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Qualifying for Weight Loss Surgery

October 23, 2010 3:04 am

The National Institutes of Health (NIH) has set the criteria for qualifying for weight loss surgery. Most surgeons and insurance companies abide by these guidelines. Surgery should be considered for individuals who can show that dietary attempts at weight control have been ineffective and have a BMI greater than 40 or greater than 35 in the presence of comorbidities. If your BMI is between 35 and 39.9 your insurance company may require that that you also have at least one of the following obesity related comorbidities: sleep apnea, diabetes or hypertension. Check with your insurance company on their policy. Patients considering weight loss surgery should be well-informed and motivated with acceptable operative risks. The patient must clearly and realistically understand how their lives may change after operation and be able to participate in treatment and long-term follow-up. These guidelines apply to adults only.

BMI Calculator

Body mass index (BMI) is a measure of body fat based on height and weight that applies to both adult men and women. BMI does not differentiate between body fat and muscle mass. Therefore, body builders and people who have a lot of muscle bulk will have a high BMI but are not overweight. A BMI > 35 indicates you may qualify for weight loss surgery. Calculate you Body Mass Index (BMI) Free BMI Script by BMI-Club Waist circumference BMI Range Meaning < 18.5 Underweight 18.5 – 24.9 Normal 25.0 – 29.9 Overweight 30.0 – 39.9 Obese 40.0 – 49.9 Morbid Obesity > 50 Super Morbid Obesity

Obesity Comorbidities

To follow is a list of comorbidities (additional conditions or diseases) related to obesity which may help you in qualifying for weight loss surgery.

Family history of heart disease
Family history of stroke
Family history of diabetes
Family history of heart attacks
Hyperinsulinemia
Diabetes
High blood pressure
Coronary-artery disease
Hypertension
Migraines or headaches directly related to obesity or cranial hypertension
Congestive heart failure
Neoplasia
Dyslipidemia
Anemia
Gallbladder disease
Osteoarthritis
Degenerative arthritis
Degenerative disc
Degenerative joint disease
Recommended joint replacement from specialist
Accelerated degenerative joint disease
Asthma
Repeated pneumonia
Repeated pleurisy
Repeated bronchitis
Lung restriction
Gastroesophageal reflex (GERD)
Excess facial & body Hair (Hirsutism)
Rashes
Chronic skin infections
Excess sweating
Frequent yeast infections
Urinary stress incontinence
Menstrual irregularity
Hormonal abnormalities
Polycystic ovaries
Infertility
Carcinoma (breast, colon, uterine cancer)
Sleep apnea
Pseudotumor cerebri
Depression
Psychological/sexual dysfunction
Social discrimination
Premature death

For more information on the NIH qualifications for weight loss surgery: Gastrointestinal surgery for severe obesity. Proceedings of a National Institutes of Health Consensus Development Conference, March 25-27, 1991.

Vitamin D

October 23, 2010 1:01 am

Benefits of Vitamin D

– Builds strong bones and teeth. – Protects against virus infections such as the common cold. – May be stored in the liver and skin.

Best Absorbed Form

Cholecalciferol (D3)

Take With

Calcium

Information on Vitamin D

In supplements vit D is available in two forms, D2 ergocalciferol and D3 cholecalciferol. The two forms have traditionally been regarded as equivalent based on their ability to cure rickets, but evidence has been offered that they are metabolized differently. Vit D3 could be more than three times as effective as vit D2 in raising serum 25(OH)D concentrations and maintaining those levels for a longer time, and its metabolites have superior affinity for vit D-binding proteins in plasma. [44-46] As a result it is preferable to supplement with D3 cholecalciferol. According to the AACE/TOS/ASMBS Guidelines [51] for post-op Duodenal Switch patients in cases of severe vitamin D malabsorption, oral doses of vitamin D2 or D3 may need to be as high as 50,000 to 150,000 IU/day, and the more recalcitrant cases may require concurrent oral administration of calcitriol (1,25-dihydroxyvitaminD). It is very important to be aware that if you receive a prescription for a high dosage of vit D, like the 50,000 i.u., often these prescription vit D pills are for D2 ergocaliciferal, not D3, and they are usually an oil based pill which as a post op DSer we do not absorb well. For a 50,000 i.u. vit D supplement in dry form visit Vitalady.com Check with your surgeon for the suggested post-op daily supplementation. For more information on vit D from post op DSers see these two threads on the Obesity Help Duodenal Switch Forums. Vitamin D Very Low My Endocrinologist Called…

