Office Hours: Monday - Friday 8:00am - 5:00pm

Category: Revision of RNY

Cholecystectomy-Gallbladder Removal

September 10, 2018 9:44 am

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.

Gallbladder, Duct and Duodenum

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.

Cystic Duct & Common Bile Ductgallbladder duct anatomy

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

PolyCystic Ovarian Syndrome PCOS

September 04, 2018 9:58 am

PolyCystic Ovarian Syndrome PCOS is a complex condition. The exact cause of PCOS is unknown however, it involves hormones imbalance and multiple ovarian cysts, irregular menses, and infertility.  In some cases, PCOS can be compounded by diabetes, hypertension and other metabolic conditions. PCOS has been shown to effect approximately 10% of women of childbearing age with symptoms of menstrual abnormalities, poly cystic ovaries, and excess androgen (male sex hormone). PCOS should be diagnosed by ensuring there are no other underlying endocrine issues. There are several associated disease processes that seem to be related to PCOS. These related disease processes are Type 2 Diabetes, higher depression and anxiety, increased cardiovascular risks, stroke, hyperlipidemia, sleep apnea, overall inflammation, and endometrial cancer.

Anatomically, numerous cysts are found on the ovaries. These are usually diagnosed by ultrasound, blood levels of hormones, and symptoms described above.

Poly Cystic Ovarian Syndrome
Examples of Poly Cystic Ovarian Syndrome

Bariatric Surgery and PolyCystic Ovarian Syndrome PCOS

Bariatric Surgery can improve PCOS in those individuals with Type 2 Diabetes Mellitus. Further information on weight loss surgery and its effect on PCOS here. 

Parathyroid Scan

July 09, 2018 11:48 am

A Parathyroid scan or Sestamibi scan may be needed if the typical weight loss surgical reasons for elevated PTH levels have been addressed. Sestamibi is a small protein which is labeled with the radio-pharmaceutical technetium-99. This very mild and safe radioactive agent is injected into the veins of a patient with overactive parathyroid and is absorbed by the overactive parathyroid gland. If the parathyroid is normal it will not absorb the agent. The scan below shows the uptake of the agent.

Calcium, Vitamin D and Parathyroid hormone are routinely measured on yearly follow up for most post weight loss surgical (WLS) patients. Elevated parathyroid hormone (PTH) may be caused by Vitamin D deficiency or calcium deficiency (most common in post WLS) or by over active parathyroid gland(s). In the latter case, if one of the four glands  is overactive then this is knows as a parathyroid Adenoma. If all 4 are over active and are secreting too much PTH, this is known as hyperplasia. Ultrasound of the neck, may identify an enraged parathyroid gland (adenoma) which is located behind the thyroid gland. Given the large area where the parathyroid gland may be located, additional tests are needed to not only identify the location of the gland(s) but also to distinguish between single gland (adenoma) or multiple glands (hyperplasia) cause for the elevated PTH. It is important to investigate all avenues and testing in parathyroid hormone elevation and in some cases, not to rely on one test for your diagnosis.  It is also imperative that weight loss surgical patients take their supplements routinely and consistently and have their laboratory studies followed at least yearly.

Informative Video on Vitamin D: here

 

Candy Cane Gastric Bypass – RNY

June 21, 2018 1:05 pm

One of the findings following Gastric Bypass is a Candy Cane Gastric Bypass. Nausea and vomiting , upper abdominal pain is a common complaint of patient who have had the Gastric Bypass RNY operation. This is in addition to the high incidence of patients who experience the complications of weight regain and or dumping syndrome.

Quite frequently the symptoms of  nausea, vomiting and upper abdominal pain of a patient with history of gastric bypass is evaluated by a primary care, referred to a gastroenterologist. The “routine” work up recommended is X-ray of the abdomen, maybe contrast study (Ct scan or upper GI) and for sure and upper endoscopy. The result quite frequently reported as “…nothing wrong”.

