Category: Duodenal Switch
Feeding Tube
April 20, 2015 11:43 am
Feeding tubes are catheters that are placed in the lumen of the gastrointestinal tract. They are used to provide or supplement the nutritional intake. The feeding tubes can be placed in the stomach (gastrostomy tube, G-tube) or the small bowel (jejunostomy tube J-tube). Patients who are having a revision of gastric bypass, VBG, or other weight loss surgical procedure that involves the stomach in our practice will have a feeding jejunostomy placed. The reasoning behind this is that in the unlikely event of a leak, or if the patient cannot tolerate adequate water or protein early on, this provides a way of getting hydration and nutrients. In the case of a patient with a small leak drained by the drainage tubes in place, a re-operation may be avoided if adequate nutrition can be provided to the patient by the feeding tube. Given that the J tube is placed in the small bowel, the patients usually require small, frequent feeding-hydration throughout the day.
The jejunostomy tubes are easily removed in the office.
Gastrostomy tubes are placed in the stomach. They can be placed endoscopically in an intact GI tract (they can not be placed in a gastric bypass patient without taking the patient to the operating room for a surgical approach). These tubes are easy to place, and large volumes of food and hydration can be administered simultaneously.
Additional information is also available here.
Different surgeons have different practice philosophies and approaches. After the revision of hundreds of failed gastric bypasses to the duodenal switch operation, It is my opinion that the benefits of a feeding jejunostomy far outweigh the short-term care issues associated with it.
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Shared Success Story- Dr. D. Brown
April 13, 2015 11:38 am
I had Roux-en-Y (RNY) gastric bypass surgery in February 2004. I was told it was the “Gold Standard” procedure and it was the only one my insurance would approve (according to the surgeon’s office). I lost around 130 pounds with some minor bounce back. Kept it off for 7 years. I had so much energy; I decided to go back to school to become a doctor.
In medical school I really began to regain, for a total of 75 pounds over 5 years. I tracked food and found that if I ate more than 1300-1400 calories daily, I was gaining. I had absolutely no sugar dumping or satiety or restrictive effects left from the RNY Gastric Bypass, only my metabolism’s memory of starvation mode.
In fact, I never had one incident of dumping syndrome; I only felt satiety for the first 2 years and was able to eat well over 2 cups of food per meal by year 7. Lack of dedicated exercise, extreme stress (time, financial & academic) as well as poor food choices all contributed to my regain. However, the RNY Gastric Bypass surgery only has an average long-term excess weight loss of around 50%, so that still makes my weight regain close to the acceptable range.
Finally, I looked into revision surgery. Not only is surgery always a major decision, but also a revision to a DS is a very technically complicated surgery. I extensively researched all the options to make the right decision. The Duodenal Switch surgery has the best long-term statistics for maintained weight loss in all the medical studies (close to 75% excess weight). The major feature is nutrient malabsorption. The amount is dependent on an individual basis but most fat and some protein calories are not absorbed. There is an initial restrictive component as well. With the nutrient malabsorption also comes vitamin/mineral malabsorption. However, RNY also causes vitamin malabsorption and I was already taking vitamins, so what’s a few more? I am just 4 weeks post-op now and am still in trial-&-error mode, but I have found a safe plan for returning back to work. I really could not have afforded any complications and am so glad that I placed my trust in Dr. Keshishian.
Dr. D. Brown
Starting wt: 274.0
Vitals for 4-16-15 (4 weeks post DS)
wt = 249.0
T = 97.7
P = 88
BP = 108/80
Vitamin K1
April 08, 2015 7:16 pm
Vitamin K1 is a found in dark green leafy vegetables, asparagus, brussels sprouts, some grains, olive oil, prunes, soy bean oil, and canola oil. The body has limited storage capacity for Vitamin K and uses a recycle system to reuse it.
Vitamin K1 is a fat-soluble vitamin that after Duodenal Switch is not as easily absorbed due to the limiting contact of the food product with the bile until the common channel. Bile is needed to absorb fatty acids and fat-soluble vitamins.
Duodenal Switch patients in need of Vitamin K1 supplements should take “Dry” or water miscible type of Vitamin K1, such as Biotech brand. The patients laboratory studies will determine if a patient requires Vitamin K1 supplement. Duodenal Switch patients should have laboratory studies drawn and evaluated at least on a yearly basis. Vitamin K works in a delicate balance with other supplements and should be monitored by a physician, in at risk people.
Vitamin K1 is most know for it’s coagulation effect and the clotting cascade. Vitamin K1 works with calcium and proteins in order to accomplish coagulation synethesis. Care should be taken with Vitamin K supplementation and anti-coagulation (blood thinners) therapy. Please see your physician regarding any supplementation of Vitamin K and blood thinner medications.
A discovery of Vitamin K dependent proteins has led to research on Vitamin K1 in bone health. Bone matrix proteins, specifically osteocalcin, undergo gamma carboxylation with calcium much the way coagulation factors do; this process also requires Vitamin K. Osteocalcin is a Gla-protein that is regulated by Vitamin D. The calcium binding ability of osteocalcin requires several Vitamin K carboxylations to exert it’s effects on bone mineralization.
