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Results for : "Vitamin A"

Bile Reflux

June 21, 2017 5:56 am

Bile Reflux or Duodenogastroesophageal Reflux (DGER) can be difficult to differentiate from acid reflux. Bile reflux happens when bile and contents from the duodenum, the first part of the small intestine, backs up into the stomach and possibly the esophagus causing gastritis or esophagitis. It is important to note that Acid Reflux and Bile Reflux are two different conditions.  You can not distinguish between Acid Reflux and Bile Reflux by symptoms alone. It is also possible to have a combination of Acid and Bile reflux. Bile reflux into the stomach may occur  in some patients with no symptoms. The problem arises when patient who are diagnosed solely on the symptoms of “reflux” are inadequately worked up and are placed on PPI, proton pump inhibitor medication  or similar, unsuccessfully.

What is bile?

Bile is a digestive fluid continually produced by the liver up to a liter a day. Bile is made of water, cholesterol, bicarbonate, bile acids and salts, electrolytes and copper. Bile travels through the hepatic duct and is stored in the gallbladder, if a person has a gallbladder. When the gallbladder is removed, the bile produced by the liver, continuously travels to the small bowel.

What does bile do?

Bile has a specific function in fat digestion.  Bile acts as an emulsifying agent to breakdown fatty acids into small particles, micelles, so they can be absorbed. Bile is important in dietary fat and fat soluble vitamin absorption. Bile is also the means for the body to dispose of the byproduct of blood breakdown, bilirubin. Bile is also important in cholesterol regulation and removes some excess cholesterol into the stool.

Anatomy of Bile Pathway

Approximately 20-30 minutes after eating the gallbladder will secrete bile into the first part of the small intestines called the Duodenum through the Common Bile Duct. The Common Bile Duct will release bicarbonate and water into bile. Once in the Duodenum, the bile will mix with the food product entering from the stomach.

Symptoms of Bile Reflux:

  • Heartburn
  • Chest Pain
  • Food Regurgitation
  • Upper Abdominal Pain
  • Nausea
  • Unexplained Weight Loss
  • Vomiting
  • Coughing
  • Hoarseness

Possible Causes of Bile Reflux:

  • Gastric Bypass RNY or SADI/SIPS/Loop
  • Peptic Ulcer
  • Gastric Motility dysfunction (Diabetic gastroparesis)
  • Pyloric Valve Dysfunction
  • Gallbladder Surgery (Cholecystectomy)
  • Biliary tree bypass surgery (Choledochoduodenostomy)
  • Medication

What is Bile Reflux or Duodenogastroesophageal reflux?

Bile Reflux or Duodenogastroesophageal Reflux is caused by the contents of the Duodenum entering the stomach and the esophagus causing symptoms and damage to the stomach and esophagus.

What is Gastroeseophageal Reflux?

It is know as heartburn or reflux and if you are experiencing more than twice a week you should be evaluated by a physician to investigate the cause. The contents of the Duodenum and Bile have a negative effect on the stomach and esophagus Long-term exposure can cause dysplasia, intestinal metaplasia, ulcers and malignancy in the stomach, and Barrett’s esophagus and various forms of esophageal malignancy [1].Past blog on Gastroesophageal Reflux Disease GERD

What is Esophagitis?

Esophagitis is the inflammation (-itis) of the esophagus. An irritant that can be acid, bile, food and digestive enzymes coming back up the esophagus can cause irritation and swelling of the cells lining the esophagus. If left untreated, it can damage the lining of the esophagus to the point of erosion and scarring. There is a relationship between DGER occurrence and the severity of esophageal lesions.

What is Gastritis?

Gastritis is the inflammation of the lining of the stomach. This may cause erosion of the lining of the stomach. This could be caused by bacterial growth or bile reflux. Gastritis can be either a acute or chronic issue that left untreated can lead to more severe problems such as bleeding or cancer.

 How to Diagnose Bile Reflux or Duodenogastroesophageal reflux?

Diagnosis takes careful consideration due to the high likelihood that DGER most often happens in conjunction with GERD and the symptoms of both are similar.  Medical treatment with medication to treat GERD and assist with DGER. Other important diagnostic test may include:

  • PH study
  • Motility, Gastric emptying study
  • Upper endoscopy and biopsy
  • Esophogeal Bilirubin Monitoring Bilitec
  • Proton Pump Inhibitor Test

Treatments options:

  • Lifestyle:
    • Avoid eating at least 3 hours prior to bedtime or reclining
    • Weight loss if needed
    • Avoid fatty foods, caffeine, peppermint, alcohol, garlic, onions, tomato products
    • Cessation of smoking
  • Medications: Acid and Pepsin suppression therapy
    • Proton Pump Inhibitor *PPI use increases  risk of Clostridium difficile colitis and bacterial gastroenteritis
    • H2 Blocker
    • Bile Acid Sequestrants
    • Ursodeoxycholic acid
  • Surgery

Surgery for Bile Reflux:

The Stand-Alone Duodenal Switch procedure without a Sleeve Gastrectomy or Gastric Bypass pouch was developed by Dr. Tom R. DeMeester in the 1980’s to treat bile-reflux gastritis, a condition in which the stomach and esophagus are irritated by bile that goes back through the pylorus to the stomach.  The DeMeester procedure creates a shorter bilipancreatic channel than the Biliopancreatic Diversion with Duodenal Switch for weight loss.  The Bile Reflux Duodenal Switch biliopancreatic channel is approximately 25-110 cm and alimentary channel 50 – 110 cm depending on symptoms, health history, weight, etc. These measurements are significantly different than the Biliopancreatic Diversion with Duodenal Switch for weight loss.

