insulin response,” said Dr. Roslin. “They have rapid emptying of the pouch that leads to reactive hypoglycemia. The combination of an empty pouch and low blood sugar leads to hunger.” The findings have led him to question whether gastric bypass surgery should remain the gold standard procedure for treating obesity, he added. At the very least, surgeons should consider the possible need to include a valve in gastric bypass.

The study evolved from clinical observations during patients’ periodic postoperative visits. A growing number of patients complained of weight regain and loss of restriction. The complaints often had a common ring.” Patients were saying that one or two hours after eating, they were ravenously hungry,” said Dr. Roslin. “It sounded a lot like hypoglycemia to me.” To investigate the origin of the symptoms, Dr. Roslin and colleagues studied 63 patients who had undergone gastric bypass procedures. All the patients had a 100-g glucose tolerance test, wherein the maximum/minimum glucose ratio was assessed one to two hours after the glucose challenge.The investigators defined reactive hypoglycemia as a glucose value <60 mg/ dL, or a decrease of 100 mg/dL or more within two hours and no glucose value exceeding 200 mg/dL. They defined hyperglycemia as any value >200 mg/dL and no value <80 mg/dL. Follow-up from surgery averaged about four years. The mean age of the group was 48.5, and 81% were women. The patients’ average preoperative weight was 138 kg, with an average body mass index of 49. One-third had preoperative diabetes. The percentage of excess BMI lost averaged 55%, and the patients had regained an average of 12 kg. Glucose tolerance tests showed six patients with hyperglycemia, including five who had normal fasting blood glucose levels. In addition, 35 patients had reactive hypoglycemia, while eight had hyper- and hypoglycemia. “The hyperglycemic cohort was characterized by a rapid rise to high sugar levels,” said Dr. Roslin. “The fact that most of these patients had normal fasting glucose means we need to be very careful of what we call cure or control of diabetes.” Reactive hypoglycemia manifested as a rapid upsurge of glucose levels that correlated with a rise in insulin and then a rapid decline during the second hour after the glucose challenge. Patients with both hyper- and hypoglycemia had even more pronounced swings in glucose and insulin levels, said Dr. Roslin.

The most dramatic rises and falls in blood glucose have been associated with small pouches and wide anastomoses, he added. The findings suggest a need to consider alterations in the standard gastric bypass procedure, such as use of valves, or possibly abandonment of the procedure in favor of another approach. “I believe that vertical-sleeve gastrectomy and duodenal switches that are not severely malabsorptive will be the best options in the future,” said Dr. Roslin.

Editorial: The about article was sent to me by Vicki Blackburn- Thank you Vicki. This was one of the many presentations that was made at the ASMBS meeting held in Dallas. I will be sharing other presentation in the future newsletters. This article describes what those if us that have been preforming duodenal switch operation have knows for years. This explains why the size of the pouch does not matter, that dumping does not protect against weight gain and why duodenal switch operation is far better option that the alternatives. As with other procedures the science will eventually shed light on all the facts. Dr. Roslin indicates the time is now to consider what should be the benchmark standard for weight loss.
Ara Keshishian MD, FACS

The term “probiotic” is getting much attention in professional circles as well as in the advertising media but is still poorly understood by many. The term describes beneficial bacteria that are added to our diet to help populate our digestive system with a healthy population of good bacteria. It is becoming ever clearer that a healthy population of bacteria is very important for our overall health. Our gut is the most intimate contact between the interior of our body and the outside world much as our skin is. The gut must remain permeable to nutrients which we absorb from foods yet impermeable to invading bacteria and viruses. The bacterial population of our gut plays important roles in both of those functions. It is also very important in the function of our overall immune function. I will leave that for another time. The purpose today is to discus the use and function of probiotic products.

The human gut is populated by tens of billions of bacteria of a yet to be discovered number of species. In excess of six hundred have already been isolated and identified. Some of these species are beneficial, some are harmful and some are a bit of both. Unfortunately modern society tends to have a negative impact on the health and balance of the members of the probiotic population. Chlorinated water, antibiotics both as medications and in our food and even our food choices can cause an imbalance in this population. When this balance is severely disrupted it is termed “Disbiosis”. A disbiotic gut is not a happy thing. We perceive this disbiosis as digestive symptoms of some sort. We may have gas and bloating, constipation or diarrhea, or even both or all of the above. One of the unfortunate aftereffects of having bariatric (weight loss) surgery is it can allow the gut to become disbiotic more easily.

