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Category: Lap Band

Revision from failed AGB to Duodenal Switch

January 10, 2018 2:10 pm

A few times a month during consultation for weight loss surgery , I’m ask as to why I do not offer the adjustable gastric banding as an alternative to the patients. As I have said over the years when a patient considers an weight loss surgery the totality of the risk should be considered. This includes the operative, immediate postoperative course, the maintenance and the follow-ups needed. The potential complications of the procedure in addition to the long-term success off each operation should also be taken into account.

Unfortunately, some patients are led to believe that any perceived benefit in the short operative time and the ease of the adjustable gastric banding also translates to a better outcome. This is in fact the opposite of what the published data have shown, a recent study published in April 2017 by Vinzes et.al, shows that 71% of patient lost their band by 10 years out.

Long-term_AGB_outcome-791x1024

What is also interesting that more patients underwent revision from failed AGB to the duodenal switch than the sleeve gastrectomy (Fig 1.). This is what I also recommend.

More importantly, The patients who underwent a revision from failed AGB to the duodenal switch operation had the best long term results of all patients (Fig 2.) note the “rBPD” line that is the highest of %EBMIL.

Complication’s were broad and frequent (Table 3.)

Further information on revision from failed AGB to Duodenal Switch or other failed weight loss surgeries can be found here.

Success Story: Hasmik

January 13, 2016 2:47 pm

Failed Band: My earliest memory of feeling ashamed of being “too heavy” is from kindergarten. For over 30+ years I have struggled with  gaining weight, trying to lose weight, or going mad maintaining my weight. There is no shortcut that does not come back to bite you in the butt. There is no diet that effectively changes you permanently. For me exercise is a mindful struggle I sometimes successfully commit to over small periods of time.

I was desperate and ready for a real change. I wanted a genuine difference in the way I consumed and related to food and decided the lap band was the way to go. It was marketed as a “non intrusive, non permanent, easily reversible weight loss tool” and that is EXACTLY what I thought I needed and wanted. I was so very wrong, after my surgery I was considered a “success”. In fact up until the removal of my second slipped failed band, esophagus damage, and poor nutrition; I was considered a success. I look back and think how troubling this was/is. How very damaging to the person struggling and dealing with weight issues. Truly, it messed with my mind and my ability to speak up, admit to myself and out loud the band was NOT working for me. In fact, if I’m completely truthful, it was dangerous and turned me into a residue of the person I once was. I was not able to eat comfortably or  eat out any place I happen to be. With the Band, I would need to consider how long I was going to be away from home because I could only eat small bites in small quantities to ensure I did not get stuck or worse vomit what I put inside my mouth. Yes, I had lost almost 100 lbs, but I had given my quality of life as payment. My guilt ensured I would never speak up or complain since I felt “fortunate” and grateful to have had this second chance at life. In my mind, speaking up meant possibly losing the tool (lap band) that allowed me to change my life and reality. Because for the first time in memory, I was the same weight at the start, middle, and end of the year. I did not have to buy different sizes of clothing or underclothing. I could predict what I might wear since my size was stable and my clothes fit. The reality is and was far from this corrupted self truth. I was unhealthy with the restrictive nature of how the lap band worked. In fact my band slipped twice after a severe stomach virus. I later learned of many other symptoms I was making excuses for and quite frankly straight out ignored.

I met Dr. Keshishian (Dr. K) at my lowest weight and at the lowest point in my health. I finally realized, the lap band needed to come out after it had slipped again. It was clear I needed a doctor who would be straight with me and cared for my health and not his/her “success” rates and have the expertise to deal with my failed band. I researched and called several bariatric surgeons then attempted to make appointments with each to discuss the urgent band removal surgery I needed (not as simple as you would think). I was also hopeful I might have the option to undergo the bariatric sleeve surgery because I knew I would not be able to keep my weight under control on my own.  I was unwilling to undergo the emotional and mental torment of gaining and losing weight for the rest of my days. I succeeded in making three appointments and truthfully after meeting and speaking to Dr. K and his office staff I canceled them immediately. Let me start with the staff as that REALLY is important; they help you feel comfortable with the doctor, the procedure, and overall experience. They represent and reflect how the doctor you’re about to see will treat his patients. The expected standard within Dr. Keshishian’s office immediately made me feel like I called the right place. I was taken by the knowledgable, kind tone and efficient manner in which they requested the necessary information to effectively help me get from the starting point to the end goal. When I got to my appointment, Dr. Keshishian BLEW MY MIND. He not only presented himself as an approachable person I  immediately felt at ease with but also reveal my concerns and questions.  He treated me like a person. This may sound strange but this doctor made me feel like a human being with real concerns. He listened to me, asked questions rather than talked at me, and explained how and what was happening to my body and mind. He spent 3 hours with me to answer all my questions (even if I repeated them), draw diagrams, show me video to better help me understand what was happening, and then just sat with me while I cried for a moment. I cried because my 30+ years journey of ups and downs, crazy and insanity finally led me to the door of a man who understood and knew how to help without judgment. WHICH DOCTOR DOES THIS! None that I know.

