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Results for : "length of bowel"

Laparoscopic Appendectomy

June 08, 2016 12:09 pm

What is a Laparoscopic Appendectomy?

Appendicitis is one of the most common surgical problems. One out of every 2,000 people has an appendectomy sometime during their lifetime. Treatment requires an operation to remove the infected appendix. Traditionally, the appendix is removed through an incision in the right lower abdominal wall. In most laparoscopic appendectomies, surgeons operate through 3 small incisions while watching an enlarged image of the patient’s internal organs on a monitor. In some cases, one of the small openings may be lengthened to complete the procedure.

What is the Appendix?

The appendix is a long narrow tube (a few inches in length) that attaches to the first part of the colon. It is usually located in the lower right quadrant of the abdominal cavity. The appendix produces a bacteria destroying protein called immunoglobulins, which help fight infection in the body. Its function, however, is not essential. People who have had appendectomies do not have an increased risk toward infection. Other organs in the body take over this function once the appendix has been removed.

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Advantages of Laparoscopic Appendectomy

Results may vary depending upon the type of procedure and patient’s overall condition. Common advantages are:

  • Less postoperative pain
  • May shorten hospital stay
  • May result in a quicker return to bowel function
  • Quicker return to normal activity
  • Better cosmetic results

Laparoscopic Appendectomy

Are You a Candidate for Laparoscopic Appendectomy?

Although laparoscopic appendectomy has many benefits, it may not be appropriate for some patients. Early, non-ruptured appendicitis usually can be removed laparoscopically. Laparoscopic appendectomy is more difficult to perform if there is advanced infection or the appendix has ruptured. A traditional, open procedure using a larger incision may be required to safely remove the infected appendix in these patients.

Category :

Inadequate Weight loss and Weight Regain

May 24, 2016 7:56 am

There were numerous causes for the inadequate weight loss and or weight regain after weight loss surgery.

These factors may include:
1-Type of the surgery: Duodenal Switch, RNY, Adjustable Gastric Banding, Intragastric Balloon, etc.
2-Patients metabolic state (age, activity level, hormones state etc)
3-Co-morbidities
4-Patient compliance
5-Other

Each and every one of these may be an independent factor or may be a contributing cause.

In our experience, patients non-compliance is not as common as others believe. Frequently, we see patients in our office where they have been told that the poor outcome of the surgery is “their fault”
We see this with RNY, and Band patients as well as some of the duodenal switch patients who are seeking advice for weight regain or inadequate weight loss.

I would like to talk about the issues of inadequate weight loss or regain post Duodenal Switch specifically. Duodenal switch operation as described by Dr. Hess, outlined the division of the small bowel lengths to be proportional to each and every patients own total bowel lengths. This meant that two patients with the same BMI and weight will end up with two different lengths for common and alimentary limbs if there total length of the bowel is different. Unfortunately, too often patients are given a “standard”  or “set” ( not clear what that word means, since there is no established standard in the literature) length for common channels and alimentary  channels regardless of the total small bowel length. In some patients, those lengths may result in acceptable weight loss. However, quite frequently a patient with a preselected length for the common and alimentary limbs will end up either loosing too much weight and have nutritional problems or not loose adequate weight. As with all practices, we have over the years had patients who have had nutritional deficiencies and excessive weight loss or have had inadequate weight loss. Looking at the raw numbers however, we have had more patient from other practices that have come to us for revisions and corrections of lengths of the bowel lengths from other practices that our own patients have required.

Another level of the confusion is the improper interchanging of the “SIPS and SADI” procedures with the duodenal switch operation. As I have said in the past repeatedly, SIPS and SAID are not the same as the duodenal switch- and attempt to call these different procedures the same is misleading to say the least.

The other category of weight regain or inadequate weight loss includes medications and new health issues.  Discussed in a previous blog, there are many medications that can influence weight gain.  It is important to work with your health care provider to find medications that have a positive effect on symptoms without added side effects whenever possible.

In summary, weight re-gain or inadequate weight loss can have many facets.  However, surgical technique can provide an advantage.  Each aspect should be addressed and identified.

Fat, Protein – Post Duodenal Switch Diet

May 23, 2016 6:43 am

Fat and Protein after weight loss surgery…. This is a subject that seems to come up all the time.

What I recommend is “…Water, protein, vitamins, supplements and every thing else….”

Dehydration can cause a lot of problems, stay hydrated.

Weight Loss Surgery (WLS) is a surgically imposed catabolic state (surgical induced starvation).  The weight is lost by not allowing enough caloric intake/absorption and forcing the body rely on stored sources of energy, mostly fat mass.  The rationale for the high protein intake is to minimize net muscle mass loss during the catabolic state.   Low carbs and low fat further push the body into catabolizing the fat mass, and reducing the net loss of protein content. As the fat mass is broken down it will release hormones and other byproducts that the body will eliminate. Hydration is crucial to every bodily function and even more so in the weight loss phase to allow for elimination of some of these byproducts.

The mechanism by which Duodenal Switch works during the weight loss phase is by limiting the caloric intake.  Long term  Duodenal Switch keeps the weight off due to the malabsorptive component as the caloric intake increases. Protein intake, Vitamin/Mineral supplementation and diligence in surveillance of vitamin/mineral levels is imperative and a life long commitment after WLS.

There are a number of different types of  Fatty Acids.  Our bodies naturally produce, from other components,  all but 2 essential fatty acids: Omega 3 and Omega 6.  Most fatty acids require bile salts to be absorbed within the small intestines.  Those are the fatty acids that are absorbed to a lesser degree after Duodenal Switch.  Medium chained fatty acids do not require bile salts and can be absorbed into the blood stream from the small intestines. Medium chained fatty acids are used for energy as they are processed in the liver. Medium chained fatty acids are actually given to patients with Short Bowel Syndrome to decrease fatty stool and increase their body weight.  This is also a possible reason some fats cause DS patients more loose stools and others do not (medium chained fatty acids). Adding fats is a purely individualized process.  Each person has a different length of small bowel, alimentary limb, common channel, percentage of excess weight to lose and metabolism. Patient’s tolerance for fat in regards to vitamin/mineral levels, stool consistency and frequency is completely individualized.

