Potential Treatment for Coronavirus-19
March 15, 2020 7:34 pm
Coronavirus – Protect Yourself And Those Around You
March 15, 2020 6:19 pm
Stapled Anastomosis
December 30, 2019 11:23 am
As I was looking over old archives, I came across the following pictures that were taken years ago. These were photographs taken to demonstrate the technique for the construction of the anastomosis of the biliopancreatic channel and alimentary channel of the Duodenal Switch.
The steps of doing the stapled anastomosis of the Duodenal Switch is generally unchanged during the laparoscopic approach to the procedure.
The stitches are placed to secure the bowel together. Two small openings are made in each limb of the bowel to be stapled together (the biliopancreatic limb on the bottom and the alimentary on the top of the image).
It is important to also align the bowel in the same peristalsis direction. This means that the contraction and the relaxation motion of the bowel should all point in the same direction. This should reduce the risk of complications such as intussusception.
When the stapler is fired in opposite direction, a very wide anastomosis is created.
Once the anastomosis is created, then the last staple is used to close the opening that was made. This staple line is perpendicular to the direction of the anastomosis to avoid making the opening narrow.
We originally published this technique in 2003 on Obesity Surgery Journal.
Long Term Health Implications of PPI Use, Antacids
November 19, 2019 12:38 pm
The FDA had initially approved almost all PPI’s, and antacids with an explicit limit placed on the duration of the therapy, which ranged in days to weeks. At that time there were no long term studies done on the health benefits, or side effects of the long term use of the PPI.
This Summary Letter outlines all the concerns dating back to 2011. I have found the information in this letter a good overview of the supporting medical evidence and lack of any long term data in regards to long term PPI.
The FDA made changes in the Black Box warning of the PPI medications. This was done with the mounting evidence and the health concerns of long term PPI use.
PPI’s have been shown to have detrimental long term side effects. It is prudent that a patient is continuously monitored and evaluated for identification of the possible underlying causes of the reflux, that may be the reason for the PPI use. There are a whole host of potential causes of reflux and other options for treatment.
There have been numerous studies recently published:
It can lead to increase risk of fractures and in a large study from the VA system it has been associated with the risk of premature death
Copper Deficiency Intravenous SupplementationExclusive Member Content
November 17, 2019 9:23 pm
Protein Intake
October 14, 2019 7:08 am
Protein intake requirements change over time following weight loss surgery. This is based on the requirements imposed on our body by a number of variables. These include, activity level, muscle mass, over all health condition to name a few.
A very young muscular athletic male with a BMI or 30 will require much higher protein intake (and absorption) that an inactive older Female with the same BMI. The same young athletic male will require much higher protein intake is he is recovering from a surgery than his baseline.
As we have stated in the past, the protein intake, should be adequate and not excessive. High level of protein intake that are not accounted for based on muscle mass and activity level, will eventually result in weight gain. The best measure of protein intake in a stable weight patient over 3-4 years post op is their albumin and protein level. Following your yearly laboratory values at a minimum is an important part of weight loss surgery follow up care.
You also need to adjust protein intake when necessary. Protein needs increase depending on physical needs, infection, healing, pregnancy, surgery, age, injury, etc. Plastic surgery requires higher protein needs for appropriate healing.
Information on protein sources and quality here.
The basic formula for protein intake is 1gm/kg of ideal body weight. The calculator below will provide a guide for the protein into based on your stable weight in lbs.
Overfed But Undernourished
October 01, 2019 11:27 am
Obesity is related to as many as 400,000 deaths each year in the US and it has increasingly been recognized as a risk factor for several nutrient deficiencies. This may seem surprising given the likelihood of over consumption of calories, however these additional calories are not from nutritious sources. One of the main reason for these nutritional deficits is the greater availability of inexpensive foods that are rich in calories and are nutrient deficient. This has led some medical professional to conclude that there is a certain group of people who are overfed but undernourished. Even with the epidemic of the obesity, there is significant nutritional deficiencies noted.
Obese subjects have increased blood volume, cardiac output, adiposity, lean mass and organ size all of which can influence volume of distribution, in addition, treatment for severe obesity involving surgical procedures can worsen these nutrient deficiencies and in some cases may cause new ones to develop.
This table shows the percentage of population below the estimated average requirement (EAR) by body weight status in adults more tan 19 years old, showing that almost 90 to 100 percent of people including normal weight (NW) are below the EAR of vitamin D and Vitamin E.
