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Category: Duodenal Switch

Nearly 16 years Post DS

January 29, 2015 3:24 am

I was recently lucky enough to be able to have dinner with my first private practice Duodenal Switch (DS) patient from almost 16 years ago.  This DS journey has been amazing, enlightening and humbling. I am continually impressed with how people change their lives and go on to exceed their own expectations. It was wonderful to see my rationale for promoting DS as the weight loss surgical procedure with the best long term outcomes and “normal” eating ability perfectly represented. Patient #1 has maintained her weight loss long term, ate the variety of foods served at about 50% of what others around the table ate and has continued to thrive in her life.  Our meal consisted of protein, vegetables, rice and even a bit of dessert. She runs a company with numerous employees and interacts with clients on a daily basis. She has maintained her laboratory studies with consistent daily protein, vitamin and mineral supplementation.  She has not needed iron infusions or any other additional nutritional support. There are many misconceptions out in the bariatric and general community regarding the DS. DS patients do not normally have accidents, have an odor about them, or spend all day in the bathroom unless they have eaten something that does not agree with them. Nor is weight loss surgery an easy way out.  It is a lifetime commitment of protein, vitamin and mineral supplementation with yearly laboratory study surveillance. I have always believed that giving the patient the most “normal” eating ability with long term weight loss success is the best outcome. Dr. Bruce MacPherson was my mentor in Pontiac, Michigan where I learned Hess technique for DS. Dr. MacPherson was personally trained by Dr. Douglas Hess.  My private practice experience with DS started in 1999. I truly believe that Hess technique gives the best overall outcome and lifestyle to the patient. In my opinion,  the Hess technique is comparable to taking normal anatomy and reducing it down to overcome metabolic disruption.  The above is an example of one patient’s outcome.  Each patient’s experience is individualized based on their health history, anatomy, metabolism and surgical outcome.

Hernia Repair And Weight loss surgery

December 22, 2014 3:35 pm

Patients having weight loss surgery (WLS) either primary or revision are sometimes also diagnosed with having a hernia.  Whether a hernia can be repaired concurrently with WLS or not, depends on the type of the hernia and also type of weight loss surgery.

The 2 most common hernias encountered in weight loss surgical patient’s are  1.Ventral (incisional),  or 2. Hiatal hernias. Ventral hernia refers to defects or weaknesses of the abdominal wall.  If this involves a previous midline incision then an incisional hernia is diagnosed.   These hernias may present with any or all of the following findings; protrusions or bulging of the anterior abdominal wall tissue through the abdominal muscle cavity, abdominal pain, and nausea and/or vomiting.

Hiatal hernias are located inside the abdominal cavity at the junction of the esophagus and the stomach at the level of the diaphragm.  This condition is where the upper portion of the stomach this is usually located in the abdominal cavity has migrated through the esophageal hiatus into the chest cavity.  These hernia’s usually present with reflux, episodes of nausea and are quite frequently seen in patients with experienced complications of the LAP-BAND.

The surgical treatment of these hernias are very different:

Ventral hernia repairs may require mesh placement. There are different mesh products that are available.  Some are made with non absorbable material  and other are absorbable- biologic material that last long enough to allow incorporation by the patients own tissue.  In general, when a mesh is used, the incidence of hernia recurrence goes down significantly. However,  there is an increase in complications associated with the use of mesh.  These may include infection of the mesh, indications of synthetic material, and serum and rejection indications of non synthetic material.   To add another layer of  complexity, when the hernia is encountered at the time of weight loss surgery, especially when the GI track  has to be opened ( in the case of duodenal switch, revision from a failed gastric bypass with a duodenal switch)  then it is recommended that no mesh be placed because of the high incidence of mesh infection or the associated complications.  In extreme cases where the abdominal wall cannot be closed, biologic meshes may be used with the understanding that a repeat hernia repair may be required at a later date.

