Category: revision of Duodenal Switch
Dual Testimonial: Cameron’s Gastroparesis surgery & Scott’s Revision of a Duodenal Switch
February 01, 2016 8:04 am
In 2015, I came into contact with the most unique, passionate, urgently responsive; talented beyond belief and caring surgeon I have ever met. Our oldest son who is a 21-year-old cancer survivor, has had nearly five years of medical nightmare as diagnosed with severe gastroparesis resultant from his vagal nerve being severed during a previous Nissen Fundoplication surgery. We didn’t find out that this had happened until nearly two years later and only after a 4 hour gastric emptying test showed that Cameron’s stomach was only about 30% emptied after four hours (should be empty after an hour) due to gastroparesis.
I had heard about Dr. Keshishian on a Bariatric support group page on which I post and get great advice. The surgeon back in Central, IL where we live told us that Cameron needed a subtotal gastrectomy to remove 80% of his stomach! This sounded radical and no way in the world was that going to happen. I was given Dr. Keshishian’s email address so I could consult with him for his advice. It was a Saturday morning around 7 AM Central time when I sent off an email to Dr. Keshishian detailing Cameron’s medical history and current issues. I was in hoping that his office would get the email on Monday and hopefully get back to me within a week. I went out to my kitchen to get a cup of coffee and when I returned I had a missed call with a California area code. Yep, it was Dr. Keshishian. I called back and we talked for 45 minutes. He suggested several things and told me that any good general surgeon in my area could do surgery on Cameron and fix him, well that was the only time he was wrong. We couldn’t find anyone in our area who would do the surgery.
So we talked and agreed that Cameron needed a Roux-en Y drain put in place to physically drain his stomach by way of gravity (not for any weight loss as very little small bowel was bypassed). Dr. Keshishian got us in the next week and we flew out to Glendale where he met with Cameron for an examination on that Monday. On Tuesday, Dr. Keshishian performed surgery to fix Cameron’s herniated diaphragm, loose Nissen wrap, performed the Roux-n Y limb and anastomosis to the stomach. Dr. Keshishian also found a Meckel’s diverticulum (a congenital small bowel defect that can cause internal bleeding and serious issues). The following Sunday, Cameron developed severe pain due to chronic pain from his Cancer treatment and 12 subsequent surgeries, many on his abdomen. Dr. Keshishian saw Cameron in the ER and spent 3 hours fixing Cameron’s pain issue and making sure he was medically sound so we could fly home the next day.
Today, Cameron has very little to no issues which you wouldn’t have believed possible six months earlier. In the past, he had violent retching, dry heaving and bad nausea daily which had him severely incapacitated and very depressed due to a feeling of hopelessness and pain from the Gastroparesis. He didn’t believe he had a chance at a normal life but Dr. Keshishian gave Cameron his life back. We are eternally grateful for your huge heart and talent Dr. Keshishian. Thank you!
During our time in Glendale in 2015 for Cameron’s surgery Dr. Keshishian and I began discussing my situation. I had been given a virgin Duodenal Switch performed by a surgeon in Illinois in September of 2013. A year later in 2014 and 180 lbs lighter, I ended up in the hospital as I was passing out. I had a resting heart rate of 35 BPM, a blood pressure in the 75/40 range and incredibly bad labs including anemia, low copper, low zinc, and dangerously low albumin and total protein. A full cardiac work up was completed and I spent a week in intermediate care. Why? I was extremely malnourished even though I was consuming 200-250 grams of protein daily! Why was I malnourished? Because my original surgeon performed a “cookie cutter DS” on me where he didn’t measure my small bowel and arbitrarily gave this 6’2 man a 100 cm common channel and a 150 cm Alimentary limb. Way too short on the AL! Had the Hess method been followed (the only way the DS should be allowed to be completed) my CC would have been 100 cm (that was okay) but my Alimentary channel should have been 275 cm! Simply put, my absorbing portion of small bowel was 34% and the Biliopancreatic limb (non-absorbing) was 66%. It should have been a 50/50 ratio with 100 cm CC, 275 cm AL and a 375 cm BPL. In order to combat my severe malnutrition that September of 2014 I went on a pancreatic enzyme (CREON) to assist my nutrient absorption. I was taking with meals right around 400,000 IU’s of CREON (a boat load) and this was barely keeping my nutrients in range and lab values barely in range. After speaking with Dr. Keshishian, he recommended that I give it until around September of 2015 to see if my absorption increased enough to where a revision wouldn’t be required. Towards the end of July, I all of the sudden lost nearly 20 pounds in two weeks from my already frail and scrawny body. I saw my surgeon in Peoria as I was very alarmed; and I had been having bad cramping and other issues point to a possible bowel obstruction His exact words to me were “see me in 30 days, you are like the DS poster boy of good nutrition”. As you can imagine I found that completely unacceptable and soon as I was out of that appointment I emailed Dr. Keshishian. He told me that if I couldn’t get a revision ASAP I would need to immediately go on TPN. Two weeks later my wife and I landed at LAX and were in Glendale on Monday morning for an exam with Dr. Keshishian.