My life post surgery is what I always hoped it would be. I am able to eat vegetables, leafy greens, fruit, grains and basically a well rounded diet. What’s amazing is that I naturally do not crave sweets, heavy creamy dressings, sauces and fill up quickly. There is after all a difference between the restriction of a lap band and the feeling of being full with the sleeve which Dr. K patiently explained. Today I am able to go any where,  at any time, enjoy the moment and the company rather than worry about what I’m not able to consume. My days of scanning to locate the nearest bathroom in case I need to dash to it are over.

As I write this today, I feel like a real person, not some transient hoping to savor my life at glimpses. I am a person that is balanced in my heart with the average person’s anxiety and mindful eating habits. The sleeve is not a magic end to weight gain, it does give you the fighting chance to make choices in life leading up to results you’re willing to work for.

~ Grateful and Mindful, Hasmik (September 2015 Sleeve Op Patient)

2015 ASMBS Summary

November 11, 2015 7:31 am

The 2015 ASMBS meeting was held November 2-6, 2015.  It was combined with TOS (The Obesity Society) and had more than 5,600 attendees from all over the world in every aspect of obesity treatment.  There were some interesting additions and deletions from this meeting compared to the past.

The one sentence that comes to my mind is “I told you so”.

One important addition was a DS course for Surgeons and Allied Health.  This was very exciting, except the content and questions seemed to gravitate to  SADI/SIPS/Loop rather than DS.  Dr. Cottam was one of the moderators of the course.  It seems that they have found the value in preserving the pyloric valve. It was clear that the discussion was driven by the need to come legitimize the single anastomosis procedures at this early stage with almost no data to prove long term outcome. With many of the Vertical Sleeve Gastrectomies having re-gain and the they are looking for a surgery that the “masses” can perform. This was actually the term used by one of the presenters, implying that the duodenal switch needed to be simplified so that all surgeons, those who have pushed all other procedures can not offer Duodenal Switch to their patients with less than desirable outcome.   Several surgeons also voiced their concern and dissatisfaction with the issues and complication of the RNY and want an alternative.  There was much discussion regarding SADI/SIPS/Loop being investigational and that it shouldn’t be as it is a Sleeve Gastrectomy with a Billroth II.  Dr. Roslin and Dr. Cottam discussed their SIPS nomenclature saying they wanted to stay away from something that had Ileostomy, suggesting bowel issues, or the word “SAD”i  due to negative connotations. The point to be made is that the SADI and SIPS and the loop are all the same.  I have also noticed other surgeons using SADS (Single Anastomosis Duodenal Switch).  There is a great deal of industry behind these procedures and many surgeons being trained in courses funded by industry. One surgeon stood up and informed the entire course that they need to be clear with their patients about the surgery they are performing, as he had been in Bariatric chat rooms and there is upset within the community about SADI/SIPS/Loop being toted as “the same or similar to Duodenal Switch”.

There was also presenter who said “We are doing something new about every five years.” No,  “we” are not. Some of us have stood by the surgery and techniques with the best long term outcomes and not gone with every “new” thing out there. The process of  Duodenal Switch may have changes, open Vs. Lap, drains, location of incisions, post operative care and stay, but the tested procedure with the best outcome has been the duodenal switch operation and not the shortcut versions. Although, those of us that are standing by long term results seems to be in the minority. Why do I stand by Duodenal Switch?  Because it works, when done correctly by making the length of the bowel proportional to the patient total bowel length, and height, and not just cookie cutter length for all patients,  with the right follow-up, patient education, vitamin and mineral regime and eating habits.

A new addition was the Gastric Balloon, which in the research presented had a 60-70% re-gain rate and a no more than 10-15% weight loss one year only. This data represents more than 70% weight regain when the balloon is taken out.  The Gastric Balloons can be left in between 4-6 months depending on the brand or type of balloon. The Gastric Balloon is not new to the Bariatrics and was first introduced in 1985. After 20 years and 3,608 patients the results were  and average of 17.6% excess weight loss. It seems that we are re-gurgiating old procedures. There are many new medications that were front and center in this meeting.

