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Category: Gastric Bypass

Zoom Group Meeting

September 21, 2020 7:10 am

We are excited to announce we will be having a Zoom group meeting Tuesday, September 22, 2020 at 7:00 PM PST.  We hope to see you online!

Registration is required. Please follow the link to the meeting registration.

Topic: Group meeting question and answer
Time: Sep 22, 2020 07:00 PM Pacific Time (US and Canada)
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These meetings are for general topics and/or basic question and answers.  If you need a more in-depth meeting we would suggest a video or in-person consultation with Dr. Keshishian.  You can request a consultation via this link.  Contact Us

Medication Absorption After Weight Loss Surgery

March 30, 2020 8:01 am

Weight loss surgical procedures, in one form or another, achieve the desired effect of weight loss by altering absorption of fat, protein, and carbohydrates. This results in decreased total absorption of required calories.

An unintended consequence is the altered absorption of medications. Frequently I am asked about the specific medication. Usually the answer is vague since the information is limited on specific medications. If the desired effect is not achieved, then it is probably  not being absorbed well. Specially, if the same dose of the same medication working well before surgery.

There is a summary article about the Theoretical absorption pattern of different weight loss surgical procedures.

Articles

March 22, 2020 6:57 pm

We have added a new section of compiled articles to our website. This page will allow us to compile sicentific articles all in one place for easy reference. The page allows the reader to search for articles based on the subject matter. We will continue to add to this list of article as new ones become available.

Stapled Anastomosis

December 30, 2019 11:23 am

As I was looking over old archives, I came across the following pictures that were taken years ago. These were photographs taken to demonstrate the technique for the construction of the anastomosis of the biliopancreatic channel and alimentary channel of the Duodenal Switch.

The steps of doing the stapled anastomosis of the Duodenal Switch is generally unchanged during the laparoscopic approach to the procedure.

The fist step is to align the bowel to be joined.

The stitches are placed to secure the bowel together. Two small openings are made in each limb of the bowel to be stapled together (the biliopancreatic limb on the  bottom and the alimentary on the top of the image).

It is important to also align the bowel in the same peristalsis direction. This means that the contraction and the relaxation motion of the bowel should all point in the same direction. This should reduce the risk of complications such as intussusception.

The stapler is then fired in opposite directions to create wide anastomosis.

When the stapler is fired in opposite direction, a very wide anastomosis is created.

 

Closure
Closing the opening that was made

Once the anastomosis is created, then the last staple is used to close the opening that was made. This staple line is perpendicular to the direction of the anastomosis to avoid making the opening narrow.

We originally published this technique in 2003 on Obesity Surgery Journal.

Sunscreen

June 27, 2019 3:03 am

Recently there has been some research and concern regarding sunscreen and the chemicals within them. This has led to findings that can be concerning but that need further research.

Post weight loss surgical patients, and in general patients who suffer with obesity, before or after weight loss surgery, have low vitamin D level. This may be caused by a number of factors. One such factor may be the reluctance to get skin exposed to sunlight in order for the bodies natural Vitamin D pathways functioning.

The recommendations are for daily exposure to sun. This not only is critical to the vitamin D metabolic pathways, but also help with bone health, immune function, mood, counteracting depression.

In a recently published online article, concerns were raised that some of the ingredients of some of few sunscreens are absorbed in the blood stream. This is a small study, and as the results indicates, it is not recommending to stop using the sun screens. Be aware of your sun exposure, timing exposure, and the ingredients in your sunscreen.

You can find past blog posts on Vitamin D, Bone health, etc here

Thyroid Medication Absorption And Weight Loss Surgery

June 10, 2019 8:59 am

Question : “Do I have to take higher dose of thyroid medication after the duodenal switch? ”

Answer : “Maybe”

With all weight loss surgical procedures, there may be changes to absorption of medications. It is easily understood why duodenal switch may results in decreased absorption of fat-soluble medication. What is not as clear is the reduction in absorption of other medication with procedures that do not explicitly change the absorption at the level of the small bowel directly.

The research data is all over on this topic. There is published literature that shows improvement in the thyroid function after gastric bypass and the sleeve gastrectomy.  However, the exact mechanism is not completely understood.

There is research that reports “…decreased postoperative levothyroxine requirements.” Other have shows no correlation between the length of the bowel distal to duodenum to absorption of thyroid medication.

With all this confusing data, the best course would be to always “treat the patient and not the lab results.”

If a patients who has been on medications with stable number and symptoms,  suddenly presents with complaints of hypothyroidism after weight loss surgery, it’s possible the medications should be up adjusted even if the thyroid lab values may not be as defining.

