For the protection of our patients, the staff will wear mask in the office.
For Telehealth follow-up and new consultations please contact us Here
1-818-812-7222 Office Hours: Monday and Wednesay 8:00 AM to 5:00 PM
10 Congress St., Suite #405
Pasadena, CA 91105

Category: SADI

GERD, Nausea and Vomiting- Don’t ignore it!

April 28, 2015 11:30 am

Gastroesophageal Reflux Disease is a serious matter and should not be left untreated. It is know as heartburn or reflux and if you are experiencing more than twice a week you should be evaluated by a physician to investigate the cause. Listed below are some of the causes and end results of not treating GERD.

Esophagitis – An irritant that can be acid, bile, food and digestive enzymes coming back up the esophagus can cause irritation and swelling in the esophagus. If left untreated, it can damage the lining of the esophagus to the point of erosion and scarring. Bile Reflux may also be a cause of esophagitis and Duodenogastroesphogeal reflux (DGER). Bile Reflux information here.

Esophageal Stricture – Scar tissue can cause the lumen of the esophagus to become smaller and narrow.  This stricture makes it difficult or painful to swallow foods. If a stricture is narrow enough food may become stuck and require intervention for removal and treatment.  This can also put a person at risk for choking. The treatment includes ballon dilation with an endoscope and in cases where it recurs surgery may be required.

Esophageal Ulceration– If GERD is left untreated it can progress to actual ulcerations in the esophagus.  Patients may cough up or vomit blood or see it in their stool as dark tarry or coffee ground type stool.

Gastric Stricture– After weight loss surgery such as sleeve gastrectomy, RNY Gastric Bypass, Duodenal Switch, SADI/Loop,  Adjustable Gastric Banding, or other gastric surgeries a narrowing of the inner opening of the stomach can result from scar tissue forming.  This will require a surgical procedure to rectify.  The symptoms can be food intolerance, full feeling, nausea and/or vomiting. (See pictures below)

Hiatal Hernia– An anatomical weakening or enlargement of the opening of the diaphragm muscle where the esophagus meets the stomach.  This defect can allow a portion of the stomach to slide or roll into the chest cavity. This then causes reflux of gastric juice and content.  Hiatal Hernia’s can also form on weight loss surgical patients.  There are several examples within this blog here.

Breathing Difficulties– The acid aspiration while sleeping can make asthma and other breathing difficulties worst and can cause coughing and other issues.

Dental Issues – The acid, food, digestive enzymes backing up into the esophagus and mouth can cause dental issues such as erosion and tooth decay.  In regards to dental issues after weight loss surgery there are also other vitamin and mineral deficiencies that can cause oral health issues. Dental Issues after WLS here.

Lower Quality of Life– GERD can affect a person’s quality of life.  If you are in discomfort from acid reflux or having food intolerance it can make life difficult.  It can also alter food choices and impact nutrition.

Barrets Esophagus– Pre-cancerous changes in the bottom portion of the esophagus due to long term acid exposure from gastric reflux. Diagnosis requires and endoscopic procedure (EGD) and biopsy.

Esophageal Cancer– There is a significant rise in the western world in esophageal adenocarcinoma. The main risk factors are alcohol use, smoking, untreated GERD, and poor diet.

Reflux and difficulty with swallowing caused by stricture is not normal. These problems are quite frequently encountered as complication of Adjustable gastric banding, with slipped band or a band that is too tight and scarred in placed resulting is belt effect. This results in the esophagus not being able to empty and propel the food down. The end result is significant reflux, with difficulty swallowing, nausea, vomiting etc.  Similar problems are seen with Gastric bypass where the anastomosis between the stomach pouch and the small bowel RNY limb is too narrow. In Gastric Sleeve and Duodenal Switch operations, is the sleeve is made too narrow, or misshaped (hour glass, funnel, cork screw) it will result in the patient having reflux and symptoms of stricture. One specific problem with the new operation of SADI is the concern for  risk of bile reflux, similar to the BillRoth I procedure.

Gastric bypass patient with stricture at the gastro-jejunostomy before and after balloon dilation. Fig A

Screen-Shot-2015-05-13-at-7

After balloon dilation. Fig B

Screen-Shot-2015-04-28-at-9.31

Fig. C : Lap band Patient with stricture where the band as removed at another facility and the scar tissue formed around the GE junction was not taken down. The patient had to be taken back to the operation room after his symptoms persisted even though the band had been removed 3 months prior.

Screen-Shot-2015-04-28-at-9.33

A corkscrew stomach of a Duodenal Switch done at another facility, with the patient presented with persistent reflux, nausea and vomiting for years after surgery.     Fig. D

Screen-Shot-2015-04-28-at-9.35

This is not an inclusive discussion of GERD and the treatment.  Please see your healthcare providers if you are experiencing any symptoms pertaining to GERD or any other health care issue.

Single-Anastomosis DuodenoIleal Bypass (SADI)

June 23, 2014 6:30 pm

Single anastomosis duodenal switch, also known as Single Anastomosis DuodenoIleal Bypass (SADI)  is a procedure that is being discussed in literature. There have been a  few series of case reports that have been published in the last few years. I would like to review the procedure and share my opinion.

The theory behind the SADI has been to simplify the duodenal switch procedure. In  “classical” duodenal switch procedure, the small bowel is divided in two places, (duodenum, and distal ileum) and two anastomosis are created (duodeno-ileostomy, and ileo-lieostomy). This can theoretically provide two potential places for leak, bleeding, adhesions as complications. In SADI, there is a single bowel division of the duodenum and a single anastimosis of the duodenum and the ileum. The sleeve component of the procedure is the same for both procedures. This is where their similarities end.

In the duodenal switch operation, the bowel is partitioned in to two parallel limbs- one that carries the biliopancreatic juices and a parallel limb that bring the food down from the post pyloric duodenum. They then join and form the common channel.  The length of the biliopancreatic limb is so long that it does not allow bile to reflux back into the duodenum or back to the stomach causing the complication of bile reflux gastritis. With the single anastomosis of the SADI, the length of the bowel where the bile meets the duodenum is shorter than it is in normal anatomy. This significantly increases the possibility of the bile reflux.  The second difference is the selective nature of the reduced absorption of the fat in the duodenal switch, in comparison to that of the carbohydrates. Duodenal switch operation has two absorptive lengths- the Alimentary channel, which is involved with protein and carbohydrate absorption, and the common channel that absorbs, fat, protein and carbohydrates. One can make changes to the common channel and impact the fat absorption significantly more than that of the carbohydrate and the proteins.  In SADI procedure, that common channel and the alimentary limb are both the same- there is no way to selectively adjust the fat absorption without making significant changes to that of the protein and carbohydrate absorption.

 
Other than the obvious anatomical variations described above, it is important to mention that the concerns outlined above are mostly theoretical.

There are a number of publications that have reported the short-term outcome of the SADI procedure. They appear promising, but they are short-term results. Long-term data is needed. If the outcome does not change significantly over time, then I could see a role for SADI in the treatment for obesity. In the mean time, patients need to be made aware that the suggestion that SADI is the same as the duodenal switch is probably not correct since we do not have the data to support this oversimplification.

 

The animation of the Duodenal switch is here.

For comparison of duodenal Switch and SADI please check our web site here.