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Category: Gastric Bypass

GI Bleed following Weight Loss Surgery

September 17, 2018 10:28 am

Gastrointestinal (GI) Bleed following weight loss surgery is rare but does require knowledge of the particular bariatric surgical procedure the patients has and how to proceed with diagnostics to fully evaluate the situation. Acute or chronic gastrointestinal bleeding can cause anemia in patients. However, Anemia may also be caused by nutritional deficiencies (iron, vitamin , minerals), Kidney disease, bone marrow disease  and others. The work-up for anemia following weight loss surgery follows a routine protocol. If there is an evidence of bleeding from intestine  (bloody emesis, bloody bowel movement, “tar” like black bowel movements) then the diagnostic work up would include an upper and lower endoscopy.

Endoscopic Procedures:

Upper endoscopy Esophagogastroduodenoscopy (EGD): evaluates the esophagus, stomach and a limited area of the duodenum past pyloric valve.

Normal Anatomy
Normal Anatomy

Lower endoscopy Colonoscopy or coloscopy: evaluates the rectus and the entire colon.

Between these two tests, there is still a considerable amount of the small bowel that is not accessible or visualized with endoscopic procedures. For the small bowel, examination Capsule endoscopy is an option in an intact GI tract. Patients who have had Gastric bypass RNY or the Duodenal Switch, the large segments of the small bowel can not be visualized or examined with capsule endoscopy.

RNY Gastric Bypass
RNY Gastric Bypass

 

Duodenal Switch Two Anastomosis
Duodenal Switch Two Anastomosis

 

SADI-S Single Anastomosis Duodeno-ileal – Sleeve

Patients who have had Duodenal Switch, Gastric Bypass and SADI – S would need a tagged red cell scan or CT angiography if GI bleed is suspected in areas of the small intestine that are inaccessible by endoscopic procedures.

Candy Cane Gastric Bypass – RNY

June 21, 2018 1:05 pm

One of the findings following Gastric Bypass is a Candy Cane Gastric Bypass. Nausea and vomiting , upper abdominal pain is a common complaint of patient who have had the Gastric Bypass RNY operation. This is in addition to the high incidence of patients who experience the complications of weight regain and or dumping syndrome.

Quite frequently the symptoms of  nausea, vomiting and upper abdominal pain of a patient with history of gastric bypass is evaluated by a primary care, referred to a gastroenterologist. The “routine” work up recommended is X-ray of the abdomen, maybe contrast study (Ct scan or upper GI) and for sure and upper endoscopy. The result quite frequently reported as “…nothing wrong”.

A typical upper GI in a Candy Cane Gastric Bypass situation may look like this:

Upper GI

A common and underreported problem may be a Candy Cane finding.  The “blind” end of the small bowel anastomosis is too long and this results in food settling in the hook of the candy cane. The symptoms of the nausea, vomiting and upper abdominal pain may be from the residual food and liquids that do not drain from this area. This can cause symptoms such as coughing or hoarseness due to reflux, nausea, vomiting, reflux of food or acid, weight regain and epigastric pain, especially when eating.

Flow of oral Intake

 

Candy Cane Gastric Bypass finding

Candy Cane

Candy Cane Gastric Bypass cases will require surgical intervention to shorten the length of the blind segment of the small bowel to improve symptoms.

It is my recommendations that any patient with history of weight loss surgery who is having any persistent gastrointestinal symptoms be evaluated by weight loss surgeon.

Calcium Lab Results

June 05, 2018 3:26 pm

Calcium is measured to evaluate function and adequacy of a physiologic processes. Calcium plays a critical role in several body functions such as, coagulation pathways, bone health, nerve conduction, and other functions. It is important whenever you are evaluating laboratory results that you look at the whole picture of the person, including medications, other laboratory studies and health history.  One value is not a stand alone result.  There are many factors that effect calcium results.

Factors that effect calcium results: (not an all inclusive list)

pH

Albumin

Lactate

Heparin

Vitamin D deficiency

Magnesium depletion

Anticonvulsants

Renal Disease

Pancreatitis

Parathyroid

Thyroid

The two most common issues following Weight loss Surgery  or Duodenal Switch may be albumin level and Vitamin D level.  Please see past blogs on Vitamin D. Magnesium may also play a role in a Duodenal Switch patient.

