“…What is the length of my common channel” is probably one of the frequently asked questions about the duodenal switch operation in the office. This usually comes up at the initial consult when patients repost credible sources such as Dr. Google and Dr. Facebook for patient with different bowel length have done well or not so after duodenal switch operation. Dr. Hess described the Duodenal Switch by using total bowel length measurements and creating the common channel as a percentage of the total small bowel length. However, it seems that this is being done less and less.
This leads to my explanation that is on the website
Hess calculator : Bowel Length Calculator
How the actual measurements matters: Bowel length video link
In 2019, Bekheit et.al published a very interesting study comparing total small bowel length (TSBL) to a number of variables such as height, weight, sex and BMI. They identified a few loose correlations. Male patient have longer TBSL than females. There was correlation between TSBL and height stronger in males than females but not statistically significant.
In Conclusion they reported ” Despite statistical significance of the correlation between the TSBL and the height and weight of the included participants, the correlation seems to have no clinical meaning since the effect size is negligible. ”
As I have previously discussed this Making the common and alimentary length standard for every duodenal switch patient will make some loose too much and other not enough weight.
Figure 1 shows TSBL on the horizontal axis, and height, weight, BMI and Age on the vertical axis. For the most part what they all show is that one can not predict how long a patients bowel is by any of the measures that we take in the office as a part of the routine exam.
This raises, the concerns that I had raised previously. How could two similar patients who have the same weight, age, sex and BMI have the same surgery and expect the same result if one of them has TSBL of 400 cm and the other one 800cm?
If both of the patients get the same “cookie cutter” duodenal switch with the same lengths, then the patient with TSBL of 400 will have much longer common channel if the surgeon does not customize the length of the bowel. This is an example of many patients whom we have revised over the years where they had a duodenal switch done with the “standard” 125cm common channel and when we measured the total length the patient had 500 cm TSBL.
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.
Flagyl is sometimes prescribed for excessive gas and diarrhea. It is an antibiotics that works well on certain bacteria that accumulates in the GI tract and contributes to the gas and the bloating.
These bad bacteria flourish when patients consume significant and excessive fiber and carbohydrates (sugars, salad, pasta etc.) The FIRST line of defense against flatulence, bloating, and diarrhea should be eleminating the culprits in the diet. This point can not be stressed enough. Adding a daily dose of yogurt may improve symptoms due to yogurts probiotic benefits. To be beneficial, Yogurt should contain live bacteria cultures, not contain artificial sweeteners or have a high sugar content.
Artificial sweetness also area source of the excessive gas and should be avoided.
Before Flagyl is prescribed, it is important that the diet is critically examined to make sure that the carbohydrates and the fiber as source of gas and bloating is minimized or eliminated. Excessive use of medications that may be needed for other infections should be avoided.
Chronic diarrhea should be evaluated to rule out GI infection with C. diff bacteria or other bacteria or parasite.
Additional Information on C. Diff (Clostridium Difficile) and probiotics.
Vitamin A is one of the 4 fat soluble vitamins along with vitamin D, Vitamin E and Vitamin K. It is multifunctional and essential which means that it is not produced by the body. In this article we will touch on aspects of Vitamin A absorption and it’s effect on wound healing as well as its metabolism.
We often think of Vitamin A as the critical vitamin for vision, however it has several other roles that related to immune function, protein synthesis, and cellular communication. Vitamin A deficiency is a concern world wide because of the natural of the side effects. Vitamin A deficiency is the leading cause of preventable childhood blindness in the world according to UNICEF and sometimes it may be undetected until there is irreversible damage.
There are 2 chemical forms of vitamin A in diet:
Retinoids (Preformed vitamin A) This group include retinol, retinyl esters, and retinal they are mostly found in animal sources like liver, egg yolk or fish oils.
Carotenoids (Provitamin A) This group includes beta-carotene, alpha-carotene and lycopene, mainly found in plant sources like leafy vegetables or yellow/orange vegetables and fruits.
1.- Ingested food is digested in the stomach where retinyl palmitates (esters) are released from proteins. Retinol and beta-carotene are absorbed directly into the small intestine where retinyl esters and betacarotene are transformed into retinol . Retinol is the most easily absorbed form of vitamin A.
