The difference between causation, coexistence, and correlation
Causation refers to a condition causing an effect.
Coincidence refers to two conditions present together at the same time, with neither causing the other.
Correlation refers to two conditions that may occur together, with no causation.
Study size refers to the research data on which the information is based. The larger the population size studied, the better the sample data and the more conclusive the results.
Confounding factors.
As I stated before, there is no clear evidence that cholecystectomy causes bile reflux gastritis. That does not mean that patients with bile reflux gastritis have not had a cholecystectomy.
Bile reflux is commonly seen after cholecystectomy, and yet only some develop bile reflux gastritis, why?
Those afflicted with this difficult condition are likely dealing with contributing factors as well, which should not be ignored and addressed.
Let’s discuss the publication:
The Prevalence of Bile Reflux Gastritis Following Cholecystectomy: A Meta-Analysis and Systematic Review.
If we read past the title and conclusion, all of the points 1-4 noted above are outlined, addressed, and discussed in the provided publication.
This study is very small and limited. The review article is based on 135 patients from hundreds of articles that they reviewed from multiple sources, between 2000 and 2004.
In the introduction, the authors clearly indicate that the “…loss of storage function…, loss of neuro hormonal responses causing motility changes in the upper GI may lead to duodenogastric reflux…” They further state that “The mechanism leading to bile reflux following cholecystectomy is not fully understood.” The authors state that cholecystectomy may increase the risk of bile reflux gastritis, but other factors, such as H. pylori, diabetes, motility dysfunction, hormonal changes, and the Sphincter of Oddi, may also be risk factors.
There is no causation, only correlation and coexistence. To be clear, bile reflux gastritis is common after cholecystectomy, but not clear whether it is caused by it.
This leads to a discussion of prevalence and incidence. The prevalence of bile reflux gastritis in a support group for the condition is extremely high, but the incidence in the general population is very small. The authors clearly state that the prevalence is nearly 50%.
Patients who develop bile reflux gastritis may have other contributing factors that should be evaluated. There is no clear evidence that cholecystectomy causes bile reflux gastritis, even though there is a higher incidence than in the general population. This distinction suggests that other risk factors may contribute to the onset of bile reflux gastritis, in addition to cholecystectomy.
There are 4 parathyroid glands which are located behind the thyroid gland, among other functions, are the main regulators of calcium, phosphorous, and magnesium in the blood. Elevations of parathyroid hormone (hyperparathyroidism) can be: 1-Primary, 2-Secondary, 3-Tertiary
Primary hyperparathyroidism means the parathyroid glands themselves are hyperactive. This may involve only one of the four glands: a) an adenoma, a benign tumor that needs surgical removal, or b) hyperplasia, when all 4 glands are hyperactive and/or enlarged, and in some cases, most of the 4 glands need to be removed.
Secondary hyperparathyroidism means that the elevated PTH level is caused by an external regulatory stimulus, such as low calcium, which itself may be due to low vitamin D, low calcium intake, or other causes.
Tertiary hyperparathyroidism is seen only in specific renal failure and transplant patients.
Regardless of the type of hyperparathyroidism, the end result is the same. Because the parathyroid gland aims to maintain normal calcium levels, it will do everything to achieve them. This includes increasing calcium absorption from the GI tract, breaking down bone to increase the blood calcium supply, and increasing calcium reabsorption from the urine.
Distinguishing between primary and secondary is critical, as primary is more likely than not a surgical problem that needs to be addressed. Secondly, it may be responding to metabolic deficiencies (low CA, low Vitamin D) that need to be corrected and take some time.
Not all cases require surgical intervention, as labs (vitamin D, calcium, and alkaline phosphatase) and imaging studies, such as neck ultrasound, CT scan, and Sestamibi scan, provide the information needed to dictate the treatment plan. Please stay up to date with your yearly lab results to catch changes sooner rather than later.
After weight-loss surgery, some patients may experience a transient elevation in liver function tests that resolves over time. We have previously reported on this. IT is essential to distinguish between the Duodenal switch and the SIPS/SADI procedure, where some patients are led to believe they are identical. These procedures differ physiologically, and their weight loss and metabolic behaviours vary significantly.
Other than the stress of the weight loss, obesity, and comorbidities of obesity, there may be other anatomical post-surgical causes for elevated liver function test. This has also been discussed extensively.
A recent literature review supports the protective effects of vitamin D supplementation.
Elevated liver enzymes may be caused by many factors, including nutritional deficiencies, excessive supplementation (turmeric), medications, alcohol, adhesions causing partial bowel obstruction, and increased enterohepatic bile reabsorption . I would be very cautious about associating vitamin D supplementation with elevated liver function test results, even if the vitamin D level is in the very high normal range, regardless of the daily dose (much less frequent with injectable).
Endoscopic sleeve gastroplasty (ESG) differs from Laparoscopic sleeve gastrectomy (LSG).