In my practice, Hiatal hernias are always repaired at the time of the weight loss surgical procedures.   Depending on the type of the weight loss surgery the patient has had previously, the type of the hernia repair, and whether or not a mesh needs to be utilized, and the amount of stomach and fundus remains for the repair, will dictate how the Hiatal hernia is repaired.

Additional information regarding hernias in a newsletter.

Holiday Survival Tips by: Marylin Calzadilla, Psy.D.

November 17, 2014 8:23 pm

The holidays are almost here, and it’s a time of year that traditionally involves spending much time with loved ones as well as engaging in one of America’s greatest pastimes, eating.  For the most people, holiday memories are strongly tied to traditional dishes and treats – turkey and ham, stuffing, mashed potatoes, and pie.  But for those who have had weight loss surgery, or even if you are simply trying to be conscious of your health and weight, it is important to step back and think about the holidays from a different perspective.  Below are six ideas not only for survival but for success this holiday season.    

 

REFLECT

Think about what the holidays truly mean for you, and take the time to ask yourself what you want from this holiday season. Most of us get caught up in the rat race and never really stop and think what it’s all about. Vast amounts of money are spent on marketing campaigns aimed at luring us into shopping malls and grocery stores to buy the  “indispensable” items of the holiday.  Rather than get caught up in the hustle and consumerism of the season, I encourage everyone to stop and ask themselves what they’re truly wanting from the holidays.  For some it may be spending time with those they care about, for others it may be to take time for oneself.  Write down your goals on an index card and post it in a prominent place at home or at work as a reminder of what your holidays are going to be about this year.

SUPPORT, SUPPORT, SUPPORT

Tap into your support network. We know that strong, available support networks are key to long-term weight loss success. Often we are afraid to ask for help as if requesting assistance were symbolic of weakness.  Often we have a double standard when it comes to support. We like helping others yet dislike asking others for help.  Just as it feels quite rewarding to help someone that you care for, let the individuals in your life be there for you.  Allow yourself to talk about your feelings, share your experiences, both positive and negative.    There is also no better time to attend support group meetings.  You can gain extensive comfort being around those facing similar issues. You can also learn from their mistakes as well as their successes.

ALLOWANCES

It’s difficult to achieve success if you feel deprived all the time. You may want to think about the dishes that are truly special to you and allow yourself to consciously indulge in a treat, if it’s appropriate for your level of post-operative diet. If you look forward to Aunt Marie’s delicious sweet potato pie every Thanksgiving, then allow yourself to enjoy this once-a-year tradition.   Don’t tell yourself you will never be able to eat your favorite foods again. The bottom line is that long-term success with weight loss is about quality and quantity.  Allow yourself to savor each and every bite, and remember portion control.  Also strike a deal with yourself to manage any extra calories you’re taking in with increased exercise or careful eating on other days.

KEEP ACTIVE

Make a realistic exercise plan and stick to it. It’s easy to forego exercise during this busy time of year, but you shouldn’t compromise on your health. You will be spending more time around food and probably consuming a little more than you typically do.  Sticking to your exercise routine will help you to indulge without feeling guilty and will allow you to get through the holidays without losing your hard-won progress on your weight loss.  Plus, exercise will help you keep your energy and endorphins up so you can get everything done and feel good while you’re doing it. 

CREATE

Spend some time researching new bariatric friendly recipes.  You might actually really enjoy the process, and it’s also an opportunity to introduce some healthy alternatives to friends and family. The truth is, everyone is thinking about smart food choices these days, and people will appreciate a tasty, healthy alternative to the usual holiday fare.  At the very least if you prepare a nutritious side or appetizer for a social gathering, you’ll know that there will be at least one healthy dish for you to eat.