In the DS gut food reaches the large intestine far more nutrient rich than in the “normal” gut. This provides the population of bacteria living there much more food. Given more food the population can flourish. If this population is out of balance it is even more sensitive to poor food choices thereby making the symptoms of this imbalance even worse. This is why the DS patient needs to make prudent food choices and may well enjoy great benefit from proper doses of high quality probiotic products containing the correct species.

The problem is that not all probiotic products are what they say they are and not all probiotic products have the same species. Add to that the fact that each gut is individual. We may need to do some experimentation to find the right combination of dose and product.

Some people have what I term a McDonald’s mentality. A Big Mac in one town is exactly the same as one from a different town or, as another example, a gallon of Shell unleaded gasoline is essentially the same as a gallon of gas from the Chevron station. This is not the case with probiotic products. Some products contain only one species and some contain thirteen or more. These various species, with one exception fall, into two large groups these are Lactobacillus species which predominate in the small intestine and Bifidobacterium species which predominate in the large intestine. The one exception is actually not a bacterium at all but rather a specific yeast. This yeast is very important and beneficial. It is called Saccharomyces boulardii. Some patients have reported good results with single species products such as Align (B. infantus), Culturelle (L. rhamnosus) or Floristor (S. boulardii). My feeling is that these products are overly expensive as they are heavily advertised and that cost is built into the price. They also tend to be rather low dose.

We also need to address the correct dosage. It is important to read the label. Minimum “therapeutic” dosage is thought to be 20 billion colony forming units (CFU’s). I personally am using 50 billion CFU’s per day as maintenance. I have taken as much as 200b CFU’s per day. I am also aware of research going on that also is looking at similarly high dosage.

I think a good product to start with is “Primal Defense Ultra”. Make sure it is the “Ultra” as it is the stronger blend. It is reasonably priced and contains a total of 13 species including the very important S. boulardii. For DS patients experiencing a disbiosis creating very foul flatus and stool. This species as an ingredient is very important. The S. boulardii has very specific activity against some of the nastiest bad guys in our gut such as Clostridium difficile, Candida albicans and even Entameba histolytica and Giardia lamblia which have been shown to enhance the effectiveness of conventional therapy for these conditions. In less severe cases the probiotics alone may be sufficient to correct the disbiosis but more severe cases antibiotic therapy may be indicated.

As stated previously the dosage needs to be sufficient. Three caps per day of Primal Defense Ultra (PDU) is a commonly used dose. This provides a total of 45b CFU’s with 12b of that total as S. boulardii. This was the dose used in a recent case study looking at DS patients with recurring frank C.diff treated with antibiotic and S. boulardii. Statistically very significant benefit was shown.

Also as stated previously every gut is different. Some may do well on small doses and some may need more. Every patient needs to find the dose that works for them. We need to start slowly and work up. Some increase in gas and bloating may occur. Once the disbiosis is improved patients can experiment with different blends. It is suggested that there be several species of both the lacto and bifido groups. The only allergic reaction I have heard of is one patient who developed a slight rash which subsided after lowering the dose. You can find this is most health food stores but it is a much better deal on line. Typically about 90 caps for $37 vs. 218 caps for about $50. General rule of thumb is that the refrigerated brands are superior to the less expensive freeze dried ones. But, many do well with the less expensive brands. Again, you need to experiment.

Also as stated prudent food choices are extremely important. Things like lean protein, complex carbohydrates and whole grains. Avoidance artificial sweeteners and simple sugars and white flour are all prudent decisions.

By: David Caya, DC

Weight Loss Surgery: Benefits and Risks
Dr. Ara Keshishian, Bariatric Surgeon
Tuesday, September 28, 2010
12:20 to 1:20 in SB 243
“”Weight Loss Surgery: Benefits and Risks”” is a free lecture at Glendale
Community College to be presented on Tuesday, September 28 as part of
the monthly Science Lecture Series.