A typical upper GI in a Candy Cane Gastric Bypass situation may look like this:

Upper GI

A common and underreported problem may be a Candy Cane finding.  The “blind” end of the small bowel anastomosis is too long and this results in food settling in the hook of the candy cane. The symptoms of the nausea, vomiting and upper abdominal pain may be from the residual food and liquids that do not drain from this area. This can cause symptoms such as coughing or hoarseness due to reflux, nausea, vomiting, reflux of food or acid, weight regain and epigastric pain, especially when eating.

Flow of oral Intake

 

Candy Cane Gastric Bypass finding

Candy Cane

Candy Cane Gastric Bypass cases will require surgical intervention to shorten the length of the blind segment of the small bowel to improve symptoms.

It is my recommendations that any patient with history of weight loss surgery who is having any persistent gastrointestinal symptoms be evaluated by weight loss surgeon.

New Pasadena Office Map and Parking

August 12, 2017 8:35 am

We’ve created a helpful map and parking diagram for our new Pasadena, CA office location.  It also has a general layout of the Huntington Memorial Hospital Campus and Pre-operative intake and testing area.  We hope that you find it helpful on your next visit to see Dr. Ara Keshishian, General and Bariatric Surgeon.   Map and Parking Dr. Keshishian's office Dr. Ara Keshishian has performed more than 2,000 Duodenal Switch procedures, thousands of Sleeve Gastrectomies and more than 500 revisions from other Weight Loss Surgeries such as RNY Gastric Bypass, Adjustable Gastric Band, and Sleeve Gastrectomy to Duodenal Switch as well as General Surgical cases over the last 18 years of private practice.

Insurance Appeals And Denials

August 07, 2017 7:08 am

Whenever you are dealing with insurance issues it is important to have a general understanding of insurance ins and outs. The Obesity Action Coalition has a good general guide to the insurance process here.  If you are having issues with out of network, out of area, or insurance appeals and denials for Duodenal Switch, there may be some additional assistance from two individuals who have had the Duodenal Switch procedure themselves. We are grateful that they have provided assistance throughout the years to the Duodenal Switch community. The following is their statement on insurance.

The majority of insurance companies are in the business of making money (for profit). They can deny requests for preauthorization with impunity. These denials are often complexly worded and difficult to comply with and overcome, and are definitely overwhelming to the patient, and the busy surgeon’s office. The vast majority of patients faced with demanding if not impossible to achieve prerequisites, or denial of the request for preauthorization simply give up, and the insurance companies pocket the savings.

If you find yourself  facing impossible pre-op hurdles, or a denial, we urge you to appeal, and to seek assistance in preparing the appeal. You can hire an attorney, of course, but there is an informal and free resource we suggest that you investigate as well.

If you go to BariatricFacts.org (a non-profit, patient-run site), you will find individuals who are long-term DS postops, and patient advocates.  They have been helping patients, pro bono (for free), for over 10 years. They will help you draft your appeal letters, provide supporting medical and legal documentation, and prepare draft letters of medical necessity to be reviewed and signed by your surgeon supporting your appeal. They will not represent you directly, but they will help you best represent yourself.  in many cases it is necessary to exhaust all internal appeals (because the insurance companies are unlikely to overrule themselves), and then file for external review, where independent reviewers often overrule improper denials. If you join and then post on BariatricFacts.org asking for help, you will be connected with them and you can decide if you want their help.

Please note that this is just a suggestion. It is neither legal nor medical advice, nor a guaranty regarding their services, and you should always consider getting legal advice and assistance from an attorney who will represent you directly. The members at BariatricsFacts.org will help you draft your own letters, but will not be your legal or medical representatives; you will be required to do a fair amount of your own work on your appeals, and to sign them yourself.

It is suggested that before or at the same time as you contact the resources suggested at the site, you gather as much of the following information as you can:

  • A copy of your Evidence of Coverage, which is the usually 100+ page insurance contract between your employer and the insurance company, which  you can obtain it from your HR department. If you are self-insured, it will be available directly from your insurance company. Note: it is NOT the Summary of Benefits – it needs to be the contract itself.
  • If your insurance is through an employer, you need to determine whether your plan is self-funded or fully-funded. Your rights are significantly different under the two types of plans.
  • If your insurance company has a separate bariatric surgery policy, provide a copy of that, too.
  • A copy of your surgeon’s request for preauthorization, which provides the ICD-10 and CPT codes submitted.
  • A copy of your denial letter, including the section regarding your appeal rights.

