Category: Duodenal Switch
Unfortunately, we have been informed that the company we order our Vitamin A injections from will no longer have Vitamin A available. We have contacted several other companies and they also do not have it available. The manufacturer of Vitamin A states that there is a nationwide shortage of injectable Vitamin A and it may be available next year.
Our office has a few vials left and we are hoping that we can get to as many people as possible before we are completely out. We will continue to look for a source of Vitamin A injections. We will let you know when it is no longer available and when we receive a new shipment. Thank you for your understanding and we apologize for this issue.
Information on Vitamin A deficiency here.
You can find our list of recommended supplements here.
Just as a reminder, we have no financial interest in any of the vendors that are recommended on our website. Also, please note that this is not in ANY form or fashion a substitute for the evaluation by your surgeon or primary care physician. This is informational only and is not to be taken as a recommendation for any patients’ condition.
We’ve created a helpful map and parking diagram for our new Pasadena, CA office location. It also has a general layout of the Huntington Memorial Hospital Campus and Pre-operative intake and testing area. We hope that you find it helpful on your next visit to see Dr. Ara Keshishian, General and Bariatric Surgeon.
Dr. Ara Keshishian has performed more than 2,000 Duodenal Switch procedures, thousands of Sleeve Gastrectomies and more than 500 revisions from other Weight Loss Surgeries such as RNY Gastric Bypass, Adjustable Gastric Band, and Sleeve Gastrectomy to Duodenal Switch as well as General Surgical cases over the last 18 years of private practice.
Whenever you are dealing with insurance issues it is important to have a general understanding of insurance ins and outs. The Obesity Action Coalition has a good general guide to the insurance process here. If you are having issues with out of network, out of area, or insurance appeals and denials for Duodenal Switch, there may be some additional assistance from two individuals who have had the Duodenal Switch procedure themselves. We are grateful that they have provided assistance throughout the years to the Duodenal Switch community. The following is their statement on insurance.
The majority of insurance companies are in the business of making money (for profit). They can deny requests for preauthorization with impunity. These denials are often complexly worded and difficult to comply with and overcome, and are definitely overwhelming to the patient, and the busy surgeon’s office. The vast majority of patients faced with demanding if not impossible to achieve prerequisites, or denial of the request for preauthorization simply give up, and the insurance companies pocket the savings.
If you find yourself facing impossible pre-op hurdles, or a denial, we urge you to appeal, and to seek assistance in preparing the appeal. You can hire an attorney, of course, but there is an informal and free resource we suggest that you investigate as well.
If you go to BariatricFacts.org (a non-profit, patient-run site), you will find individuals who are long-term DS postops, and patient advocates. They have been helping patients, pro bono (for free), for over 10 years. They will help you draft your appeal letters, provide supporting medical and legal documentation, and prepare draft letters of medical necessity to be reviewed and signed by your surgeon supporting your appeal. They will not represent you directly, but they will help you best represent yourself. in many cases it is necessary to exhaust all internal appeals (because the insurance companies are unlikely to overrule themselves), and then file for external review, where independent reviewers often overrule improper denials. If you join and then post on BariatricFacts.org asking for help, you will be connected with them and you can decide if you want their help.
Please note that this is just a suggestion. It is neither legal nor medical advice, nor a guaranty regarding their services, and you should always consider getting legal advice and assistance from an attorney who will represent you directly. The members at BariatricsFacts.org will help you draft your own letters, but will not be your legal or medical representatives; you will be required to do a fair amount of your own work on your appeals, and to sign them yourself.
It is suggested that before or at the same time as you contact the resources suggested at the site, you gather as much of the following information as you can:
- A copy of your Evidence of Coverage, which is the usually 100+ page insurance contract between your employer and the insurance company, which you can obtain it from your HR department. If you are self-insured, it will be available directly from your insurance company. Note: it is NOT the Summary of Benefits – it needs to be the contract itself.
- If your insurance is through an employer, you need to determine whether your plan is self-funded or fully-funded. Your rights are significantly different under the two types of plans.
- If your insurance company has a separate bariatric surgery policy, provide a copy of that, too.
- A copy of your surgeon’s request for preauthorization, which provides the ICD-10 and CPT codes submitted.
- A copy of your denial letter, including the section regarding your appeal rights.