The lecture will be held at 12:20 p.m. in Santa Barbara Building room 243.

Admission is free and open to the public.

The speaker is a bariatric surgeon, Dr. Ara Keshishian. He is the medical
director of Bariatric and Metabolic surgery at Verdugo Hills Hospital and has
a private practice in Glendale, Ca. Dr. Keshishian will discuss the subject beyond the billboards, radio ads and TV commercials and explore the future of weight loss surgery and treatment of obesity.

Fatty acids are a byproduct of fat metabolism. These are acids that are produced when fat is broken down in our body. Fatty acids are important in a number of metabolic functions in our body. They help move oxygen, keep skin healthy, prevent aging at a cellular level, promote weight loss by promoting cholesterol processing by the body, and prevent build up of plaques in blood vessels. Examples of different types of Omega fatty acids are Omega-3, Omega-6, and Omega-9.

Omega-3 and Omega-6 fatty acids are essential fatty acids (EFA) because unlike other fatty acids, our body is not able to make them. Omega-9 fatty acids can be produces in out body.

These EFA are involved more specifically in regulation of blood pressure, cardiovascular health and others.

I have looked and have not found any studies regarding any relationship (positive or negative) associating Duodenal Switch and Omega Fatty acids.

I would however make some educated guesses here: The fact is that the lipid profile improves significantly with the duodenal switch operation is known. The duodenal switch operation can be performed with limited or not gastrectomy to correct significant lipid disorders that are either non responsive to medical treatments, or in cases where the side effect of statin medications are debilitating.

With this known, I would guess that even if the Omega fatty acids are not absorbed as well at least some of the beneficial effects are not lost. I would recommend that a healthy diet be used to assure adequate absorption of EFA.

There are numerous sources available on the internet for patients to search for information. The information that one can find ranges from scientific to anecdotal. Patients individually have asked me a number of questions and I will peridically address them in an “Ask Dr. K” newsletter. I would also like for my opatients to submit their questions by emailing it to me.

“Problems Over The Years”

Question:
“What are the main things we should be looking for “symptom wise” at 3, 5, 7, or 10, etc. years out. I’d like to know how the duodenal switch effects teeth? On hydration as I think my body pulls water from my stool when I’m not drinking enough. Actually – it’s not “enough” it’s that my body passes it out my kidneys if I am not sipping constantly throughout the day. Is that normal? Omega Fatty Acids – are we screwed? What do those deficiencies look like?”

Answer:
I do not know of any particular study that looks at the health of the
teeth specifically, however, I would assume that if a patient is not
complaint with their Calcium, or even complaint, and they are deficient
in minerals such as Calcium, Vitamin D, Magnesium, and others, then
one can develop poor teeth. Hydration is a very important issue. Surgery or not, most of us tend to run around a little “dry”. Constipation may be a side effect of inadequate water intake.
For the Omega fatty acids, see the next newsletter dated 9/22.

Question:
I would love to know what types of problems are seen in post operative patients and what the distributions are by years post-op.

Answer:
In very broad terms, I can classify them in both time frame, and in term of causes of complication (mechanical vs. nutritional). See table 1.

Please note that this is by-no-means a complete list, only a brief, very brief, overview of some of the potential problems that may surface. This list is not meant to be all inclusive or complete.

Deep Vain Thrombosis (DVT) Where a blood clot is formed in the deep venous system of the lower legs and can travel and block the flow of the blood to the lungs. If large enough in it a common cause of death in post operative patients. DVT’s are not the same as varicose veins.

Pulmonary Embolism (PE) A clot or a tumor that is dislodged from one part of the venous circulatory system and blocks the flow of the blood to the lungs. The most common source for the PE is a DVT.

Wound Dehiscence Complete or partial breakdown of the suture line at the deep layers where the bowel may become unprotected. In some cases this needs re-operation on an urgent fashion.