ESG (Endoscopic Sleeve Gastroplasty) is promoted and advocated as a low-risk, equal alternative to the Laparoscopic Sleeve Gastrectomy, but it is not.
Anatomically speaking:
Endoscopic Sleeve Gastroplasty is an endoscopic procedure performed under general anesthesia. During this procedure, a specialized endoscope is inserted through the mouth into the stomach. Multiple plastic “H”-type anchors are used to create a fold in the stomach, thereby reducing its size. No part of the stomach is removed. Initial limited weight loss occurs as the patient feels full after consuming small volumes of food. This effect resembles what happens with the lap band and gastric balloon, and we know how the story ends with those.
LSG is performed laparoscopically with incisions on the abdomen under general anesthesia. Seventy-five to eighty-five percent of the stomach, along its greater curvature, is removed, eliminating the part of the stomach that produces the Ghrelin hormone, which controls and modulates hunger. This is why patients feel fuller with a smaller volume of food and experience significantly reduced hunger.
Results:
Please read the fine print
The summary results indicate
“Our results suggest that ESG is safe and effective for the treatment of obesity, with durable
long-term results for at least up to 5 years after the procedure. “
When you look at the details of the results, however, it states:
“At 5 years, mean TBWL was 15.9% (95% CI, 11.7-20.5, p < .001) and 90 and 61% of
patients maintained 5 and 10% TBWL, respectively.”
This means that five years after ESG, 90% of the patients have only lost 10% of their TBWL (total body weight loss), and 61% would have lost 10% of their TBW (Total Body Weight).
This serves as an illustration of how actual outcomes are obscured within the fine print, resulting in a lack of attention from individuals seeking the optimal outcome devoid of perceived risk. The same principle applies to the ongoing discourse regarding GLP-1 medications. The genuine risk associated with ESG and PLG-1 is that patients have undergone alterations to their anatomy and physiology without demonstrable results. Several years into contemplating a treatment promising sustained outcomes, we find that the alterations have increased the overall risk.
As a surgeon, I encourage people to always ask questions and demand that scientific proof be provided. I am not opposed to progress; considering the nature of our practice, we have witnessed and have unrgone significant evolution over the past 30 years, transitioning from performing open cases necessitating a hospitalization period of 4 to 6 days to performing the same cases laparoscopically and robotically in some cases outpatient procedures.
The gastrointestinal staplers simultaneously pass six rows of staples and cut in between them to create two secure lines of staples, three rows on each side. The staples come in different thicknesses and lengths for various applications. Staple cartridges that are used for colon surgery are usually thicker tissue staples than those that are used for small bowel stapling.
Different manufacturers have different color coding.
Another question I frequently get asked is, How does a stapler staple and cut at the same time? The stapler needs to be thick enough to not tear through the tissue and provide uniform pressure for control of bleeding and prevent leaks. It can not be too large either.
When stapling on the stomach for sleeve gastrectomy, the stomach wall thickness is different. We use different-sized staples to accommodate the thicker part of the lower stomach toward the thinner part of the stomach where it meets the esophagus.
Stapler and resulting discharged lines of staples.
Cheers! Let’s take a minute to look at alcohol metabolism. It’s that time of year when it seems we are going from one Holiday or Christmas party to another, and then we get together with the family and have a little more alcohol. The following diagram shows how alcohol metabolism takes place.
Alcohol is a caloric intake, and we all need to keep close tabs on it. Alcohol is very easily metabolized and the calories add up quickly. Every stage of alcohol processing in the liver involves the extraction of calories and free radicals, which are toxins. Excess calories not used in bodily functions can be stored as fat mass. Alcohol can be a roadblock in weight loss. Those drinks add up!
Here is a short video as a reminder while everyone waits to get ready for the next party.
Patients are frequently asked to explain why they take high fat- or water-soluble vitamin doses. They are have often been scared by their well meaning healthcare providers that their higher levels of vitamin supplements will end up with vitamin toxicity.
Let’s clarify one point: there is such a thing as too much vitamin.
However, the point that is often overlooked in teaching within professional schools (medical, nursing, pharmacy, etc.) and drug manufacturers is that recommendations are based on “how much to take” and not how much is needed to keep a patient’s blood level in the normal range.
This table highlights how toxicity is described and what requirements are recommended. Vitamin toxicity is seen rarely in post-weight loss surgical patients who take them proactively in as many doses as needed to get their blood levels in the normal range. I see more patients in the office who suffer from low vitamin levels, such as vitamin D and A levels (duodenal switch and sleeve), than any patient with high or toxic levels of any vitamins.
