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Category: Weight Loss Surgery

Shared Success Story- Brad P.

January 29, 2015 9:53 pm

Before and after Duodenal Switch
Before and after Duodenal Switch
From Fat to Fine – Becoming half the man I used to be!
I started life big – 11lb 13oz to be precise.  From that point, I just grew.
I was the tallest and biggest kid in my class.  I was picked on for my size, but I learned to live with it.  Growing up on a farm, I was active, but never at a loss for a big meal and good food.  Couple that with two war brides as grandmothers, I always cleaned my plate.
I graduated high school well over 350lbs, but at 6’6” I wore it well.  Then before I knew it, I found myself over 450 lbs through most of my 20’s.  I knew this was not sustainable, and albeit I was healthy overall, I tired easily, and wasn’t able to do the things that I used to be able to do.   Everyone told me that I ate too much, and I felt that I was constantly watched whenever I would order food.
I tried everything… I went to the gym five days a week for an hour and a half… lost 12 lbs over 6 months.  Did every diet imaginable- Slimfast, Medifast, Adkins… Even entertained bariatric surgery once in my mid 20’s, but I just saw too many people gain it back afterwards.   During this time my weight fluctuated, and my doctor kept on telling me it was because I ate too much.  Was this the case when I spent six months eating 1200 calories a day?  I think not.
Fast forward to being 495 lbs at 28 years old with a new baby and diabetes on the horizon.  Through researching various options available to me, I learned about the Duodenal Switch.   My wife was interested as well, since she spent most of her life in the same boat as me.  As we researched it, we couldn’t believe that the chances of regain were much less compared to other weight loss surgeries and with the fact that I would be able to partake in the foods that I loved (in moderation of course) post recovery almost confused me.  Could this be real?  You mean I can eat bacon and meat and the normal things that I grew up on in moderation and still be healthy?  This can’t be true! 
 
I met Dr. Keshishian through a local support group.  On his advice, I met with other doctors who performed the same procedure, but I came right back to him.  My wife had her surgery performed June of 2013 (You’ll learn about her soon) I had mine six weeks later on July 22nd.  Eleven months later, I went from a size 54 waist and 5x shirts to XL Shirts and a 38 waist.  But that’s not the most important part.  I’m healthy.  I have the energy to chase my three year old daughter around, and for once in my life, I finally feel like I’m part of the group.  If you are in a position to lose a great deal of weight, the Duodenal Switch is the ONLY way to go.
Surgery Weight: 485
Current Weight: 265
Brad P.
Bakersfield, CA

Congratulations Brad on all your success and weight loss!  You have accomplished a remarkable transformation!

Hernia Repair And Weight loss surgery

December 22, 2014 3:35 pm

Patients having weight loss surgery (WLS) either primary or revision are sometimes also diagnosed with having a hernia.  Whether a hernia can be repaired concurrently with WLS or not, depends on the type of the hernia and also type of weight loss surgery.

The 2 most common hernias encountered in weight loss surgical patient’s are  1.Ventral (incisional),  or 2. Hiatal hernias. Ventral hernia refers to defects or weaknesses of the abdominal wall.  If this involves a previous midline incision then an incisional hernia is diagnosed.   These hernias may present with any or all of the following findings; protrusions or bulging of the anterior abdominal wall tissue through the abdominal muscle cavity, abdominal pain, and nausea and/or vomiting.

Hiatal hernias are located inside the abdominal cavity at the junction of the esophagus and the stomach at the level of the diaphragm.  This condition is where the upper portion of the stomach this is usually located in the abdominal cavity has migrated through the esophageal hiatus into the chest cavity.  These hernia’s usually present with reflux, episodes of nausea and are quite frequently seen in patients with experienced complications of the LAP-BAND.

The surgical treatment of these hernias are very different:

Ventral hernia repairs may require mesh placement. There are different mesh products that are available.  Some are made with non absorbable material  and other are absorbable- biologic material that last long enough to allow incorporation by the patients own tissue.  In general, when a mesh is used, the incidence of hernia recurrence goes down significantly. However,  there is an increase in complications associated with the use of mesh.  These may include infection of the mesh, indications of synthetic material, and serum and rejection indications of non synthetic material.   To add another layer of  complexity, when the hernia is encountered at the time of weight loss surgery, especially when the GI track  has to be opened ( in the case of duodenal switch, revision from a failed gastric bypass with a duodenal switch)  then it is recommended that no mesh be placed because of the high incidence of mesh infection or the associated complications.  In extreme cases where the abdominal wall cannot be closed, biologic meshes may be used with the understanding that a repeat hernia repair may be required at a later date.

In my practice, Hiatal hernias are always repaired at the time of the weight loss surgical procedures.   Depending on the type of the weight loss surgery the patient has had previously, the type of the hernia repair, and whether or not a mesh needs to be utilized, and the amount of stomach and fundus remains for the repair, will dictate how the Hiatal hernia is repaired.

Additional information regarding hernias in a newsletter.