Long-Term Outcomes and Consequences of Distal Gastric Bypass (D-GB) In Severe Clinical Obesity

Sugerman et.al.-Surgery, Virginia Commonwealth University, Richmond, VA

This study was conducted to measure longterm weight loss and metabolic results in Distal Gastric Bypass (D-GB) patients within a 24 year time span. Through a bariatric database and office visits statistics were inquired about a 3 year cliental list of 40 super – obese and 6 morbidly obese cases that had the D-GB done with the Roux-En-Y bypass. Preoperative BMI in patients was 59 kg/m2 (80% being women) and the average age was around 36 years old. In addition, approximately 40% of the patients required limb-lengthening revision as a result of protein-calorie malnutrition, and thirteen patients required another surgery. Unfortunately, six to nineteen years later after the D-GB surgery was performed, eight patients died. As a followup, patients who did not have revision surgery showed some weight loss, resulting in a BMI of 34 kg/m2 and an initial excess weight loss of 67%. Patients did have beneficial results in terms of weight loss; however, the protein-calorie malnutrition was too high and some patients’ levels of iron and vitamin D dropped. Distal-GB isn’t the best primary operation for morbid or super obese patients.

Editorial: There has been a resurgence of the distal gastric bypass as a salvage operation for failed proximal gastric bypass operation. The distal gastric bypass operation is a tested procedure, with is known complication rates. The number of distal procedures had gone down significantly, till recently when some centers and surgeons started offering is a revision to other restrictive procedures. It is my opinion that the distal gastric bypass has significant metabolic and nutritional sequel that do not justify its superior weight loss. It is also important to remember that distal gastric bypass is not the same as the duodenal switch or the BPD operation.
Ara Keshishian, MD

Short Term Outcomes Comparing Roux-En-Y Gastric Bypass vs. Sleeve Gastrectomy as Treatment for Failed or Complicated Gastric Banding

Lieb et.al. Cleveland Clinic Florida, Weston, FL

Laparoscopic adjustable gastric band (LAGB) is a commonly performed bariatric operation; however, when major problems take place or weight loss disappoints a revision surgery may take place; Laparoscopic Roux-En-Y Gastric Bypass (LRYGB) and Laparoscopic Sleeve Gastrectomy (LSG) are the most popular options. This study was conducted to compare the efficiency of LRYGB and LSG from 2003 until 2008 analyzing weight loss in terms of the body mass index (BMI). A total of 25 conversions were performed, 13 from LAGB to LRYGB (patients losing 10 BMI points) and 12 from LAGB to LSG (8 points lost in BMI). Hence, after a year the LAGB to LRYGB portrayed more weight loss in comparison to the LAGB to LSG.

Editorial: A common patient presented to our office is a gastric bypass or a lap band that has had less than desirable weight loss. More so, some patients are presenting with complications, such as dumping syndrome, weight regain, nutritional deficiencies, slipped band, dilation of the esophagus and other. There are solutions that are being offered, and most are nothing more than a band aid. I believe that the best reversional operation for failed gastric bypass and the adjustable gastric banding is the duodenal switch operation. This issue was discussed at length last in July 2009 newsletter.
Ara Keshishian, MD

Insurance Mandated Medical Programs Prior to Bariatric Surgery: Do Good Things Come to Those Who Wait?

Timothy Kuwada Division of Minimally Invasive and bariatric Surgery, Carolinas Medical Center, Carolinas Laparoscopic and Advanced Surgery Program, Charlotte, NC

This study was conducted to define the influence of a mandated medical program (MMP) on pre and post operative weight loss. Data was accumulated regarding patients undergoing nonrevisional Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) or Laparoscopic Adjustable Gastric Banding (LAGB) in a three year time span. Cases were separated into the MMP and No MMP in which the MMP patients went through a guided program by medical bariatricians and nutritionists. Three hundred patients (mostly LAGB) were studied separately in terms of time to surgery and %EWL before surgery and various times after surgery. When comparing MMP and non MMP patients, there was no large difference in preoperative %EWL or later %EWL. Patients who undergo a standardized MMP have a significant delay in time to surgery and no major benefits in terms of weight loss. Hence, insurances shouldn’t assign preoperative medical weight loss programs for patients, since the data does not support any benefit to this requirements.

Note that this study did not include the duodenal switch or the sleeve gastrectomy procedures.