Category: Uncategorized
Feeding TubeExclusive Member Content
April 20, 2015 11:43 am
Zinc InformationExclusive Member Content
April 17, 2015 7:22 am
Copper InformationExclusive Member Content
April 17, 2015 7:21 am
Shared Success Story- Dr. D. Brown
April 13, 2015 11:38 am
I had Roux-en-Y (RNY) gastric bypass surgery in February 2004. I was told it was the “Gold Standard” procedure and it was the only one my insurance would approve (according to the surgeon’s office). I lost around 130 pounds with some minor bounce back. Kept it off for 7 years. I had so much energy; I decided to go back to school to become a doctor.
In medical school I really began to regain, for a total of 75 pounds over 5 years. I tracked food and found that if I ate more than 1300-1400 calories daily, I was gaining. I had absolutely no sugar dumping or satiety or restrictive effects left from the RNY Gastric Bypass, only my metabolism’s memory of starvation mode.
In fact, I never had one incident of dumping syndrome; I only felt satiety for the first 2 years and was able to eat well over 2 cups of food per meal by year 7. Lack of dedicated exercise, extreme stress (time, financial & academic) as well as poor food choices all contributed to my regain. However, the RNY Gastric Bypass surgery only has an average long-term excess weight loss of around 50%, so that still makes my weight regain close to the acceptable range.
Finally, I looked into revision surgery. Not only is surgery always a major decision, but also a revision to a DS is a very technically complicated surgery. I extensively researched all the options to make the right decision. The Duodenal Switch surgery has the best long-term statistics for maintained weight loss in all the medical studies (close to 75% excess weight). The major feature is nutrient malabsorption. The amount is dependent on an individual basis but most fat and some protein calories are not absorbed. There is an initial restrictive component as well. With the nutrient malabsorption also comes vitamin/mineral malabsorption. However, RNY also causes vitamin malabsorption and I was already taking vitamins, so what’s a few more? I am just 4 weeks post-op now and am still in trial-&-error mode, but I have found a safe plan for returning back to work. I really could not have afforded any complications and am so glad that I placed my trust in Dr. Keshishian.
Dr. D. Brown
Starting wt: 274.0
Vitals for 4-16-15 (4 weeks post DS)
wt = 249.0
T = 97.7
P = 88
BP = 108/80
Evaluations of Gallbladder Disease And Function
April 11, 2015 7:03 am
Gallbladder disease can include both anatomical and functional condition. We are familiar with gallstones. Bile acids, Lecithin (a phospholipid), and cholesterol are present in the Bile. When the proportional percentage of each one of them is outside a very narrow range, gallstones are formed. Approximately 75% of the gallstones are formed because of the supersaturation of the content of the gallbladder with cholesterol which results in cholesterol stone formation. The rest are pigmented stones.
Gallstones are usually identified by ultrasound and they are seen as shadows.
There are patients that have a normal gallbladder ultrasound result that continue to have signs and symptoms of gallbladder disease, such as abdominal pain in the right upper quadrant, nausea and vomiting with fatty meals, and bloating to name a few. These patients should be evaluated by a dynamic HIDA scan.
A dynamic HIDA scan study evaluates the function of the gallbladder, by creating a movie of the gallbladder, where as an ultrasound takes pictures of the gallbladder.
In a dynamic HIDA scan, and contractility of the gallbladder is reported in form of ejection fraction (%EF). This represent the amount of gallbladder contraction in response to the stimulation by a fatty meal mediated thru cholecystokinin (CCK). A normal EF is greater that 35%. Anything less than than with the sign and symptoms of gallstones, should be highly suspect for acalculous cholecystitis. Calculus because there is no stone.
(The bright white collection represents the filling of the gallbladder)
This short movie represents the uptake of the radio nuclear material in the gallbladder and its normal secretion in the small bowel.
These are the static images before the injection of CCK.
Following the injection, digital subsection of the images measure the amount of nuclear activity of the gallbladder before and after contraction and an Ejection Fraction is calculated.
Vitamin K1
April 08, 2015 7:16 pm
Vitamin K1 is a found in dark green leafy vegetables, asparagus, brussels sprouts, some grains, olive oil, prunes, soy bean oil, and canola oil. The body has limited storage capacity for Vitamin K and uses a recycle system to reuse it.