For more information on Vitamin D

Vitamin D in a New Light Vitamin D2 Is Much Less Effective than Vitamin D3 in Humans Understanding Vitamin D Cholecalciferol Studies on vitamin D3 and the intestinal absorption of calcium and other ions in the rachitic chick

Calcium

October 23, 2010 12:59 am

Benefits of Calcium

– It builds strong bones and teeth. – It helps in facilitating the movement of nutrients across cell membranes. – It helps prevent osteoporosis. – It is needed for muscle contraction, blood vessel contraction and expansion.

Best Absorbed Form

Citrate

Take With

Vitamin D

Don’t Take With

Iron, zinc and caffeine

Information on Calcium

The two main forms of calcium found in supplements are carbonate and citrate. Other forms of calcium in supplements or fortified foods include calcium gluconate, lactate, and phosphate. An acidic environment is required to absorb calcium (and vitamin D). Calcium carbonate neutralizes stomach acid and as a result the calcium (and vitamin D) are not absorbed well. Calcium citrate does not neutralize stomach acid so is more readily absorbed and as a result does not interfere with the absorption of vitamin D which is essential for the uptake of calcium into the bones. Calcium citrate is better absorbed in individuals, like post-op DS patients, who have decreased stomach acid. [52-54] Calcium citrate contains 21% elemental calcium. For more information on elemental calcium and understanding supplement labels see our Vitamin and Mineral Supplement Basics. Calcium absorption depends on the total amount of calcium consumed at one time and whether the calcium is taken with food or on an empty stomach. Absorption from supplements is best in doses 500 mg or less because the percent of calcium absorbed decreases as the amount of calcium in the supplement increases [47, 48]. Therefore, someone taking 1000 mg of calcium in a supplement should take 500 mg twice a day instead of 1000 mg calcium at one time. The most efficient absorption of calcium is dependent on the presence of vitamin D in the body and this is why you should take vitamin D with calcium. Check with your surgeon for the suggested post-op daily supplementation.

Caffeine and Calcium

Caffeine has a small effect on calcium absorption by temporarily increasing calcium excretion and may modestly decrease calcium absorption. This effect is easily offset by increasing calcium consumption in the diet [49]. Moderate caffeine consumption, (1 cup of coffee or 2 cups of tea per day), in young women who have adequate calcium intakes has little to no negative effects on their bones [50].

Suicide Risk

October 11, 2010 11:46 am

To follow are studies focused on suicide risk after bariatric surgery. Risk of Suicide after Long-term Follow-up from Bariatric Surgery. Tindle et al. Sept 2010 PubMed Abstract Full Article PURPOSE: Bariatric surgery is recognized as the treatment of choice for class III obesity (body mass index >/= 40) and has been increasingly recommended for obese patients. Prior research has suggested an excess of deaths due to suicide following bariatric surgery, but few large long-term follow-up studies exist. We examined postbariatric surgery suicides by time since operation, sex, age, and suicide death rates as compared with US suicide rates. METHODS: Medical data following bariatric operations performed on Pennsylvania residents between January 1, 1995 and December 31, 2004 were obtained from the Pennsylvania Health Care Cost and Containment Council. Matching mortality data from suicides between September 1, 1996 and December 28, 2006 were obtained from the Division of Vital Records, Pennsylvania State Department of Health. RESULTS: There were 31 suicides (16,683 operations), for an overall rate of 6.6/10,000; 13.7 per 10,000 among men and 5.2 per 10,000 among women. About 30% of suicides occurred within the first 2 years following surgery, with almost 70% occurring within 3 years. For every age category except the youngest, suicide rates were higher among men than women. Age- and sex-matched suicide rates in the US population (ages 35-64 years) were 2.4/10,000 (men) and 0.7/10,000 (women). CONCLUSIONS: Compared with age and sex-matched suicide rates in the US, there was a substantial excess of suicides among all patients who had bariatric surgery in Pennsylvania during a 10-year period. These data document a need to develop more comprehensive longer-term surveillance and follow-up methods in order to evaluate factors associated with postbariatric surgery suicide.