Fats and Fatty acids can be divided according to their structure in groups:

A) Saturated  Fat (animal fats, butter, lard- solid in room temperature)

B) Unsaturated Fat (liquid in room temperature)

           1-PolyUnsaturated Fats
                    a)Omega 3-fattty acids (fish, shellfish, soybean, walnut, flaxseed)
                    b)Omega 6-fatty acids (corn oil, sunflower oil)
            2-Monounsaturated fats
                    a)Omega 9-fatty acids (olive oil, avocados, peanuts, almond

The main focus in the weight loss phase should be hydration, hydration, hydration, protein, low carb, low fat and vitamin/mineral supplementation (page 22).  Rest is key in the early post op phase but gradually adding exercise is also important in ensuring the body does not breakdown muscle mass.  Adequate intake of protein and use of muscles diminishes the bodies natural response of breaking down muscle mass in a low caloric intake state.

Post Surgical Needs for the first 90 days in order of importance:
This is to allow healing to take place before adding additional stress on the body and surgical sites.
Minimum of 64 ounces of fluids daily
Minimum 80-100 grams of protein daily (protein requirements are based on ideal body weight)
30 gms by 30 days post-op
60 gms by 60 days post-op
90 gms by 90 days post-op
Vitamin/Mineral Supplements
Low carb
Low fat
Rest (early Post-op)
Exercise

Proteins are important, not only for structure (muscle) but for functions. We know that proteins and amino acids are involved in all aspects of our body’s function. This is even more critical during the rapid weight loss phase. Protein needs may increase and change based on health status, pregnancy, surgeries, healing, etc.

When it comes to fat, I do not recommend patients consuming excessive amounts of fat- At the same time I do not recommend patients go on a low fat diet.  There is this misconception that since DS is causing fat and fat soluble vitamin malabsorption, then taking more fat (in excessive amounts) can solve the problem of vitamin deficiency. How about the possibility that some patients are causing their own vitamin deficiency by taking large volumes of fat which may results in more frequent bowel movements and decreased vitamin absorption.

It is not to be forgotten that each patient will respond differently with dietary changes after duodenal switch. Some patients may tolerate more and some less fat in their diet.  After the initial 90 day post op phase I recommend that patients go slowly in adding new food items by giving it several days before adding another food item. i.e.; add carrots for 3-5 days to see how your body handles it before attempting to add another new item.  The above is not the entire weight loss process or education and is only a small portion of the education needed before undergoing any WLS procedure. These recommendation are my recommendations for my patients with the Hess technique for Duodenal Switch.

FAQ

March 19, 2016 10:38 pm

We have compiled a list of frequently asked questions. Please view the questions below or click on a link to jump to the section.

Pre-Operative (Before Surgery) Questions

Will my insurance pay for the surgery?

Your surgery may be covered depending on which insurance you have. We will contact your insurance company and obtain detailed information on the “Coverage and Benefits”. To do this, we ask that you complete the information on our New Patient Inquiry page, as well as fax us a copy of the front and back of your insurance card. We will then verify the coverage and contact you.

How long does it take before I can have surgery?

It usually takes 4 weeks between the time of the initial consultation in the office and the surgery.

Are there any other fees that are not covered by my insurance?

Yes, you are responsible for Copay, deductible, and share of costs. Additionally, you may be required to pay a program fee for a particular type of surgery with services provided that is not covered by your health insurance plan. This will all be discussed with you in detail after your insurance coverage has been verified.

How long do I have to stay local to the hospital?

10-14 days. Some patients may be released back home sooner, while others may need to stay longer.

How often do I have to come back for follow-up?

If you have the Duodenal Switch operation, you are required to follow up with us in months 1, 3, 6, 9, 18, and 24 after surgery (post-op). You are also recommended to follow up afterwards on a yearly basis. This schedule is also the same if you are having another weight loss surgery revised to the Duodenal Switch.

Do I need to keep my follow up appointments? Can’t my primary doctor do the follow ups closer to home?

Yes, it is very important to keep your appointments. We need to know that you are effectively absorbing your nutrients and are not losing the weight too fast or too slow. We can also evaluate to make sure that the weight loss is mostly fat and not muscle. Failing to keep your appointments puts your health at risk. While your primary doctor will play a big role in your follow up, we also need to see you and will send requests for the necessary lab tests.

If you are having adjustable gastric banding, or Lap Band®, you will then be expected in our office 7 to 14 days after surgery. The first adjustment will take place 4 weeks later. Different patients require different numbers of port adjustments to optimize the size of the band. The average patient may need 4 to 9 adjustments.

Are the surgeries done open or Laparascopically?

The Duodenal Switch operation is done both open and Laparoscopically. The majority of the revisions are done with open surgery. Lap Band® is performed with laparoscopic surgery

How do I decide if I should have the Duodenal Switch or the Lap Band®?

We do not recommend the adjustable gastric banding procedures for anyone. It has shown to have high complication rate and a very poor long-term weight loss.

Will I have saggy/extra skin after my weight loss surgery?

You may or may not. It will depend on a number of factors, such as your BMI, age, or the presence of another disorder or disease.

How much protein should I take every day?

An individual’s protein intake is based on his or her weight in Kilograms. The requirements are also dependent on the needs of each patient. Additional protein is needed for healing after surgery. Most patients should aim for 1 Gram of protein for each Kg of their lean body weight. This may be difficult to calculate precisely, so the average patient may safely aim for 80 to 100 grams of protein every day.

How do I convert pounds (lb) to kilograms (kg)?

1 lb = 0.453 kg or 1 kg = 2.2 lb
Example: 5 kg equals 5×2.2=11.0 lb
Example: 5 lb equals 5×0.453=2.27 kg

What is Sugar alcohol?

Sugar and sugar alcohols are each considered nutritive sweeteners because they provide calories when consumed. Sugar alcohols, or polyols, contain fewer calories than sugar. Sugar provides 4 kcal/gram and sugar alcohols provide an average of 2 kcal/gram (a range from 1.5 kcal/gram to 3 kcal/gram). Contrary to the name, sugar alcohols are neither sugars nor alcohols. They are carbohydrates with structures that only resemble sugar and alcohol.

Foods that contain sugar alcohols can be labeled sugar-free because they replace full calorie sugar sweeteners. Sugar alcohols have been found to be a beneficial substitute for sugar for reducing glycemic response, decreasing dental cavities, and lowering caloric intake.

