Category: Lap Sleeve Gastretomy
Protein intake requirements change over time following weight loss surgery. This is based on the requirements imposed on our body by a number of variables. These include, activity level, muscle mass, over all health condition to name a few.
A very young muscular athletic male with a BMI or 30 will require much higher protein intake (and absorption) that an inactive older Female with the same BMI. The same young athletic male will require much higher protein intake is he is recovering from a surgery than his baseline.
As we have stated in the past, the protein intake, should be adequate and not excessive. High level of protein intake that are not accounted for based on muscle mass and activity level, will eventually result in weight gain. The best measure of protein intake in a stable weight patient over 3-4 years post op is their albumin and protein level. Following your yearly laboratory values at a minimum is an important part of weight loss surgery follow up care.
You also need to adjust protein intake when necessary. Protein needs increase depending on physical needs, infection, healing, pregnancy, surgery, age, injury, etc. Plastic surgery requires higher protein needs for appropriate healing.
Information on protein sources and quality here.
The basic formula for protein intake is 1gm/kg of ideal body weight. The calculator below will provide a guide for the protein into based on your stable weight in lbs.
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
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.
Sleeve gastrectomy (SG) is the most commons performed weight loss surgery in the US. There is a subset of patients for which Sleeve Gastrectomy will be inefficient/ineffective. Sleeve Gastrectomy failure may be defined as inadequate weight loss or weight regain. However, in some cases this may also include non resolution of some of the co-morbidities of obesity, and/or recurrence of others.
Biertho, et. al, (Surgery for Obesity and Related Diseases 14 (2018) 1570–1580) Published a study titled “Second-stage duodenal switch for sleeve gastrectomy failure: A matched controlled trial” where 118 patients were decided in two groups. One group had the duodenal switch as a singe procedure, and the second group had the sleeve gastrectomy followup by the second stage duodenal switch. They concluded that “Second-stage DS is an effective option for the management of suboptimal outcomes of SG, with an additional 41% excess weight loss and 35% remission rate for type 2 diabetes. At 3 years, the global outcomes of staged approach did not significantly differ from single-stage BPD-DS; however, longer-term outcomes are still needed.”
They showed that the remission rate of the obesity related co-morbidities were improved.
The weight loss rate that had stopped, or in some cases where weight gain had been noted, were both reversed where by at at average of 24 months after addition of the DS to the SG patients would experience additional 39% Mean excess weight loss.
With regards to alternative approaches they indicate “ Other forms of revisions have been described, (i.e., adjustable or nonadjustable gastric band, plication, endoscopic balloon), with limited scientific evidence on their efficacy or safety. These procedures are mostly considered investigational and should be performed under Ethical Review Board approved protocols.”
In summary, patients may be offered a number of alternative if they are experiencing weight regain, inadequate weight loss, or return of co-morbidities after sleeve gastrectomy failure. We have seen a variety of them in our office. Patients who have had band placed on the sleeve, or are scheduled to have gastric balloons placed. As I have always said, buyers beware and know your outcomes and resolution of co-morbities.
Duodenal switch operation, (not the single anastomosis look alike) results in sustained weight loss and resolution of the co-morbidities. A second stage Duodenal Switch can mean adding the intestinal procedure to an existing Sleeve Gastrectomy. Some patients have required an adjustment to their Sleeve Gastrectomy in addition to adding the Duodenal Switch intestinal portion. Finding the right balance for each patient is a crucial part of our practice.
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”
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.
There are differing opinions, based on a broad set of scientific publication, wether or not gallbladder should be removed at the time of weight loss surgery. Obviously, Cholecystectomy is a stand alone general surgical procedure that is often performed due to gallstones and/or gallbladder disease with a variety of symptoms. However, the focus of this blog will deal with Bariatric Surgery and Cholecystectomy.
Rapid weight loss can increase a patients chance of forming gallstones. This rapid weight loss can be as little as 3-5 pounds per week. Weight loss surgery can increase your risk for gallstone formation. Several of the common thought processes the mechanism of this is, obesity may be linked to higher cholesterol in the bile, larger gallbladders, high fat diet and larger abdominal girth.