Economic Impact of Bariatric Surgery

October 10, 2010 1:45 pm

Articles highlighting the return on investment and economic impact of bariatric surgery. Economic Impact of the Clinical Benefits of Bariatric Surgery in Diabetes Patients With BMI >/= 35 kg/m(2). Klein et al. Sept 2010 PubMed Abstract ABSTRACT: The medical costs for a type 2 diabetes patient are two to four times greater than the costs for a patient without diabetes. Bariatric surgery is the most effective weight-loss therapy and has marked therapeutic effects on diabetes. We estimate the economic effect of the clinical benefits of bariatric surgery for diabetes patients with BMI >/= 35 kg/m(2). Using an administrative claims database of privately insured patients covering 8.5 million lives 1999-2007, we identify obese patients with diabetes, aged 18-65 years, who were treated with bariatric surgery identified using Healthcare Common Procedure Coding System codes. These patients were matched with nonsurgery control patients on demographic factors, comorbidities, and health-care costs. The overall return on investment (RoI) associated with bariatric surgery was calculated using multivariate analysis. Surgery and control patients were compared postindex with respect to diagnostic claims for diabetes, diabetes medication claims, and adjusted diabetes medication and supply costs. Surgery costs were fully recovered after 26 months for laparoscopic surgery. At month 6, 28% of surgery patients had a diabetes diagnosis, compared to 74% of control patients (P < 0.001). Among preindex insulin users, insulin use dropped to 43% by month 3 for surgery patients, vs. 84% for controls (P < 0.001). By month 1, medication and supply costs were significantly lower for surgery patients (P < 0.001). The therapeutic benefits of bariatric surgery on diabetes translate into considerable economic benefits. These data suggest that surgical therapy is clinically more effective and ultimately less expensive than standard therapy for diabetes patients with BMI >/= 35 kg/m(2). Medication utilization and annual health care costs in patients with type 2 diabetes mellitus before and after bariatric surgery. Makary et al. Aug 2010 PubMed Abstract OBJECTIVE: To examine the relationship of bariatric surgery with the use of diabetes medications and with total health care costs in patients with type 2 diabetes mellitus. DESIGN: We studied 2235 adults with type 2 diabetes and commercial health insurance who underwent bariatric surgery in the United States during a 4-year period from January 1, 2002, through December 31, 2005. We used administrative claims data to measure the use of diabetes medications at specified time intervals before and after surgery and total median health care costs per year. SETTING: Seven states in the Blue Cross/Blue Shield Obesity Care Collaborative. PATIENTS: Two thousand two hundred thirty-five patients with type 2 diabetes mellitus who underwent bariatric surgery. RESULTS: Surgery was associated with elimination of diabetes medication therapy in 1669 of 2235 patients (74.7%) at 6 months, 1489 of 1847 (80.6%) at 1 year, and 906 of 1072 (84.5%) at 2 years after surgery. Reduction of use was observed in all classes of diabetes medications. The median cost of the surgical procedure and hospitalization was $29,959. In the 3 years following surgery, total annual health care costs per person increased by 9.7% ($616) in year 1 but then decreased by 34.2% ($2179) in year 2 and by 70.5% ($4498) in year 3 compared with a preoperative annual cost of $6376 observed from 1 to 2 years before surgery. CONCLUSIONS: Bariatric surgery is associated with reductions in the use of medication and in overall health care costs in patients with type 2 diabetes. Health insurance should cover bariatric surgery because of its health and cost benefits. A Study on the Economic Impact of Bariatric Surgery Bushwald et al. Sept 2008 PubMed Abstract OBJECTIVE: To evaluate the private third-party payer return on investment for bariatric surgery in the United States. STUDY DESIGN: Morbidly obese patients aged 18 years or older were identified in an employer claims database of more than 5 million beneficiaries (1999-2005) using International Classification of Diseases, Ninth Revision, Clinical Modification code 278.01. Each of 3651 patients who underwent bariatric surgery during this period was matched to a control subject who was morbidly obese and never underwent bariatric surgery. Bariatric surgery patients and controls were matched based on patient demographics, selected comorbidities, and costs. METHODS: Total healthcare costs for bariatric surgery patients and their controls were recorded for 6 months before surgery through the end of their continuous enrollment. To account for potential differences in patient characteristics, we calculated the cost differential by estimating a Tobit model. A return on investment was estimated from the resulting coefficients. Costs were inflation adjusted to 2005 US dollars using the Consumer Price Index for Medical Care, and the cost savings were discounted by 3.07%, the 3-month Treasury bill rate during the same period. RESULTS: The mean bariatric surgery investment ranged from approximately $17,000 to $26,000. After controlling for observable patient characteristics, we estimated all costs to have been recouped within 2 years for laparoscopic surgery patients and within 4 years for open surgery patients. CONCLUSIONS: Downstream savings associated with bariatric surgery are estimated to offset the initial costs in 2 to 4 years. Randomized or quasiexperimental studies would be useful to confirm this conclusion, as unobserved characteristics may influence the decision to undergo surgery and cannot be controlled for in this analysis. The impact of weight reduction surgery on health-care costs in morbidly obese patients. Christou et al. Aug 2004 PubMed Abstract BACKGROUND: The treatment of obesity and related comorbidities are significant financial burdens and sources of resource expenditure. This study was conducted in order to assess the impact of weight-reduction surgery on health-related costs. METHODS: This was an observational two-cohort study. The treatment cohort included patients having undergone weight-reduction (bariatric) surgery at the McGill University Health Centre (MUHC) between 1986 and 2002. The control group included age and gender matched obese patients who had not undergone weight-reduction surgery from the Quebec provincial health insurance database (RAMQ). The cohorts were followed for a maximum of 5 years from inception. The primary outcome measure was overall direct healthcare costs. Secondary outcomes included cost analysis by diagnostic category for the treatment of new medical conditions following cohort inception. RESULTS: The cohorts were well-matched for age, gender and duration of follow-up. Patients having undergone bariatric surgery had significant reductions in mean percent initial excess weight loss (67.1%, P <0.001) and in percent change in initial body mass index (34.6%, P <0.001). Bariatric surgery patients had higher total costs for hospitalizations (per 1,000 patients) in the first year following cohort inception (surgery cohort = CDN 12,461,938 dollars; control cohort = CDN 3,609,680 dollars). At 5 years after cohort inception, average cumulative costs for operated patients were CDN 19,516,667 dollars versus CDN 25,264,608 dollars, for an absolute difference of almost CDN 6,000,000 dollars per 1,000 patients. CONCLUSION: Weight-reduction surgery in morbidly obese patients produces effective weight loss and decreases long-term direct health-care costs. The initial costs of surgery can be amortized over 3.5 years.

