Category: WLS
Shared Success Story- Theresa & Rodney (Duodenal Switch)
August 05, 2017 8:41 am
Life before surgery seems like a lifetime ago for both my wife and I. Being extremely overweight is not only a burden on your general health but a burden on your lifestyle in general. You have the awful label of being called obese, or morbidly obese. This is such a wonderful word that makes you feel as if you have been judged a misfit in society. We were both overweight all of our lives and had done all of the diets known on the planet throughout the years. Some worked a little some not at all and we always found ourselves back to where we were before and usually larger than that. The main focus though as we were getting older was our health. For Theresa it was very difficult. Along with being over 400 pounds she had a severe case of asthma which caused her episodes where she felt she was going to suffocate. She also had very little muscle mass which made it very difficult to get up and down from seating or lying positions. Theresa had her surgery in February of 2014 and not a moment too soon. If she had done nothing it is a good chance that she was facing a horribly short future. She also has a slight heart murmur which did not bode well for a person with her weight. She did not have diabetes thank goodness but her A1C was on the rise as was her BP. She did have sleep apnea as well and had to have a CPAP machine.
I was also severely overweight, my highest weight was nearly 400 pounds and on surgery day I was 355 pounds. I was also under the illusion that I had more control over my weight and that once Theresa had her surgery I would just be able to diet and exercise my way to a healthy weight. I was able to do this in my younger years to a certain extent and I was naive enough to think I could continue to do so. How wrong I was. I had found that no matter how much diet and exercise I did my weight would drop a bit at first but then stall and I would have to essentially starve to lose any more and of course that just makes for a bad outcome. My A1C shot up to 7.6 and this was with 1000mg of metformin a day! My BP was very high with both numbers over 100, well over. This is with a high dose of BP meds. I had a severe case of sleep apnea and could not even consider sleeping without a CPAP machine with a high pressure. I have an artificial hip that was being burdened by my 350 pound plus frame and would probably need to be replaced sooner rather than later. My future was not looking good. Dying before I was 60 seemed like a reality for me and that is not the future I was hoping for. The decision to have weight loss surgery for the both of us was tough. You of course hear the nay sayers spout what a cop out it is and it’s the easy way out! You are just weak and just simply need to not eat hamburgers, French fries and donuts. Just stick with non-fat and low calories and you will reach the promised land. What a load of BS.
Once you wrap your head around the fact that your body is wired in such a way that it will always seek a higher weight every time you lose weight, it’s time to consider the type of surgery. Everyone has heard of the Gastric bypass and that seemed to be the path at the time of Theresa’s surgery. The thing about Theresa and what I admire very much is her persistence and her ability to research to the point where a decision is spot on. She looked at all of the four possible surgeries and quickly realized that the Duodenal Switch was a no brainer. It had the greatest measure of success in the long term as well as short term. Reading about the process and talking to others who have had the surgery it became clear that it was the right choice. Finding out where to go and have the surgery was a real challenge. We were lucky to find Dr. Ara Keshishian and have the ability to travel to his location to have the surgery.
Theresa’s Stats Rodney’s Stats
Surgery Weight: 410 Surgery Weight: 355 Pounds
Total Weight Loss: 215 pounds Total Weight Loss: 170 Pounds
Surgery Type: Duodenal Switch Surgery Type: Duodenal Switch
Surgery Date: February 2014 Surgery Data: May 2016
Surgeon: Dr. Ara Keshishian Surgeon: Dr. Ara Keshishian
Life after surgery is an amazing series of challenges, changes, and a journey that transforms your life in a huge way. For Theresa, it was freedom. Freedom from the overbearing weight she was carrying that kept her from essentially moving or doing anything but staying at home. We did very little outside of the house before surgery. Only the necessities of shopping and keeping up the house on the inside and out. Even that was difficult and went by the wayside all too often. Of course eating out was easier than going to the grocery store and that made the scale just go higher. After surgery, Theresa began to lose weight and you could see day by day the changes. After the first month, you could see a dramatic change not only in her look but the fact that she was moving again! She had dropped 35 pounds in that first month and it made a huge difference. As the weight kept coming off over the next few months we began doing things we have not done before. We started to do a lot of walking and a lot more things around the house that needed to be done. Shopping became a breeze and we ate out a lot less. The dramatic change was in her health. A number of changes for the better were happening on that front. The main one and a huge relief was the asthma. It simply was no longer there. She was no longer short on breath and was simply out moving me! I could barely keep up with her. She also had a bad case of psoriasis which before surgery she could do nothing about. Since the surgery it has disappeared. It might be due to the increased in vitamins, particularly the D vitamin. Her sleep apnea went away and now she is healthy and happy. It is almost difficult to describe the changes until you see them for yourself. For Theresa it has been a life changing experience that has transformed the both of us in ways we never imagined. Theresa eats a normal diet and after 3 ½ years post op she fluctuates about 5 pounds either way. It is amazing.