When a patient is having the Duodenal Switch (DS) Bariatric operation, or having a revision of a failed gastric bypass to the DS, I always remove the gallbladder. This is because there isn’t an anatomical route to utilize endoscopic procedure for an ERCP should the need rise.
In the case of a patient undergoing Vertical Sleeve Gastrectomy, if there are any indications or complaints of abdominal pain then an ultrasound is done. If there are findings of gallstones or other disease of the gallbladder, then a cholecystectomy is performed at the same time as the Sleeve Gastrectomy.
In my opinion, every patient having the Gastric Bypass (RNY) should also have the gallbladder removed because of the anatomical limitations after surgery that prevents the use of ERCP if needed. Some clinicians will place the patient on a long term medications to reduce the chance of gladstone formation after surgery, which themselves have side effects limiting the compliance in most patients.
Further information on Common Bile Duct Dilatation and ERCP
The Prize winners are Jo and Kimberly! Congratulations ladies and enjoy the Obesity Help National Conference! Thank you to all that participated in the Giveaway!
We are holding a review and update giveaway for two different prizes! Thank you for your
One Prize and One Grand Prize
Prize: two tickets to Obestiy Help National Conference Sept. 30-Oct 1, 2016
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hotel stay October 1, 2016
Conference: 11999 Harbor Boulevard Garden Grove, California 92840 Event link here
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12221 Harbor Boulevard
Garden Grove, California
How to Enter and eligibility: All entrants and winners must be 18 years of age or older at the time of entry. Up to 5 entries per person.
- Write a review of Dr. Ara Keshishian on one or all of the sites below or do an update on your profile on Obesity Help between now and Sept. 8, 2016 at 5:00 PM
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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)
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.
When I think back as far into my childhood as I can remember my weight was always a problem. I grew up being made fun of and missed out on the simple things that normal kids do growing up because my weight caused limitations.
Even into early adulthood I was still made fun of, but I learned to deal with it. I tried different methods of trying to lose weight. I went to a gym, tried diet pills, followed diets, cut out foods, sodas, alcohol, etc. Sure these things worked (very slowly) for a period of time, but then I would plateau and became discouraged and gain whatever little weight I lost plus some. By the time I was 27yrs old I found myself at my heaviest at 245lbs and I was also pregnant with my first child. I was lucky enough to have a healthy pregnancy. However after I had my daughter, I went up to 265lbs and just couldn’t get it off. I felt the toll the weight was taking on my body. My hips would ache, go numb, my lower back would get stiff, I would become winded just walking upstairs, it was difficult to get up from sitting, my feet would be sore if I was standing too long. I began to realize this was just going to get worse as time went on and as my daughter got older parenting would become more difficult. It became an even bigger concern to be healthier now that I had a little one depending on me and looking up to me.
I decided to explore the option of surgery in late 2013. I knew it was something that my insurance would cover so long as I met the requirements so I set out to find a reputable surgeon in my area.
Surprisingly I reached out into a Facebook group and was overwhelmed with recommendations for Dr. Keshishian (I was originally interested in the DS surgery). I went for my consultation in December of 2013. Upon meeting with Dr. Keshishian I knew I wouldn’t have wanted anyone else to perform this surgery on me. He was very upfront, honest, and straightforward with information regarding what was to come and the effort that needed to be put forth in order for this to work. The Gastric Sleeve was brought up and I decided to go with the sleeve surgery. I pushed forth and the staff at Dr. K’s office began the process of approval which happened to move very swiftly and smoothly.
I ended up having my surgery on 4/11/14 and I weighed 265lbs on the day of. Today, as I write this I am, approaching my 30th birthday healthier than I think I have ever been and I currently weigh 152lbs. The adjustment post-op was not an easy one, but it was well worthwhile. I am much more active, able to keep up and play with my daughter. I feel like I am living a normal life for once. I was scared, nervous, and had so many worries running through my head prior to surgery but now that I have gone through it I would make the same decision all over again in a second’s time.