Not too long ago, I saw an old patient who had seen me years ago after having had a lap band placed for weight loss. At the time, I recommended that the lap band be removed and that alternative plans be made. I suspected a slipped band. We discussed the reality that after the band removal, weight gain is to be expected. Several surgical options were discussed, and the patient dismissed them as “too radical.” The patient decided to “deal” with the ongoing nausea and vomiting since it was a small price to pay for the weight loss. I warned the patient that elective removal of the band is much safer than an emergency procedure in the middle of the night when it is least convenient. The patient did end up with an emergency lap band removal and was started on GLP-1 Agonists (Wegovy) because of the weight gain that followed the band removal. The side effects of the medication were debilitating, with nausea, dizziness, and fainting due to low blood sugar. The drug has all been stopped, and most, not all, of the side effects are resolved. The plan is to get this patient in a better shape and, reevaluate the esophagus and the stomach, and formulate a strategy based on the blood work, upper endoscopy, upper GI study findings and decide if the patient will be a good candidate for the Laparoscopic sleeve or the duodenal switch operation.
Here are my recommendations:
Patients should avoid lap bands. Those with lap bands, regardless of how they feel and whether they are having issues with them, should have the lap band removed immediately before they end up in the emergency room or have irreversible changes to the cells or function of the stomach and esophagus.
Patients who have the lap band removed will have less weight loss with the sleeve than those who have the sleeve as the primary procedure (the lesson here is that a less invasive, seemingly easy solution is much worse long term; more on this below). Lap Band patients should be revised to the duodenal switch, SPIS, SADI, or Gastric bypass if they have substantial weight to lose.
GLP-1 agonist medication should be avoided. It is not a solution to the underlying problem but a band-aid covering the metabolic derangement.
GLP-1 agonist medication needs to be taken long term, and there is no exit strategy– when the patients stop taking the drug, the weight comes back, in addition to the complication associated with it.
I have also heard that “if it were bad, then the FDA would not approve it.” well, let’s think about it: the FDA approved the Lap band and Phen-Fen, and we all know how these worked out.
There are no shortcuts, simple injections, or a pill for the complex, multifaceted condition of obesity. Advocating solutions with no long-term outcome, significant complications, and safety concerns is irresponsible.
A diabetic patient should take the medication LIFELONG to control their blood sugars, including the GLP-1 agonist class of drugs. The concerns are for these medications being used for the treatment of obesity
Radiology film of normal position and a slipped LapBand
SUMMARY: Buyers beware- those who choose to embark on the dangerous load of GLP-1 agonist medications should be prepared to deal with the short and long-term complications of the medication and its withdrawal. This is like the problems that are being seen with patients who choose to have a lap band because it was advocated as simple, reversible, and the Phen fen medication for weight loss with the associated cardiac complication.
I was asked if my opinion of SIPS-SADI has changed since ASMBS endorsed it.
Let me remind everyone that ASMBS also endorses Adjustable Gastric Banding. We know what happened to the story. Is anyone considering Lap Band, even though ASMBS endorses it?
I am a member of ASMBS. The endorsement of the ASMBS does not unequivocally validate the outcome of a procedure; it only states that is an available alternative.
As stated previously, patients should be clear that SIPS-SADI procedures are not Duodenal Switch operations. Any suggestion is misleading. The physiology of SIPS-SADI is very different than that of the duodenal switch operation. Complications are associated with them, as reflected by the revisions we do to convert them to a Duodenal switch with percentage-based measurement of the small bowel.
In our practice, we have had to revise SIPS-SADI to duodenal switch operation due to compilation such as bile reflux gastritis and inadequate weight loss.
Let’s discuss the publication:
The Prevalence of Bile Reflux Gastritis Following Cholecystectomy: A Meta-Analysis and Systematic Review.
If we read past the title and conclusion, all of the points 1-4 noted above are outlined, addressed, and discussed in the provided publication.
This study is very small and limited. The review article is based on 135 patients from hundreds of articles that they reviewed from multiple sources, between 2000 and 2004.
In the introduction, the authors clearly indicate that the “…loss of storage function…, loss of neuro hormonal responses causing motility changes in the upper GI may lead to duodenogastric reflux…” They further state that “The mechanism leading to bile reflux following cholecystectomy is not fully understood.” The authors state that cholecystectomy may increase the risk of bile reflux gastritis, but other factors, such as H. pylori, diabetes, motility dysfunction, hormonal changes, and the Sphincter of Oddi, may also be risk factors.
There is no causation, only correlation and coexistence. To be clear, bile reflux gastritis is common after cholecystectomy, but not clear whether it is caused by it.
This leads to a discussion of prevalence and incidence. The prevalence of bile reflux gastritis in a support group for the condition is extremely high, but the incidence in the general population is very small. The authors clearly state that the prevalence is nearly 50%.
Patients who develop bile reflux gastritis may have other contributing factors that should be evaluated. There is no clear evidence that cholecystectomy causes bile reflux gastritis, even though there is a higher incidence than in the general population. This distinction suggests that other risk factors may contribute to the onset of bile reflux gastritis, in addition to cholecystectomy.