In adults, the causes of Vitamin K1 deficiency include the following :
Chronic illness
Malnutrition
Alcoholism
Multiple abdominal surgeries
Long-term parenteral nutrition
Malabsorption
Cholestatic disease
Parenchymal liver disease
Cystic fibrosis
Inflammatory bowel disease
Medications: Antibiotics (cephalosporin), cholestyramines, warfarin, salicylates, anticonvulsants, Cefamandole, cefoperazone, salicylates, hydantoins, rifampin, isoniazid, barbiturates, and certain sulfa drugs, higher Vitamin E can antagonized Vitamin K)
Massive transfusion
Disseminated intravascular coagulation (DIC) – Severe
Chronic kidney disease/hemodialysis
Additional information: https://lpi.oregonstate.edu/infocenter/vitamins/vitaminK/
Intake of Vitamin K1 and K2 and bone fracture risk
As always, discuss with your physicians and/or surgeon any changes in medications and supplements. This is not meant to be an all inclusive discussion of Vitamin K.
First Duodenal Switch Patient- Dr. Hess
April 05, 2015 3:35 pm
I had the opportunity to be in a meeting with Dr. Hess in November of 2004. He presented a lecture about the history of the Duodenal Switch and his collaborative work with Dr. Scopinaro, the pioneer surgeon of the Biliopancreatic Diversion. The BPD was the the foundation of the Duodenal Switch operation. The first patient ever to have had the Duodenal Switch was a revision from a failed vertical banded March of 1988 by Dr. Douglas Hess. At the time of this particular meeting (in 2004), the patient was 17.5 years post op.
This is a copy of the slide that he shared with the surgeons present at the Duodenal Switch meeting on November 21, 2004.
Vitamin B6 Toxicity
April 01, 2015 7:58 pm
In recent years, we have noticed a trend of increased Vitamin B6 (Pyroxidine) levels in post Duodenal Switch patients’ laboratory studies. Vitamin B6 is a water soluble vitamin, however, toxicity can happen with an increase in supplementation. The increased availability and amounts of Vitamin B6 in more supplements such as Calcium, multivitamins and B Complex supplements could be the cause of the trend post weight loss surgery. Please be sure to check the amounts of Vitamin B6 within your daily supplements.
Vitamin B6 Function:
Vitamin B6 is an important water soluble vitamin which functions as co-enzymes in a number of metabolic pathways including amino acids, fatty acids, glycogen, and steroid hormones (estrogen, cortisol, androgens and Vitamin D) metabolism. Other biological functions are hemoglobin synthesis, immune function and inflamation, neurotransmission and gene expression. B6 has been shown to improve carpal tunnel syndrome, PMS, AADHD, Alzheimer’s, acne, lung cancer, high homocysteine levels, asthma, kidney sones, and some cases of depression and arthritis. The U.S. Daily Recommended dose ins 1.2-2mg for adults.
Toxicity has most often happened from increased supplementation and rarely from food alone except for in a subset of people who may have increased sensitivity, gene mutations or other issues with Vitamin B6. In the average person, doses of 1000mg per day which is about 800 times the daily amount from food can cause neuropathy and neurotoxicity. There have been instances of toxicity issues at doses of 500mg daily. Other symptoms associated with high levels of B6 are skin rashes, nausea, vomiting, loss of appetite, increased liver function tests, sensitivity to sunlight. Nerve damage or numbness and tingling of the feet, legs and hand, if left untreated, can become irreversible. Stop taking B6 if you experience any of these symptoms. The daily U.S. no adverse effects dose is set at a max of 200mg daily. The daily recommend max limit is 100mg daily.
Drug interactions with high doses of B6 levels are phenobarbital, phenytoin and L-Dopa and cause decrease effectiveness. B6 deficiency is a side effect of oral contraceptives, isoniazid, cycloserine, pencil amine, methylxanthines, and long term NSAIDs use due to impaired Vitamin B6 metabolism.
Once B6 levels are elevated it is important to to try to decrease intake as much as possible and levels will usually drop in weeks to months. Read your labels of drinks, energy drinks, multi-vitamin, cold supplements, high B6 foods, protein supplements, and other sources. These are items that typically have added high levels of B6 supplement. You can also avoid group Vitamin B supplements and go to individual B vitamins that are needed.
Additional information on Vitamin B6. Please have your surgeon or your primary care physician review your laboratory studies. Seek medical attention if you are experiencing any of the above symptoms or any other unusual symptoms.
Medications that negatively affect bone loss and contribute to Osteoporosis (Moved)
March 31, 2015 4:07 pm
An Example of Medications that may cause bone loss
It should be noted that this list is NOT all inclusive and gives the type of medication but does not list all the medications in that category that may affect bone health. I would also like to point out that the Proton Pump Inhibitor labels should probably be changed to “Acid Reducers” as reducing acid is the issues. https://americanbonehealth.org
“Obesity Docs Should Consider Duodenal Switch”
March 10, 2015 3:10 pm
Obesity Doctors Should Consider Duodenal Switch
by Dr. Ara Keshishian
Recent article published on MEDPAGE.com
Shared Success Story- Brad P.
January 29, 2015 9:53 pm
Congratulations Brad on all your success and weight loss! You have accomplished a remarkable transformation!