The job Dr. Keshishian did describing what he was going to do, and of course this was a visual presentation with Dr. Keshishian drawing (you know Dr K’s love of drawing) out for us what he was going to do. He thoroughly explained for my wife and I so she was comfortable with what was going to happen and we fully understood what he was going to do. Doc also found an umbilical hernia that he was going to repair and I had an anal fissure as well that wouldn’t heal so we discussed what he would do to examine and possibly fix during my revision surgery. The next day Dr. Keshishian performed surgery where he fixed the umbilical hernia, measured my total small bowel length to determine appropriate channel lengths and found an repaired a huge mesenteric defect (intestinal hernia and Dr K has a picture of my guts with the huge hole in the mesentery that he has posted on his blog discussing intestinal hernias and blockages), fixed my fissure (Thank you!) and put in a side by side anastomosis that effectively lengthened my AL by 125 cm and my CC by 25 cm worth of absorption. This put my absorbing intestine to BPL ratio where it should have been in the first place (50/50 ratio).
I am pleased to say that I immediately went off the CREON and my absorption and subsequently my lab values improved tremendously. At surgery on August 18, 2015 I weighed a whopping 170 lbs. Today I am weighing in at 183 pounds and well on my way to Dr. Keshishian’s suggested optimal weight target of 205.
Dr. Keshishian is absolutely amazing and the best in the world when it comes to performing the Duodenal Switch and revision to DS Surgery (Band to DS, RnY to DS, Channel extending revision to DS). I would recommend Dr. Keshishian to any patient who needs a virgin Duodenal Switch to get their health back and especially to those who were sold a garbage RnY or Crapband procedure that ultimately failed you (it failed you, you did not fail). In fact, I am trying very hard to convince my brother and Step Mother to fly to Glendale and have Dr. Keshishian perform a Duodenal Switch on them. They very much need it for their health and Dr. Keshishian is the best in the world having performed over 2,000 DS procedures.
I don’t say this lightly. Ara, you are one of the finest human beings I have ever had the good fortune of knowing and your surgical skills are second to none. I really do admire and love this gentleman like a brother and consider him to be a friend. Thank you for using your incredible skill to fix my health issues resultant from the failed cookie cutter Duodenal Switch I was given two years earlier by another surgeon. Had I met you back then and knew what I know now, you would have performed my virgin DS and I would not have suffered for two plus years. Thank you from the bottom of my heart, Dr. K!
Revision of a Sleeve Gastrectomy or RNY
August 31, 2015 6:32 am
These are examples of two types of patients referred to us for revision surgery.
The first example is a gastric bypass that we revise to the duodenal switch operation. The upper GI series after the revision, shows a “banana shaped” stomach, the pyloric valve and the duodo-ilesotomy anatomosis component of the duodenal switch.
The second example, images noted below, is that of a sleeve revised to the duodenal switch – both operations done at different institution. Note how the stomach is not a “banana shaped” and more like a funnel with a narrowing at the bottom of the stomach- a stricture.