 Duodenal Switch for Bile Reflux References: 

1 Stein HJ, Kauer WKH, Feussner H, Siewert JR: Bile acids as components of the duodenogastric refluxate: detection, relationship to bilirubin, mechanism of injury and clinical relevance. Hepatogastroenterology. 1999, 46: 66-73.

Duodenalgastroesophageal Reflux medical and surgical https://www.ncbi.nlm.nih.gov/pubmed/18507090

Omeprazole to treat both acid and bile; https://www.ncbi.nlm.nih.gov/pubmed/8076761

Category :

Compounding Pharmacy

March 22, 2017 7:40 pm

We have received notice that the FDA and the compounding pharmacy have changed their regulations for several medications.  Unfortunately, this affects our office and Duodenal Switch patients in regards to injectable Vitamin D and Vitamin A. In the past, we have been able to have injectable Vitamin A and injectable Vitamin D in bulk in our office.  The new regulations require that a patient be assigned to the medication, so we will be unable to have it on hand in our office. This is out of  our hands and control.

We are requesting that if you are anticipating the need for injectable vitamins that you have your laboratory results in our office at least 3 weeks prior to your office visit.  This will give our staff adequate time to order your injectable vitamins to be available at your visit.

Injectable Vitamin D may be needed in some cases of Vitamin D deficiency or inability to increase Vitamin D level with oral supplements. Vitamin D is a fat soluble vitamin. It plays an important role in bone metabolism and structure. It has also been found to affect the immune regulation, control off- inflammatory reactions, and also be involved in a number of broad cellular functions throughout the body.

Research and information regarding Injectable Vitamin D.

Thank you for your understanding in this manner.

Back on Track 2017 Giveaway

January 10, 2017 10:03 am


Let’s get back on track 2017 after the holiday season! The holidays were wonderful but if you find yourself with a few extra souvenirs don’t feel alone. The average American gains between 1-8 pounds during the holiday season and I am no exception. Let’s get back on track 2017 together.

Time to clear out the kitchen! Disposing of temptations and high trigger foods is the first step to getting back on track. If the food isn’t easily acquired then it is less likely to be consumed.

Stock up on high protein and whole, unprocessed foods that are low carbohydrate and nutrient dense. When quality foods are easily available we are more likely to stay on track with the types of foods we should be eating. Simple sugars/carbohydrates are the biggest culprit of holiday weight gain. We need to go back to the basics of hydration, high protein, low carbohydrate/sugar, vitamin/mineral supplements and exercise. Simple sugars and carbohydrates are easy for our bodies to use and absorb and cutting them back can jump start your weight loss. Each individual needs to identify the daily carbohydrate intake that works for them. Some people stay under 50 grams of carbohydrates daily. You may also need to look at your protein and fat intake. All excess nutrients absorbed have the potential to turn into fat mass and inhibit weight loss. Metabolism video.

Hydration is an important ways to start getting back on track. Water is essential to life functions. The brain is 85% water, blood is 80% and muscle is about 70% water. Hydration aids in digestion, eliminating waste, byproducts and toxins. It also can decrease the feeling of hunger. Lack of hydration can increase fatigue which can lead to craving high carbohydrate foods to increase energy.

Protein’s importance in almost every bodily function and muscle mass can not be ignored. High quality complete Protein sustains muscle mass during weight loss, aids immunity, antioxidant function, and enhances leptin and insulin function. Filling up on protein first will help with carbohydrate carvings and give a sustained satisfied feeling. A prior blog post gives additional information on the importance of protein and the effects of protein malnutrition. WLS makes daily protein intake important but especially after Duodenal Switch, protein is a necessity of daily life.

Vitamins, minerals and supplements will ensure the body has the nutrients it needs to function adequately and can keep cravings at bay. Deficiencies in vitamins and minerals can cause cravings for foods. Vitamin and minerals are essential to muscle function, red blood cell production, bone health, and numerous other physiologic functions. We may all slack off on our supplements occasionally but now is the time to get back into the habit of daily vitamins and mineral supplements. A daily vitamin, mineral, and supplement routine is a lifetime commitment after Duodenal Switch or any WLS. Here is a list of commonly used supplements.

Exercise can increase weight loss, overall well being, mental well being, mood, alertness, improve digestion, improve sleep, and increases energy levels. Exercise does not have to be a daunting task. Simply adding 15-30 minutes of activity can give added benefits. Yoga, walking, dancing, lifting weights, hiking, and sports activities can be included or added to more traditional forms of exercise. There are many free online videos for all types of exercise available.