PLAN ACTIVITES

Most holiday time is spent around the kitchen and the dinner table, but don’t be afraid to change it up.  Create some fun activities your guests can engage in. Some friends of ours host a karaoke contest after their Thanksgiving meal. Other families go out for a walk, play charades, or even have contests on the Wii, Xbox, or any other home gaming system.  Don’t be afraid to create a new tradition that gets everyone laughing, moving and having a good time.     
Integrating some of these ideas can help keep you, your goals and the holiday season on track, healthy, and happy.  All of the above tips may need to be adjusted depending on your situation and post surgical status.Best Wishes,
Marylin Calzadilla, Psy.D
 





Laboratory Blood Specimen Collection Change

October 30, 2014 5:20 pm

Older and Newer Blood Specimen Tubes

No one likes surprises at the lab when you are about to get your blood drawn. The picture above is of the older vacutainers blood specimen tubes and a new type of tube that is being introduced. There is currently a change over of blood specimen tubes in laboratories across the country.  Locally we are seeing the use of SARSTEDT tubes/syringes.  This change over is for several reasons. First and foremost is to reduce blood bourne pathogen exposure due to needle sticks and tube breakage. However, these blood specimen tubes offer some additional benefits, especially to people who frequently have lab draws. One of which is the ability to use aspiration of the specimen to decrease the incidence of hemolysis.  Hemolysis skews laboratory studies and damages the red blood cells in the collected specimen causing the need for repeated testing.  Aspiration is also easier on fragile veins due to the decrease pressure versus vacuum. The SARSTEDT tubes are versatile in that they can also be used as a vacuum tube if needed.

Hope this knowledge will alleviate at least some anxiety on your next trip to the lab for your blood draws.  Remember that follow up laboratory studies after weight loss surgery is a lifetime commitment that ensures your health and adjustment of vitamins and supplements.

Dental Issues after Weight Loss Surgery

October 13, 2014 10:53 pm

Please click the link to view the webinar on Dental Issues after Weight Loss Surgery.  A special thank you to Armen Mardirossian, DDS, MS Diplomate for his contributions to this article.

Update for Feb. 2017 Dental Resources here.

Dental Issues after Weight Loss Surgery Webinar here.

alveolar-bone
Anatomy of a Tooth
Dental Issues after Weight Loss Surgery
Factors that contribute to Dental Issues

This is a review of data regarding weight loss surgery and dental health.  I am not a Dentist so please follow up with your Dental Health Care Providers if you are having any issues.  Always keep your health care providers informed of your overall health status.

Controversies of Duodenal Switch -Staged or Single Stage

September 27, 2014 5:29 pm

There is almost no science supporting the two staged duodenal switch. The “theory” advocated was that one can try a less invasive procedure and then if it does not work, proceed with the more complex operation. This was also advocated as a risk reduction tool for patient to have the sleeve component done as a planned first stage to reduce the operative and the anesthesia risk of the full duodenal switch operation. The “DS” surgeons soon recognized that the weight loss after sleeve is limited and not long lasting.

Laparoscopic Sleeve Gastrectomy has received a great deal of attention in the last few years. Most of this attention is contributed to the almost universal failure and high complication rate of the adjustable gastric banding (AGB) procedures. Since some practices and surgeons promised a low risk, minimally invasive procedure with the AGB procedures, they had to find an alternative as the complications and the failure of the AGB procedures mounted. This is when the Sleeve Gastrectomy started gaining more acceptance by surgeons who previously had performed AGB.  Sleeve Gastrectomy is becoming one of the most commonly performed weight loss surgical procedure in several areas in the country and world.

It is worth mentioning, that Sleeve Gastrectomy is nothing new to the surgeons who perform Duodenal Switch procedures.  Duodenal Switch has been performed as a single stage procedure since it’s inception.In fact every classical Duodenal Switch procedure is a Sleeve Gastrectomy with two small bowel anastomosis, first described by Dr. Hess in 1988. Duodenal Switch surgeons were also first to offer Sleeve Gastrectomy as the first stage of a two staged procedure.

BiliopancreaticDiversion-Duodenal Swtich: Independent Contributions of Sleeve Resection andDuodenal Exclusion, Marceu P, Biron S, Marceau S, et al. Conclusion: SG and DS independently contribute to beneficial metabolic outcomes after BPD-DS. Long-term weight loss and correction of metabolic abnormalities were better after DS favoring its use as first stage in BPD-DS; one-stage BPD-DS outcomes were superior to two-staged.