17 Year Old Bariatric Surgery Patient Jessy Inspires Others

October 09, 2010 1:47 pm

Meet one of the most inspiring Duodenal Switch patients. 17 year old bariatric surgery patient Jessy inspires others seeking a solution to obesity. Her weight loss surgery journey and her post-op transformation moves me to tears. At 11 months post-op Jessy had lost 129 pounds and posted stunning pictures of herself before heading out to her prom. “I danced all night tonight and don’t hurt at all!” She reminds so many of us of the courage and tenacity it can take to fight to have surgery and why we chose this path to embark on the journey towards improved health and enhanced quality of life. Jessy was just 17 when she had Duodenal Switch surgery July 11, 2009 with Dr. Marchesini in Brazil. She is no longer 17, is growing up and moving on with her life. Her story is worth the read.

Jessy’s Story in Her Own Words

My life since having Duodenal Switch (DS) surgery one year ago is absolutely wonderful. I mean that! It’s better then I could have ever imagined. All this time I’ve been thinking about being “one year out”. I was wondering if I should tell my back story, so here goes!

About 4 years ago my mom’s older brother was sent to Mississippi to a training camp because he was going to be deployed to Iraq once he was done. But while going from one training camp to the other his Humvee was hit from behind by a man high on drugs, my uncle and the man in the driver’s seat were instantly killed.

You may wonder what this has to do with anything, but this was a big part of me being able to get my DS.

