Category: Duodenal Switch
Types of HyperParathyroidism
February 20, 2026 4:05 pm
There are 4 parathyroid glands which are located behind the thyroid gland, among other functions, are the main regulators of calcium, phosphorous, and magnesium in the blood. Elevations of parathyroid hormone (hyperparathyroidism) can be: 1-Primary, 2-Secondary, 3-Tertiary
Primary hyperparathyroidism means the parathyroid glands themselves are hyperactive. This may involve only one of the four glands: a) an adenoma, a benign tumor that needs surgical removal, or b) hyperplasia, when all 4 glands are hyperactive and/or enlarged, and in some cases, most of the 4 glands need to be removed.
Secondary hyperparathyroidism means that the elevated PTH level is caused by an external regulatory stimulus, such as low calcium, which itself may be due to low vitamin D, low calcium intake, or other causes.
Tertiary hyperparathyroidism is seen only in specific renal failure and transplant patients.
Regardless of the type of hyperparathyroidism, the end result is the same. Because the parathyroid gland aims to maintain normal calcium levels, it will do everything to achieve them. This includes increasing calcium absorption from the GI tract, breaking down bone to increase the blood calcium supply, and increasing calcium reabsorption from the urine.
Distinguishing between primary and secondary is critical, as primary is more likely than not a surgical problem that needs to be addressed. Secondly, it may be responding to metabolic deficiencies (low CA, low Vitamin D) that need to be corrected and take some time.
Not all cases require surgical intervention, as labs (vitamin D, calcium, and alkaline phosphatase) and imaging studies, such as neck ultrasound, CT scan, and Sestamibi scan, provide the information needed to dictate the treatment plan. Please stay up to date with your yearly lab results to catch changes sooner rather than later.
Vitamin D level and Liver Function Test (LFT) elevation
February 08, 2026 11:21 am
After weight-loss surgery, some patients may experience a transient elevation in liver function tests that resolves over time. We have previously reported on this. IT is essential to distinguish between the Duodenal switch and the SIPS/SADI procedure, where some patients are led to believe they are identical. These procedures differ physiologically, and their weight loss and metabolic behaviours vary significantly.
Other than the stress of the weight loss, obesity, and comorbidities of obesity, there may be other anatomical post-surgical causes for elevated liver function test. This has also been discussed extensively.
A recent literature review supports the protective effects of vitamin D supplementation.
Elevated liver enzymes may be caused by many factors, including nutritional deficiencies, excessive supplementation (turmeric), medications, alcohol, adhesions causing partial bowel obstruction, and increased enterohepatic bile reabsorption . I would be very cautious about associating vitamin D supplementation with elevated liver function test results, even if the vitamin D level is in the very high normal range, regardless of the daily dose (much less frequent with injectable).
Vitamin D, as a fat-soluble vitamin, however, protects the liver and improves liver function test even in very high serum level . In rare cases, prolonged, elevated vitamin D levels may strain the liver. In Fact, the association of the vitamin D level and liver disease, including cirrhosis, leads to hepatocellular carcinoma (HCC) and dea h. Vitamin D protects the liver from HCC but cannot reduce the risk of cirrhosis.
Bile Reflux Gastritis and Cholecystectomy
May 21, 2025 2:41 pm
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.
How does a stapler staple and cut at the same time
February 11, 2025 12:27 pm
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.
Video of stapler demonstration
Feeding Tube with Duodenal Switch
February 03, 2025 9:53 am
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.
Additional informationVitamin Toxicity
December 17, 2024 1:36 pm
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.
Here is an example of critical vitamin A deficiency and night blindness and how, with aggressive large-dose supplementation, her condition was corrected.
Bile Reflux Gastritis
August 02, 2024 10:53 am
Bile Reflux
Bile Reflux is primarily a diagnosis of exclusion. All other possible causes must be ruled out, and bile reflux gastritis is made with the pertinent symptoms. The reason for this is that there is no primary test that can prove the diagnosis. When it comes to treatment, the surgical option requires preventing the bile from coming back to the stomach. The procedure we have performed routinely for bile reflux gastritis is the duodenal switch (without a reduction in the stomach size). This allows the food to go through an intact stomach and pyloric valve with normal stomach physiology (to prevent dumping syndrome). The bile is diverted through 100 cm of the small bowel as the biliary and alimentary limbs to prevent backflow of bile to the stomach (if it’s made too short). The procedure referenced (https://www.americanjournalofsurgery.com/article/S0002-9610(03)00213-7/abstract) is nearly 20 years old. It is rarely, if at all, performed due to its very complex and relatively high-risk nature. Its primary role for a surgeon is to reconstruct the biliary tract flow. This operation involved transecting the common bile duct and creating a biliary tree to small bowel anastomosis. This is, at times, done when there is injury, obstruction, or a tumor of the bile duct. This anastomosis has its complications, including stricture and sump syndrome. Therefore, hepaticojejunostomy or hepato-duodenostomy anastomosis is reserved for cases with no alternatives.
SIPS-SADI and ASMBS
December 31, 2023 1:21 pm
COVID Vaccines
March 05, 2021 3:50 pm
There are no known contraindications from a weight-loss surgical perspective to prevent a post-surgical patient from getting the COVID vaccines.
A patient who has had a Duodenal Switch, Lap Sleeve Gastrectomy, RNY Gastric Bypass, or revisions to Weight Loss Surgery should have the COVID vaccine. The vaccination should be avoided for a few weeks after surgery. For other possible contraindications, please consult your PCP.
Here is a summary of the vaccines and the details of each one approved as of the publication date.
Zoom Group Meeting
September 21, 2020 7:10 am
We are excited to announce we will be having a Zoom group meeting Tuesday, September 22, 2020 at 7:00 PM PST. We hope to see you online!
Registration is required. Please follow the link to the meeting registration.