* It is strongly recommended that you obtain a copy of your surgeon’s LOMN (letter of medical necessity) before it is submitted to your insurer or for external review, so we can assist your busy surgeon in making the strongest possible case for you.
Don’t be deterred by a denial. It is unfortunately more common than it should be, but it can often be overcome if you meet the requirements for bariatric surgery, if you get help navigating the process.
Life before surgery seems like a lifetime ago for both my wife and I. Being extremely overweight is not only a burden on your general health but a burden on your lifestyle in general. You have the awful label of being called obese, or morbidly obese. This is such a wonderful word that makes you feel as if you have been judged a misfit in society. We were both overweight all of our lives and had done all of the diets known on the planet throughout the years. Some worked a little some not at all and we always found ourselves back to where we were before and usually larger than that. The main focus though as we were getting older was our health. For Theresa it was very difficult. Along with being over 400 pounds she had a severe case of asthma which caused her episodes where she felt she was going to suffocate. She also had very little muscle mass which made it very difficult to get up and down from seating or lying positions. Theresa had her surgery in February of 2014 and not a moment too soon. If she had done nothing it is a good chance that she was facing a horribly short future. She also has a slight heart murmur which did not bode well for a person with her weight. She did not have diabetes thank goodness but her A1C was on the rise as was her BP. She did have sleep apnea as well and had to have a CPAP machine.
I was also severely overweight, my highest weight was nearly 400 pounds and on surgery day I was 355 pounds. I was also under the illusion that I had more control over my weight and that once Theresa had her surgery I would just be able to diet and exercise my way to a healthy weight. I was able to do this in my younger years to a certain extent and I was naive enough to think I could continue to do so. How wrong I was. I had found that no matter how much diet and exercise I did my weight would drop a bit at first but then stall and I would have to essentially starve to lose any more and of course that just makes for a bad outcome. My A1C shot up to 7.6 and this was with 1000mg of metformin a day! My BP was very high with both numbers over 100, well over. This is with a high dose of BP meds. I had a severe case of sleep apnea and could not even consider sleeping without a CPAP machine with a high pressure. I have an artificial hip that was being burdened by my 350 pound plus frame and would probably need to be replaced sooner rather than later. My future was not looking good. Dying before I was 60 seemed like a reality for me and that is not the future I was hoping for. The decision to have weight loss surgery for the both of us was tough. You of course hear the nay sayers spout what a cop out it is and it’s the easy way out! You are just weak and just simply need to not eat hamburgers, French fries and donuts. Just stick with non-fat and low calories and you will reach the promised land. What a load of BS.
Once you wrap your head around the fact that your body is wired in such a way that it will always seek a higher weight every time you lose weight, it’s time to consider the type of surgery. Everyone has heard of the Gastric bypass and that seemed to be the path at the time of Theresa’s surgery. The thing about Theresa and what I admire very much is her persistence and her ability to research to the point where a decision is spot on. She looked at all of the four possible surgeries and quickly realized that the Duodenal Switch was a no brainer. It had the greatest measure of success in the long term as well as short term. Reading about the process and talking to others who have had the surgery it became clear that it was the right choice. Finding out where to go and have the surgery was a real challenge. We were lucky to find Dr. Ara Keshishian and have the ability to travel to his location to have the surgery.
Theresa’s Stats Rodney’s Stats
Surgery Weight: 410 Surgery Weight: 355 Pounds
Total Weight Loss: 215 pounds Total Weight Loss: 170 Pounds
Surgery Type: Duodenal Switch Surgery Type: Duodenal Switch
Surgery Date: February 2014 Surgery Data: May 2016
Surgeon: Dr. Ara Keshishian Surgeon: Dr. Ara Keshishian
Life after surgery is an amazing series of challenges, changes, and a journey that transforms your life in a huge way. For Theresa, it was freedom. Freedom from the overbearing weight she was carrying that kept her from essentially moving or doing anything but staying at home. We did very little outside of the house before surgery. Only the necessities of shopping and keeping up the house on the inside and out. Even that was difficult and went by the wayside all too often. Of course eating out was easier than going to the grocery store and that made the scale just go higher. After surgery, Theresa began to lose weight and you could see day by day the changes. After the first month, you could see a dramatic change not only in her look but the fact that she was moving again! She had dropped 35 pounds in that first month and it made a huge difference. As the weight kept coming off over the next few months we began doing things we have not done before. We started to do a lot of walking and a lot more things around the house that needed to be done. Shopping became a breeze and we ate out a lot less. The dramatic change was in her health. A number of changes for the better were happening on that front. The main one and a huge relief was the asthma. It simply was no longer there. She was no longer short on breath and was simply out moving me! I could barely keep up with her. She also had a bad case of psoriasis which before surgery she could do nothing about. Since the surgery it has disappeared. It might be due to the increased in vitamins, particularly the D vitamin. Her sleep apnea went away and now she is healthy and happy. It is almost difficult to describe the changes until you see them for yourself. For Theresa it has been a life changing experience that has transformed the both of us in ways we never imagined. Theresa eats a normal diet and after 3 ½ years post op she fluctuates about 5 pounds either way. It is amazing.
