1-818-812-7222 Office Hours: Monday - Friday 9:00AM - 5:00PM
10 Congress St., Suite #300
Pasadena, CA 91105

Category: Duodenal Switch

Adhesions, Internal Hernia And Bowel Obstruction

December 15, 2018 2:35 pm

Adhesions are fibrous bands of scar tissue that form during the healing process. Following surgery, many people live normally with this scar tissue. However, they are also the cause of bowel obstruction when the adhesions form in such a way that causes a segment of the bowel to either get trapped, or form a “knot”. In both of those cases, the end result is a partial narrowing or a complete blockage of the intestines. This is called bowel obstruction.

Without treatment, the blocked parts of the intestine can die, leading to serious issues. However, with prompt medical care, intestinal obstruction often can be successfully treated.

Other causes of bowel obstruction:

  • In children, the most common cause of intestinal obstruction is telescoping of the intestine (intussusception).
  • Intussusception telescoping of the interstine
  • Hernias — portions of intestine that protrude into another part of your body
  • Inflammatory bowel diseases, such as Crohn’s disease
  • Diverticulitis — a condition in which small, bulging pouches (diverticula) in the digestive tract become inflamed or infected
  • Twisting of the colon (volvulus)
  • Impacted feces
  • Colon Cancer
Adhesion band with trapped bowel

 

Internal Hernia

In patients who haven’t Bariatric / weight loss surgery or an untouched GI track, bowel obstruction may manifest itself by symptoms of loss of appetite, constipation, nausea, vomiting, enlarged abdomen, abdominal pain, cramping, with no passage of gas or bowel movements.

However, patients who have had a weight loss surgery (Duodenal Switch, or the Gastric Bypass) because of the parallel limbs of the small bowel, the symptoms outlined above may not present. The diagnosis of a bowel obstruction, when suspected, should be identified with CT scan of the abdomen and pelvis with Oral and IV contrast. A CT scan with no oral contrast or water instead of oral contrast is inadequate and may lead to a delay in diagnosis and surgical intervention. Examples of Bowel Obstruction CT findings were discussed previously.

The treatment for an internal hernia and adhesions causing a bowel obstruction depending on the severity may range from observation to  surgical intervention in order to release the small bowel from the constraints of the adhesions.

GI Bleed following Weight Loss Surgery

September 17, 2018 10:28 am

Gastrointestinal (GI) Bleed following weight loss surgery is rare but does require knowledge of the particular bariatric surgical procedure the patients has and how to proceed with diagnostics to fully evaluate the situation. Acute or chronic gastrointestinal bleeding can cause anemia in patients. However, Anemia may also be caused by nutritional deficiencies (iron, vitamin , minerals), Kidney disease, bone marrow disease and others. The work-up for anemia following weight loss surgery follows a routine protocol. If there is an evidence of bleeding from intestine (bloody emesis, bloody bowel movement, “tar” like black bowel movements) then the diagnostic work up would include an upper and lower endoscopy.

Endoscopic Procedures:

Upper endoscopy Esophagogastroduodenoscopy (EGD): evaluates the esophagus, stomach and a limited area of the duodenum past pyloric valve.

Normal Anatomy
Normal Anatomy

Lower endoscopy Colonoscopy or coloscopy: evaluates the rectus and the entire colon.

Between these two tests, there is still a considerable amount of the small bowel that is not accessible or visualized with endoscopic procedures. For the small bowel, examination Capsule endoscopy is an option in an intact GI tract. Patients who have had Gastric bypass RNY or the Duodenal Switch, the large segments of the small bowel can not be visualized or examined with capsule endoscopy.

RNY Gastric Bypass
RNY Gastric Bypass
Duodenal Switch Two Anastomosis
Duodenal Switch Two Anastomosis
SADI-S Single Anastomosis Duodeno-ileal - Sleeve
SADI-S Single Anastomosis Duodeno-ileal - Sleeve

Patients who have had Duodenal Switch, Gastric Bypass and SADI – S would need a tagged red cell scan or CT angiography if GI bleed is suspected in areas of the small intestine that are inaccessible by endoscopic procedures.

Parathyroid Scan

July 09, 2018 11:48 am

A Parathyroid scan or Sestamibi scan may be needed if the typical weight loss surgical reasons for elevated PTH levels have been addressed. Sestamibi is a small protein which is labeled with the radio-pharmaceutical technetium-99. This very mild and safe radioactive agent is injected into the veins of a patient with overactive parathyroid and is absorbed by the overactive parathyroid gland. If the parathyroid is normal it will not absorb the agent. The scan below shows the uptake of the agent.

Calcium, Vitamin D and Parathyroid hormone are routinely measured on yearly follow up for most post weight loss surgical (WLS) patients. Elevated parathyroid hormone (PTH) may be caused by Vitamin D deficiency or calcium deficiency (most common in post WLS) or by over active parathyroid gland(s). In the latter case, if one of the four glands is overactive then this is knows as a parathyroid Adenoma. If all 4 are over active and are secreting too much PTH, this is known as hyperplasia. Ultrasound of the neck, may identify an enraged parathyroid gland (adenoma) which is located behind the thyroid gland. Given the large area where the parathyroid gland may be located, additional tests are needed to not only identify the location of the gland(s) but also to distinguish between single gland (adenoma) or multiple glands (hyperplasia) cause for the elevated PTH. It is important to investigate all avenues and testing in parathyroid hormone elevation and in some cases, not to rely on one test for your diagnosis. It is also imperative that weight loss surgical patients take their supplements routinely and consistently and have their laboratory studies followed at least yearly.

