Category: Duodenal Switch
Hypertrophy of Small Bowel and Weight Gain Years After Duodenal Switch
August 21, 2015 7:53 pm
Duodenal switch (DS) operation results in the highest success rate of all weight loss surgical procedures. Patients, over time, will experience some weight gain many years after DS procedure. There are a number of suspected mechanisms that may be responsible for the weight gain:
1-Ageing may slow the metabolism and the activity down.
2-Over time patients may not be as adherent to healthy dietary and lifestyle changes as they may have been immediately after surgery.
3- Hypertrophy of the alimentary and common channels over time increases in surface area f allowing greater caloric absorption leading to increased weight gain.
It has been demonstrated in bowel resection studies, as well as rat studies, that the nutrient stimulated regions of small intestine increase villus height and total weight, crypt depth and proliferation as well as wall thickness, as an adaptation to compensate for the loss of absorptive capacity in the resected bowel. This observation may be applied to DS procedure as seen in histological slides from a patient who had to have an operation done requiring bowel resection. The segment of the bowel resected included the junction of the biliopancreatic, common and alimentary limbs.
Internal Hernia And Bowel Obstruction
August 21, 2015 7:49 pm
Whenever there is a bowel resection with anastomosis made there will be a defect in the mesentery (the tissue that holds the blood supply and the nerves etc going to and from the bowel) that needs to be closed. In this particular case, the stitches that were used to close the defect were intact and yet the tissue had separated from it. The result is an internal hernia. This can cause bowel obstruction, where by a loop of the bowel can go through the defect and kink the bowel causing the blockage. In some cases, the internal hernia may reduce itself with intermittent symptoms of the bowel obstruction and in other cases it may require immediate emergent surgery. A CAT scan with oral and IV contrast is needed after Duodenal Switch to visualize the alimentary and bioliopancreatic limbs.
Symptoms may include but are not limited to:
- nausea
- vomiting
- abdominal bloating
- abdominal tenderness
- cramping abdominal pain
- diarrhea, constipation
- feeling of inability to completely empty bowels
- fever
- severe abdominal pain.
Surgical Treatment of Gastric Fistula
August 05, 2015 7:45 pm
Alcohol and Weight Loss Surgery Webinar May 20, 2015
July 27, 2015 7:27 am
Shared Success Story- Andrea R.
July 22, 2015 8:00 am
Since I was about 10 yrs old I have struggled with weight. I was always the chubby kid in class, and as I got older I was always the chubby friend. Being overweight didn’t affect me until I hit 220lbs at 15 years old, and as you know, kids can be mean and hurtful. At 18 years old I had my first child, during that time I dropped a little weight then ended up gaining it back and more. At the age of 19 I was sitting at 250lbs.
Fast forward 3yrs, I had my second child and once again, I lost weight just to gain back double what I lost. So now, at the age of 22 I was up to about 290lbs. Every day life became a struggle. I tried my best to stay active, but being overweight made me tired and made me feel like hiding. Over those years I tried everything from low carb diets, to diet pills, to b12 shots, and Weight Watchers; you name it, I tried it. Finally, I was fed up! I couldn’t take it anymore and I was ready to look into different options. I was 26 years old, 5ft 8inches tall, and a mother of 2 who just wanted to be active and healthy for my kids.
I decided that weight loss surgery was what I needed to do. At this point I was morbidly obese and at my highest of 326lbs. I met with Dr. Keshishian, and after going through the consultation we decided the duodenal switch would be the best option for me. On August 26th, 2013, I had my surgery weighing in at 306lbs. Dr. Keshishian is amazing! I didn’t have any complications. I was able to drink and eat small amounts normally.
Since having the surgery, just shy of the 2 year mark, I am now down to 178lbs. My life has changed so much since losing the weight! I honestly can’t describe how grateful I am that I was able to have the surgery withScreen Shot 2015-07-20 at 1.55.13 PM such an amazing Dr. and staff. Anytime I had a question or concern they were willing to hear me out and do whatever they could to assist me. Since losing the weight I am able to be the active mother I wanted to be for myself and my kids. Now I’m taking the steps needed to ensure my kids learn healthy eating habits and helping them understand how important exercise is.