Vitamin K1 is a fat-soluble vitamin that after Duodenal Switch is not as easily absorbed due to the limiting contact of the food product with the bile until the common channel. Bile is needed to absorb fatty acids and fat-soluble vitamins.
Duodenal Switch patients in need of Vitamin K1 supplements should take “Dry” or water miscible type of Vitamin K1, such as Biotech brand. The patients laboratory studies will determine if a patient requires Vitamin K1 supplement. Duodenal Switch patients should have laboratory studies drawn and evaluated at least on a yearly basis. Vitamin K works in a delicate balance with other supplements and should be monitored by a physician, in at risk people.
Vitamin K1 is most know for it’s coagulation effect and the clotting cascade. Vitamin K1 works with calcium and proteins in order to accomplish coagulation synethesis. Care should be taken with Vitamin K supplementation and anti-coagulation (blood thinners) therapy. Please see your physician regarding any supplementation of Vitamin K and blood thinner medications.
A discovery of Vitamin K dependent proteins has led to research on Vitamin K1 in bone health. Bone matrix proteins, specifically osteocalcin, undergo gamma carboxylation with calcium much the way coagulation factors do; this process also requires Vitamin K. Osteocalcin is a Gla-protein that is regulated by Vitamin D. The calcium binding ability of osteocalcin requires several Vitamin K carboxylations to exert it’s effects on bone mineralization.
In adults, the causes of Vitamin K1 deficiency include the following :
Chronic illness
Malnutrition
Alcoholism
Multiple abdominal surgeries
Long-term parenteral nutrition
Malabsorption
Cholestatic disease
Parenchymal liver disease
Cystic fibrosis
Inflammatory bowel disease
Medications: Antibiotics (cephalosporin), cholestyramines, warfarin, salicylates, anticonvulsants, Cefamandole, cefoperazone, salicylates, hydantoins, rifampin, isoniazid, barbiturates, and certain sulfa drugs, higher Vitamin E can antagonized Vitamin K)
Massive transfusion
Disseminated intravascular coagulation (DIC) – Severe
Chronic kidney disease/hemodialysis
Additional information: https://lpi.oregonstate.edu/infocenter/vitamins/vitaminK/
Intake of Vitamin K1 and K2 and bone fracture risk
As always, discuss with your physicians and/or surgeon any changes in medications and supplements. This is not meant to be an all inclusive discussion of Vitamin K.
BADAS-Bowel Associated Dermatosis Arthritis Syndrome
April 05, 2015 9:51 am
https://www.mayoclinicproceedings.org/article/S0025-6196(12)60341-3/fulltext
https://www.ncbi.nlm.nih.gov/pubmed/6694433
https://www.ncbi.nlm.nih.gov/pubmed/21332683
Weight loss Surgery Coverage Changes
January 20, 2015 10:30 pm
Weight loss surgical procedures have been proven to be the only viable option for sustained weight loss when compared to all other modalities, including diet, exercise, behaviors modifications, appetite suppressant, and other less scientific approaches. Different weight loss procedures have had varying degree of success as measured with resolution of the co-morbidities and long term weight loss.
One such specific modification in policy involves primary and revision weight loss surgery.
These policy changes have significant practical implications for those seeking surgical treatment for morbid obesity and associated co-morbidities.
First of all, they create a road block for those patients who are not able to provide documentation for the “…6 continuous months, in the 2 years prior to surgery, to enable both behavioral changes and adequate assessment of anticipated postoperative dietary maintenance.” It also places the responsibility on the surgeon by requiring that compliance with these requiremens are “…. fully appraised and documented by the physician requesting authorization for surgery.”
For all those who are not in California, please note that a lot of policies do start here and propagate to the rest of the country. I would propose that everyone take time to contact their state health insurance providers regulatory agency and voice their opposition to the proposed changes.