Other than some extreme cases, there is no indication to offer the sleeve as a staging operation since in vast majority of the cases the patient will require to have an alternative procedure done when the weight loss stops, and in some cases weight gain is experienced.

The reasons one should avoid a staged procedure is the evidence in the research data does not support that staging a procedure benefits the patient. There is also consideration for two general anesthesia exposures. Anesthesia time is based on surgical experience, technique and past patient surgical history. The argument that a patient should have the Sleeve Gastrectomy, to improve the risk for Duodenal Switch has almost no support in the peer-reviewed literature. One should also consider that a patient having had a Sleeve Gastrectomy may not qualify for the second stage Duodenal Switch procedure due to lower BMI or the insurance benefits mandating only one weight loss procedure in a lifetime.

There may be patients who may benefit from the Sleeve Gastrectomy long term, but in my opinion to offer Sleeve Gastrectomy as a planned first phase of the the duodenal switch is not indicated in majority of the cases.

Telogen Effluvium: Hair Loss After WLS (Weight Loss Surgery)

September 14, 2014 12:56 pm

Telogen Effluvium is the premature pushing of the hair root into a resting state and can be chronic or acute. It is usually brought on by a shock to your body such as high fevers, childbirth, severe infections, severe chronic illness, severe psychological stress, major surgery or illnesses, over or under active thyroid gland, crash diets with inadequate protein, and a variety of medications. Most hair loss from medications, is this type of hair loss, and the related medications include retinoids, beta blockers, calcium channel blockers, antidepressants, and NSAIDS (including ibuprofen). Supplements that can also cause or increase telogen effluvium are higher doses of iron and Vitamin A.

hair-2Bcycle
Hair cycle

The hair begins to fall out in differing amounts and can start weeks to months after the initial shock to the body or medication initiation. The hair loss can continue up to 6 weeks and typically slows at 8 weeks after the start of the hair loss.

Weight loss surgical patients experience this due to the stress of surgery and the low protein state directly after surgery. Although there is no specific treatment for Telogen Effluvium, there are steps that can be taken to potentially slow the hair loss and help support the new hair growth.

The most important steps to take are to maintain your protein supplementation at a minimum of 80-100 grams of protein daily and hydration (at least 64 ounces daily) after weight loss surgery.

Hair loss pattern from telogen effluvium
Hair loss pattern from telogen effluvium

Protein, particularly L-lysine, are the building blocks of hair and nails, without adequate protein your body will forgo making hair and nails to maintain critical muscle mass. Also hydration is important to flush the body of toxins, due to fat breakdown in the liver during the rapid weight loss phase, that will prevent further new hair growth.

Vitamin B6 and B12 deficits can also contribute to hair loss. Multivitamin supplementation is essential to maintaining the required levels of these vitamins. The recommended multivitamin supplementation is two multivitamins daily that are equivalent to Centrum brand multivitamin.

Some people add Zinc supplements to increase hair production. However, if you are adding Zinc it is advised to also add a Copper supplement as they compete with each other for absorption. Copper is important for red blood cell production and a copper deficiency can exacerbate iron deficiency anemia. Inactivity can also decrease zinc levels, therefore exercise/activity will naturally maintain zinc levels.

Biotin is also a B vitamin that can be helpful in new hair growth.

Folicure is a supplement tablet that contains many vitamins and minerals that some people find helpful for hair re-growth. They also manufacture a shampoo that can be used.

There are many shampoos and topical treatments that people use and report satisfaction in their results. However, it is important to note that a topical treatment may make your hair appear thicker but the hair regrowth will only be supported by internal nutritional maintenance. Minoxidil is a liquid vasodilator medication applied to the scalp that is the exception to this rule and can help with hair regrowth. However, Minoxidil will not work to it’s optimal level in the absence of adequate nutritional status.

We always go back to our basics after weight loss surgery of hydration, protein and exercise to maintain health of body and hair.