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Category: Gastric Bypass

Yearly lab and medication requests

October 17, 2011 5:28 pm


As a practice matures and evolves, decisions are made and changes are instituted to assure that the delivery of quality care is not compromised. Most of our decisions are driven by factors (medical, regulatory, and legal) that are out of our control. There are two significant changes that we have had to make to our laboratory ordering process.

First, we now have preferred laboratories that have partnered with us. The laboratory results are expected to be sent to us electronically, which should cut down on the time between the blood draw and when the results are available to us. The information on the preferred labs is located at:  Needless to say, there are no financial incentives for us. You should also check with one of the labs, as well as with your insurance company, to make sure that they are a contracted facility and that the order is covered under your policy. It is your responsibility to make sure that your insurance company will pay for the labs ordered. We are in no way responsible for the verification of benefits for the laboratory services that we order.

Second, we have had to change the way we order our yearly lab work. As most of you are aware, it is critical that weight loss surgical patients have continuous yearly follow-up care and monitoring. It is critical that the patients continue to receive yearly follow-up care, not only by doing their scheduled laboratory studies, but also by a yearly follow up in office exam. We provide a comprehensive follow-up plan to the patients who have had the the Duodenal Switch or Revision from other failed weight loss surgical procedures. This includes ordering the laboratory studies, review and interpretation of the results, as well as office visits as frequently as required or deemed necessary. 
Due to medical, legal, and insurance issues, we can not order yearly laboratory studies without having seen the patient in our office prior to writing the order. Some patients may choose to have their labs ordered by their primary care physicians, in which case we suggest they review the information on our websiteThis is to assure that we are not ordering tests on patients who will not follow up with us, and the PCP’s that  have ordered the labs will be able to review the results and make recommendations.  We apologize for this change, however, our hands are figuratively tied.

Over the years, patients have also requested that medication be prescribed solely based on lab results, even if the patient has not been seen by our office in years.   We will not prescribe medication to any patient who has not been recently seen by our practice. An exception would be for patients or conditions whose treatment we have a firsthand knowledge of, that are not new findings based on a patient’s long-term condition.  There are cases when a patient calls our office 8 years after surgery asking for Flagyl to treat gas, which we will not prescribe. 

Vitamin D supplements

August 01, 2011 1:12 am

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.  Until a few years ago, very little attention was given to vitamin D levels. More recently, we have realized that due to a number of factors, there is a tendency for vitamin D deficiency to be present in the U.S. adult population. This finding is even more pronounced and severe in overweight patients.
The recommended dose for vitamin D supplements is much larger today than it was a few years ago. For example, it is not too uncommon to recommend an average dose of a 50,000 (IU) international unit of vitamin D Dry Water Miscible (Water Soluble) by mouth on a daily basis after the duodenal switch operation. Since vitamin D is a fat soluble vitamin, it is important that the appropriate type be utilized. Dry formulation of vitamin D is needed to ensure adequate absorption. There are a number of manufacturers that produce these. When searching for one “Dry” D3-50 the patient would be looked for. Some larger supplement manufacturer’s carry these products. The links to these manufacturers is located here.

Vitamin A

May 17, 2011 7:20 pm

Vitamin A occurs in animal tissue as retinol. There are a number of different provitamins in food of vegetable origin. Disorder yellow and red carotenoid pigments can be changed to vitamin A in the liver.

A number of functions for vitamin A have been found, including defense mechanisms, maintenance of healthy epithelial tissues, and most importantly, a function in the visual system.  A deficiency may manifest itself by: 1.) A scale-like appearance in the skin and occasional acne, 2.) A failure of growth in young animals, including C. station of skeletal growth, and 3.) A failure of reproduction associated with atrophy of the epithelial cells of the testes and interruption of the female sexual cycle.  A deficiency may also represent a decreased visual acuity, and more specifically, night blindness. This was found in a patient who complained that they were unable to read a particular sign at night while driving, but was able to read it during the day

Over the last few decades, the incidence of vitamin A deficiency in the United States has significantly decreased. It is only when the patient shows signs and symptoms associated with the malabsorption of fat soluble vitamins that he or she may be diagnosed with a deficiency.

Vitamin A Deficiency Treatment

Injectable Vitamin A

When a patient is diagnosed with a deficiency, the treatment will require aggressive oral supplementation. For cases in which vitamin A levels do not respond to “Dry” Vitamin A oral supplementation, intramuscular injections may be required. The usual injected dosage is between 25,000-50,000 international units. Repeated injections in a 3-month interval have been required in some patients to normalize their level, as well as resolving the symptom of night blindness.

