Telehealth appointments available use the Book Appointment button
1-818-812-7222 Office Hours: 8:00 AM to 5:00 PM
10 Congress St., Suite #300
Pasadena, CA 91105

Category: Bariatric surgery

Diabetes and Weight Loss Surgery

April 06, 2020 5:51 am

The scientific literature is riddled with evidence pointing to the benefit of early metabolic surgery as a superior treatment, remission and possible cure option for diabetes.  Unfortunately, the medical education, pharmaceutical companies, primary care healthcare delivery systems and third party payers (health insurance companies) have not caught up with the published data. The American Diabetes Association has changed their guidelines to reflected the benefit for combating diabetes with weight loss surgery.

There is ample evidence of the superior outcome of surgery as a treatment option for diabetes when compared to medical managment. Cummings et.al, in a published article in Diabetes Care, showed sustained stabilization of the Hemoglobin A1C six years after surgery. In contrast, there was no significant changes noted in the non-surgical group.

 

 

Jans et.al. , in November of 2019 showed that the patients who had NOT been on Insulin,  and had metabolic surgery had the highest long term success for resolution and remission of the diabetes. This identifies that having a patient be proactive in their care by having metabolic surgery improves success rates.

 

The exact mechanism by which the diabetes is resolved is unclear. The weight loss may play a role. There are numerous hormones and neuroendocrine modulators which control the complex metabolic pathways. Batterham et.al., in Diabetes Care (2016),  published a summary overview of the possible mechanism involved in diabetes improvement following metabolic surgery.

 

Neuroendocrine pathways involved with regulation of blood sugars.

 

There are a number of overlapping and sequential layers for possible reasons why diabetes resolves after weight loss/metabolic surgery. These may be directly related to surgery and the reduction of the calorie intake or absorption. It may also involve the neuroendocrine modulators.

 

What can be said definitively is that early surgical intervention is best and most likely the only permanent solution to type II diabetic resolution. There is no medical justification in not considering metabolic surgery in diabetic patients who may also have difficulty with meaning a BMI< 35.

 

Medication Absorption After Weight Loss Surgery

March 30, 2020 8:01 am

Wight loss surgical procedures, in one form or another, achieve the desired effect of weight loss by altering absorption of fat, protein, and carbohydrates. This results in decreased total absorption of required calories. An unintended consequence is the altered absorption of medications. Frequently I am asked about the specific medication. Usually the answer is vague since the information is limited on specific medications. If the desired effect is not achieved, then it is probably  not absorbed. Specially if the same dose of the same medication working well before surgery. There is a summary article about the Theoretical absorption pattern of different weight loss surgical procedures.

Articles

March 22, 2020 6:57 pm

We have added a new section of compiled articles to our website. This page will allow us to compile sicentific articles all in one place for easy reference. The page allows the reader to search for articles based on the subject matter. We will continue to add to this list of article as new ones become available.

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 fist step is to align the bowel to be joined.

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.

The stapler is then fired in opposite directions to create wide anastomosis.

When the stapler is fired in opposite direction, a very wide anastomosis is created.

 

Closure
Closing the opening that was made

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.

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.

Osteoporosis Medications, Action and Side Effects

May 25, 2019 3:40 pm

Recently I had a short live presentation on the subject of osteoporosis, osteoporosis medications, and the treatment options of this deteriorating bone condition. A patient who has had a bone scan may be diagnosed with Osteopenia and/or Osteoporosis. This information is usually conveyed by the forms of a Low T score. Both of these indicated demineralization of the bones, and the end result is  worsening of the bone structure. This leads to weaker bones and higher chance of fracture due to stress or trauma.

Treatment options should be approached is a global and systemic fashion. It is critical that the nutritional status is at its best possible and optimized for important healthy bone vitamins and minerals. Low protein needs to be corrected. Special attention should be given to nutrients, minerals and vitamins. These include ProteinCalcium, Magnesium, Vitamin D, and Vitamin K1/K2to name a few.

Healthy bones require ongoing and routine force in the form of exercise to remain health. Just as exercise improves muscle strength, it also improves bone health. Exercise is also critical in improving bone structure and density. Ideally, exercise should be weight bearing and resistance.  Examples include: hiking, walking, jogging, climbing stairs, playing tennis, and dancing. Resistance type exercise is weight lifting and resistance bands.  These exercise work by creating a pull or force on the bone either by gravity, movement or weight.  Always check with your physician before beginning an exercise routine, start slowly and building up to longer periods of time.  The ideal goal would be at least 30 minutes a day, every day, if you are able.

We frequently see patients immediately started on osteoporosis medications without checking or improving some of the nutritional markers noted above or without looking at exercise history. In some case, the medication recommended are contraindicated due to nutritional status.

The medications can be grouped in to those  that help with new bone formation (Anabolic agents) or those that help by suppressing the bone breakdown phase (Antiresorptive agents).

Groups of Medication

 

National Osteoporosis Foundation has an exhaustive list (below) of medications for treatment of Osteoporosis.

The table below outlines the side effects and mechanism of the actions of the common medications used for treatment of  osteoporosis which was published by the University Health News Publication on August of 2014.

Mechanism Of Action And Side Effects

 

With all this information, the few points to remember is that the most important factors in healthy bone structure are the nutritional status Protein, Calcium, Magnesium, Vitamin D, and Vitamin K1 levels.