*      It is strongly recommended that you obtain a copy of your surgeon’s LOMN (letter of medical necessity) before it is submitted to your insurer or for external review, so we can assist your busy surgeon in making the strongest possible case for you.

Don’t be deterred by a denial. It is unfortunately more common than it should be, but it can often be overcome if you meet the requirements for bariatric surgery, if you get help navigating the process.

Weight Gain after Gastric Bypass

January 04, 2017 9:12 am

Weight loss surgical procedures have different long term results and some procedures have more dramatic weight loss than others. Some procedures also result in much more sustained and long term weight loss. Unfortunately, what may be not obvious is that the patient has very little control over the outcome of the surgery in most cases. IT is very easy to blame the patient for weight regain after weight loss surgery. However, it is important to remind ourselves that the long term data reporting outcomes of the surgical procedures in most cases, includes all patient population. All these studies include the most compliant and not so compliant patients. Comparison chart of outcomes of weight loss surgical procedures.

A larger percentage of gastric bypass patients will require revision for weight regain, or other problems. There is no evidence that the size of the pouch or the anastomosis between the pouch and the small bowel changes the weight regain outcomes. Yet, quite frequently I will see patient who have had gastric bypass revision for weight regain, by reducing the size of the pouch or the anastomosis. Here are some publications that support the notion that other than extreme dilation, the size of the pouch and the size anastomosis does not predict the outcome of the surgery. There is some correlation with the site of the pouch, anatsmosis and weight loss, but there is no correlation between the size of the pooch, the opening and the failure rate. This means that patient with smaller pouch do not have better long term outcome that the ones with larger pouch, only that the patient with smaller pouch or anatsmaosis will loose more weight.

“Influence of pouch and stoma size on weight loss after gastric bypass”

“Impact of gastrojejunostomy diameter on long-term weight loss following laparoscopic gastric bypass: a follow-up study”

Weight regain after RNY Gastric Bypass may also be caused by a Gastro-gastric fistula, which is a new connection between the pouch and the remnant stomach. Here is further information on Weight Loss Surgery Revisions.

When considering a primary weight loss surgical procedure, be informed.  Investigate all your options and consider the long term outcomes.  This may mean investigating different weight loss surgical procedures on your own.

Review & Update Giveaway!

August 31, 2016 6:27 pm

Keshishian Giveaway Ticket

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 participation!

One Prize and One Grand Prize

Prize: two tickets to Obestiy Help National Conference Sept. 30-Oct 1, 2016

Grand Prize: two tickets to Obesity Help National Conference and one night
hotel stay October 1, 2016

Conference: 11999 Harbor Boulevard Garden Grove, California 92840 Event link here

Hotel Prize: SHERATON GARDEN GROVE – ANAHEIM SOUTH HOTEL
12221 Harbor Boulevard
Garden Grove, California

Official Rules:

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.

  1. 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

2. Take a screen shot of the review or update with your username and date.

3. E-mail the screenshot to contact@dssurgery.com with your contact information (name, phone number, e-mail, and mailing address )

4. Entries must be a verifiable patient of Dr. Ara Keshishian in Glendale, CA.

Promotion Timing:

The Review & Update Giveaway begins September 1, 2016 and ends September 8, 2016 at 5:00pm PST

How Winners are Chosen:

Winners will be chosen by random draw.  Odds of winning vary upon the number of entries received for the giveaway.

Winner Notification and the Claiming of Prizes:

Winners will be notified via the email provided at time of entry and also published on our blog comments www.dssurgery.com/blog and on our FaceBook page. The winner will have 72 hours to respond to the winning notification email or the prize will be forfeited.  The prizes have no cash value. The prizes are non-transferable and must be accepted as awarded. No changes may be made to the prizes. There is no cash value for the prizes.