When taking oral vitamin A, it is important for patients who have had the Duodenal Switch operation to specifically look for a “Dry” or water miscible form. This is to maximize the amount of vitamin A that can be absorbed even in the presence of reduced fat absorption.

“Common bile duct is dilated”

March 10, 2011 8:16 am

Common Bile duct is part of the “plumbing” that drains the secretion of the liver (bile) into small bowel (duodenum).  The size of the common bile duct, if dilated, may suggest a blockage downstream. This is a specific finding that is looked for when a patient gets an ultrasound for a suspected liver or Gallbladder disease. When a patient has their gallbladder removed, the common bile duct dilates over some time. Dilated common bile after a cholecystectomy is of no significance by itself and should only be considered important if there are other findings, such as pancreatitis or elevated liver function tests. It is, however, important to remember that for any patient who has had the Duodenal switch operation, or the Gastric bypass procedure, the altered anatomy precludes the option of ERCP as a diagnostic or Therapeutic study.
Ara, Keshishian, MD, FACS, FASMBS

Get informed

September 26, 2009 6:56 pm

As a surgeon, one of my duties is to discuss Informed Consent. There are two components to this, one of which is the consent part. This is where the discussion of risks, benefits, and complications takes place. It is also where options are discussed. A patient cannot give consent if he or she is not informed, which is the second component. The patient should only grant his or her consent if provided with details and every available option.
In my clinical practice, I routinely discuss all the surgical options with a prospective patient. It is my duty to explain in great detail what the surgical alternatives are, what their relative risks are when compared to each other, and the pros and cons of each procedure. Once this information is presented, I would then discuss the rationale as to why certain procedures are superior in certain clinical conditions. It is ultimately the patient who makes the decision as to which procedure is right for the treatment of morbid obesity. In some cases, however, if I do not believe that the procedure the patient has decided on will serve the patient’s long or short-term health needs, I will ask that the patient seek another surgeon.  One of the most common examples of this situation is when patients are seen in my office for surgical treatment of morbid obesity and inquire about the Lap Band®. They have seen an advertisement on television, radio, or even on a billboard. There are even those patients that are told by the primary care physicians that they should ONLY have the Lap Band® done because it will solve all of their problems. The promotional marketing material is only a small portion of a large body of information that is made available to patients and their primary care physicians. To most patients, Adjustable Gastric Banding (Lap Band®, Realize Band®) are “drive-thru” procedures.  They have been advertised as a procedure in which a patient goes to a surgeon’s office, gets examined, operated on, loses weight, and lives happily ever after. This is untrue on a number of fronts and far from the way it actually works for the overwhelming number of patients that get the Lap Band® done. I am not against the adjustable gastric banding procedures. I only advocate that the expectations be set for the patients on an appropriate level.  First of all, the Lap Band® is not for everyone. The scientific information on this matter is overwhelming. The educational booklet that is available and published by Allergan (the manufacturer of the band) has a list of conditions in which the band should not be used. Then there is the relative efficacy of the banding procedure compared to the Duodenal Switch and the Gastric Bypass operation. The questions a patient and a primary care physician should ask:
Are the treatment options effective in both treating and resolving the specified conditions of each patient? 
What are the chances that a patient suffering from diabetes, high cholesterol, or high blood pressure will be cured of these conditions if they have the Gastric bypass, Duodenal Switch, or the Lap Band done. 
The reality is that, in my opinion, most patients opting for the Lap Band procedure have not been educated and provided with the information necessary to make an informed decision. When you consider how little most patients will lose with the Lap Band, one has to realize that the risks, as little as they may be compared to other procedures, are not worth taking. 

Weight loss information

September 22, 2009 4:22 am

I have posted a new newsletter to our web site. It is located here. I will continue to update the information both here and on our website.
I also read an interesting article in Newsweek Magazine dated September 21, 2009. While I know it is not a scientific journal, this particular article had medical sources quoted as the basis of the content. For anyone who believes obesity is just about overeating and lack of exercise, I encourage you to read it. Does overeating and lack of activity contribute to obesity? Yes, but there is much more to it than that. We should stop blaming the patients for a condition over which they may have little control.
Different weight loss surgical procedures have different outcomes, independent of the type of surgical procedure. The long term success and complications of these procedures is summarized on our website.