Parathyroid Scan

Calcium Lab Results

June 05, 2018 3:26 pm

Calcium is measured to evaluate function and adequacy of a physiologic processes. Calcium plays a critical role in several body functions such as, coagulation pathways, bone health, nerve conduction, and other functions. It is important whenever you are evaluating laboratory results that you look at the whole picture of the person, including medications, other laboratory studies and health history. One value is not a stand alone result. There are many factors that effect calcium results.

Factors that effect calcium results: (not an all inclusive list)

pH

Albumin

Lactate

Heparin

Vitamin D deficiency

Magnesium depletion

Anticonvulsants

Renal Disease

Pancreatitis

Parathyroid

Thyroid

The two most common issues following Weight loss Surgery or Duodenal Switch may be albumin level and Vitamin D level. Please see past blogs on Vitamin D. Magnesium may also play a role in a Duodenal Switch patient.

The most common calcium result drawn is the total calcium level. Laboratory results may not explicitly label it as such, however, it measures the calcium that is bound to protein. Ionized calcium is the free calcium that is representative of the true total calcium. Ionized Calcium can be measured by ordering specific lab. Alternatively, the Ionized calcium can be calculated by the following formula: Corrected calcium mg/dL = (0.8 * (Normal Albumin – Pt’s Albumin)) + Serum Ca ) or use the calculator at the bottom of this post.

Calcium bound to albumin Keshishian
calcium metabolism
Duodenal Calcium Metabolism

The low Albumin level accounts for the low calcium level. This may be the reason for a patient with a low albumin/protein level, also having their calcium level reported as low. However, when adjusted for the protein deficiency the corrected calcium comes into normal range. Video of Trouseau’s sign of a patient with calcium deficiency.

The first step in a patient who has low calcium reported, is to make sure their protein and albumin levels are normal, along with Vitamin D.

Calcium levels are managed by two processes major regularly hormones and influencing hormones. Controlling or major regulatory hormones include PTH, calcitonin, and vitamin D. In the kidney, vitamin D and PTH stimulate the activity of the epithelial calcium channel and the calcium-binding protein (ie, calbindin) to increase calcium absorption. Influencing hormones include thyroid hormones, growth hormone, and adrenal and gonadal steroids.

Further information on protein.

Further information on calcium.

Videos/Webinars on several of the above topics.

Corrected calcium = 0.8 * (4.0 – serum albumin) + serum calcium

Compounding Pharmacies

January 22, 2018 2:38 pm

New FDA regulations for compounding pharmacies has spurred changes in our pricing and ability to provide injectable Vitamin A and Vitamin D.  The compounding pharmacies are no longer compounding injectable Vitamin A and there is a nationwide shortage of the national brand of injectable Vitamin A.  We have a tentative date of February 2018 when we may be able to obtain injectable Vitamin A. We won’t be able to quote pricing on Vitamin A injections until we are able to orders.

We are able to obtain and supply our patients with injectable Vitamin D but with a price increase.

The following is the letter we received from our compounding pharmacy.

“The healthcare industry has continuously undergone changes in regulations and legislation. The compounding industry is no exception and has faced rigorous regulatory requirements this past year such as new testing specifications and compliance standards.

We are set on facing these demanding challenges by meeting and exceeding these new regulatory requirements. We want to assure you we will continue to provide the best products on the market for you and your patients. Quality and safety remain a top priority. We understand that our pharmacy plays a vital role in providing care to your patients. The increase in pricing is a reflection of the additional cost in producing and testing the product based on regulatory specifications.”

Revision from failed AGB to Duodenal Switch

January 10, 2018 2:10 pm

A few times a month during consultation for weight loss surgery , I’m ask as to why I do not offer the adjustable gastric banding as an alternative to the patients. As I have said over the years when a patient considers an weight loss surgery the totality of the risk should be considered. This includes the operative, immediate postoperative course, the maintenance and the follow-ups needed. The potential complications of the procedure in addition to the long-term success off each operation should also be taken into account.

Unfortunately, some patients are led to believe that any perceived benefit in the short operative time and the ease of the adjustable gastric banding also translates to a better outcome. This is in fact the opposite of what the published data have shown, a recent study published in April 2017 by Vinzes et.al, shows that 71% of patient lost their band by 10 years out.

Long-term_AGB_outcome-791x1024

What is also interesting that more patients underwent revision from failed AGB to the duodenal switch than the sleeve gastrectomy (Fig 1.). This is what I also recommend.

More importantly, The patients who underwent a revision from failed AGB to the duodenal switch operation had the best long term results of all patients (Fig 2.) note the “rBPD” line that is the highest of %EBMIL.