We would like to thank Miguel Rosado, MD for his significant contribution provided for this Blog.
Flagyl
September 25, 2019 9:07 am
Flagyl is sometimes prescribed for excessive gas and diarrhea. It is an antibiotics that works well on certain bacteria that accumulates in the GI tract and contributes to the gas and the bloating.
These bad bacteria flourish when patients consume significant and excessive fiber and carbohydrates (sugars, salad, pasta etc.) The FIRST line of defense against flatulence, bloating, and diarrhea should be eleminating the culprits in the diet. This point can not be stressed enough. Adding a daily dose of yogurt may improve symptoms due to yogurts probiotic benefits. To be beneficial, Yogurt should contain live bacteria cultures, not contain artificial sweeteners or have a high sugar content.
Artificial sweetness also area source of the excessive gas and should be avoided.
The Flagyl eliminates and reduces the bad bacteria. Along with a Probiotic and healthy dietary choices Flagyl can help to significantly improved or eliminate those symptoms of gas and diarrhea.
Before Flagyl is prescribed, it is important that the diet is critically examined to make sure that the carbohydrates and the fiber as source of gas and bloating is minimized or eliminated. Excessive use of medications that may be needed for other infections should be avoided.
Chronic diarrhea should be evaluated to rule out GI infection with C. diff bacteria or other bacteria or parasite.
Additional Information on C. Diff (Clostridium Difficile) and probiotics.
Vitamin A, Absorption, and Wound Healing
September 25, 2019 8:39 am
Vitamin A is one of the 4 fat soluble vitamins along with vitamin D, Vitamin E and Vitamin K. It is multifunctional and essential which means that it is not produced by the body. In this article we will touch on aspects of Vitamin A absorption and it’s effect on wound healing as well as its metabolism.
We often think of Vitamin A as the critical vitamin for vision, however it has several other roles that related to immune function, protein synthesis, and cellular communication. Vitamin A deficiency is a concern world wide because of the natural of the side effects. Vitamin A deficiency is the leading cause of preventable childhood blindness in the world according to UNICEF and sometimes it may be undetected until there is irreversible damage.
There are 2 chemical forms of vitamin A in diet:
Retinoids (Preformed vitamin A) This group include retinol, retinyl esters, and retinal they are mostly found in animal sources like liver, egg yolk or fish oils.
Carotenoids (Provitamin A) This group includes beta-carotene, alpha-carotene and lycopene, mainly found in plant sources like leafy vegetables or yellow/orange vegetables and fruits.
The Physiology of the Vitamin A is as follows:
1.- Ingested food is digested in the stomach where retinyl palmitates (esters) are released from proteins. Retinol and beta-carotene are absorbed directly into the small intestine where retinyl esters and betacarotene are transformed into retinol . Retinol is the most easily absorbed form of vitamin A.
2.-That retinol absorbed by the enterocytes in the ileum (small intestine) along with bile is then transported to the liver with the help of chylomicrons a protein that transports fat.
3.-Fifty to 80% of the vitamin A is stored in the liver and the remaining is deposited into adipose tissue, lungs and kidneys.
4.-When stored retinol is released from the liver into the circulation to target organs, it is bound to plasma retinol-binding protein (RBP4) a transporting protein produced by the liver that requires ZINC, which is synthesized by the liver; This complex is stabilized by transthyretin (TTR), which reduces renal excretion.
Retinol is a crucial component for reproduction, embryological development, cellular differentiation, growth, protein synthesis, and immunity in the form of retinoic acid and vision in the form of retinal.
One of Vitamin A additional roles is in epithelial health of skin and mucous membranes. It increases epithelial turnover which is crucial during would healing. It also has anti-oxidative effects which prevent cell damage and can prevent or reverse the effects of other damaging agents. In addition to these benefits it has also been associated with increasing collagen, fibronectin, keratinocytes and fibroblast, all important in wound tissue structure. There have been some studies that suggest giving higher doses of Vitamin A in patients with non or slow healing wounds.
It is important to remember that we have documents delayed diagnosis of adult vitamin A deficiency leading to significant night blindness in adults. It is critical that the patients and their primary care physicians are acutely aware of this possibility. In majority of the patients with low vitamin A, post weight loss surgery, aggressive supplementations, including injections need to be considered as a part of the treatment regimen.
We would like to thank Miguel Rosado, MD for his significant contribution provided for this Blog.
Sleeve And Weight Regain
July 22, 2019 9:50 am