The most common calcium result drawn is the total calcium level. Laboratory results may not explicitly label it as such, however, it measures the calcium that is bound to protein. Ionized calcium is the free calcium that is representative of the true total calcium. Ionized Calcium can be measured by ordering specific lab. Alternatively, the Ionized calcium can be calculated by the following formula: Corrected calcium mg/dL = (0.8 * (Normal Albumin – Pt’s Albumin)) + Serum Ca  ) or use the calculator at the bottom of this post.

 

The low Albumin level accounts for the low calcium level. This may be the reason for a patient with a low albumin/protein level, also having their calcium level reported as low. However, when adjusted for the protein deficiency the corrected calcium comes into normal range. Video of Trouseau’s sign of a patient with calcium deficiency. Calcium bound to albumin Keshishian

The first step in a patient who has low calcium reported, is to make sure their protein and albumin levels are normal, along with Vitamin D.

Calcium levels are managed by two processes major regularly hormones and  influencing hormones. Controlling or major regulatory hormones include PTH, calcitonin, and vitamin D. In the kidney, vitamin D and PTH stimulate the activity of the epithelial calcium channel and the calcium-binding protein (ie, calbindin) to increase calcium absorption. Influencing hormones include thyroid hormones, growth hormone, and adrenal and gonadal steroids.

Further information on protein.

Further information on calcium. 

Videos/Webinars on several of the above topics.

calcium metabolism
Duodenal Calcium Metabolism

Corrected calcium = 0.8 * (4.0 – serum albumin) + serum calcium

Corrected Calcium Level Calculator

Weight Gain after Gastric Bypass

January 04, 2017 9:12 am

Weight loss surgical procedures have different long term results and some procedures have more dramatic weight loss than others. Some procedures also result in much more sustained and long term weight loss. Unfortunately, what may be not obvious is that the patient has very little control over the outcome of the surgery in most cases. IT is very easy to blame the patient for weight regain after weight loss surgery. However, it is important to remind ourselves that the long term data reporting outcomes of the surgical procedures in most cases, includes all patient population. All these studies include the most compliant and not so compliant patients. Comparison chart of outcomes of weight loss surgical procedures.

A larger percentage of gastric bypass patients will require revision for weight regain, or other problems. There is no evidence that the size of the pouch or the anastomosis between the pouch and the small bowel changes the weight regain outcomes. Yet, quite frequently I will see patient who have had gastric bypass revision for weight regain, by reducing the size of the pouch or the anastomosis. Here are some publications that support the notion that other than extreme dilation, the size of the pouch and the size anastomosis does not predict the outcome of the surgery. There is some correlation with the site of the pouch, anatsmosis and weight loss, but there is no correlation between the size of the pooch, the opening and the failure rate. This means that patient with smaller pouch do not have better long term outcome that the ones with larger pouch, only that the patient with smaller pouch or anatsmaosis will loose more weight.

“Influence of pouch and stoma size on weight loss after gastric bypass”

“Impact of gastrojejunostomy diameter on long-term weight loss following laparoscopic gastric bypass: a follow-up study”

Weight regain after RNY Gastric Bypass may also be caused by a Gastro-gastric fistula, which is a new connection between the pouch and the remnant stomach. Here is further information on Weight Loss Surgery Revisions.

When considering a primary weight loss surgical procedure, be informed.  Investigate all your options and consider the long term outcomes.  This may mean investigating different weight loss surgical procedures on your own.

Don’t lose your Pyloric Valve over a Failed Gastric Sleeve

June 22, 2016 9:32 am

duodenal-switch
Diagram of Duodenal Switch

In my opinion, there are very few reasons to lose your Pyloric Valve after sleeve gastrectomy. Recently, I am hearing of people who have had regain due to a failed Sleeve Gastrectomy being revised to Gastric Bypass RNY and then seeking a Duodenal Switch due to regain from Gastric Bypass RNY.  A better option is to go from Sleeve Gastrectomy to Duodenal Switch, due to the long term excess weight loss maintenance of Duodenal Switch. The benefit of the pyloric valve can not be taken lightly.