After my uncle’s tragic death my mother received a call from my aunt (this was around the time that I was getting very serious about getting the DS) telling us that my uncle had left her just enough money to cover my weight loss surgery. To this day it saddens me that he died, but in a way he helped saved my life… without that money I would not have been able to get the DS in time. That funding came JUST in time. I was 16 years old and weighing in at 535 pounds, my body was completely broken. I always had this feeling, no matter how hard things got, no matter how scary, that I was not going to die at such a young age. It was not acceptable or believable to me.

I had gotten to the point where I could not turn myself over in my bed, I could not do anything. I felt like this gigantic burden to my mom and sister’s, my sister was a “pre-teen” and she was ashamed of me. I’ve always had confidence no matter how big I was, so I tried not to pay attention to those things. But it got harder and harder. I started to develop lymphedema in my legs. I had no idea what it was at the time, I went to a local ER and as soon as the doctor saw me he said “it’s just fat” and walked out.

I was so ashamed of my weight that I hadn’t gone to a PCP for a while, because the last time I did she did nothing but hurt me, emotionally. She blamed me for “trying to kill” myself by eating, my reply to her was “oh yeah, because I totally enjoy dying a SLOW PAINFUL death.” (HEAVY sarcasm) The last straw with her was when she told me that she would have a bet that I would die before I turned 20. She also refused to even let me think about WLS as an option because she said I “simply needed to stop eating so much” even though at that time I was on a STRICT diet (and she knew).

My mom finally convinced me to go to her PCP, and so out of desperation I agreed. He turned out to be a wonderful man who played a big role in me getting the DS. When I went to see him for the first time I had not been weighed in a very long time. I got on that scale and it read 500 pounds and I cried. I cried like I never cried in my life, when I saw that number it felt like I was looking death in the face. I cried and he and my mother sat with me, he was the first doctor to ever treat me kindly.

He looked me in the eyes and told me that there is something WAY more wrong with me then just “over eating” (he knew I wasn’t) and said that it would take something more then just over eating to get me to my weight I was at. I finally had met someone who understood; who didn’t blame and bash me, someone who knew that it was my body that was messed up, and not my mind! It was one of the best feelings in the world to meet someone who finally believed me, who finally saw my pain and frustration and who was just as puzzled as I was!

He himself only knew about the lap-band and the RNY (like a majority of the doctors) and so he told me that he supported me 100% in my pursuit of weight loss surgery (WLS) and that he would fill out every paper and do every lab I needed done, as soon as possible. At that time I only knew about the RNY and lap-band as well and so we submitted my paperwork to the only RNY surgeon in Alaska. And after we did, I had to wait.

I was sleeping when the RNY office called. My mom came down to me with a red swollen face from crying and hugged me and told me that the RNY surgeon’s assistant said they would not do my surgery and told me to loose 100 pounds and then come back to them. I lost all hope. That was the worst feeling in my life; loosing my hope. I remember sitting there and there was no feelings. I felt empty, then the rejection began to sink in and I felt the worst pain I’ve ever felt in my life, I knew that without WLS I was going to die and I felt like death was my only option left and I felt like I was just going to sit in my home and eventually just pass on.

For the next couple days after my rejection the only way I could get myself up in the morning was by promising myself that I would take my own life rather then succumb to my obesity. I already felt so ashamed for being the size I was, and I felt that I would be even more ashamed if I let obesity be my cause of death (and obviously it would have been). Looking back at that time in my life, how I promised myself that I would take my own life hurts me. I’ve never been one to feel like that, to say such a thing. I’ve always loved life no matter my size, but I had come to the realization that I would never get to enjoy a life at that size and I saw no reason to live anymore.

I would set my day to when I wanted to possibly end it all, and I would make a mental promise. But something, something kept me waiting. I would say “next Sunday.” and when Sunday came around I would say “next Tuesday.” and when that day came I would say another day.

But then one day I remembered the Obesity Help website, I hadn’t been on it in a while and so basically as a last straw when I went and posted about being rejected for RNY surgery and many lovely people came to my aid, and told me about this wonderful WONDERFUL weight loss surgery, Duodenal Switch! I am SO thankful to all those people everyday of my life; every single day. The more time I spent on the Obesity Help website and the more people that educated me about the DS, I began to get my hope back and that was one of the best feelings I have felt.