Andrea R.
Informed Surgical Consent
July 18, 2015 9:39 pm
Surgical informed consent is the document that summarizes the discussion that has been carried out between the treating physician and the patient. It also outlines the expectations as well as the potential complications of the treatment being proposed.
An informed consent should mean that the patient is absolutely clear as to the procedure agreed upon and that is reflected on the consent. No abbreviations are allowed on the consent forms. Clearly, there are instances when a physician or surgeon providing service may have to deviate from the proposed plan and agreed upon procedure on the consent because of unexpected findings in the operating room.
Any patient undergoing surgery should be acutely aware of the terminology and the language used. With regards to weight loss surgical procedures, RNY and GB is not acceptable because they are both abbreviations.
Duodenal Switch is a distinct well described procedure with its unique identifiable code (43845 for open procedure) that is recognized by hospitals, insurance companies and the surgical societies.
Duodenal Switch operation is not SADI, SIPS nor a loop Duodenal switch. Any attempt to interchanges these terms or operations is inaccurate the say the least.
A surgical informed consent is signed by the patient ( or the guardian) and the treating physician. This document however is reviewed and confirmed by all those involved in the patient’s care delivered in the hospital. The consent is reviewed by the admission staff when taking the patient for surgery, preoperative nursing and administrative staff, operating room circulating nurse as well as the anesthesia staff. One step most patients may not be aware is initiated after the general anesthesia is induced. The operating room staff, anesthesia staff and the operating physician all go through a set of checklist known as “Time out”.
“Time out” involves confirming the patient’s identification as well as the proposed procedure as the patient had discussed with the staff and confirming the consent.
It is imperative that a patient have complete understanding of their surgical options available to them and critical that they have full knowledge of the type of surgical procedure that has been consented to and performed.
Vena Cava Filter
July 06, 2015 7:09 am
Example of a Vena Cava Filter Video:
Shared Success- Whitney a RNY to DS revision
June 09, 2015 7:43 am
I was always the big girl, pleasingly plump, chubby. I was put on my first diet at age 12. By the time I graduated High School I had yo-yoed up to 200 pounds at College graduation I was up to close to 300 pounds. In 2002 I had RNY Gastric Bypass surgery. I was 39 and weighted 280 pounds. I was told it was the Gold Standard. The Band was still considered experimental and the Duodenal Switch was never mentioned as an option. In fact, I did not even know it existed.
I lost 110 pounds and was considered a WLS success. I did not have any food restrictions and I felt great and maintained the loss for five years. Then I started to slowly gain weight. In little under 5 years I gained 70 pounds. I developed Dumping Syndrome and my Stoma was stretched out. I joined Weight Watchers and lost 5 pounds in a year. Nothing worked. I developed ulcers, osteoarthritis, planter fasciitis and could barley walk a couple of blocks without pain. I was miserable. I felt like a failure
In 2012 started to research surgical options. A local surgeon wanted to “revamp” my already tiny stomach, put a band around my stoma, and “clean up my intestines”. I asked about revision to Duodenal Switch and was strongly discouraged, but I wasn’t going to settle because that was what he was only capable of doing.
I wanted the best. I wanted long term success. So I travelled from Northern CA to Southern CA for a consult with Dr. Keshishian. The only choice for me was to revise to DS. In December of 2012, I had revision surgery of my RNY to Duodenal Switch. One week after surgery, still in the hospital, I went in for a second surgery. Dr. Keshishian found a small leak. I spent an additional two weeks in the hospital. My experience was not the norm and a leak can happen in any surgery involving the stomach.
Recovery was slow but steady. The first 2 weeks Dr. Keshishian called me every three days to make sure I was doing ok. I still have his cell number in my phone. I was back to work 14 weeks after surgery. I could have gone back sooner.
Over the past year I have lost 115 pounds. My BMI is 20, and I feel great. I have my life back. All pre-op issues have been resolved and I am going to start training for a 5K.