Sugar alcohols naturally occur in many fruits and vegetables, but are most widely consumed in sugar-free and reduced-sugar foods. The sweetness of sugar alcohols varies from 25% to 100% and is as sweet as table sugar (sucrose). The amount and type that is used will be dependent on the food. The following table lists the details of each of the sugar alcohols.

sugar-alcohols

How do I make an appointment?

Appointments can be made by contacting our office at 818-812-7222. A new patient inquiry can also be submitted online and our staff will contact you to schedule a consultation.

How much am I looking at spending out of pocket?

This varies depending upon your insurance benefits. These can be determined by faxing your insurance card front and back to 818-952-0990 or e-mailing a copy to contact(at)dssurgery.com

Why do I have to see a psychologist?

Most insurance companies require that a psychological evaluation be performed prior to weight loss surgery based on the recommendation of the National Institute of Health (NIH). A psychologist is usually available for consultation at the time of your initial appointment with us. His fee of $200.00 is not included with the cost of your consultation.

If I go to my own psychologist, what do I tell him? Is there a guideline I can take to him?

We do not have a specific guideline that must be followed. Most psychologists are aware of the type of evaluation required for weight loss surgical patients.

What room and board accommodations are available in Glendale?

Accomodation options include  hotel chains and vacation rentals.

What does the program fee cover?

The program fee covers two years of follow-up care, workbook and education on topics critical to the patient’s health, nutrition, and weight loss, as well as support group meetings and the completion and processing of one’s disability/leave form.

What is the Duodenal Switch and how is it different than the Gastric Bypass?

The Duodenal Switch operation is restrictive as well as a malabsorptive, which makes the stomach less absorbent of food. Gastric bypass operation is only a restrictive procedure. The mechanism of action, safety profile, short and long term complications, short and long term success between the two procedures are different. It is our opinion that the duodenal switch operation is a far better procedure compared to the gastric bypass surgery. It is very important, however, that patients educate themselves about all the surgical procedures prior to making a decision.

Does my insurance usually approve the surgery?

We can’t give a general answer to this question. There are thousands of insurance policies, each with their own requirements. Even if weight loss surgery is a covered benefit of your plan, this does not guarantee that your surgery will be approved. Each patient’s case requires individual review, at which time coverage will be determined.

How long does it take to get an approval?

This depends on how quickly the patient completes his or her work-up. Once the work-up is complete, authorization is requested by your insurance. The waiting period for approval depends on the type of insurance you have. It can take anywhere from 5 to 45 working days

Post-Operative (After Surgery) Questions

I have been having diarrhea since my surgery. What causes that?

An increased number of bowel movements are normal shortly after the Duodenal Switch operation. Some patients will also experience very loose bowel movements. Excessive diarrhea can lead to dehydration. You need to look at the amount of fats in your diet, as well as the type of protein you are consuming. Whey proteins can cause diarrhea because of the milk products content. Other dairy products, such as milk, cheese, sour cream, etc., may also cause diarrhea, as well as fried or fast foods, and need to be avoided. Artificial sugars can also cause diarrhea. Try keeping a food diary in order to recognize trigger items. If your bowel movements continue to be excessive call the office for a follow up appointment.

Should I avoid all fats to help me lose weight?

This will depend if you have had the Duodenal Switch or the Lap Band® operation. It is generally okay to consume some fat after the Duodenal Switch operation, since you will only be absorbing a small portion.

Why do I need to drink so much fluid following surgery?

In addition to nausea, vomiting, weakness, and confusion, dehydration can also lead to blood clots, as your blood becomes thicker and stickier. You can get into a vicious cycle with the loss of fluids, as the more dehydrated you get, the less you may be able to take in by mouth. This may require hospitalization so that Intravenous hydration can be provided. Drinking a lot of fluid is a top priority and it is important not to fall behind in this regard.

I cannot take much in by mouth. What is the most important for me to take?

Water is by far most important to take in, as you need to avoid getting dehydrated. At times, this may result in nausea or dark infrequent urine. The surgeon will make specific recommendations depending on each case.

I am constipated, should I take a laxative to help me go?

The first step is to make sure that you are drinking enough water. No laxative is needed or recommended. After the Duodenal Switch operation, a patient will absorb far less amounts of ingested fats. Increasing your fat intake in moderation will sometimes help with constipation. Call our office if the problem persists.

Is drainage from the incision normal? How do I care for it?

Some patients have some drainage from the top or bottom of the wound a few days after being discharged from the hospital. This is expected because of the poor healing properties of the fatty layer under the skin. In some patients, other conditions may contribute to this. These include diabetes, a history of smoking, etc.

Keep the area clean and dry by showering 1 to 2 times daily. Wash the area with soap and water and remember to dry well. The drainage should subside after a short time, but varies from patient to patient. If the wound or drainage changes in any way, such as pain, redness, warmth, color, thickness, smell, etc., call the office immediately.

Is it normal to feel hungry after surgery?

Yes, you should still be able to tell when you are hungry, but need to learn to the difference between mental hunger and actual hunger. This is hard to do in the first few weeks as you learn to cope with the separation from food and allow yourself time to get through the situation. Most patients after the Duodenal Switch may not be able to tell the difference between feeling full or hungry. The safest approach to this is to err on the side of having small frequent meals rather than large meals to satisfy “hunger.”

For the past two weeks I have been having episodes of nausea and vomiting, is that normal?

No. It does not matter if days, weeks or months have passed since the operation. Whether you had the Duodenal Switch or the Lap Band®, persistent episodes of nausea and vomiting should be evaluated by a doctor.

What happens if I lose too much weight?

We can usually stop excessive weight loss with prescription supplements that allow you to absorb more of the food that you eat. This process will generally slow or stop the weight loss and prevent you from needing surgery to correct the problem. Call us if you are concerned that you may be losing too much weight. The treatment for excessive weight loss after Duodenal Switch includes enzyme supplementation and possible surgery to lengthen the common channel. With Lap Band®, it may be as simple as taking the fluid out of the band and making sure there are no other issues.

The health food store has Enzymes that the clerk says would be good for me, should I take them?

No. Enzymes will “undo” the malabsorbtion component of your surgery, which means you will absorb much more of what you eat and begin regaining weight. You must take the supplements recommended by your surgeon. If you have any questions regarding any product or supplement, contact your surgeon.

Why can't we take Iron and Calcium together?

Calcium inhibits Iron absorption. This blocking effect of iron absorption is dose independent, meaning that even a very little amount of Calcium may block most of the Iron absorption.

How far apart should we separate taking Iron and Calcium?

