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

Category: Sleeve Gastrectomy

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

 

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.

Shared Success- Samantha had a Sleeve to Duodenal Switch Revision

July 14, 2017 9:30 am

After struggling with obesity for most of my life I was finally fed up. I had heard about weight loss surgeries before but was always under the common misconception that it was for people who wanted the “easy” way out of a hard situation. I had been working out and reducing calories and tried every popular diet and trainer you could think of. I was still huge and each time I would stop one of these extreme programs I would only end up larger than I was before.

My husband’s cousin had the sleeve surgery and she raved about it. Watching her success is what started to open my mind to surgery, but I was only considering the sleeve gastrectomy. I went to a center in another state that offers Duodenal switch, lapband, RNY and the sleeve. The surgeon I met with strongly suggested RNY to me, but I was stuck on the sleeve. I didn’t want my intestines touched period. I had the sleeve surgery on October 9, 2013.

My high weight was 402 lbs and I weighed 343 on the day of my sleeve surgery. I actually did well with the sleeve and was able to get down to 218 as my lowest. However it was

before

still much like dieting. It was so stressful. After a while my body wouldn’t drop the weight regardless of how little I ate and exercised. I was eating 800-1200 calories a day and low fat meals and working out and kept slowly gaining weight. I was frustrated  and honestly I gave up. My reflux wouldn’t go away so I visited a bariatric surgeon in my area who suggested that we essentially re-do the sleeve surgery to make my sleeve small again so that I would eat less and lose weight again. I got a second opinion and that surgeon suggested I revise to RNY. I went to obesity help’s website to explain my situation and a lot of people with much more experience than me HIGHLY urged me to see Dr Keshishian before making a decision. He was said to be an expert in revision weight loss surgery. I almost cancelled my appointment and didn’t have hope with this doctor either, but since I was in a dead end I went anyway. Dr Keshishian told me it wasn’t my fault. WHAT!? I had never heard that before. I usually get the shame from doctors who assume I must not be trying or that I am secretly eating something wrong. He ordered tests and told me it was “simply science” and I just LOVED him! I had a stricture in my Sleeve that needed to be repaired so since I needed surgery anyway I decided to go ahead and revise to a surgery that has the highest success rate, Duodenal Switch.

 

after Sleeve to Duodenal Switch revision

I was so scared of my intestines being cut and Dr. Keshishian eased my fears. I wish I had went that route the first time but then I might not appreciate it like I do now. Duodenal switch is the ONLY surgery I would recommend to anyone. As Dr K says it’s simple numbers. It’s the surgery with the highest percent of excess weight lost and kept off. I was 252 before my revision from Sleeve to Duodenal Switch and I am just at a year out and today I weigh in the low 190’s and I am still losing. Dr K’s goal for me was about 180. My goal is about 175.  I eat more fat now than I ever did even when I was 400 lbs. I enjoy what I eat and I enjoy exercising and most of all I get to enjoy seeing results from my hard work. Food no longer causes me stress and anxiety. I know with 100% certainty that I made the right decision. Thank you Dr. K for your great skill and I don’t mean just with the knife but with the way you are able to make a high anxiety situation seem like no big deal.

After Sleeve to Duodenal Switch Mud Run
I was able to complete a Mud Run since my Sleeve to Duodenal Switch revision.

After Duodenal Switch Mud Run

 

Metabolism following Reconstructive Surgery

April 18, 2017 7:47 am

I’ve had some questions regarding how Reconstructive Surgery can affect weight loss and metabolism after Duodenal Switch, Vertical Sleeve Gastrectomy, weight loss surgery and even in people who have not had weight loss surgery. There are several components that can effect a change in metabolism following Reconstructive Surgery that relates to physiological, functional, social and emotional mechanisms. These possible effects can vary person to person based on body type, age, weight, motivation, etc.

Fat mass resection and liposuction

Liposuction or the removal of fat mass by panniculectomy or abdominoplasty can have effects on lipid profile, leptin, waist hip ratio and glucose metabolism for 3-12 months depending on the individual and their health status. This have been researched and documented in both normal and higher BMI individuals. There is also an improvement noted in post bariatric surgical patients having breast reduction and abdominal plastic surgery. Of course, these effects can be controversial, conflicting and further research is needed.

Decrease in inflammatory markers

There is some evidence that the excision or liposuction of fat mass an decrease inflammatory markers and insulin resistance. This can affect C-reactive protein, TNF and cytokines levels. Little is known about the actual mechanism of this effect but the potential for this physiological change is present.