   

Osteoporosis Medications, Action and Side Effects

May 25, 2019 3:40 pm

Recently I had a short live presentation on the subject of osteoporosis, osteoporosis medications, and the treatment options of this deteriorating bone condition. A patient who has had a bone scan may be diagnosed with Osteopenia and/or Osteoporosis. This information is usually conveyed by the forms of a Low T score. Both of these indicated demineralization of the bones, and the end result is  worsening of the bone structure. This leads to weaker bones and higher chance of fracture due to stress or trauma.

Treatment options should be approached is a global and systemic fashion. It is critical that the nutritional status is at its best possible and optimized for important healthy bone vitamins and minerals. Low protein needs to be corrected. Special attention should be given to nutrients, minerals and vitamins. These include ProteinCalcium, Magnesium, Vitamin D, and Vitamin K1/K2to name a few.

Healthy bones require ongoing and routine force in the form of exercise to remain health. Just as exercise improves muscle strength, it also improves bone health. Exercise is also critical in improving bone structure and density. Ideally, exercise should be weight bearing and resistance.  Examples include: hiking, walking, jogging, climbing stairs, playing tennis, and dancing. Resistance type exercise is weight lifting and resistance bands.  These exercise work by creating a pull or force on the bone either by gravity, movement or weight.  Always check with your physician before beginning an exercise routine, start slowly and building up to longer periods of time.  The ideal goal would be at least 30 minutes a day, every day, if you are able.

We frequently see patients immediately started on osteoporosis medications without checking or improving some of the nutritional markers noted above or without looking at exercise history. In some case, the medication recommended are contraindicated due to nutritional status.

The medications can be grouped in to those  that help with new bone formation (Anabolic agents) or those that help by suppressing the bone breakdown phase (Antiresorptive agents).

Groups of Medication

 

National Osteoporosis Foundation has an exhaustive list (below) of medications for treatment of Osteoporosis.

The table below outlines the side effects and mechanism of the actions of the common medications used for treatment of  osteoporosis which was published by the University Health News Publication on August of 2014.

Mechanism Of Action And Side Effects

 

With all this information, the few points to remember is that the most important factors in healthy bone structure are the nutritional status Protein, Calcium, Magnesium, Vitamin D, and Vitamin K1 levels.

This is an animation of normal bone Metabolism. It shows how bone structures is taken down and rebuilt continuously. This allows for a healthy bone maintainence as we age. The key is the balance of breakdown (osteoclast) and the build up (osteoblast) activity is regulated. Osteoporosis develops when there is more breakdown that build up.

With permission of Dr. Susan Ott of University of Washington.

Additional information available on her site.

Past blogs on Bone Health.

Protein Sources

May 16, 2019 10:26 am

Not all proteins are created equally. The protein that we digest serves as the source of the essential amino acids, (the building blocks which make up a protein). The essential amino acids can not be made in out body. Protein sources can be animal or plant based.  We’ve written a in-depth explanation of protein sources in this previous blog: Protein Optimization

The proteins can also be decided into two categories:

1-High quality  or Complete proteins

Complete proteins contain all the indispensable amino acids that we need. Animal based proteins for the most part are complete proteins. These include cheese, mean, fish, mild, yogurt, egg and poetry.

 

2-Low quality or Incomplete proteins

Incomplete protein are mostly plant based proteins. In most cases, the incomplete proteins either lack or have insufficient about of the one or a number of amino acids to be able to satisfy our nutritional requirements.

This is why we general recommend animal based proteins.

Following weight loss surgery there are some guidelines that can be helpful in our previous blog: Importance of Protein.

There is also much discussion on whey protein. There is a brief and good explanation on this subject here.

Recipes for protein shakes.

 

 

SIPS, SADI-S, Loop DS

May 01, 2019 9:03 am

The American Society for Metabolic and Bariatric Surgery (ASMBS) and MBSAQUIP-A on March of 2019, published and updated list of “Endorsed Procedures and Devices”

Endorsed Procedures and Devices | American Society for Metabolic and Bariatric Surgery

Note that any surgical procedures that does not employ two anastomosis, are not endorsed and are only recommended to be performed with an IRB (Institutional Review Board) or an IRB exemption. Duodenal Switch, Sleeve Gastrectomy, Roux en Y Gastric Bypass, Gastric Balloon, Adjustable Gastric Banding, and Nerve Blocking which are endorsed procedures.

SIPS, SADI-S, SIPS, Loop DS are all in the category of the “Non-Endorsed Procedures and Devices”. To see an anatomical comparison of these procedures to the Duodenal Switch procedure.

Patients should request that their consent be clearly defined and should explicitly outline the procedure that is being proposed to them. This is to avoid a patient having a procedure that they assumed, or are led to believe to be a Duodenal Switch operation with two anastomosis. Do your due diligence and know the procedure you want. Investigate if the surgeon you are working with performs the procedure you are interested in. Have them draw a picture of the procedure or give you a diagram of the procedure.