Holiday Survival Tips by: Marylin Calzadilla, Psy.D.

November 17, 2014 8:23 pm

The holidays are almost here, and it’s a time of year that traditionally involves spending much time with loved ones as well as engaging in one of America’s greatest pastimes, eating.  For the most people, holiday memories are strongly tied to traditional dishes and treats – turkey and ham, stuffing, mashed potatoes, and pie.  But for those who have had weight loss surgery, or even if you are simply trying to be conscious of your health and weight, it is important to step back and think about the holidays from a different perspective.  Below are six ideas not only for survival but for success this holiday season.    

 

REFLECT

Think about what the holidays truly mean for you, and take the time to ask yourself what you want from this holiday season. Most of us get caught up in the rat race and never really stop and think what it’s all about. Vast amounts of money are spent on marketing campaigns aimed at luring us into shopping malls and grocery stores to buy the  “indispensable” items of the holiday.  Rather than get caught up in the hustle and consumerism of the season, I encourage everyone to stop and ask themselves what they’re truly wanting from the holidays.  For some it may be spending time with those they care about, for others it may be to take time for oneself.  Write down your goals on an index card and post it in a prominent place at home or at work as a reminder of what your holidays are going to be about this year.

SUPPORT, SUPPORT, SUPPORT

Tap into your support network. We know that strong, available support networks are key to long-term weight loss success. Often we are afraid to ask for help as if requesting assistance were symbolic of weakness.  Often we have a double standard when it comes to support. We like helping others yet dislike asking others for help.  Just as it feels quite rewarding to help someone that you care for, let the individuals in your life be there for you.  Allow yourself to talk about your feelings, share your experiences, both positive and negative.    There is also no better time to attend support group meetings.  You can gain extensive comfort being around those facing similar issues. You can also learn from their mistakes as well as their successes.

ALLOWANCES

It’s difficult to achieve success if you feel deprived all the time. You may want to think about the dishes that are truly special to you and allow yourself to consciously indulge in a treat, if it’s appropriate for your level of post-operative diet. If you look forward to Aunt Marie’s delicious sweet potato pie every Thanksgiving, then allow yourself to enjoy this once-a-year tradition.   Don’t tell yourself you will never be able to eat your favorite foods again. The bottom line is that long-term success with weight loss is about quality and quantity.  Allow yourself to savor each and every bite, and remember portion control.  Also strike a deal with yourself to manage any extra calories you’re taking in with increased exercise or careful eating on other days.

KEEP ACTIVE

Make a realistic exercise plan and stick to it. It’s easy to forego exercise during this busy time of year, but you shouldn’t compromise on your health. You will be spending more time around food and probably consuming a little more than you typically do.  Sticking to your exercise routine will help you to indulge without feeling guilty and will allow you to get through the holidays without losing your hard-won progress on your weight loss.  Plus, exercise will help you keep your energy and endorphins up so you can get everything done and feel good while you’re doing it. 

CREATE

Spend some time researching new bariatric friendly recipes.  You might actually really enjoy the process, and it’s also an opportunity to introduce some healthy alternatives to friends and family. The truth is, everyone is thinking about smart food choices these days, and people will appreciate a tasty, healthy alternative to the usual holiday fare.  At the very least if you prepare a nutritious side or appetizer for a social gathering, you’ll know that there will be at least one healthy dish for you to eat.

PLAN ACTIVITES

Most holiday time is spent around the kitchen and the dinner table, but don’t be afraid to change it up.  Create some fun activities your guests can engage in. Some friends of ours host a karaoke contest after their Thanksgiving meal. Other families go out for a walk, play charades, or even have contests on the Wii, Xbox, or any other home gaming system.  Don’t be afraid to create a new tradition that gets everyone laughing, moving and having a good time.     
Integrating some of these ideas can help keep you, your goals and the holiday season on track, healthy, and happy.  All of the above tips may need to be adjusted depending on your situation and post surgical status.Best Wishes,
Marylin Calzadilla, Psy.D

 

Laboratory Blood Specimen Collection Change

October 30, 2014 5:20 pm

Older and Newer Blood Specimen Tubes

No one likes surprises at the lab when you are about to get your blood drawn. The picture above is of the older vacutainers blood specimen tubes and a new type of tube that is being introduced. There is currently a change over of blood specimen tubes in laboratories across the country.  Locally we are seeing the use of SARSTEDT tubes/syringes.  This change over is for several reasons. First and foremost is to reduce blood bourne pathogen exposure due to needle sticks and tube breakage. However, these blood specimen tubes offer some additional benefits, especially to people who frequently have lab draws. One of which is the ability to use aspiration of the specimen to decrease the incidence of hemolysis.  Hemolysis skews laboratory studies and damages the red blood cells in the collected specimen causing the need for repeated testing.  Aspiration is also easier on fragile veins due to the decrease pressure versus vacuum. The SARSTEDT tubes are versatile in that they can also be used as a vacuum tube if needed.