60 minutes or so will provide adequate time for the stomach to empty.

Can we take Iron with other Medications?

No. The best way to take Iron is on an empty stomach with some orange juice.

What is ADEKs?

ADEK stands for the fat-soluble vitamins, A, D, E and K.

Others are taking ADEKs, should I be on ADEKs?

No. ADEK is prescribed to patients after the Duodenal Switch operation and only after their lab results demonstrate deficiency of one or more of these fat-soluble vitamins.

Calcium Citrate Vs. Calcium Carbonate is always a hot topic. Which is better. Why?

calcium-citrate-vs-calcium-carbonate

The above table indicates that Calcium Citrate is absorbed easier, but more is needed for the same amount of elemental calcium. Less Calcium Carbonate is needed to get the same amount of elemental calcium, but the absorption is less efficient. Medical literature provides supporting data for recommending either one. We believe that at least in the beginning, most people could take either type. The decision of which one to take should be based on which is tolerated better. Later recommendations for changes will be made.

I have received a letter from your office about a Vitamin D3-50 prescription and I am unable to have it filled at my local pharmacy. What do I do now?

Vitamin D3-50 is vitamin D3, 50000IU. There are a number of places that you can get it from. The letter sent to you had one of the sources. Another place where you can get it from is here.

What is dry vitamin A? why can I not have regular vitamin A? Where do I get dry vitamin A from?

Vitamin A is fat soluble. After the Duodenal Switch operation, you may not absorb adequate fat and vitamin A (which is fat soluble). To resolve this problem, vitamin A is formulated to become “water soluble”. “Dry” or “water soluble” vitamin A does not rely on fat absorption to be absorbed.

Hernia Questions

What is a hernia?

A hernia is a weakness in one of the layers of the abdominal wall. This allows for the content of the abdominal to be displaced and move closer to the skin.

How do I get my hernia removed?

A hernia is repaired surgically, but not removed.

How can I tell if I have a hernia?

A hernia may show itself in the form of an asymmetrical “bulge” around your incision. The best way to know, however, is to ask your physician.

What does it feel like?

Depending on the location, size, and content of the hernia, the feeling may be different for each individual. Some patients may only have the protrusion under the skin, while others may get very sick with nausea and vomiting. As previously indicated, the best way of identifying a hernia is to be seen by your physician, who can provide the correct diagnosis and treatment options.

Why is a small hernia more dangerous than a large one?

Small hernias have a much higher chance of trapping their content, which is called an incarcerated hernia. A large hernia has such a large opening that it would be less likely for its content to not reduce back.

Should I wait to have my hernia fixed?

This is a very complex question and depends on the size and location of the hernia, as well as the presence or absence of any symptoms; based on this information, your surgeon’s recommendation will differ. Please be seen by your physician for an evaluation.

What is a mesh?

Some hernias are large enough that the two edges cannot be secured together without tension. In those cases a mesh is used. A mesh can either be a synthetic or natural product. The synthetic mesh materials are permanent. The surgeon may choose which type of mesh to use depending on the details of each particular case.

Can I feel the mesh?

Most patients are unable to feel their mesh. Some will feel the edge where it is secured to your natural tissue.

Why do some people keep getting hernias?

The causes of hernias are multiple. A number of factors may cause recurrent hernias, including patient related conditions, such as the presence of infection, diabetes, smoking, etc. Large hernias in active males are also more prone to recurrences.

Can I prevent getting a hernia?

You can probably significantly reduce the chance of recurrence by following your surgeon’s recommendations. There is no sure way to prevent a hernia. Wearing an abdominal binder does not prevent a recurrence.

Can my hernia and a tummy tuck be done at the same time?

In most cases, two operations can be done at the same time. There are instances, however, in which each procedure needs to be done separately.

Lap Band

How much weight will I lose after Lap band?

The amount of weight loss varies from patient to patient and depends on lifestyle and eating habits. A weight loss of 2 to 3 pounds a week in the first year after the operation is possible, but one pound a week is more likely. Twelve to eighteen months after the operation, weekly weight loss is usually less.

What is placed inside of the Lap Band®?

Sterile Saline (salt water) is used to adjust the Lap Band.

Does my insurance company pay for the adjustments?

This will depend to your insurance and the health plan.

On average, how much is spent on adjustments?

It only takes a few minutes to adjust the band, which is done in the office.

How many adjustments will I need?

This varies from patient to patient. The goal for each patient is to stay in the “green zone.” For some patients, this may require more frequent adjustments, but less for others. It is very important to appreciate that a close follow-up is imperative for the successful weight loss after an adjustable gastric banding procedure.

For the Lap Band, what does the insurance cover?

Most insurance, if they cover weight loss surgery, will cover the cost of the operation and the follow up for a period of 30 to 90 days.

Does the gastric banding system limit any physical activity?

No, the gastric band does not affect or hamper physical activity including aerobics, stretching, and strenuous exercise.

Can the band be removed?

The band and the port can both be removed if there is a medical reason for it. Weight regain is almost certainly expected after band removal.

Do I have to worry about the access port? How do I care for it?

There is nothing you have to do for the access port. The port is placed in the fatty tissue under your skin. If there is any persistent discomfort, redness, or discharge from the port area, talk to your doctor as soon as possible.

Category :

SADI-SIPS

March 19, 2016 8:28 pm

Single Anastomosis Duodeno-Ileostomy (SADI) and Stomach Intestinal Pylorus-Sparing (SIPS) surgeries are not the same as the Duodenal Switch (DS) procedure.

Any suggestion that SADI or SIPS are the same as the Duodenal Switch is misleading and inaccurate. Long-term studies on the outcome of the SIPS and SADI procedures are not in existence. The only anatomical similarity between these procedures and Duodenal Switch is the presence of the pyloric valve as a functional part of the post surgical anatomy. The small bowel portion of the SIPS-SADI is different than that of the duodenal switch. In the duodenal switch operation, the absorption of the fat is primarily limited to the common channel, which is usually 10% of the total length (if the surgeon performing the duodenal switch bases the common and alimentary limb lengths as a percentage of the total length as described by Dr. Hess). The combined alimentary/common channel of the SADI-SIPS procedure is closer to 40-50% of small bowel length. Additionally, bile reflux, internal hernia, inadequate weight loss and even weight regain are all possible complication that are much more likely with the SADI-SIPS than with the DS. I would also like to make the point that revisions of the SADI-SIPS may not be as simple as some suggest. The Length of the small bowel, location of the anastomosis in relation to the colonic mesentery, and the length of the duodenal stump all are factor in dictating how easy or difficult the revision of the SADI-SIPS to DS will be.