So from there on I did my research on DS and my hope grew and grew. I knew that I was going to have to travel for the DS because no one here in Alaska does it and I was ok with that. I took all the information I could find on the DS and showed my mom, and my PCP. Because of my age I needed them, I had to convince them. And I did.

The DS was all I ever talked about, I was on the Obesity Help website everyday reading all the success stories to my mom. Because we were on a budget and because of my age (which was annoying!) I started to look at out of USA options and I found Dr. Marchesini in Brazil. I talked to his past patients and I liked him more and more. I remember asking my mom what her reaction would be if I told her we had to go to Brazil for my surgery. Her answer was “NO WAY. I am not going out of the country!” But as we all know she ended up changing her mind lol!

I remember being worried about my size, being as big as I was I felt like no one would take me, such a high risk. Plus my age bothered some surgeons. But I began to talk to Dr. Marchesini through e-mails and he told me he would love to help me, and he’d love to do my surgery. And from there on I was set. I got all my paperwork done, and I waited. My surgery date was set for July 11th.

And so I have just been loving my DS ever since.

Now in my life I feel like I can do anything, I have high expectations for myself because my obesity is no longer holding me back as much. I am still pretty big but that’s ok, I know my DS is still working and I am still doing what I need to do. While I was at my biggest I wasn’t able to do school, so I did online classes, something happened with the home school program computer system and they lost my grades and refused to give me my credits so I am still in high school just finishing up my last year. I go to a public school now that I found right after getting home. It’s wonderful because at that time I was still healing, and I couldn’t go to a normal school everyday but this school has a flexible schedule and I love it.

I currently have straight A’s and I only have a couple classes to finish and I graduate!

Some WOW Moments:

Before surgery I wanted to be able to drive SO bad, but I could not fit. At one year post-op I am down 141 pounds and I now I fit and have my license!!!
I can wear regular size flats!! My feet no longer look pudgy and weird in flats! They look like normal people feet! I love flats!!
My younger sister and I share some clothing (she’s a lot smaller then me, but some things fit her lol! if that makes sense)
I go on a bike ride at least once a day, and go on walks all the time! I love them!
I can stand for so long now.
I can feel my knees. Before my sister use to tease me and saw “Wheres your knee cap Jessica??” and she would feel around and it was funny. She went to tease me the other day and was saying “Where’s….” and she said “WHOA! I can feel your knee cap! Ah….weird….I’m not use to feeling you all bony….this isn’t fun.” and we laughed so hard. I was so excited that I yelled “MOM! I CAN FEEL MY KNEE CAPS!!” and she clapped. Awesome.
I am now a size 9 shoe 🙂 I use to be a 10 or 11 wide. Now I’m just a normal 9.

Sept 2010 Update – Down 180 pounds since surgery

Jessy got her first job!

“I went in for the interview with two other ladies applying for the same position, I having no past work experience felt that I didn’t really have a chance. But going with my personality and my ability to learn fast and work hard I kept with it, went through the hour long interview, submitted my paperwork and waited. For the first time in my life I didn’t feel that my weight could or would hold me back. I didn’t go into that building worrying I’d be the biggest person there; I didn’t shoot myself down standing next to much smaller women. I had confidence (something I’ve always had) but I was also at peace with myself. The whole interview the thought “oh no I won’t get this job because I’m fat” never ran through my head like it would of.

Another amazing day living life with my DS.”

More WOW Moments:

All of the things above are amazing wow’s! But for me the one that tops them all was when I went with my mom to her doctor appointment (we have the same PCP) when he walked in and saw my weight loss he said “Holy sh*t” he then went on to say “excuse my language but you are a success! I haven’t had a weight loss surgery patient loose as much as you! Amazing!”
I got to play tag with my youngest sister the other day. We all went on a long walk and it was awesome!
2X shirts are on their way to becoming baggy!
My double chin is almost gone!

Jessy, we wish you continued success in your weight loss journey and look forward to continued updates.