Complication’s were broad and frequent (Table 3.)

Further information on revision from failed AGB to Duodenal Switch or other failed weight loss surgeries can be found here.

Vitamin A injections

October 25, 2017 10:31 am

Unfortunately, we have been informed that the company we order our Vitamin A injections from will no longer have Vitamin A available.  We have contacted several other companies and they also do not have it available.  The manufacturer of Vitamin A states that there is a nationwide shortage of injectable Vitamin A and it may be available next year.

Vitamin A injections

Our office has a few vials left and we are hoping that we can get to as many people as possible before we are completely out. We will continue to look for a source of Vitamin A injections. We will let you know when it is no longer available and when we receive a new shipment. Thank you for your understanding and we apologize for this issue.
Information on Vitamin A deficiency here.
You can find our list of recommended supplements here.

Just as a reminder, we have no financial interest in any of the vendors that are recommended on our website. Also, please note that this is not in ANY form or fashion a substitute for the evaluation by your surgeon or primary care physician. This is informational only and is not to be taken as a recommendation for any patients’ condition.

New Pasadena Office Map and Parking

August 12, 2017 8:35 am

We’ve created a helpful map and parking diagram for our new Pasadena, CA office location.  It also has a general layout of the Huntington Memorial Hospital Campus and Pre-operative intake and testing area.  We hope that you find it helpful on your next visit to see Dr. Ara Keshishian, General and Bariatric Surgeon.

Map and Parking Dr. Keshishian's office
Map and Parking Dr. Keshishian's office

Dr. Ara Keshishian has performed more than 2,000 Duodenal Switch procedures, thousands of Sleeve Gastrectomies and more than 500 revisions from other Weight Loss Surgeries such as RNY Gastric Bypass, Adjustable Gastric Band, and Sleeve Gastrectomy to Duodenal Switch as well as General Surgical cases over the last 18 years of private practice.

Insurance Appeals And Denials

August 07, 2017 7:08 am

Whenever you are dealing with insurance issues it is important to have a general understanding of insurance ins and outs. The Obesity Action Coalition has a good general guide to the insurance process here.  If you are having issues with out of network, out of area, or insurance appeals and denials for Duodenal Switch, there may be some additional assistance from two individuals who have had the Duodenal Switch procedure themselves. We are grateful that they have provided assistance throughout the years to the Duodenal Switch community. The following is their statement on insurance.

The majority of insurance companies are in the business of making money (for profit). They can deny requests for preauthorization with impunity. These denials are often complexly worded and difficult to comply with and overcome, and are definitely overwhelming to the patient, and the busy surgeon’s office. The vast majority of patients faced with demanding if not impossible to achieve prerequisites, or denial of the request for preauthorization simply give up, and the insurance companies pocket the savings.

If you find yourself  facing impossible pre-op hurdles, or a denial, we urge you to appeal, and to seek assistance in preparing the appeal. You can hire an attorney, of course, but there is an informal and free resource we suggest that you investigate as well.

If you go to BariatricFacts.org (a non-profit, patient-run site), you will find individuals who are long-term DS postops, and patient advocates.  They have been helping patients, pro bono (for free), for over 10 years. They will help you draft your appeal letters, provide supporting medical and legal documentation, and prepare draft letters of medical necessity to be reviewed and signed by your surgeon supporting your appeal. They will not represent you directly, but they will help you best represent yourself.  in many cases it is necessary to exhaust all internal appeals (because the insurance companies are unlikely to overrule themselves), and then file for external review, where independent reviewers often overrule improper denials. If you join and then post on BariatricFacts.org asking for help, you will be connected with them and you can decide if you want their help.

Please note that this is just a suggestion. It is neither legal nor medical advice, nor a guaranty regarding their services, and you should always consider getting legal advice and assistance from an attorney who will represent you directly. The members at BariatricsFacts.org will help you draft your own letters, but will not be your legal or medical representatives; you will be required to do a fair amount of your own work on your appeals, and to sign them yourself.

It is suggested that before or at the same time as you contact the resources suggested at the site, you gather as much of the following information as you can:

  • A copy of your Evidence of Coverage, which is the usually 100+ page insurance contract between your employer and the insurance company, which  you can obtain it from your HR department. If you are self-insured, it will be available directly from your insurance company. Note: it is NOT the Summary of Benefits – it needs to be the contract itself.
  • If your insurance is through an employer, you need to determine whether your plan is self-funded or fully-funded. Your rights are significantly different under the two types of plans.
  • If your insurance company has a separate bariatric surgery policy, provide a copy of that, too.
  • A copy of your surgeon’s request for preauthorization, which provides the ICD-10 and CPT codes submitted.
  • A copy of your denial letter, including the section regarding your appeal rights.

*      It is strongly recommended that you obtain a copy of your surgeon’s LOMN (letter of medical necessity) before it is submitted to your insurer or for external review, so we can assist your busy surgeon in making the strongest possible case for you.

Don’t be deterred by a denial. It is unfortunately more common than it should be, but it can often be overcome if you meet the requirements for bariatric surgery, if you get help navigating the process.