My advice for anyone contemplating Weight Loss Surgery is to research all of the options available. Do not settle for a substandard surgery. Get a second or even third opinion. It’s not a decision to be taken lightly. It’s your life fight for it!
Whitney B.
Neuromuscular Disease After Weight Loss Surgery
June 08, 2015 11:30 am
Weight loss surgical procedures may result in varying degrees of nutritional deficiencies. Some of these nutritional deficiencies may cause neuromuscular disease if left untreated, these include vitamins, minerals, and protein. The long-term effect of these deficiencies may presents as neuromuscular conditions including, weakness, numbness, confusion and all others if not-diagnosed and untreated. It is important to note that all weight loss surgical procedures require lifetime vitamin, mineral supplements and protein monitoring and possible supplements.
The table below outlines some of the specific neurological and neuromuscular disease complications following bariatric surgery. The most common deficiencies seen with the duodenal switch operation are fat soluble vitamin deficiencies. These include, Vitamin A, D, E and K. Duodenal Switch patients need oral supplements of Dry “Water Miscible” type of Vitamin A, D, E, and K based on their laboratory studies and needs.
The neurological deficiencies are manifested much more frequently with the Gastric Bypass than the duodenal switch operation. The most common nutritional deficients are that of B1, B12, Folate deficiencies that are common in Gastric Bypass. A list of possible neurologic deficiencies and there associated symptoms were summarized by Becker (2012). Another article with Nutritional Neuropathies.
Nutritional deficiencies are seen in a number of illnesses including weight loss surgery patients.
Duodenal Switch and Fat in The Diet
May 21, 2015 12:35 pm
When I perform the duodenal switch operation, the common channel is a percentage of the total small bowel length and I also account for the patient’s metabolic rate. Two individuals with a BMI of 50, should not have the same common channel. If we compare two patients, one of them is a 20 years old male who is 6’2″ and the second patient is a 60 year old female who is 5’4″, we can see how this applies. These two patients have very different metabolic needs and requirements. When the Duodenal Switch is performed in this fashion, the common channel based on a percentage of total small bowel length and metabolic needs, the patients post op diet works best when it is a well balanced, protein based diet. The basic principals are : Hydration (water), Protein and Everything else, low carb, avoid artificial sweeteners, avoid carbonated drinks, have frequent smaller meals and avoid processed food. Listen to you body as to what it tolerates and what it doesn’t. This is what I recommend for my patients.
I am not aware of any scientific evidence that proves any benefit to excessive amounts of fat for DS patients who have had their length of the common and alimentary bowels based as a percentage of the total length.
My recommendation are to have a well balanced high protein diet. I do not recommend a low fat diet, except in the healing phase after surgery. However, there is no reason to consume excessive amounts of fat long term.
High fat diet is used to facilitate bowel movements for some patients who have constipation. It may be prudent to try and identify what may be causing the constipation and correct or eliminate them before one resorts to a very high fat diet as a “treatment” for constipation after Duodenal Switch. The possible causes for constipation after duodenal switch may be metabolic-organic (where some patients have infrequent bowel movements before DS, hypothyroidism), length of the common and the Alimentary channels and medications (pain meds, narcotics, antidepressants).
In addition, Medium Chain Fatty Acids do not require bile salts to be absorbed and are directly absorbed into the Portal Vein in the liver. Medium Chain Fatty Acids are not malabsorbed post Duodenal Switch. Medium Chain Fatty Acids included Caproic acid, Caprylic acid, Capric acid, and Lauric acid. Commonly found in varying amounts within coconut oil and palm oil. MCT supplement is made with Medium Chain Fatty Acids.
In summary, I recommend that Duodenal Switch patients who have had surgery with our practice have a high protein balanced diet. I do not recommend avoiding fat, or going on a low fat diet. I am not sure if there a reason to consume excessive amount of fat, which may in fact have unexpected metabolic and nutrient consequences.
Every patient, as their weight stabilizes, will find what works and what does not work for them. Some patients will tolerate a higher fat intake and other will not be able to tolerate higher fat intake.