Gastro-gastric fistula after gastric bypass operation
May 10, 2013 9:09 pm
One of the complications of gastric bypass is a gastro gastric fistula. This happens when a connection between the gastric bypass pouch develops to the remnant stomach. In a gastric bypass operation, a very small pouch is created from the stomach, and connected to a segment of the small bowel.
The purpose of this operation is to decrease over 95% of the volume of the stomach. In theory, the benefits of this is to reduce the volume of food that can be consumed. Over time, the size of the stomach pouch, and/or size of the gastro-jejunostomy anastomosis might stretch. This result in weight regain that is very commonly seen in about 3 years after a gastric bypass operation.
One of the complications of gastric bypass is a gastro gastric fistula. This happens when a connection between the gastric bypass pouch develops to the remnant stomach. In a gastric bypass operation, a very small pouch is created from the stomach, and connected to a segment of the small bowel.
The purpose of this operation is to decrease over 95% of the volume of the stomach. In theory, the benefits of this is to reduce the volume of food that can be consumed. Over time, the size of the stomach pouch, and/or size of the gastro-jejunostomy anastomosis might stretch. This result in weight regain that is very commonly seen in about 3 years after a gastric bypass operation.
Another possible explanation for weight regain may be an abnormal connection that may develop over time between the bypassed stomach and the small pouch that was created. This abnormal connection is known as a gastro-gastric fistula. In a patient who may have a gastro-gastric fistula, the food can travel down the gastric bypass path or enter the bypassed stomach and go down the path of a normal anatomy.
In these cases, the physiological effect of a gastric bypass procedure becomes ineffective.
The treatment that I favor most for correcting the complication of the gastro-gastric fistula is is to revise the gastric bypass to the duodenal switch operation.
Slipped Band
November 02, 2012 10:40 pm
Revision or Reversal of the Duodenal Switch
September 08, 2012 7:00 pm
A significant portion of my practice involves the revision of the Gastric bypass and Adjustable Gastric Banding procedures to the Duodenal Switch operation. The re-operations are necessary to correct the complications that have been caused by these procedures. There are also instances of required revisions due to inadequate weight loss or weight regain. Our website contains detailed information regarding reasons for revision and the reversal of weight loss surgical procedures. I think it is important to mention that these complications are very common and almost never have anything to do with the patient’s behavior.
Duodenal switch operations may also require reversal or revision. The general reasons for a revision or reversal of the Duodenal Switch is the same as for all weight loss surgical procedures and include a variety of reasons. The reversal or revision of the Duodenal Switch operation is one of the simplest revision surgeries that I perform.
Let’s review a few facts about Duodenal switch.
The Duodenal Switch procedures has two components:
1.) The sleeve gastrectomy
2.) The separation of the biliopancreatic secretions from the food to limit its absorptions.
Clearly, the portion of the stomach that has been removed cannot be reintroduced to the abdominal cavity. The second part of the operation can, however, be easily “undone.
The assumption is that the bowel needs to be divided again and re-anastomosed to reconstitute its continuity. This revision or reversal of the Duodenal Switch operation is done by simply creating a new connection between a new anastomosis, located between the biliopancreatic limb, and the alimentary limb.
If a complete reversal is needed, then the connection is made just distal to the ligament of Treitz. Ligament of Treitz is the transition point between the duodenum and Jejunum. This single anastomosis is safe and simple to perform and does not involve removing the previous staple lines.
If a partial revision is needed, or the common channel needs to be lengthened, then the anastomosis is made further proximal to the junction of both the alimentary limb and the biliopancreatic limb, but distal to the ligament of Treitz to allow for increased absorption of the calories and nutrientsIn my opinion, the revision and reversal of the Duodenal Switch operation is, from a technical perspective, the simplest of all revisional weight loss surgical procedures.
In my opinion, the revision and reversal of the Duodenal Switch operation is, from a technical perspective, the simplest of all revisional weight loss surgical procedures.
Yearly lab and medication requests
October 17, 2011 5:28 pm
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: https://www.dssurgery.com/lab. 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.