The Adjustable Gastric Bands were missing from the exhibit hall this year. It is my hope and feeling from the other attendees that we may be seeing the era of the Adjustable Gastric Band being placed in patients come to an end.  Although there are some still holding out that there are some patients that can do well with the Band.

Attending the 2015 ASMBS meeting this year, as it has every year, only reemphasized the importance of avoiding what has become the norm of chasing a simple solution that is fashionable and easy now. We stay convinced that the duodenal switch operation with the common channel and the alimentary length measured as a percentage of the total length is by far the best procedure with the proven track record. The patient should avoid the temptation of settling for an unproven procedure or device, because if history holds true, there will be a need for revision surgeries in the future.

 

 

 

 

Staying on Track and Surviving Halloween

October 27, 2015 6:07 am

happy-halloween-clipart_3

Halloween is the start of  temptations during the holiday season and surviving Halloween is possible. It’s a time of high carbohydrate treats that can turn into a nasty trick of regain or slowed weight loss. Halloween is a fun holiday that you can participate in with some foresight and planning.  Sugar and simple carbohydrates are easily absorbed and can decrease weight loss or regain. The following are some helpful tips to keep you on track.

  • Stay steady with high protein, hydration, vitamins and minerals.  Protein and hydration will keep you full and help curb the carb cravings.
  • Make you own high protein treats.  There are so many great recipes out there.
  • If you give out candy don’t buy candy that you like.  In fact, do the opposite and buy candy you dislike.
  • Don’t give out candy at all. Instead opt to do a non-candy type item, stickers, pencils, rings, trinkets, easers, small coloring books, or other small items.
  • Keep a list of your goals posted in a visible place.
  • Make a picture collage of your goals, achievements you want, and non-scale victories you’d like to achieve posted in a high visibility location.

Stay strong and avoid the pitfalls of temptation.

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.

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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.

Hernia Repair And Weight loss surgery

December 22, 2014 3:35 pm

Patients having weight loss surgery (WLS) either primary or revision are sometimes also diagnosed with having a hernia.  Whether a hernia can be repaired concurrently with WLS or not, depends on the type of the hernia and also type of weight loss surgery.

The 2 most common hernias encountered in weight loss surgical patient’s are  1.Ventral (incisional),  or 2. Hiatal hernias. Ventral hernia refers to defects or weaknesses of the abdominal wall.  If this involves a previous midline incision then an incisional hernia is diagnosed.   These hernias may present with any or all of the following findings; protrusions or bulging of the anterior abdominal wall tissue through the abdominal muscle cavity, abdominal pain, and nausea and/or vomiting.

Hiatal hernias are located inside the abdominal cavity at the junction of the esophagus and the stomach at the level of the diaphragm.  This condition is where the upper portion of the stomach this is usually located in the abdominal cavity has migrated through the esophageal hiatus into the chest cavity.  These hernia’s usually present with reflux, episodes of nausea and are quite frequently seen in patients with experienced complications of the LAP-BAND.

The surgical treatment of these hernias are very different:

Ventral hernia repairs may require mesh placement. There are different mesh products that are available.  Some are made with non absorbable material  and other are absorbable- biologic material that last long enough to allow incorporation by the patients own tissue.  In general, when a mesh is used, the incidence of hernia recurrence goes down significantly. However,  there is an increase in complications associated with the use of mesh.  These may include infection of the mesh, indications of synthetic material, and serum and rejection indications of non synthetic material.   To add another layer of  complexity, when the hernia is encountered at the time of weight loss surgery, especially when the GI track  has to be opened ( in the case of duodenal switch, revision from a failed gastric bypass with a duodenal switch)  then it is recommended that no mesh be placed because of the high incidence of mesh infection or the associated complications.  In extreme cases where the abdominal wall cannot be closed, biologic meshes may be used with the understanding that a repeat hernia repair may be required at a later date.

In my practice, Hiatal hernias are always repaired at the time of the weight loss surgical procedures.   Depending on the type of the weight loss surgery the patient has had previously, the type of the hernia repair, and whether or not a mesh needs to be utilized, and the amount of stomach and fundus remains for the repair, will dictate how the Hiatal hernia is repaired.

Additional information regarding hernias in a newsletter.

Adjustable Gastric Band Easily Reversible?

November 24, 2014 3:25 pm

The Adjustable Gastric Band  (AGB) procedures have been advertised as “easily reversible” minimally invasive procedures. A point of interest is why doesn’t anyone ask the question, “Why would a successful device and/or procedure need to be revised or removed?”