General Conditions:

By entering the Giveaway, entrants agree to abide by and be bound by these Official Rules and the decisions of the Sponsor, which are final and binding in all matters relating to the Giveaway, and release and hold harmless Sponsor and its affiliates, directors, officers, employees and assigns from and against any liability, claims, lawsuits, judgments, losses, damages of any kind, injuries, death, property damage, costs and expenses, arising from, resulting from or in connection with the Giveaway, the participation in the Giveaway, or the receipt, possession, use or misuse of any prize. Sponsor is not responsible for lost, late, incomplete, inaccurate, stolen, delayed, misdirected, undelivered or illegible entries or for lost or stolen entry boxes or other errors or difficulties of any kind whether human, mechanical, electronic, typographical, printing or otherwise relating to or in connection with the Giveaway, including, without limitation, errors or difficulties which may occur in connection with the administration of the Giveaway, the processing of entries, the announcement of the prizes, or in any Giveaway-related materials. Sponsor is not responsible for technical, hardware, software or telephone malfunctions of any kind, lost or unavailable network connections, or failed, incorrect, incomplete, inaccurate, garbled or delayed electronic communications caused by the user or by any of the equipment or programming associated with or utilized in the Giveaway. Persons who tamper with or abuse any aspect of the Giveaway or who are in violation of these Official Rules, as solely determined by Sponsor, will be disqualified and all associated entries will be void. The Sponsor reserves the right, at its sole discretion, to cancel, terminate, modify or suspend the Giveaway if, in Sponsor’s opinion, it is not capable of running as planned, including, but not limited to, due to tampering, unauthorized intervention, fraud, technical or phone line failures or any other problems beyond the control of the Sponsor, and select the winners for affected drawing(s) from among all eligible entries timely received for such affected drawing(s) prior to cancellation.

Don’t lose your Pyloric Valve over a Failed Gastric Sleeve

June 22, 2016 9:32 am

duodenal-switch
Diagram of Duodenal Switch

In my opinion, there are very few reasons to lose your Pyloric Valve after sleeve gastrectomy. Recently, I am hearing of people who have had regain due to a failed Sleeve Gastrectomy being revised to Gastric Bypass RNY and then seeking a Duodenal Switch due to regain from Gastric Bypass RNY.  A better option is to go from Sleeve Gastrectomy to Duodenal Switch, due to the long term excess weight loss maintenance of Duodenal Switch. The benefit of the pyloric valve can not be taken lightly.

Let’s start by reminding ourselves as to how the Sleeve Gastrectomy has gained popularity.   In the quest for a simple solution to the complex problem of obesity, adjustable gastric banding gained popularity only fail to deliver anything close with the results that were promoted and heavily marketed.   The focus was then changed to another seemingly simple procedure, laparoscopic sleeve gastrectomy.  For some surgeons this is a new procedure.  Surgeons that had been doing the duodenal switch operation for decades,  sleeve gastrectomy has not been a new procedure.  Surgeons that just started doing sleeve gastrectomy as a stand alone procedure started experiencing complications of the sleeve gastrectomy, such as regain and are now looking for another option for these patients.  This complication are even more frequent when they’re done following a failed adjustable gastric band procedures due to the metabolic issues after revising one weight loss surgery to another. A similar short sighted  approach is also being promoted with SIPS/SADI procedures,  which is significantly simpler to perform than the duodenal switch operation.

Laparoscopic sleeve gastrectomy  has a predictable profile for weight loss.  It will not have as good on the long-term success rate as a duodenal switch operation. Complications of the sleeve gastrectomy including reflux, stricture, fistula, inadequate weight loss which may warrant  evaluation and possible intervention.  In my opinion, as a surgeon who does the duodenal switch operation routinely, a sleeve gastrectomy requiring revision should almost never be revised to a gastric bypass.  I have seen number of patient’s who have had an adjustable gastric banding which was revised to the sleeve gastrectomy then to a gastric bypass.  We are contacted for a possible revision to Duodenal Switch operation because of the weight regain.  One can argue that the patient should not have had the sleeve gastrectomy or gastric bypass.  It is critical that the complexity of the disease of the obesity is clearly appreciated that it purely restrictive procedure will not yield  the desirable outcome long-term.