Duodenal Switch operation has by far the best long-term outcome of all weight loss surgical procedures. There isn’t long-term data available for SIPS and SADI and their alimentary/common channel lengths. It is critical that patients are very well informed (informed consent) as to the exact operation that is being performed on them. As stated above, Duodenal Switch procedure is not the same as SADI or SIPS. The notion that these procedures can be interchanged is anatomically and medically inaccurate.

Category :

Revisional Weight Loss Surgery*

March 19, 2016 8:27 pm

revision-ad-3

Each weight loss surgical procedure has a different short and long-term result, as well as unique and long-term complications. Patients who have had complications or ill effects as a result of weight loss surgery may require other procedures to correct the original operation. These types of operations are called revisional weight loss surgical procedures. In the last 18 years, Dr. Ara Keshishian has performed more than 500 revisions from other Weight Loss Surgeries such as RNY Gastric Bypass, Adjustable Gastric Band, and Sleeve Gastrectomy to Duodenal Switch on patients who have come from all over the United States and other countries. He first published his data on Revisional Weight Loss Surgery in 2004.

 

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Conditions that may require Revisional Weight Loss Surgery include:

  • Inadequate weight loss.
  • Weight regain after initial weight loss.
  • Dumping syndrome.
  • Solid intolerance.
  • Marginal ulcers.
  • Nutritional deficiencies, including vitamins, minerals, etc.
  • Anemia.
  • Significant bowel dysfunction (constipation, diarrhea, malodors flatulence).
  • Significant gastroesophageal reflux disease.
  • Infection involving implanted devices (ports or bands).
  • Erosion or slippage of the adjustable band.
  • Partial resolution of the comorbid conditions or recurrence of the comorbid conditions after initial or partial resolution.
  • Stricture (narrowing at the site of bowel anastomosis).

Animation of Revision of Gastric Bypass to Duodenal Switch

The goal of the revisional weight loss surgery is to:

  • Correct the problem that brings a patient under our care, including the correction of any of the above outlined conditions.
  • Make the revisional weight loss surgery a definitive procedure. This will be discussed further with each type of procedure that we revise.
  • Accomplish the primary goal of the weight loss surgical procedure, which is maintenance of the weight in a favorable range and resolution of the patient’s comorbid conditions.
  • Revisional Weight Loss sSurgery should have acceptable risk as a surgical intervention.

The majority of patients seeking a revisional weight loss surgery are those who experienced an acceptable short-term outcome after the initial weight loss surgical procedure. They may have lost the weight only to gain it back, or experienced inadequate weight loss. There are also certain patients who have had ill effects from their primary operations, including ulceration and stricture in the case of a Roux-en-Y gastric bypass, and slippage or erosion in the case of an adjustable gastric banding. While there are some patients who have been able to lose the weight and keep it off, this comes at the expense of near constant nausea and frequent episodes of vomiting. It has been our experience that the failure of primary weight loss surgical procedures is quite frequently blamed on the patient, which is usually not the case. In the majority of cases, a less than ideal outcome of a weight loss surgical procedure can be traced back to a procedure itself. A similar circumstance would involve a patient trying a number of blood pressure medications to find the one that works best. Even the best possible outcome may be inadequate for the patient and his or her particular conditions.

The causes of failure of primary weight loss surgical procedures may be:

Cause
  • Dilated pouch stoma
  • Fistula (gastro-gastric, gastro-enteric)
  • Marginal ulcer
  • Significant nutritional deficiency including iron deficiency anemia
  • Stricture
  • Excessive diarrhea or debilitating malodorous flatus
  • Significant protein calorie malnutrition
  • Gastric bypass revisions are indicated for any of the above conditions
  • Significant nutritional deficiency including iron deficiency anemia
  • Excessive diarrhea or debilitating malodorous flatus
  • Significant protein calorie malnutrition
  • Slipped Band
  • Erosion of the Band
  • Port problem including flipped port or infection
  • Inadequate weight loss
  • Incomplete resolution of co-morbidities
  • Revision of a lap band may be indicated for any of the above conditions

Each one of the surgical procedures will be discussed in great length with the rationale for the recommended revisional weight loss procedure.

Sleeve Gastrectomy

The popularity of Sleeve Gastrectomy has increased the number of people who have had this procedure. However, in certain circumstances the weight loss might be inadequate or a person might experience regain following Sleeve Gastrectomy. The procedure for converting a Sleeve Gastrectomy to Duodenal Switch can be achieved to maximize weight loss and/or regain.

Roux-en-Y, Gastric Bypass

Roux-en-Y Gastric Bypass is a procedure in which a small stomach pouch is created and connected to a limb of small bowel in which a deliberately small opening is made. The purpose of the small pouch and the small opening is to restrict the amount of food that a patient can eat in any given setting and to purposefully delay the emptying of the pouch to give the patient a longer period of feeling full.

Complications of the Roux-en-Y gastric bypass include dumping syndrome, marginal ulcer, cases of persistent nausea and vomiting with solid intolerance, inadequate weight loss, and weight regain. In our opinion, the best option for cases of Roux-en-Y gastric bypass in need of revision is the Duodenal Switch operation. Adjustable gastric banding (Lap Band) placement as a revisional weight loss surgery for a primary Roux-en-Y may only be considered for patients who have experienced an initial success of weight loss followed by weight regain. This should, however, only be used for those not experiencing dumping syndrome, marginal ulcer, or reflux disease, as it can potentially get exacerbated by placement of the band on top of a gastric pouch.

Adjusting the length of the common channel, or alimentary limb, allows a revisional weight loss surgery to be tailored to the patient’s needs. An example would be if a patient is experiencing persistent nausea and vomiting and seeks the revision of a failed gastric bypass to a Duodenal Switch. If a patient seeks the revision of Roux-en-Y for persistent nausea and vomiting while experiencing adequate weight loss, a relatively long common channel and alimentary limb (percentage based) will be set for the patient, thus preventing any further weight loss while correcting the persistent nausea and vomiting problem.