The long term success data shows that the AGB procedure is the most inferior of all bariatric  procedures. It is important, that when looking at the published data,  special attention is given to the definitions in that particular study. An example would be that if a study defines “successful outcomes as weight loss for 30 days!” then all procedure will be successful.

The following is an example of a patient who had the Lap Band (R) a several years ago in another institution. She was seen for surgical follow up with minimal weight loss over a short period of time. She then developed the typical complications of the band, namely the upper abdominal pain, reflux, inability to swallow solids, persistent nausea and vomiting. Her symptoms were all “worked up” and  was told that all the studies were normal.  All of her  symptoms were contributed to her eating habits, even though they persisted after the Lap Band (R) was completely empty.

The patient then presented n our office for a second opinion. After being seen in our office and having a full work up, she had the Lap Band removed and was revised to a Laparoscopic Sleeve Gastrectomy. She had complete resolution of all of her prior presenting symptoms.

Adjustable Gastric Band Easily Reversible?
Adjustable Gastric Band Easily Reversible?
Pictured is the LapBand being dissected. There is significant scarring that has to be dissected to expose the band.
Adjustable Gastric Band Easily Reversible?
Adjustable Gastric Band Easily Reversible?
With the band removed a very thick band of scar tissue is exposed. This is a typical outcome- and it explains why most patients continue to experience the same symptoms even with the band completely empty.
Adjustable Gastric Band Easily Reversible?
Adjustable Gastric Band Easily Reversible?
The thick scar tissue must be dissected and removed to allow for the underlying tissue to return to near normal anatomy. The scar tissue act like a restrictive band. If this scar tissue is not removed the patient will continue to have problem after the band is removed.
Hopefully this will reassure patients who are having problems with the band after it’s reservoir is emptied. Scar tissue formation under the band is most likely the contributing factor to the continued and significant symptoms of abdominal pain, nausea, vomiting, and reflux.  If you are having continued symptoms after your band has been deflated seek other surgical opinions.

Weight Loss before Weight Loss Surgery?

October 19, 2014 2:54 pm

I am frequently confronted by the question “Are you going to make me lose weight before I have weight loss surgery”? My answer is no, for several reasons, it makes little or no sense and there is scant scientific data to support it.

1-Anatomical and 2-psychological-behavior related variables have been suggested as the reasoning for the recommendations for diet before weight loss surgery.

Let’s see what the scientific evidence says about this.

1-Liver can be divided into two anatomical lobes. The tail end of the left lobe may extend all the way to the upper left side of the abdomen covering the upper 1/3 of the stomach,  the gastro-esophageal junction (GEJ) and the esophageal hiatus. It was suggested that the access to the GEJ could be made easier, if the left lobe of the liver was smaller.

“A decrease in the size of the liver by 18% was shown in patients who were subjected to a very low-energy diet for 12- weeks.”  This was published by Colles et.al in a small study of 39 subjects.

Weight Loss before Weight Loss Surgery?

It is important to appreciate that this reduction in liver size meant that a patient would have to tolerate an ultra low caloric diet (less than 500/day) for 12 weeks. The interesting observation was that even with this reduction in the size of the liver there was “… no difference shown in morbidity, mortality, hospital stay, and decrease in morbidity- associated diseases whether there is preoperative weight loss or not.”

Weight Loss before Weight Loss Surgery?
Weight Loss before Weight Loss Surgery?

2-Behavior modifications have been entertained as a necessary element to the success of adjustable gastric banding. Numerous studies have shown that there is no predictive value of preoperative weight loss in relation to the weight loss after surgery.

Weight Loss before Weight Loss Surgery?
Weight Loss before Weight Loss Surgery?
Weight Loss before Weight Loss Surgery?
Weight Loss before Weight Loss Surgery?
Weight Loss before Weight Loss Surgery?
Weight Loss before Weight Loss Surgery?

The overwhelming scientific data suggest that there is no value to subjecting a weight loss surgical patient to a pre-surgical ultra low caloric diet.
“The California Department of Managed Health Care recently conducted a review of weight loss prior to bariatric surgery and concluded that “there is no literature presented by any authority that mandated weight loss, once a patient has been identified as a candidate for bariatric surgery, is indicated. This comprehensive review states that mandated weight loss prior to indicated bariatric surgery is without evidence-based support, is not medically necessary, and that the risks of delaying bariatric surgery are real and measurable.” Published by the American Society for Metabolic and Bariatric Surgery in March 2011.