For me it was not what I expected. What I mean by that is, learning to eat is a challenge. With the Duodenal Switch you are not only eating less, but what you eat is tremendously important to the success of the transformation. With the other surgeries, Lap Band, Bypass and Sleeve you do not have the degree of malabsorption. You simply eat less and you lose weight, but you are still essentially “on a diet”. With the Duodenal Switch you have to consider the malabsorption and think protein first and for most. Once you get past the first month of eating small amounts and what you can while your innards heal you need to learn what to eat and is it enough protein. You may also have to contending with the fact that you have an aversion to foods you ate before. I, for one, could not even eat cheese, and chicken. I pretty much lived on scallops, crab, shrimp and protein drinks for the first three months. Nuts were also a good source of the protein when you get to that stage. This does change and things do go back to normal as far as the taste changes, but it takes a few months. The weight in that first month pretty much peeled off. I was dropping like a pound a day. It was incredible. You think that this is going to be a breeze and you will drop it all in no time! Then that 4 week somewhat of a stall occurs. From what I can tell, everyone experiences it in one form or another. It freaks you out because you start to think about the past where you would work your butt off and either gain or drop and ounce or two. But I was lucky, my wife had gone though it two years before me so she was there to explain that it was normal. The whole “this is a journey thing”, and she was right! At the time though I was listening to the negative voice in my head from the past. That is where the support from the many groups come in. You see that pretty much everyone has the same ups and downs and then your body gives up the farm and you drop a bunch of weight in a weeks’ time. There is really a lot of science behind it. Researching and reading about this particular surgery and how it works will benefit you while you go through the process. Another important thing we face with this surgery is the necessity of Vitamins. Thank goodness for my wife and the DS groups and of course my surgeon. You will not be without knowledge if you actively join the different groups and do your research on the vitamins. I am still learning about what my body needs and am looking forward to my labs in the next month to see where I may be deficient. I have also come to realize the importance of drinking water and avoiding dehydration. I never used to drink it much before the Duodenal Switch, but since the surgery I find it aids heavily in the success if you drink it and drink a lot of it.
To conclude this has been a journey and one I wish I could have done a lot sooner in life, but it is never too late. Today Theresa and I are at weights that we are happy with and our bodies are happy with. We are more active then we have ever been before together. No more days idle in front of the television with large amounts of fast food and drinks. That is what we used to look forward too. Now we cannot wait until we go out and do something. We are not running marathons or anything but we are active and enjoy being so. We no longer have the ailments we had before surgery. Theresa’s asthma is practically nonexistent, living in the northwest with fires in the summer she may have a bout or two. Nothing even close to what she has before and a simple inhale and its gone. Both of us no longer need a CPAP! The freedom to simply lay your head on the pillow and sleep is amazing and wonderful. All of the medication we had prescribed for us are gone as well. My A1C was 5 on my last set of labs and 5.3 on the one before that. Theresa’s is the same and has been for three years. BP is normal and my hip is holding steady. Oh, and another cool thing about it is you can actually shop for clothes anywhere! Your sizes will shrink but we have found we have become quite the clothes horses since losing all this weight. It makes it fun to be able to fit into a size you haven’t seen since who knows when.
Life is always a challenge for many reasons but to remove the burden of the weight simplifies things just a bit. It is a decision we will never regret and wished we had made a long time ago. We both owe our lives firstly, to having Duodenal Switch surgery. Secondly, and most important – was in seeking out the best surgeon we could find, and that was without a doubt, Dr. Ara Keshishian. As a surgeon he is thorough, meticulous, constantly learning and keeping up on the latest research;as a person he is easy to talk to, very approachable, and genuinely cares about his patients before, during and after the surgery process. We could not imagine choosing anyone else.