For me it was not what I expected. What I mean by that is, learning to eat is a challenge. With the Duodenal Switch you are not only eating less, but what you eat is tremendously important to the success of the transformation. With the other surgeries, Lap Band, Bypass and Sleeve you do not have the degree of malabsorption. You simply eat less and you lose weight, but you are still essentially “on a diet”. With the Duodenal Switch you have to consider the malabsorption and think protein first and for most. Once you get past the first month of eating small amounts and what you can while your innards heal you need to learn what to eat and is it enough protein. You may also have to contending with the fact that you have an aversion to foods you ate before. I, for one, could not even eat cheese, and chicken. I pretty much lived on scallops, crab, shrimp and protein drinks for the first three months. Nuts were also a good source of the protein when you get to that stage. This does change and things do go back to normal as far as the taste changes, but it takes a few months. The weight in that first month pretty much peeled off. I was dropping like a pound a day. It was incredible. You think that this is going to be a breeze and you will drop it all in no time! Then that 4 week somewhat of a stall occurs. From what I can tell, everyone experiences it in one form or another. It freaks you out because you start to think about the past where you would work your butt off and either gain or drop and ounce or two. But I was lucky, my wife had gone though it two years before me so she was there to explain that it was normal. The whole “this is a journey thing”, and she was right! At the time though I was listening to the negative voice in my head from the past. That is where the support from the many groups come in. You see that pretty much everyone has the same ups and downs and then your body gives up the farm and you drop a bunch of weight in a weeks’ time. There is really a lot of science behind it. Researching and reading about this particular surgery and how it works will benefit you while you go through the process. Another important thing we face with this surgery is the necessity of Vitamins. Thank goodness for my wife and the DS groups and of course my surgeon. You will not be without knowledge if you actively join the different groups and do your research on the vitamins. I am still learning about what my body needs and am looking forward to my labs in the next month to see where I may be deficient. I have also come to realize the importance of drinking water and avoiding dehydration. I never used to drink it much before the Duodenal Switch, but since the surgery I find it aids heavily in the success if you drink it and drink a lot of it.
To conclude this has been a journey and one I wish I could have done a lot sooner in life, but it is never too late. Today Theresa and I are at weights that we are happy with and our bodies are happy with. We are more active then we have ever been before together. No more days idle in front of the television with large amounts of fast food and drinks. That is what we used to look forward too. Now we cannot wait until we go out and do something. We are not running marathons or anything but we are active and enjoy being so. We no longer have the ailments we had before surgery. Theresa’s asthma is practically nonexistent, living in the northwest with fires in the summer she may have a bout or two. Nothing even close to what she has before and a simple inhale and its gone. Both of us no longer need a CPAP! The freedom to simply lay your head on the pillow and sleep is amazing and wonderful. All of the medication we had prescribed for us are gone as well. My A1C was 5 on my last set of labs and 5.3 on the one before that. Theresa’s is the same and has been for three years. BP is normal and my hip is holding steady. Oh, and another cool thing about it is you can actually shop for clothes anywhere! Your sizes will shrink but we have found we have become quite the clothes horses since losing all this weight. It makes it fun to be able to fit into a size you haven’t seen since who knows when.