Let’s start by reminding ourselves as to how the Sleeve Gastrectomy has gained popularity.   In the quest for a simple solution to the complex problem of obesity, adjustable gastric banding gained popularity only fail to deliver anything close with the results that were promoted and heavily marketed.   The focus was then changed to another seemingly simple procedure, laparoscopic sleeve gastrectomy.  For some surgeons this is a new procedure.  Surgeons that had been doing the duodenal switch operation for decades,  sleeve gastrectomy has not been a new procedure.  Surgeons that just started doing sleeve gastrectomy as a stand alone procedure started experiencing complications of the sleeve gastrectomy, such as regain and are now looking for another option for these patients.  This complication are even more frequent when they’re done following a failed adjustable gastric band procedures due to the metabolic issues after revising one weight loss surgery to another. A similar short sighted  approach is also being promoted with SIPS/SADI procedures,  which is significantly simpler to perform than the duodenal switch operation.

Laparoscopic sleeve gastrectomy  has a predictable profile for weight loss.  It will not have as good on the long-term success rate as a duodenal switch operation. Complications of the sleeve gastrectomy including reflux, stricture, fistula, inadequate weight loss which may warrant  evaluation and possible intervention.  In my opinion, as a surgeon who does the duodenal switch operation routinely, a sleeve gastrectomy requiring revision should almost never be revised to a gastric bypass.  I have seen number of patient’s who have had an adjustable gastric banding which was revised to the sleeve gastrectomy then to a gastric bypass.  We are contacted for a possible revision to Duodenal Switch operation because of the weight regain.  One can argue that the patient should not have had the sleeve gastrectomy or gastric bypass.  It is critical that the complexity of the disease of the obesity is clearly appreciated that it purely restrictive procedure will not yield  the desirable outcome long-term.

Benefits of the Pyloric Valve:

Structures of the Stomach
Structures of the Stomach

The pylorus is the valve located at the end of the stomach. It controls the release of the liquid mixture of food from the stomach into the small intestine.

The body naturally regulates the passage of food, so food will stay in the stomach for a certain period of time. We believe it is very important to continue that feeling of fullness in between meals. As a result, one of the principle functions of the pyloric valve is to regulate the amount of food products released into the small intestine where they are absorbed. This helps prevent  dumping syndrome and ulceration.

The bodies natural diameter of stomach, pyloric valve and small intestine is left intact.  This elevates stretching of the stomas created by RNY Gastric Bypass.

Summary

These failed Sleeve Gastrectomies should be revised to Duodenal Switch unless there are overwhelming health issues that would require another option.  I always suggest several opinions from different Bariatric Surgeon’s who do a variety of Weight Loss Surgeries before deciding which type of revision to proceed with.

Shared Success Story Update- Cyndi RNY to Duodenal Switch

June 06, 2016 6:37 am

Three Years Out Cyndi E … RNY to Duodenal Switch Revision

The Journey to get to the three year mark, has been amazing! And truly, The JOY is in the JOURNEY.

I am a JOYFUL “Third Time’s the Charm Revisionista”…. This is my new title…. And I say this proudly!!

IMG_3775
Before

For too many years (like 45! at least) I carried the shame and blame of being overweight and beat myself up on the inside. I tried everything, from age 13. I tried every diet, every program, and yes, I will say it, I have had THREE, yes THREE surgeries. And then, I let others convince me, and I bought into this, that I was a failure… BUT, I am not a failure. Surgery fails. For a long time, I could not say that, again with the SHAME word. BUT, I am done with shame, and I am done with blame. I no longer blame myself and I no longer shame myself or my body, because now, she and I, my body and I, are friends, and we are nice to each other.