In contrast, a patient seeking the revision of a failed gastric bypass to a Duodenal Switch due to inadequate weight loss and/or weight gain will have a relatively shorter common alimentary channel (percentage based) in order to maximize the amount of weight loss. In our opinion, revising a failed gastric bypass, from a proximal to a distal Roux-en-Y, is an extremely poor choice in the majority of the patients, as the distal gastric bypass has the worst nutritional safety profile of all the known surgical procedures.

Adjustable Gastric Banding
Lap Band, Realize

Adjustable gastric banding is a restrictive procedure in which a very small pouch of the stomach is created and partitioned solely by the placement of a ring that can be adjusted by the addition or removal of sterile saline through a port.

In the majority of cases, the reason for inadequate weight loss may be related to inadequate adjustments or unrealistic patient expectations in regard to the anticipated weight loss. All of the published reports to date identify the amount of weight loss to be approximately 50% of the excess body weight, and patients that have a large amount of weight to lose may never attain adequate weight loss to resolve their comorbid conditions.* This may be an example of patients having attained the weight as expected by the surgery, yet experiencing a less than ideal weight loss surgical procedure for their general health condition to include their excess weight and their comorbid conditions. The majority of the patients that had adjustable gastric banding being inadequate weight loss or significant reflux disease in the presence or absence of hiatal hernia. It is our recommendation to have this procedure conversed to Duodenal Switch.

Duodenal Switch

Duodenal Switch operation is the primary weight loss surgical procedure that we perform. It is a hybrid operation in which a banana-shaped stomach is created. Additionally, two parallel limbs of small bowel are created to carry down the ingested food separately from juices from the liver and pancreas. No small bowel is removed. This limits the amount of absorption of calories and nutrition thus magnifying the amount of weight loss.

The most common reason for revision or reversal of the Duodenal Switch operation in our experience has been 1) inadequate weight loss, and a distant second) significant diarrhea. In the case of inadequate weight loss, greater than 80% of the patients in our experience have had dilated stomach which has rendered itself easily to a re-gastrectomy with excellent results. Very few patients have benefited from shortening of the common channel.

The revision/reversal of the Duodenal Switch operation for significant amounts of loose bowel movements and malodorous flatus is easily accomplished by creation of a side-by-side anastomosis.

In fact having extensive experience with revision of weight loss surgical procedures it is our opinion that from a technical perspective, revision or reversal of Duodenal Switch operation is technically the safest and easiest of all the other surgical procedures.

*https://www.dsfacts.com/pdf/agb-long-term-results-1506834076.pdf

Are you a candidate for Revisional Weight Loss Surgery? Contact our office here.

Category :

Laparoscopic Duodenal Switch

March 19, 2016 8:26 pm

Laparoscopic-Duodenal-Switch-DS-Surgery

For a comparison of Laparoscopic Duodenal Switch click here.

Dr. Ara Keshishian would prefer to help you understand the extent of your particular case, and how different surgical options may have more benefits than others. If you have questions, he is glad to answer them and help you understand your options. Educating our patients is one of our highest priorities.

When it comes to your health, having experience is key. Dr. Ara Keshishian has performed over 2,000 Duodenal Switch procedures using the method described by Dr. Douglas Hess (percentage based method blog) and more than 500 revisions from other Weight Loss Surgeries such as RNY Gastric Bypass, Adjustable Gastric Band, and Sleeve Gastrectomy to Duodenal Switch over the last 18 years of private practice.

CONTACT US TODAY

Laparoscopic Duodenal Switch is a hybrid surgical procedure that has two aspects that reduce weight, restriction and limited absorption. Duodenal Switch maintains the pyloric valve and the gastric and intestinal junction, which eliminates dumping syndrome, marginal ulcers and stoma issues that are associated with Gastric Bypass. Duodenal Switch has the highest excess weight loss and maintenance of all available weight loss surgeries at this time. You may view a comparison chart here. Duodenal Switch as described by Dr. Hess using a percentage based method for constructing the intestinal limbs offers the most individualized and customizable weight loss surgery.

Duodenal Switch is the most effective option for people with metabolic disease processes such as Diabetes, PCOS, Hypertension, Hypertriglyceridemia and Cardiovascular Disease. It is also effective for people who have had previous weight loss surgeries and are considering Revisional Weight Loss Surgery due to regain, complications or inadequate weight loss.

Animation of Duodenal Switch procedure

  1. The smaller stomach size limits the amount of food that can be taken in to about 120-150cc (1/2-3/4 Cup). This results in not only a greatly reduced volume of the stomach, but also reduces ghrelin, a gastrointestinal hormone that plays a significant role in appetite regulation and control.
  2. The small bowel is reattached in such a fashion as to keep the biliopancreatic juices away from the food until the last portion of the small bowel, limiting the absorption of the food that is eaten. The stomach is decreased in size by doing a Sleeve Gastrectomy, which uses proportional amounts of the stomach areas that make important enzymes and chemicals. The hallmark of the Duodenal Switch operation is the preservation of the pyloric valve. The pyloric valve is at the last portion of the stomach and acts as a gateway to the small bowel. The food needs to be of the right chemical and mechanical consistency before the pyloric valve allows it to progress into the small bowel. The appendix and the gallbladder are also removed.
  3. Duodenal switch provides the best remedy for failed gastric bypass.
  4. When necessary, the revision or reversal of the Duodenal Switch operation is technically the safest and easiest of all revisional surgical procedures.

Category :

Dual Testimonial: Cameron’s Gastroparesis surgery & Scott’s Revision of a Duodenal Switch

February 01, 2016 8:04 am

In 2015, I came into contact with the most unique, passionate, urgently responsive; talented beyond belief and caring surgeon I have ever met. Our oldest son who is a 21-year-old cancer survivor, has had nearly five years of medical nightmare as diagnosed with severe gastroparesis resultant from his vagal nerve being severed during a previous Nissen Fundoplication surgery. We didn’t find out that this had happened until nearly two years later and only after a 4 hour gastric emptying test showed that Cameron’s stomach was only about 30% emptied after four hours (should be empty after an hour) due to gastroparesis.