This is an animation of normal bone Metabolism. It shows how bone structures is taken down and rebuilt continuously. This allows for a healthy bone maintainence as we age. The key is the balance of breakdown (osteoclast) and the build up (osteoblast) activity is regulated. Osteoporosis develops when there is more breakdown that build up.

With permission of Dr. Susan Ott of University of Washington.

Additional information available on her site.

Past blogs on Bone Health.

Dr. Facebook

March 22, 2019 8:24 am

We have become reliant on the information that we obtain from the internet, specifically platforms such as Facebook. In our practice we have to continuously correct information that patients have obtained from other patients, unmonitored sites, blogs, and postings. Most of this information is based on individual experiences that has become gospel. “Fat is good for you” is one of them. To clarify, some health fat (olive oil, avocado, Omega 3) is healthy and needed for all patients. We do not recommend “fat bombs” as a part of ones daily dietary intake.

The following article was written on the accuracy of nutritional posts in support groups on Facebook.

Koalall et. all  in  SAORD, December 2018  Volume 14, Issue 12, Pages 1897–1902 published
“Content and accuracy of nutrition-related posts in bariatric surgery Facebook support groups”

The conclusion, as suspected, that “Over half of the posts contained inaccurate content or information that was too ambiguous to determine accuracy..:”

pilot
Pilot by Dr. Ara Keshishian

It is our recommendation before any dietary recommendations are taken from facebook and the like, the source of the information should be verified.  As I have stated in the past, a frequent flier passenger is probably not qualified to fly a

commercial airplane, any more than a previous weight loss surgical patient providing medical and nutritional advice. We realize that there is significant value to the forum for exchange of information and sharing of experiences with other weight loss surgical patients as long as the information is well sourced and verified.

Previous blog with artwork.

by Rina Piccolo https://www.rinapiccolo.com/piccolo-cartoons

Gastric Balloon

March 12, 2019 9:10 am

Here we go again…. There is a new cure for obesity, Gastric Balloon, with minimal to no risk, is an outpatient procedure and/or can be done in the surgeons office with no anesthesia. Have we not similar claimed like this before (Adjustable gastric band) ?

Randomized sham-controlled trial of the 6-month swallowable gas-filled intragastric balloon system for weight loss published  in Surgery for Obesity and Related Diseases 14 (2018) 1876–1889, by Sullivan et. al  reports

“Conclusions: Treatment with lifestyle therapy and the 6-month swallowable gas-filled intragastric balloon system was safe and resulted in twice as much weight loss compared with a sham control, with high weight loss maintenance at 48 weeks.”

This sound very promising, however is very vague and leaves out significant, critical, and pertinent information.

The outcome of weight loss at 24 weeks was reported in Total Body weight loss % (TBWL%), Excess weight % (EWL), weight loss, and BMI change. Of those, the last three were statistically significant changes.

The outcome the weight loss was reported to be at 7% TBWL% at 24 weeks with some weight regain, with the patient employing post REMOVAL life style changes.

It is stated that the Gastric Balloon is temporary device that needs to be removed in 6 months and should  be considered in low BMI patients (<35kg/m2).  It is is important for those patients who are considering this temporary expensive measure for minimal weight loss to entertain the alternative of the same temporary results that may be obtained by lifestyle changes. These results may be maintained by a healthy lifestyle, exercise, and eating without the need for a device.

Adhesions, Internal Hernia And Bowel Obstruction

December 15, 2018 2:35 pm

Adhesions are fibrous bands of scar tissue that form during the healing process. Following surgery, many people live normally with this scar tissue. However, they are also the cause of bowel obstruction when the adhesions form in such a way that causes a segment of the bowel to either get trapped, or form a “knot”. In both of those cases, the end result is a partial narrowing or a complete blockage of the intestines. This is called bowel obstruction.

Without treatment, the blocked parts of the intestine can die, leading to serious issues. However, with prompt medical care, intestinal obstruction often can be successfully treated.

Other causes of bowel obstruction:

  • In children, the most common cause of intestinal obstruction is telescoping of the intestine (intussusception).
  • Intussusception telescoping of the interstine
  • Hernias — portions of intestine that protrude into another part of your body
  • Inflammatory bowel diseases, such as Crohn’s disease
  • Diverticulitis — a condition in which small, bulging pouches (diverticula) in the digestive tract become inflamed or infected
  • Twisting of the colon (volvulus)
  • Impacted feces
  • Colon Cancer
Adhesion band with trapped bowel

 

Internal Hernia

In patients who haven’t Bariatric / weight loss surgery or an untouched GI track, bowel obstruction may manifest itself by symptoms of loss of appetite, constipation, nausea, vomiting, enlarged abdomen, abdominal pain, cramping, with no passage of gas or bowel movements.

However, patients who have had a weight loss surgery (Duodenal Switch, or the Gastric Bypass) because of the parallel limbs of the small bowel, the symptoms outlined above may not present. The diagnosis of a bowel obstruction, when suspected, should be identified with CT scan of the abdomen and pelvis with Oral and IV contrast. A CT scan with no oral contrast or water instead of oral contrast is inadequate and may lead to a delay in diagnosis and surgical intervention. Examples of Bowel Obstruction CT findings were discussed previously.

The treatment for an internal hernia and adhesions causing a bowel obstruction depending on the severity may range from observation to  surgical intervention in order to release the small bowel from the constraints of the adhesions.