Bowel Habits Post-Op

October 09, 2010 10:49 am

Clinical data addressing bowel habits post-op. Gastric Emptying and Postprandial PYY Response After Biliopancreatic Diversion with Duodenal Switch. Hedberg et al. Sept 2010 PubMed Abstract BACKGROUND: Super-obesity (BMI>50) is increasing rapidly. We use the biliopancreatic diversion with duodenal switch (BPD-DS) as one option in this patient category. The aim of the present study was to investigate the emptying of the gastric tube, PYY levels and dumping symptoms after BPD-DS. METHODS: Emptying of the gastric tube was investigated with scintigraphy after an overnight fast. Twenty patients (median age 43 years, BMI 31.1 kg/m(2)) having undergone BPD-DS in median 3.5 years previously were included in the scintigraphic study. A technetium-labelled omelette was ingested and scintigraphic evaluation of gastric emptying was undertaken. Ten of the patients also underwent PYY measurements after a standardised meal and were compared to nine non-operated age-matched normal weight controls, both in the fasting state and after the test meal. Frequency of dumping symptoms was evaluated in all patients. RESULTS: The half-emptying time was 28 +/- 16 min. Lag phase was present in 30% of the patients. PYY levels were significantly higher in BPD-DS patients as compared to controls both in the fasting state (p<0.001) and after the test meal (p<0.001). Dumping symptoms were scarce and occurred in 17 of the 20 patients only few times yearly or less. CONCLUSIONS: Although the pylorus is preserved in BPD-DS, the stomach emptying is faster than in non-operated subjects. PYY levels are elevated in the fasting state after BPD-DS and a marked response to a test meal is seen, likely due to the rapid stimulation of intraluminal nutrients in the distal ileum. In spite of this, dumping symptoms are uncommon. Bowel Habits after Gastric Bypass Versus the Duodenal Switch Operation. Wasserberg et al. Aug 2008 PubMed Abstract BACKGROUND: One of the perceived disadvantages of the biliopancreatic diversion with duodenal switch operation is diarrhea. The aim of this study was to compare the bowel habits of patients after duodenal switch operation or Roux-en-Y gastric bypass. METHODS: A prospective comparative case series design was used. Forty-six patients who underwent duodenal switch (n = 28) or gastric bypass (n = 18) were asked to complete a daily diary for 14 days after losing least 50% of their excess body weight. Data were collected on number of bowel episodes, incontinence, urgency, stool consistency, and awakening from sleep to defecate. Background variables were recorded from the medical files. RESULTS: The duodenal switch group was heavier (body mass index 53.5 vs 47.0 kg/m(2), p = 0.03) and older (47.5 vs 41.0 years, p = NS) than the gastric bypass group. Median time to 50% excess body weight loss was 22 months in the duodenal switch group compared to 10.0 months in the gastric bypass group (p = 0.001). Patients after duodenal switch surgery reported a median of 23.5 bowel episodes over the 14-day study period compared to 16.5 in the gastric bypass group (p = NS). There was no between-group differences in any of the other bowel parameters studied. CONCLUSIONS: Although duodenal switch is associated with more bowel episodes than gastric bypass, the difference is not statistically significant. Bowel habits are similar in patients who achieve 50% estimated body weight loss with duodenal switch surgery or gastric bypass.

Lecture at Glendale College

September 23, 2010 10:44 pm

Weight Loss Surgery: Benefits and Risks
Dr. Ara Keshishian, Bariatric Surgeon
Tuesday, September 28, 2010
12:20 to 1:20 in SB 243
”Weight Loss Surgery: Benefits and Risks” is a free lecture at Glendale
Community College to be presented on Tuesday, September 28 as part of
the monthly Science Lecture Series.

The lecture will be held at 12:20 p.m. in Santa Barbara Building room 243.

Admission is free and open to the public.

The speaker is a bariatric surgeon, Dr. Ara Keshishian. He is the medical
director of Bariatric and Metabolic surgery at Verdugo Hills Hospital and has
a private practice in Glendale, Ca. Dr. Keshishian will discuss the subject beyond the billboards, radio ads and TV commercials and explore the future of weight loss surgery and treatment of obesity.