Life is always a challenge for many reasons but to remove the burden of the weight simplifies things just a bit. It is a decision we will never regret and wished we had made a long time ago. We both owe our lives firstly, to having Duodenal Switch surgery. Secondly, and most important – was in seeking out the best surgeon we could find, and that was without a doubt, Dr. Ara Keshishian. As a surgeon he is thorough, meticulous, constantly learning and keeping up on the latest research;as a person he is easy to talk to, very approachable, and genuinely cares about his patients before, during and after the surgery process. We could not imagine choosing anyone else.
Women with Polycystic Ovary Syndrome (PCOS) often feel hopeless and depressed with their diagnosis. Bariatric Surgery improves metabolic syndrome, diabetes resolution, cardiac improvement, quality of life, and increased life expectancy. Bariatric Surgery effects on PCOS are positive in many aspects. However, there isn’t a consensus regarding recommendation for bariatric surgery for PCOS other than morbidly obesity with co-morbities.
PCOS has been shown to effect approximately 10% of women of childbearing age with symptoms of menstrual abnormalities, poly cystic ovaries, and excess androgen (male sex hormone). PCOS should be diagnosed by ensuring there are no other underlying endocrine issues. There are several associated disease processes that seem to be related to PCOS, such as Type 2 Diabetes, higher depression and anxiety, increased cardiovascular risks, stroke, hyperlipidemia, sleep apnea, overall inflammation, and endometrial cancer.
Bariatric surgery can improve several issues related to PCOS such are Type 2 Diabetes, lower weight, sleep apnea, infertility, and hyperlipidemia. Duodenal Switch has the highest rate of Type 2 Diabetes resolution of all weight loss surgeries available at this time. Duodenal Switch also significantly improves hyperlipidemia.Weight loss surgery has been shown to improve and in some cases resolved PCOS in general. A recent meta-analysis of the effects of bariatric surgery in more than 22,000 procedures found an average weight loss of 61%, associated with the complete resolution or improvement of diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea in more than 60% of the patients. Another study looked just at PCOS patients and their metabolic improvement from 47% of the PCOS population to only 21% post Bariatric Surgery.
Several recent article have described how Bariatric Surgery effects PCOS with positive aspects related to fertility. The range of improved fertility in post Bariatric PCOS patients is a wide range of 33-100% with in the literature. It is thought that the loss of fat mass improves hormone levels and insulin resistance in PCOS and has a positive effect on fertility. One study of only 6 omen had a 100% improvement of infertility. American Society of Metabolic and Bariatric Surgery as well as the American College of Obstetricians and Gynecologist have a statement that bariatric surgery is should not be considered a treatment for infertility. The graphic below demonstrates the overlap of some of the symptomatology between PCOS, obesity and metabolic syndrome.
There are several documented positive effects and improvement in co-morbidilties related to PCOS post Bariatric Surgery. These include lipid profile, lower weight, cardiovascular risk, hypertension, and fertility. It is important to note that certain bariatric surgeries have better resolution of these co-morbidities or symptoms of PCOS. Always discuss with your physicians and surgeon what your options are and which treatments may work best for you.
In Summary, PCOS is a metabolic disease condition affecting different organ systems. Weight loss surgery should be considered as a viable treatment option and should be discussed with your OB/GYN and Infertility specialist.
I’ve had some questions regarding how Reconstructive Surgery can affect weight loss and metabolism after Duodenal Switch, Vertical Sleeve Gastrectomy, weight loss surgery and even in people who have not had weight loss surgery. There are several components that can effect a change in metabolism following Reconstructive Surgery that relates to physiological, functional, social and emotional mechanisms. These possible effects can vary person to person based on body type, age, weight, motivation, etc.
Fat mass resection and liposuction
Liposuction or the removal of fat mass by panniculectomy or abdominoplasty can have effects on lipid profile, leptin, waist hip ratio and glucose metabolism for 3-12 months depending on the individual and their health status. This have been researched and documented in both normal and higher BMI individuals. There is also an improvement noted in post bariatric surgical patients having breast reduction and abdominal plastic surgery. Of course, these effects can be controversial, conflicting and further research is needed.
Decrease in inflammatory markers
There is some evidence that the excision or liposuction of fat mass an decrease inflammatory markers and insulin resistance. This can affect C-reactive protein, TNF and cytokines levels. Little is known about the actual mechanism of this effect but the potential for this physiological change is present.