Benefits of the Pyloric Valve:

Structures of the Stomach
Structures of the Stomach

The pylorus is the valve located at the end of the stomach. It controls the release of the liquid mixture of food from the stomach into the small intestine.

The body naturally regulates the passage of food, so food will stay in the stomach for a certain period of time. We believe it is very important to continue that feeling of fullness in between meals. As a result, one of the principle functions of the pyloric valve is to regulate the amount of food products released into the small intestine where they are absorbed. This helps prevent  dumping syndrome and ulceration.

The bodies natural diameter of stomach, pyloric valve and small intestine is left intact.  This elevates stretching of the stomas created by RNY Gastric Bypass.

Summary

These failed Sleeve Gastrectomies should be revised to Duodenal Switch unless there are overwhelming health issues that would require another option.  I always suggest several opinions from different Bariatric Surgeon’s who do a variety of Weight Loss Surgeries before deciding which type of revision to proceed with.

Shared Success Story Update- Cyndi RNY to Duodenal Switch

June 06, 2016 6:37 am

Three Years Out Cyndi E … RNY to Duodenal Switch Revision

The Journey to get to the three year mark, has been amazing! And truly, The JOY is in the JOURNEY.

I am a JOYFUL “Third Time’s the Charm Revisionista”…. This is my new title…. And I say this proudly!!

IMG_3775
Before

For too many years (like 45! at least) I carried the shame and blame of being overweight and beat myself up on the inside. I tried everything, from age 13. I tried every diet, every program, and yes, I will say it, I have had THREE, yes THREE surgeries. And then, I let others convince me, and I bought into this, that I was a failure… BUT, I am not a failure. Surgery fails. For a long time, I could not say that, again with the SHAME word. BUT, I am done with shame, and I am done with blame. I no longer blame myself and I no longer shame myself or my body, because now, she and I, my body and I, are friends, and we are nice to each other.

Thankfully for me, I was in the right place at the right time, and met Dr. Ara Keshishian… My story with Dr. Keshishian, is simple. Dr. K was the first Doctor that did not blame me for my weight. He explained that each weight loss surgery has different measures of success, and percentages by weight loss surgery and outcomes. He educated me. He did not blame or shame me, he encouraged me. He also did an Endoscopy and found that I has a Gastro-Gastric Fistula.  Simply put, this was an abnormal connection between the bypassed stomach and the small pouch created by the RNY Gastric Bypass surgery. Food could travel two ways, thus rendering the Gastric Bypass ineffective causing weight gain.

Dr. Keshishian performed my revision from RNY to Duodenal Switch on May 31, 2013. The procedure corrected my anatomy, enabling me to lose weight and regain my health. I have no complications, no issues post surgery.

After
After

Today, being a “Three Year Old” RNY to Duodenal Switch revisionista, I have a better perspective as a relative “newbie”. I am not a prisoner of my weight. I have lost 125-130 pounds, I am 5’12” (6 feet lol) 61 years old and for the first time in my life at a NORMAL WEIGHT! I do not fear, any longer, that I will gain my weight back. I am, however, mindful that I am consistent in my new habits and patterns that I have put in place, that keep me on track. I am also accountable. To myself, also to my Weight Loss Support Group, here in Paso Robles, to some fellow DS girlfriends that

After
After

I talk with about challenges, and with Dr. Keshishian. I am not held captive by my limitations, or my weight, and now I live with the possibilities each day brings and the fun challenges I put in front of me to conquer.

To the “newbies” I say, please take your time, treat yourself kindly, with your inner voice. This is not a race, this is a journey. Don’t rush, it’s ok to take it slow, listen to your body. And do not compare your journey to anyone else. You are you! You do you! You can do this well, one day at a time. Listen to the sage advice of those who went before you. We too have learned by trial and error. Be willing to sacrifice in the short term, for the gift of the long term life. Your DS is forgiving, you be forgiving as well!!!

Remember: WATER, PROTEIN, SUPPLEMENTS, EVERYTHING ELSE, EAT CLOSE TO THE DIRT, ELMO DIET

With JOY, Cyndi

Cyndi’s first Shared Success Story here.