2.-That retinol absorbed by the enterocytes in the ileum (small intestine) along with bile is then transported to the liver with the help of chylomicrons a protein that transports fat.
3.-Fifty to 80% of the vitamin A is stored in the liver and the remaining is deposited into adipose tissue, lungs and kidneys.
4.-When stored retinol is released from the liver into the circulation to target organs, it is bound to plasma retinol-binding protein (RBP4) a transporting protein produced by the liver that requires ZINC, which is synthesized by the liver; This complex is stabilized by transthyretin (TTR), which reduces renal excretion.
Retinol is a crucial component for reproduction, embryological development, cellular differentiation, growth, protein synthesis, and immunity in the form of retinoic acid and vision in the form of retinal.
One of Vitamin A additional roles is in epithelial health of skin and mucous membranes. It increases epithelial turnover which is crucial during would healing. It also has anti-oxidative effects which prevent cell damage and can prevent or reverse the effects of other damaging agents. In addition to these benefits it has also been associated with increasing collagen, fibronectin, keratinocytes and fibroblast, all important in wound tissue structure. There have been some studies that suggest giving higher doses of Vitamin A in patients with non or slow healing wounds.
It is important to remember that we have documents delayed diagnosis of adult vitamin A deficiency leading to significant night blindness in adults. It is critical that the patients and their primary care physicians are acutely aware of this possibility. In majority of the patients with low vitamin A, post weight loss surgery, aggressive supplementations, including injections need to be considered as a part of the treatment regimen.
We would like to thank Miguel Rosado, MD for his significant contribution provided for this Blog.
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 Protein, Calcium, 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).
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.
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.
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)
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.
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.
Corrected calcium = 0.8 * (4.0 – serum albumin) + serum calcium
You may have heard that I will be giving a lecture at the California Dental Association’s 2017 meeting. In preparation for the lecture, I have come across some excellent information with the assistance of and dental resources from Dr. Armen Mardirossian of Mardirossian Periodontics and Implants.
The following Dental Resources are part of many of the resources I have used to complete this lecture series for the Dental Association. Periodontal disease can effect every body system and should be addressed to avoid further damage and complications. We can not over emphasize the importance of good dental care. In addition, following weight loss surgery, supplementation of vitamins and minerals is extremely important. Always seek the care of a professional when dealing with dental issues or other physical symptoms.
We are sharing these resources with our patient population in order to shed some light on this topic. You can also find a previous webinar on the topic of Dental Issues After Weight Loss Surgery here.
For complete dental resources click here (385.8 KB).
Thank you Dr. Mardirossian for your assistance.
Let’s get back on track 2017 after the holiday season! The holidays were wonderful but if you find yourself with a few extra souvenirs don’t feel alone. The average American gains between 1-8 pounds during the holiday season and I am no exception. Let’s get back on track 2017 together.
Time to clear out the kitchen! Disposing of temptations and high trigger foods is the first step to getting back on track. If the food isn’t easily acquired then it is less likely to be consumed.
Stock up on high protein and whole, unprocessed foods that are low carbohydrate and nutrient dense. When quality foods are easily available we are more likely to stay on track with the types of foods we should be eating. Simple sugars/carbohydrates are the biggest culprit of holiday weight gain. We need to go back to the basics of hydration, high protein, low carbohydrate/sugar, vitamin/mineral supplements and exercise. Simple sugars and carbohydrates are easy for our bodies to use and absorb and cutting them back can jump start your weight loss. Each individual needs to identify the daily carbohydrate intake that works for them. Some people stay under 50 grams of carbohydrates daily. You may also need to look at your protein and fat intake. All excess nutrients absorbed have the potential to turn into fat mass and inhibit weight loss. Metabolism video.
Hydration is an important ways to start getting back on track. Water is essential to life functions. The brain is 85% water, blood is 80% and muscle is about 70% water. Hydration aids in digestion, eliminating waste, byproducts and toxins. It also can decrease the feeling of hunger. Lack of hydration can increase fatigue which can lead to craving high carbohydrate foods to increase energy.
Protein’s importance in almost every bodily function and muscle mass can not be ignored. High quality complete Protein sustains muscle mass during weight loss, aids immunity, antioxidant function, and enhances leptin and insulin function. Filling up on protein first will help with carbohydrate carvings and give a sustained satisfied feeling. A prior blog post gives additional information on the importance of protein and the effects of protein malnutrition. WLS makes daily protein intake important but especially after Duodenal Switch, protein is a necessity of daily life.