Increase metabolic need for healing
The metabolic needs following plastic surgery are much greater due to the nutrient needs required for healing. Depending on the extent of skin and tissues excised, the nutrient requirements can be considerably higher. This increase in nutrient need can increase metabolic rate, meaning you need more energy for healing. This significant stress also increases the complication associated with reconstructive surgery after weight loss surgical procedures.
Many people are more motivated following plastic surgery because of the dramatic change in body appearance and ability. The increase in motivation can be either diet or physically related. Some people are more motivated to watch what they are eating and increase physical activity to increase the effect of plastic surgery. Obviously, this is an extremely individual experience and can happen in varying degrees
Possible increased restriction
In the case of abdominoplasty, there can be an increase in restriction due to tightening of the skin, muscle and inflammation of the abdominal wall. Thereby, helping to have a fuller feeling sooner when eating. This can also at times result the chance of the complication of reflux and/or stress urinary incontinence if the abdominal muscle tightening is excessive or there is weight regain later on after the abdominoplasty.
Increase mobility and functional status
Excess skin can impair mobility and physical activity for some. The removal of the excess skin can promote mobility, ease of movement, improve gait and posture, and can improve or relieve pain. Skin infections, rashes and irritation are often symptoms of excess skin especially in the abdominal or pelvic area. This is a functional improvement, and depending on the extent of the pannus, can be quite freeing.
Improved self confidence, anxiety, mood, and body image are important motivators and incentives to post bariatric and plastic surgery patients. These improvements can have an effect on social and relationship aspects. However, it’s important to note that patients undergoing cosmetic surgery should have realistic expectations. Cosmetic, plastic or reconstructive surgery is not a panacea and does not in itself solve body image, personal or psychological issues. In addition, a post Bariatric patient may need additional time to recognize their physical and psychological changes following plastic or reconstructive surgery.
There may be metabolic, physiologic, physical and psychological improvements following Reconstructive surgery either after weight loss surgery or in non weight loss patients. These changes will vary based on the individual, age, dedication, health status, adherence to instructions, past medical and psychological history. However, appropriate education, screening and realistic goals and outcomes need to be emphasized prior to undergoing any type of plastic or reconstructive surgery.
One of the leading reasons for Gastro-esophageal reflux disease (GERD) is a physical defect called a Hiatal hernia. The esophageal Hiatus is the opening in the diaphragm where the esophagus enters from chest cavity allowing the esophagus to pass into the abdominal space. If the opening in the diaphragm is much larger than the esophagus, it will result in reflux of the stomach secretions and food from the stomach into esophagus. *Note: Graphic surgical pictures below
Hiatal Hernia Causes:
- heavy lifting
- persistent vomiting
- age related
Reflux and Hernia Symptoms:
- sour taste
- chest or abdominal pain
- difficulty swallowing
- no symptoms
The treatment includes dietary changes, medication and in those who do not improve surgery.
Hiatal hernia repair includes tightening of the dilated opening of the esophageal hiatus by re-appoximating the separated muscle fibers of the right and the left crus. This tightens the defect in the diaphragm and helps prevent part of the stomach or stomach contents from entering the chest cavity.
You can find further information and dietary changes regarding Hiatal Hernia and GERD here, including information unique to weight loss surgery and Hiatal Hernia. You can also find further surgical information, as well as a surgical video here.
We have received notice that the FDA and the compounding pharmacy have changed their regulations for several medications. Unfortunately, this affects our office and Duodenal Switch patients in regards to injectable Vitamin D and Vitamin A. In the past, we have been able to have injectable Vitamin A and injectable Vitamin D in bulk in our office. The new regulations require that a patient be assigned to the medication, so we will be unable to have it on hand in our office. This is out of our hands and control.
We are requesting that if you are anticipating the need for injectable vitamins that you have your laboratory results in our office at least 3 weeks prior to your office visit. This will give our staff adequate time to order your injectable vitamins to be available at your visit.
Injectable Vitamin D may be needed in some cases of Vitamin D deficiency or inability to increase Vitamin D level with oral supplements. Vitamin D is a fat soluble vitamin. It plays an important role in bone metabolism and structure. It has also been found to affect the immune regulation, control off- inflammatory reactions, and also be involved in a number of broad cellular functions throughout the body.
Research and information regarding Injectable Vitamin D.
Thank you for your understanding in this manner.