I had heard about Dr. Keshishian on a Bariatric support group page on which I post and get great advice.   The surgeon back in Central, IL where we live told us that Cameron needed a subtotal gastrectomy to remove 80% of his stomach! This sounded radical and no way in the world was that going to happen. I was given Dr. Keshishian’s email address so I could consult with him for his advice. It was a Saturday morning around 7 AM Central time when I sent off an email to Dr. Keshishian detailing Cameron’s medical history and current issues. I was in hoping that his office would get the email on Monday and hopefully get back to me within a week. I went out to my kitchen to get a cup of coffee and when I returned I had a missed call with a California area code. Yep, it was Dr. Keshishian. I called back and we talked for 45 minutes.   He suggested several things and told me that any good general surgeon in my area could do surgery on Cameron and fix him, well that was the only time he was wrong. We couldn’t find anyone in our area who would do the surgery.

So we talked and agreed that Cameron needed a Roux-en Y drain put in place to physically drain his stomach by way of gravity (not for any weight loss as very little small bowel was bypassed). Dr. Keshishian got us in the next week and we flew out to Glendale where he met with Cameron for an examination on that Monday.   On Tuesday, Dr. Keshishian performed surgery to fix Cameron’s herniated diaphragm, loose Nissen wrap, performed the Roux-n Y limb and anastomosis to the stomach.  Dr. Keshishian also found a Meckel’s diverticulum (a congenital small bowel defect that can cause internal bleeding and serious issues). The following Sunday, Cameron developed severe pain due to chronic pain from his Cancer treatment and 12 subsequent surgeries, many on his abdomen. Dr. Keshishian saw Cameron in the ER and  spent 3 hours fixing Cameron’s pain issue and making sure he was medically sound so we could fly home the next day.

Today, Cameron has very little to no issues  which you wouldn’t have believed possible six months earlier. In the past, he had violent retching, dry heaving and bad nausea daily which had him severely incapacitated and very depressed due to a feeling of hopelessness and pain from the Gastroparesis. He didn’t believe he had a chance at a normal life but Dr. Keshishian gave Cameron his life back. We are eternally grateful for your huge heart and talent Dr. Keshishian. Thank you!

During our time in Glendale in 2015 for Cameron’s surgery Dr. Keshishian and I began discussing my situation. I had been given a virgin Duodenal Switch performed by a surgeon in Illinois in September of 2013. A year later in 2014 and 180 lbs lighter, I ended up in the hospital as I was passing out. I had a resting heart rate of 35 BPM, a blood pressure in the 75/40 range and incredibly bad labs including anemia, low copper, low zinc, and dangerously low albumin and total protein. A full cardiac work up was completed and I spent a week in intermediate care. Why? I was extremely malnourished even though I was consuming 200-250 grams of protein daily!   Why was I malnourished? Because my original surgeon performed a “cookie cutter DS” on me where he didn’t measure my small bowel and arbitrarily gave this 6’2 man a 100 cm common channel and a 150 cm Alimentary limb. Way too short on the AL!  Had the Hess method been followed (the only way the DS should be allowed to be completed) my CC would have been 100 cm (that was okay) but my Alimentary channel should have been 275 cm!   Simply put, my absorbing portion of small bowel was 34% and the Biliopancreatic limb (non-absorbing) was 66%. It should have been a 50/50 ratio with 100 cm CC, 275 cm AL and a 375 cm BPL. In order to combat my severe malnutrition that September of 2014 I went on a pancreatic enzyme (CREON) to assist my nutrient absorption.   I was taking with meals right around 400,000 IU’s of CREON (a boat load) and this was barely keeping my nutrients in range and lab values barely in range. After speaking with Dr. Keshishian, he recommended that I give it until around September of 2015 to see if my absorption increased enough to where a revision wouldn’t be required. Towards the end of July, I all of the sudden lost nearly 20 pounds in two weeks from my already frail and scrawny body. I saw my surgeon in Peoria as I was very alarmed; and I had been having bad cramping and other issues point to a possible bowel obstruction   His exact words to me were “see me in 30 days, you are like the DS poster boy of good nutrition”. As you can imagine I found that completely unacceptable and soon as I was out of that appointment I emailed Dr. Keshishian. He told me that if I couldn’t get a revision ASAP I would need to immediately go on TPN. Two weeks later my wife and I landed at LAX and were in Glendale on Monday morning for an exam with Dr. Keshishian.

The job Dr. Keshishian did describing what he was going to do, and of course this was a visual presentation with Dr. Keshishian drawing (you know Dr K’s love of drawing) out for us what he was going to do. He thoroughly explained for my wife and I so she was comfortable with what was going to happen and we fully understood what he was going to do. Doc also found an umbilical hernia that he was going to repair and I had an anal fissure as well that wouldn’t heal so we discussed what he would do to examine and possibly fix during my revision surgery. The next day Dr. Keshishian performed surgery where he fixed the umbilical hernia, measured my total small bowel length to determine appropriate channel lengths and found an repaired a huge mesenteric defect (intestinal hernia and Dr K has a picture of my guts with the huge hole in the mesentery that he has posted on his blog discussing intestinal hernias and blockages), fixed my fissure (Thank you!) and put in a side by side anastomosis that effectively lengthened my AL by 125 cm and my CC by 25 cm worth of absorption. This put my absorbing intestine to BPL ratio where it should have been in the first place (50/50 ratio).

I am pleased to say that I immediately went off the CREON and my absorption and subsequently my lab values improved tremendously. At surgery on August 18, 2015 I weighed a whopping 170 lbs. Today I am weighing in at 183 pounds and well on my way to Dr. Keshishian’s suggested optimal weight target of 205.

Dr. Keshishian is absolutely amazing and the best in the world when it comes to performing the Duodenal Switch and revision to DS Surgery (Band to DS, RnY to DS, Channel extending revision to DS).   I would recommend Dr. Keshishian to any patient who needs a virgin Duodenal Switch to get their health back and especially to those who were sold a garbage RnY or Crapband procedure that ultimately failed you (it failed you, you did not fail). In fact, I am trying very hard to convince my brother and Step Mother to fly to Glendale and have Dr. Keshishian perform a Duodenal Switch on them. They very much need it for their health and Dr. Keshishian is the best in the world having performed over 2,000 DS procedures.

I don’t say this lightly. Ara, you are one of the finest human beings I have ever had the good fortune of knowing and your surgical skills are second to none.   I really do admire and love this gentleman like a brother and consider him to be a friend. Thank you for using your incredible skill to fix my health issues resultant from the failed cookie cutter Duodenal Switch I was given two years earlier by another surgeon.  Had I met you back then and knew what I know now, you would have performed my virgin DS and I would not have suffered for two plus years. Thank you from the bottom of my heart, Dr. K!