Hope this knowledge will alleviate at least some anxiety on your next trip to the lab for your blood draws.  Remember that follow up laboratory studies after weight loss surgery is a lifetime commitment that ensures your health and adjustment of vitamins and supplements.

Weight Loss before Weight Loss Surgery?

October 19, 2014 2:54 pm

I am frequently confronted by the question “Are you going to make me lose weight before I have weight loss surgery”? My answer is no, for several reasons, it makes little or no sense and there is scant scientific data to support it.

1-Anatomical and 2-psychological-behavior related variables have been suggested as the reasoning for the recommendations for diet before weight loss surgery.

Let’s see what the scientific evidence says about this.

1-Liver can be divided into two anatomical lobes. The tail end of the left lobe may extend all the way to the upper left side of the abdomen covering the upper 1/3 of the stomach,  the gastro-esophageal junction (GEJ) and the esophageal hiatus. It was suggested that the access to the GEJ could be made easier, if the left lobe of the liver was smaller.

“A decrease in the size of the liver by 18% was shown in patients who were subjected to a very low-energy diet for 12- weeks.”  This was published by Colles et.al in a small study of 39 subjects.

Weight Loss before Weight Loss Surgery?

It is important to appreciate that this reduction in liver size meant that a patient would have to tolerate an ultra low caloric diet (less than 500/day) for 12 weeks. The interesting observation was that even with this reduction in the size of the liver there was “… no difference shown in morbidity, mortality, hospital stay, and decrease in morbidity- associated diseases whether there is preoperative weight loss or not.”

Weight Loss before Weight Loss Surgery?
Weight Loss before Weight Loss Surgery?

2-Behavior modifications have been entertained as a necessary element to the success of adjustable gastric banding. Numerous studies have shown that there is no predictive value of preoperative weight loss in relation to the weight loss after surgery.

Weight Loss before Weight Loss Surgery?
Weight Loss before Weight Loss Surgery?
Weight Loss before Weight Loss Surgery?
Weight Loss before Weight Loss Surgery?
Weight Loss before Weight Loss Surgery?
Weight Loss before Weight Loss Surgery?

The overwhelming scientific data suggest that there is no value to subjecting a weight loss surgical patient to a pre-surgical ultra low caloric diet.
“The California Department of Managed Health Care recently conducted a review of weight loss prior to bariatric surgery and concluded that “there is no literature presented by any authority that mandated weight loss, once a patient has been identified as a candidate for bariatric surgery, is indicated. This comprehensive review states that mandated weight loss prior to indicated bariatric surgery is without evidence-based support, is not medically necessary, and that the risks of delaying bariatric surgery are real and measurable.” Published by the American Society for Metabolic and Bariatric Surgery in March 2011.

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.

hair-2Bcycle
Hair cycle

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.

Hair loss pattern from telogen effluvium
Hair loss pattern from telogen effluvium

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.

Orthostatic Hypotension/Intolerance

August 26, 2014 4:02 pm

One of the possible side effects of rapid weight loss after undergoing weight loss surgery is orthostatic hypotension or orthostatic intolerance.  These terms describe a significant drop in blood pressure  upon standing from a seated or reclined position.   Drip in blood pressure causes a decrease in blood flow to the brain. There are several studies discussing this after RNY gastric bypass and sleeve gastrectomy.  However, this can also be an issue post Duodenal Switch. The process is still not completely understood but can be due to several factors.  Rapid weight loss, sympathetic nervous system dysfunction, dehydration, electrolyte imbalance, malnutrition, thyroid issues, cardiac issues, post prandial hypotension (blood pressure lowering after meals due to blood flow shifting to the gut) or medications are all suspected as possible causefor orthostatic hypotension.

Symptoms can include dizziness, lightheadedness, nausea, blurry vision, weakness, fatigue, palpitations, headache, exercise intolerance, intermittent confusion and can culminate to passing out. This can be diagnoses with blood pressure monitoring while positioning change, ECG, laboratory studies, echocardiogram, tilt table test and possibly Valsalva maneuver.

There is a direct link between obesity and hypertension. A large number of patients undergoing weight loss surgery are on anti-hypertension medications.  Patients need to be followed closely in the hospital and in the rapid weight loss phase post surgery for medication changes and eventually termination of anti-hypertensive medications. Follow up and monitoring with a primary care physician is crucial due to these rapid changes.

Dehydration, anemia, and low protein intake need close surveillance after weight loss surgery.  The patient may require laboratory studies to investigate these causes.

Treatments may include increasing hydration, protein intake, changing medications and treating anemia.  Also, allowing time for the body to adjust to the rapid weight loss if all the underlying issues are within normal limits.  If symptoms persist, after all underlying issues are investigated, the patient will need to be diligent with hydration, protein intake, supplements and other treatments.  Things that may also help is to slow down in moving from one position to the other, take a moment to adjust to your new position.  Compression stocking and increasing salt intake can also help if all other causes are investigated. Post prandial hypotension can be avoided with low carbohydrate and small meals. Also, moderately increasing salt intake can improve symptoms.