Thankfully for me, I was in the right place at the right time, and met Dr. Ara Keshishian… My story with Dr. Keshishian, is simple. Dr. K was the first Doctor that did not blame me for my weight. He explained that each weight loss surgery has different measures of success, and percentages by weight loss surgery and outcomes. He educated me. He did not blame or shame me, he encouraged me. He also did an Endoscopy and found that I has a Gastro-Gastric Fistula.  Simply put, this was an abnormal connection between the bypassed stomach and the small pouch created by the RNY Gastric Bypass surgery. Food could travel two ways, thus rendering the Gastric Bypass ineffective causing weight gain.

Dr. Keshishian performed my revision from RNY to Duodenal Switch on May 31, 2013. The procedure corrected my anatomy, enabling me to lose weight and regain my health. I have no complications, no issues post surgery.

After
After

Today, being a “Three Year Old” RNY to Duodenal Switch revisionista, I have a better perspective as a relative “newbie”. I am not a prisoner of my weight. I have lost 125-130 pounds, I am 5’12” (6 feet lol) 61 years old and for the first time in my life at a NORMAL WEIGHT! I do not fear, any longer, that I will gain my weight back. I am, however, mindful that I am consistent in my new habits and patterns that I have put in place, that keep me on track. I am also accountable. To myself, also to my Weight Loss Support Group, here in Paso Robles, to some fellow DS girlfriends that

After
After

I talk with about challenges, and with Dr. Keshishian. I am not held captive by my limitations, or my weight, and now I live with the possibilities each day brings and the fun challenges I put in front of me to conquer.

To the “newbies” I say, please take your time, treat yourself kindly, with your inner voice. This is not a race, this is a journey. Don’t rush, it’s ok to take it slow, listen to your body. And do not compare your journey to anyone else. You are you! You do you! You can do this well, one day at a time. Listen to the sage advice of those who went before you. We too have learned by trial and error. Be willing to sacrifice in the short term, for the gift of the long term life. Your DS is forgiving, you be forgiving as well!!!

Remember: WATER, PROTEIN, SUPPLEMENTS, EVERYTHING ELSE, EAT CLOSE TO THE DIRT, ELMO DIET

With JOY, Cyndi

Cyndi’s first Shared Success Story here.

Fluids and Electrolytes After Weight Loss Surgery

January 29, 2016 7:06 am

Fluids and Electrolytes after weight loss surgery are an important part of recovery and lifestyle after undergoing a weight loss surgical procedure. Potassium is an important electrolyte found in higher concentrations within the fluid of the cells. It is important in muscle contraction, heart rhythm, nerve function and co-enzyme function.

Fluids and Electrolytes

The following webinar (link) discusses the balance of fluids and electrolytes with particulaScreen Shot 2016-01-28 at 12.31.59 PMr attention to post weight loss surgery concerns. Deficiencies can cause heart arrhythmias, muscle weakness and cramping, intestinal paralysis, and neurological deficits.

 

The Daily Recommended Amount for Potassium is  4,700mg

Here is a list of Lower-carb potassium sources: This is not meant to be in inclusive list.  There are many higher carb sources of potassium also.

  • Beet Greens- 1/2C 655 mg
  • Trout 3oz – 375 mg
  • Salmon  719 mg per average filet
  • Halibut or Yellowfin Tuna 3oz – 500mg
  • Clams 3oz- 534 mg
  • Avocados 1 whole- 974 mg
  • Squash 1C- 325mg
  • Broccoli 1 cup 475m
  • Watermelon Radish 3 oz – 233mg
  • Sweet Potatoes- one potato 694mg
  • Yogurt 1C – 579mg
  • Tomato paste 1/4C – 342 mg
  • Whole milk 1C – 366 mg
  • Chicken breast meat 1 cup chopped – 358 mg
  • Cauliflower 1 cup raw– 303 mg
  • Peanut butter 2 T – 208 mg
  • Asparagus spears 6 – 194 m
  • Daikon Radish – 3″ – 280 mg
  • Nuts  100-300 mg per 30g / 1 oz serving, depending on the type
  • Dark leafy greens  160 mg per cup of raw, 840 mg per cooked
  • Kohlrabi 3oz- 98mg
  • Mushrooms 1 C- 273 mg
  • Spinach – 1 cup 167 mg Potassium
  • Walnuts 2 oz-250 mg