Vitamins, minerals and supplements will ensure the body has the nutrients it needs to function adequately and can keep cravings at bay. Deficiencies in vitamins and minerals can cause cravings for foods. Vitamin and minerals are essential to muscle function, red blood cell production, bone health, and numerous other physiologic functions. We may all slack off on our supplements occasionally but now is the time to get back into the habit of daily vitamins and mineral supplements. A daily vitamin, mineral, and supplement routine is a lifetime commitment after Duodenal Switch or any WLS. Here is a list of commonly used supplements.
Exercise can increase weight loss, overall well being, mental well being, mood, alertness, improve digestion, improve sleep, and increases energy levels. Exercise does not have to be a daunting task. Simply adding 15-30 minutes of activity can give added benefits. Yoga, walking, dancing, lifting weights, hiking, and sports activities can be included or added to more traditional forms of exercise. There are many free online videos for all types of exercise available.
Finding a new hobby can keep both your hands and mind busy, curbing the unconscious eating of foods that are high in sugar and carbohydrates. Adult coloring books, drawing, painting, knitting, crocheting, sewing, dance lessons, gardening, learning to play an instrument and many others are great ways to use your time and expand your quality of life and brain function. New hobbies can also help establish new coping skills. Our previous post on Coping Skills After Bariatric Surgery can be found here. There are a whole host of online videos for “how to” on new hobbies.
Teaming up with others can also help increase weight loss and compliance. Support from friends, family and other groups will assist you. There is a whole gamut of support group online and in person. If you have fallen out of the habit of attending our support group or webinars get back to them. You can find our schedule and announcements regarding webinars here. Our Central Valley Bariatric Facebook page also gives daily inspirational messages, protein recipes and articles and any new information or research available. There is also our Duodenal Switch Facebook Group. Anything that increases accountability is a benefit and motivates us to stay on track.
Experiment with new recipes and flavors that are bariatric friendly and within your dietary needs. There are so many options for quick and easy meals. We have several recipes on our page for all stages following weight loss surgery and Duodenal Switch. However, there are endless option on the internet in Paleo, low carb, and high protein type recipes.
In the spirit of new starts and getting back on track 2017, we are having a giveaway with the basics to get back into the swing of things. This year we are looking for before and after weight loss surgical journeys. Share your weight loss journey! Don’t be shy, your journey can inspire others and/or motivate yourself. To enter the Back on Track 2017 Giveaway, please submit your weight loss surgical journey with before and after pictures to firstname.lastname@example.org or you can also post your before and after pictures on our Facebook page. You will also need to sign a release for the use of your story on our website. We will draw 2 names from those that enter by announcing it on our FaceBook page or by e-mail on January 31, 2017. You must submit your mailing information to email@example.com in order to claim the prize.
Our practice has long discouraged the consumption of diet soda and carbonated sugary beverages for anyone, but especially our weight loss surgical patients. These products’ detrimental effects on bone health, gut microbiome, increase appetite, diarrhea, inhibited weight loss and regain shouldn’t be ignored. In addition, in the situation of limited space post Bariatric surgery, a WLS patient needs nutrient rich, protein foods. These beverages provide no nutritional value.
In addition, these products are also not recommended for non-WLS patients. Oral health, peak in insulin levels, increase weight gain, increased Type 2 DM, and diarrhea are also issues that can effect patients in addition to the above issues.
Our practice, as well as a recent article on Medical News Today Written by Jon Johnson, encourages people to:
“Saying goodbye to diet soda
Soda, whether regular or diet, is a dietary waste. Sodas have little nutrients, and have a long list of side effects. For people with diabetes, diet soda has been associated with weight gain and symptoms of metabolic syndrome. Some sweeteners in diet soda even cause sugar and insulin spikes in the blood.”
We encourage the use of Stevia, which is a natural sweetener, instead of other artificial sweeteners. Stevia is a herb type plant with leave that can be used for sweetening. It has been used for many years in other countries and cultures. It contains Magnesium, Potassium, zinc, Vitamins A, B3 and C as well as fiber.
A past blog post on Carbonated Beverages and Weight loss Surgery .