Bariatric Surgery effects on PCOS
May 17, 2017 11:02 am
Women with Polycystic Ovary Syndrome (PCOS) often feel hopeless and depressed with their diagnosis. Bariatric Surgery improves metabolic syndrome, diabetes resolution, cardiac improvement, quality of life, and increased life expectancy. Bariatric Surgery effects on PCOS are positive in many aspects. However, there isn’t a consensus regarding recommendation for bariatric surgery for PCOS other than morbidly obesity with co-morbities.
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, such as Type 2 Diabetes, higher depression and anxiety, increased cardiovascular risks, stroke, hyperlipidemia, sleep apnea, overall inflammation, and endometrial cancer.
Bariatric surgery can improve several issues related to PCOS such are Type 2 Diabetes, lower weight, sleep apnea, infertility, and hyperlipidemia. Duodenal Switch has the highest rate of Type 2 Diabetes resolution of all weight loss surgeries available at this time. Duodenal Switch also significantly improves hyperlipidemia.Weight loss surgery has been shown to improve and in some cases resolved PCOS in general. A recent meta-analysis of the effects of bariatric surgery in more than 22,000 procedures found an average weight loss of 61%, associated with the complete resolution or improvement of diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea in more than 60% of the patients. Another study looked just at PCOS patients and their metabolic improvement from 47% of the PCOS population to only 21% post Bariatric Surgery.
Several recent article have described how Bariatric Surgery effects PCOS with positive aspects related to fertility. The range of improved fertility in post Bariatric PCOS patients is a wide range of 33-100% with in the literature. It is thought that the loss of fat mass improves hormone levels and insulin resistance in PCOS and has a positive effect on fertility. One study of only 6 omen had a 100% improvement of infertility. American Society of Metabolic and Bariatric Surgery as well as the American College of Obstetricians and Gynecologist have a statement that bariatric surgery is should not be considered a treatment for infertility. The graphic below demonstrates the overlap of some of the symptomatology between PCOS, obesity and metabolic syndrome.
There are several documented positive effects and improvement in co-morbidilties related to PCOS post Bariatric Surgery. These include lipid profile, lower weight, cardiovascular risk, hypertension, and fertility. It is important to note that certain bariatric surgeries have better resolution of these co-morbidities or symptoms of PCOS. Always discuss with your physicians and surgeon what your options are and which treatments may work best for you.
In Summary, PCOS is a metabolic disease condition affecting different organ systems. Weight loss surgery should be considered as a viable treatment option and should be discussed with your OB/GYN and Infertility specialist.
Slipped Band Emergency
April 27, 2017 12:35 pm
A slipped Band emergency
This patient had a Adjustable Gastric Band (AGB) or LapBand place approximately 7 years ago. The last time this patients had a follow up with the surgeon who placed the AGB was 5 years ago. The patients has been having reflux, episodes of Nausea and vomiting on and off for about 2 years requiring multiple medical visits and procedures. He/she has had upper endoscopies, not by the surgical team and was diagnosed with esophagitis.
This patient presented in the Emergency Room with projective vomiting for 24 hours, bloody emesis, and significant dehydration. After obtaining the necessary tests and X-ray studies a plan was constructed. At this time, due to the continuous and significant nature of the symptoms this patient was taken to the Operating Room for emergency AGB removal.
The abdominal X ray showed a slipped band. Following a complicated surgical procedure, the band was removed and a segment of the stomach that had eroded into the stomach was removed. The photograph below shows the end result with a portion of the stomach removed due to the band’s erosion into the stomach.
Additional information regarding complications of Adjustable Gastric Banding here.
We have several Adjustable Gastric Banding related surgical videos here under the heading of
“Band Related”, including a slipped band emergency video.
Vitamin D status for Infertility Treatment
August 03, 2016 8:02 pm
Many people with obesity face infertility issues and seek infertility treatment or procedures. A recent article linked Vitamin D status to improved success rate of IVF (in-vito fertilization) & ICSI (interacytoplasmic sperm injection) in The Journal of Maternal-Fetal & Neonatal Medicine. It is important to check Vitamin D status for infertility treatment.
Here are the researchers results:
- Of the 252 females that completed the ICSI cycle, 42% became pregnant (n = 108).
- The mean vitamin D status was significantly higher in the pregnant group compared to the non-pregnant group (17.74 ng/ml vs 9 ng/ml, respectively; p = < 0.01).