Increase metabolic need for healing

The metabolic needs following plastic surgery are much greater due to the nutrient needs required for healing.  Depending on the extent of skin and tissues excised, the nutrient requirements can be considerably higher.  This increase in nutrient need can increase metabolic rate, meaning you need more energy for healing. This significant stress also increases the complication associated with reconstructive surgery after weight loss surgical procedures.

Increased Motivation:

Many people are more motivated following plastic surgery because of the dramatic change in body appearance and ability.  The increase in motivation can be either diet or physically related. Some people are more motivated to watch what they are eating and increase physical activity to increase the effect of plastic surgery. Obviously, this is an extremely individual experience and can happen in varying degrees

Possible increased restriction

In the case of abdominoplasty, there can be an increase in restriction due to tightening of the skin, muscle and inflammation of the abdominal wall. Thereby, helping to have a fuller feeling sooner when eating. This can also at times result the chance of the complication of reflux and/or stress urinary incontinence if the abdominal muscle tightening is excessive or there is weight regain later on after the abdominoplasty.

Increase mobility and functional status

Excess skin can impair mobility and physical activity for some.  The removal of the excess skin can promote mobility, ease of movement, improve gait and posture, and can improve or relieve pain. Skin infections, rashes and irritation are often symptoms of excess skin especially in the abdominal or pelvic area. This is a functional improvement, and depending on the extent of the pannus, can be quite freeing.

Increased confidence

Improved self confidence, anxiety, mood, and body image are important motivators and incentives to post bariatric and plastic surgery patients.  These improvements can have an effect on social and relationship aspects.  However, it’s important to note that patients undergoing cosmetic surgery should have realistic expectations.  Cosmetic, plastic or reconstructive surgery is not a panacea and does not in itself solve body image, personal or psychological issues. In addition, a post Bariatric patient may need additional time to recognize their physical and psychological changes following plastic or reconstructive surgery.

Summary

There may be metabolic, physiologic, physical and psychological improvements following Reconstructive surgery either after weight loss surgery or in non weight loss patients. These changes will vary based on the individual, age, dedication, health status, adherence to instructions,  past medical and psychological history. However, appropriate education, screening and realistic goals and outcomes need to be emphasized prior to undergoing any type of plastic or reconstructive surgery.

 

Back on Track 2017 Giveaway

January 10, 2017 10:03 am

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 contact@dssurgery.com 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 contact@dssurgery.com in order to claim the prize.

NOTE: Giveaway items may or may not be identical to the pictured items.
We are not affiliated with any of the products nor do we endorse any one type of product.There is no cash value to the prizes.

Please check with your physician before starting a new supplement and follow laboratory studies for adjustments in supplements. Vitamin information here. Mineral information here.

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.

Less Invasive, Easier?

July 20, 2016 11:02 am

There is a continuous desire for a “less invasive”, “easier” procedure for the treatment of obesity and its associated co-morbidities. We have been very clear when discussing the benefits and long term outcome of the procedures. Let’s remind ourselves that “less invasive” does not mean a better option. In almost all cases a less invasive weight loss surgery means less weight loss, lower incidence of resolution of co-morbidities, and in some cases higher complications rate. Have we forgotten the adjustable gastric banding that was advocated to be the cure all for all obesity? All we hear now are the complications, the long term sequel of the reflux, hiatal hernia, irreversible esophageal injury, in addition to inadequate weight loss or weight regain.sleeve-gastrectomy-525x700

Unfortunately, the same is to be said about the Sleeve Gastrectomy. We have said, as supported by the scientific literature, that the long term outcome of the sleeve gastrectomy is not as good as that of the Duodenal Switch procedure. This is true for the amount of weight loss as well as the resolution of the co-morbidities.  We see quite a few patients who have gained their weight back after sleeve, never lost enough weight, and/or did not achieve resolution of their co-morbidities, such as diabetes, and are having their procedure revised to Duodenal Switch procedure.

Here is a  recent publication that discusses this. 

sleeve_not _for DM_1_1

sleeve_not _for DM_2_1sleeve_not _for DM_2_2Along with the same argument, this is why I caution patients when having the SIPS or SADI procedures. There is a chance that when the long term data for SIPS/SADI is available there may be some benefits  procedure. However, as it stands at this point in time, these procedures are not the same as the Duodenal Switch procedure. So in short, less invasive, easier isn’t better.

 

 

 

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.