2015 ASMBS Summary

November 11, 2015 7:31 am

The 2015 ASMBS meeting was held November 2-6, 2015.  It was combined with TOS (The Obesity Society) and had more than 5,600 attendees from all over the world in every aspect of obesity treatment.  There were some interesting additions and deletions from this meeting compared to the past.

The one sentence that comes to my mind is “I told you so”.

One important addition was a DS course for Surgeons and Allied Health.  This was very exciting, except the content and questions seemed to gravitate to  SADI/SIPS/Loop rather than DS.  Dr. Cottam was one of the moderators of the course.  It seems that they have found the value in preserving the pyloric valve. It was clear that the discussion was driven by the need to come legitimize the single anastomosis procedures at this early stage with almost no data to prove long term outcome. With many of the Vertical Sleeve Gastrectomies having re-gain and the they are looking for a surgery that the “masses” can perform. This was actually the term used by one of the presenters, implying that the duodenal switch needed to be simplified so that all surgeons, those who have pushed all other procedures can not offer Duodenal Switch to their patients with less than desirable outcome.   Several surgeons also voiced their concern and dissatisfaction with the issues and complication of the RNY and want an alternative.  There was much discussion regarding SADI/SIPS/Loop being investigational and that it shouldn’t be as it is a Sleeve Gastrectomy with a Billroth II.  Dr. Roslin and Dr. Cottam discussed their SIPS nomenclature saying they wanted to stay away from something that had Ileostomy, suggesting bowel issues, or the word “SAD”i  due to negative connotations. The point to be made is that the SADI and SIPS and the loop are all the same.  I have also noticed other surgeons using SADS (Single Anastomosis Duodenal Switch).  There is a great deal of industry behind these procedures and many surgeons being trained in courses funded by industry. One surgeon stood up and informed the entire course that they need to be clear with their patients about the surgery they are performing, as he had been in Bariatric chat rooms and there is upset within the community about SADI/SIPS/Loop being toted as “the same or similar to Duodenal Switch”.

There was also presenter who said “We are doing something new about every five years.” No,  “we” are not. Some of us have stood by the surgery and techniques with the best long term outcomes and not gone with every “new” thing out there. The process of  Duodenal Switch may have changes, open Vs. Lap, drains, location of incisions, post operative care and stay, but the tested procedure with the best outcome has been the duodenal switch operation and not the shortcut versions. Although, those of us that are standing by long term results seems to be in the minority. Why do I stand by Duodenal Switch?  Because it works, when done correctly by making the length of the bowel proportional to the patient total bowel length, and height, and not just cookie cutter length for all patients,  with the right follow-up, patient education, vitamin and mineral regime and eating habits.

A new addition was the Gastric Balloon, which in the research presented had a 60-70% re-gain rate and a no more than 10-15% weight loss one year only. This data represents more than 70% weight regain when the balloon is taken out.  The Gastric Balloons can be left in between 4-6 months depending on the brand or type of balloon. The Gastric Balloon is not new to the Bariatrics and was first introduced in 1985. After 20 years and 3,608 patients the results were  and average of 17.6% excess weight loss. It seems that we are re-gurgiating old procedures. There are many new medications that were front and center in this meeting.

The Adjustable Gastric Bands were missing from the exhibit hall this year. It is my hope and feeling from the other attendees that we may be seeing the era of the Adjustable Gastric Band being placed in patients come to an end.  Although there are some still holding out that there are some patients that can do well with the Band.

Attending the 2015 ASMBS meeting this year, as it has every year, only reemphasized the importance of avoiding what has become the norm of chasing a simple solution that is fashionable and easy now. We stay convinced that the duodenal switch operation with the common channel and the alimentary length measured as a percentage of the total length is by far the best procedure with the proven track record. The patient should avoid the temptation of settling for an unproven procedure or device, because if history holds true, there will be a need for revision surgeries in the future.

 

 

 

 

Duodenal Switch and Fat in The Diet

May 21, 2015 12:35 pm

When I perform the duodenal switch operation,  the common channel is a percentage of the total small bowel length and  I also account for the  patient’s metabolic rate. Two individuals with a BMI of 50, should not have the same common channel. If  we compare two patients, one of them is a 20 years old male who is 6’2″ and the second patient is a 60 year old female who is 5’4″, we can see how this applies. These two patients have very different metabolic needs and requirements. When the Duodenal Switch is performed in this fashion, the common channel based on a percentage of total small bowel length and metabolic needs, the patients post op diet works best when it is a well balanced, protein based diet. The basic principals are : Hydration (water), Protein and Everything else, low carb,  avoid artificial sweeteners, avoid carbonated drinks,  have frequent smaller meals and avoid processed food.  Listen to you body as to what it tolerates and what it doesn’t. This is what I recommend for my patients.

I am not aware of any scientific evidence that proves any benefit to excessive amounts of fat for DS patients who have had their length of the common and alimentary bowels based as a percentage of the total length.

My recommendation are to have a well balanced high protein diet. I do not recommend a  low fat diet, except in the healing phase after surgery.  However,  there is no reason to consume excessive amounts of fat long term.

High fat diet is used to facilitate bowel movements for some patients who have constipation. It may be prudent to try and identify what may be causing the constipation and correct or eliminate them before one resorts to a very high fat diet as a “treatment” for constipation after Duodenal Switch. The possible causes for constipation after duodenal switch may be metabolic-organic (where some patients have infrequent bowel movements before DS, hypothyroidism), length of the common and the Alimentary channels and medications (pain meds, narcotics, antidepressants).

In addition, Medium Chain Fatty Acids do not require bile salts to be absorbed and are directly absorbed into the Portal Vein in the liver. Medium Chain Fatty Acids are not malabsorbed post Duodenal Switch. Medium Chain Fatty Acids included Caproic acid, Caprylic acid, Capric acid, and Lauric acid. Commonly found in varying amounts within coconut oil and palm oil. MCT supplement is made with Medium Chain Fatty Acids.

In summary,  I recommend that Duodenal Switch patients who have had surgery with our practice have a high protein balanced diet. I do not recommend avoiding fat, or going on a low fat diet.  I am not sure if there a reason to consume excessive amount of fat, which may in fact have unexpected metabolic and nutrient consequences.

Every patient, as their weight stabilizes, will find what works and what does not work for them. Some patients will tolerate a higher fat intake and other will not be able to tolerate higher fat intake.