The state regulatory agencies are located here. (https://www.dsfacts.com/image-files-new/agencies-by-state.pdf)
Telogen Effluvium: Hair Loss After WLS (Weight Loss Surgery)
September 14, 2014 12:56 pm
Telogen Effluvium is the premature pushing of the hair root into a resting state and can be chronic or acute. It is usually brought on by a shock to your body such as high fevers, childbirth, severe infections, severe chronic illness, severe psychological stress, major surgery or illnesses, over or under active thyroid gland, crash diets with inadequate protein, and a variety of medications. Most hair loss from medications, is this type of hair loss, and the related medications include retinoids, beta blockers, calcium channel blockers, antidepressants, and NSAIDS (including ibuprofen). Supplements that can also cause or increase telogen effluvium are higher doses of iron and Vitamin A.
The hair begins to fall out in differing amounts and can start weeks to months after the initial shock to the body or medication initiation. The hair loss can continue up to 6 weeks and typically slows at 8 weeks after the start of the hair loss.
Weight loss surgical patients experience this due to the stress of surgery and the low protein state directly after surgery. Although there is no specific treatment for Telogen Effluvium, there are steps that can be taken to potentially slow the hair loss and help support the new hair growth.
The most important steps to take are to maintain your protein supplementation at a minimum of 80-100 grams of protein daily and hydration (at least 64 ounces daily) after weight loss surgery.
Protein, particularly L-lysine, are the building blocks of hair and nails, without adequate protein your body will forgo making hair and nails to maintain critical muscle mass. Also hydration is important to flush the body of toxins, due to fat breakdown in the liver during the rapid weight loss phase, that will prevent further new hair growth.
Vitamin B6 and B12 deficits can also contribute to hair loss. Multivitamin supplementation is essential to maintaining the required levels of these vitamins. The recommended multivitamin supplementation is two multivitamins daily that are equivalent to Centrum brand multivitamin.
Some people add Zinc supplements to increase hair production. However, if you are adding Zinc it is advised to also add a Copper supplement as they compete with each other for absorption. Copper is important for red blood cell production and a copper deficiency can exacerbate iron deficiency anemia. Inactivity can also decrease zinc levels, therefore exercise/activity will naturally maintain zinc levels.
Biotin is also a B vitamin that can be helpful in new hair growth.
Folicure is a supplement tablet that contains many vitamins and minerals that some people find helpful for hair re-growth. They also manufacture a shampoo that can be used.
There are many shampoos and topical treatments that people use and report satisfaction in their results. However, it is important to note that a topical treatment may make your hair appear thicker but the hair regrowth will only be supported by internal nutritional maintenance. Minoxidil is a liquid vasodilator medication applied to the scalp that is the exception to this rule and can help with hair regrowth. However, Minoxidil will not work to it’s optimal level in the absence of adequate nutritional status.
We always go back to our basics after weight loss surgery of hydration, protein and exercise to maintain health of body and hair.
Mission Statement
August 14, 2014 1:15 pm
Mission Statement for Central Valley Bariatrics and Dr. Ara Keshishian “The best patient that I can have is the most knowledgeable patient”
This is one of the “lines” that I use during my teaching and consultations sessions. I firmly believe that a patients should have all the pertinent information before they decide to proceed with a treatment plan. Be the treatment is medical in nature or surgical the patient needs to have all the scientific facts before an informed decision is made.
Part of my duty is to provide the information in a scientific and concise fashion in non-medical terms. Additional resources, such as this blog, FB group (The one managed by our office, and those maintained by others) along with the Webinar hosted by us, all serve to complement each other for providing a forum for exchange of information.
The value of information exchanged between patients can not be underestimated. Patients who have walked the path can provide a much more practical experience that I can ever share with a patient. The information shared between patient can and should carry a wider range of topics. It is to be noted however, that no information exchanged between patients should replace the advice of a patients’ surgeon.
For most of us that offer weight loss surgery, we realize that there is a lot more to the care of our patients that just to “cut” and hope for the best! The best outcome is dependent as much on the follow up care as it is to the surgery itself.
I personally believe that the care should be compassionate, respectful, caring and professional. There is no reason why the advice given should include disrespectful, or otherwise demeaning comments, suggestions or innuendoes. These have always been the guiding principals based on which we will conduct our practice on the Facebook, our blog and in person. No one, be patients, my office staff or myself should tolerate any personal threats, foul language or disrespect. For those who may see values to demeaning and inflammatory discussion tones, I wish you the best in other venues.
Ara