Omega Fatty Acids

September 22, 2010 12:24 am

Fatty acids are a byproduct of fat metabolism. These are acids that are produced when fat is broken down in our body. Fatty acids are important in a number of metabolic functions in our body. They help move oxygen, keep skin healthy, prevent aging at a cellular level, promote weight loss by promoting cholesterol processing by the body, and prevent build up of plaques in blood vessels. Examples of different types of Omega fatty acids are Omega-3, Omega-6, and Omega-9.

Omega-3 and Omega-6 fatty acids are essential fatty acids (EFA) because unlike other fatty acids, our body is not able to make them. Omega-9 fatty acids can be produces in out body.

These EFA are involved more specifically in regulation of blood pressure, cardiovascular health and others.

I have looked and have not found any studies regarding any relationship (positive or negative) associating Duodenal Switch and Omega Fatty acids.

I would however make some educated guesses here: The fact is that the lipid profile improves significantly with the duodenal switch operation is known. The duodenal switch operation can be performed with limited or not gastrectomy to correct significant lipid disorders that are either non responsive to medical treatments, or in cases where the side effect of statin medications are debilitating.

With this known, I would guess that even if the Omega fatty acids are not absorbed as well at least some of the beneficial effects are not lost. I would recommend that a healthy diet be used to assure adequate absorption of EFA.

Ask Dr. K: Problems over the years

September 09, 2010 10:42 pm

There are numerous sources available on the internet for patients to search for information. The information that one can find ranges from scientific to anecdotal. Patients individually have asked me a number of questions and I will peridically address them in an “Ask Dr. K” newsletter. I would also like for my opatients to submit their questions by emailing it to me.

“Problems Over The Years”

Question:
“What are the main things we should be looking for “symptom wise” at 3, 5, 7, or 10, etc. years out. I’d like to know how the duodenal switch effects teeth? On hydration as I think my body pulls water from my stool when I’m not drinking enough. Actually – it’s not “enough” it’s that my body passes it out my kidneys if I am not sipping constantly throughout the day. Is that normal? Omega Fatty Acids – are we screwed? What do those deficiencies look like?”

Answer:
I do not know of any particular study that looks at the health of the
teeth specifically, however, I would assume that if a patient is not
complaint with their Calcium, or even complaint, and they are deficient
in minerals such as Calcium, Vitamin D, Magnesium, and others, then
one can develop poor teeth. Hydration is a very important issue. Surgery or not, most of us tend to run around a little “dry”. Constipation may be a side effect of inadequate water intake.
For the Omega fatty acids, see the next newsletter dated 9/22.

Question:
I would love to know what types of problems are seen in post operative patients and what the distributions are by years post-op.

Answer:
In very broad terms, I can classify them in both time frame, and in term of causes of complication (mechanical vs. nutritional). See table 1.

Please note that this is by-no-means a complete list, only a brief, very brief, overview of some of the potential problems that may surface. This list is not meant to be all inclusive or complete.

Table 1
Post operative Time Frame	Nutritional	Mechanical
Days	Dehydration	Leaks, abscesses, infection (urinary, pulmonary) DVT, PE, Wound dehiscence, Bowel Obstruction
Weeks	Dehydration, protein calorie malnutrition-acute	Wound infections, DVT, PE, Bowel Obstruction
Months	Protein Calorie Malnutrition, mineral deficiency, Kidney stones	Bowel obstruction, Cholecystitis (if your gallbladder not removed)
Years 1-3	Protein Calorie Malnutrition, mineral deficiency, Kidney stones	Bowel obstruction, Cholecystitis (if your gallbladder not removed)
Years 3-5	Occasional mineral deficiency, Kidney stones	Bowel obstruction, Skin Rashes (if applicable)
Years over 5	Occasional mineral deficiency, Kidney stones	Bowel obstruction, Skin Rashes (if applicable)

Deep Vain Thrombosis (DVT) Where a blood clot is formed in the deep venous system of the lower legs and can travel and block the flow of the blood to the lungs. If large enough in it a common cause of death in post operative patients. DVT’s are not the same as varicose veins.

Pulmonary Embolism (PE) A clot or a tumor that is dislodged from one part of the venous circulatory system and blocks the flow of the blood to the lungs. The most common source for the PE is a DVT.

Wound Dehiscence Complete or partial breakdown of the suture line at the deep layers where the bowel may become unprotected. In some cases this needs re-operation on an urgent fashion.