- Vitamin D status was positively associated with both pregnancy (p = 0.001) and endometrial thickness (p < 0.01).
- Higher vitamin D levels was associated with a 21% increase odds of clinical pregnancy (p < 0.05).
The researchers concluded,
“Deficiency of 25-OHD in females hinders the accomplishment of optimal endometrial thickness required for implantation of embryo after ICSI.”
Following weight loss surgery (WLS) there can be improvement of fertility and for that reason we recommend two forms of birth control methods during the first 18-24 months following WLS or until weight loss has stabilized for several months. This helps to ensure the best outcome and health for the mother and infant.
In our office we continue to stress the importance of Vitamin D3 for bone and dental health, pregnancy, breastfeeding and several auto-immune diseases. Vitamin D has also been shown to reduce pre-term birth Duodenal Switch patients require a dry water miscible form of Vitamin D3 due to the fat malabsorption of the DS procedure. There are several past blog posts on the topic of Vitamin D and it’s associated nutrients.
Grandfather’s Obesity May Affect Grandchild’s Health
July 21, 2016 2:36 pm
A father’s metabolic health can be passed from generation to generation, affecting not only his children but more importantly his grandchildren, suggests a study. According to the study published in the journal Molecular Metabolism, parental obesity can have harmful effects on future generations. “A baby’s health has long been considered the mother’s responsibility as soon as she falls pregnant. Now, we’ve found powerful evidence, in a mouse model, that father’s nutrition and metabolic health can influence his sons and even his grandsons,” said Catherine Suter, Associate Professor, Victor Chang Institute. Read more…
Original research article here.
Revision of a Sleeve Gastrectomy or RNY
August 31, 2015 6:32 am
These are examples of two types of patients referred to us for revision surgery.
The first example is a gastric bypass that we revise to the duodenal switch operation. The upper GI series after the revision, shows a “banana shaped” stomach, the pyloric valve and the duodo-ilesotomy anatomosis component of the duodenal switch.
The second example, images noted below, is that of a sleeve revised to the duodenal switch – both operations done at different institution. Note how the stomach is not a “banana shaped” and more like a funnel with a narrowing at the bottom of the stomach- a stricture.
Informed Surgical Consent
July 18, 2015 9:39 pm
Surgical informed consent is the document that summarizes the discussion that has been carried out between the treating physician and the patient. It also outlines the expectations as well as the potential complications of the treatment being proposed.
An informed consent should mean that the patient is absolutely clear as to the procedure agreed upon and that is reflected on the consent. No abbreviations are allowed on the consent forms. Clearly, there are instances when a physician or surgeon providing service may have to deviate from the proposed plan and agreed upon procedure on the consent because of unexpected findings in the operating room.
Any patient undergoing surgery should be acutely aware of the terminology and the language used. With regards to weight loss surgical procedures, RNY and GB is not acceptable because they are both abbreviations.
Duodenal Switch is a distinct well described procedure with its unique identifiable code (43845 for open procedure) that is recognized by hospitals, insurance companies and the surgical societies.
Duodenal Switch operation is not SADI, SIPS nor a loop Duodenal switch. Any attempt to interchanges these terms or operations is inaccurate the say the least.
A surgical informed consent is signed by the patient ( or the guardian) and the treating physician. This document however is reviewed and confirmed by all those involved in the patient’s care delivered in the hospital. The consent is reviewed by the admission staff when taking the patient for surgery, preoperative nursing and administrative staff, operating room circulating nurse as well as the anesthesia staff. One step most patients may not be aware is initiated after the general anesthesia is induced. The operating room staff, anesthesia staff and the operating physician all go through a set of checklist known as “Time out”.
“Time out” involves confirming the patient’s identification as well as the proposed procedure as the patient had discussed with the staff and confirming the consent.
It is imperative that a patient have complete understanding of their surgical options available to them and critical that they have full knowledge of the type of surgical procedure that has been consented to and performed.
Iron Deficiency & Anemia July 15, 2015 Webinar Recording
July 16, 2015 1:52 pm
Vena Cava Filter
July 06, 2015 7:09 am
Example of a Vena Cava Filter Video:
Adjustable Gastric Band Removal & Hiatal Hernia Repair
April 21, 2015 6:30 pm
The band in place and after being taken down
The dissection of the wrap over the band that shows erosion


