Finding a new hobby can keep both your hands and mind busy, curbing the unconscious eating of foods that are high in sugar and carbohydrates. Adult coloring books, drawing, painting, knitting, crocheting, sewing, dance lessons, gardening, learning to play an instrument and many others are great ways to use your time and expand your quality of life and brain function. New hobbies can also help establish new coping skills.  Our previous post on Coping Skills After Bariatric Surgery can be found here.  There are a whole host of online videos for “how to” on new hobbies.

Teaming up with others can also help increase weight loss and compliance. Support from friends, family and other groups will assist you. There is a whole gamut of support group online and in person. If you have fallen out of the habit of attending our support group or webinars get back to them. You can find our schedule and announcements regarding webinars here. Our Central Valley Bariatric Facebook page also gives daily inspirational messages, protein recipes and articles and any new information or research available. There is also our Duodenal Switch Facebook Group. Anything that increases accountability is a benefit and motivates us to stay on track.

Experiment with new recipes and flavors that are bariatric friendly and within your dietary needs.  There are so many options for quick and easy meals.  We have several recipes on our page for all stages following weight loss surgery and Duodenal Switch. However, there are endless option on the internet in Paleo, low carb, and high protein type recipes.

In the spirit of new starts and getting back on track 2017, we are having a giveaway with the basics to get back into the swing of things. This year we are looking for before and after weight loss surgical journeys.  Share your weight loss journey! Don’t be shy, your journey can inspire others and/or motivate yourself. To enter the Back on Track 2017 Giveaway, please submit your weight loss surgical journey with before and after pictures to contact@dssurgery.com or you can also post your before and after pictures on our Facebook page. You will also need to sign a release for the use of your story on our website. We will draw 2 names from those that enter by announcing it on our FaceBook page or by e-mail on January 31, 2017. You must submit your mailing information to contact@dssurgery.com in order to claim the prize.


Please check with your physician before starting a new supplement and follow laboratory studies for adjustments in supplements. Vitamin information here. Mineral information here.

Crohn’s Disease and Ulcerative Colitis

June 07, 2016 6:33 am

Crohn’s Disease and Ulcerative Colitis are two disease processes that effect the large intestine to varying degrees and in the case of Crohn’s possibly part of the small intestines. Both fall under the category of Inflammatory Bowel Disease however there are differences between Crohn’s Disease and Ulcerative Colitis even though they may share some symptomatology.

Crohn’s Disease (CD) is an inflammatory bowel disease (IBD) that causes deep tissue inflammation of the digestive lining tract. It affects the gastrointestinal (GI) tract, extending from the mouth to the rectum. CD has an asymmetrical progression, where it does not affect the entire tract uniformly (1). It is commonly found at the end of the small bowel (ileum) to the start of the large bowel (colon).

Complex interactions between three factors contribute to the occurrence of CD:

  1. Immune Response: Foreign environmental substances may elicit an overactive immune response. T-cell mediated immune response identifies threatening affluences and works to protect the body. This stimulates inflammation, often times without control, in the body as the body’s natural defense mechanism (2,3).
  2. Inherited Genes: Variation in genes that produce proteins involved in immune function may disrupt intestinal cell’s ability to respond normally to bacteria. Studies also show genetic deviation in chromosomes 5 and 10, which contain IBD loci. Alterations at this locus may lead to the increased risk of CD.
  3. Environmental Factors: Factors such as smoking, those between the ages of 10-40 yrs. (commonly diagnosed before 30 yrs.), diets high in sugar/sweeteners, fats/oils, and total fat may lead to the increased risk of developing CD.

Common symptoms of CD include frequent diarrhea, rectal bleeding, fatigue, fever, weight loss, reduced appetite, abdominal pain/cramps, and fever. Inflammation in CD is unevenly widespread throughout the GI tract. Inflammation in the mouth, esophagus, and stomach can lead to ulcers. However, they are rather uncommon. Inflammation in the small intestine, colon, and rectum may lead to ulcers as the severity increases (5). The complications in CD are due to chronic inflammation, which may lead to:

Inflammation in CD & UC
Inflammation in CD & UC
Differences in Crohn's Disease and Ulcerative Colitis
Key Differences in Crohn’s Disease and Ulcerative Colitis
  1. Intestinal narrowing (stricture)
  2. Abscess: collection of pus
  3. Fistula: abnormal connection or tract
  4. Colon Cancer
  5. Other disorders such as anemia, osteoporosis, gallbladder/liver disease, etc.

Antibiotics, anti-inflammatories, corticosteroids, and immunomodulators have been proven to regulate the mechanisms of CD. Surgical treatment may also benefit the patient. There are several surgical options that may be performed depending on the symptoms and findings.

  1. Strictureplasty
  2. Resection
  3. Proctocolectomy or Colectomy

There is no known cure for Crohn’s Disease; however these treatment options may control it.

Ulcerative Colitis (UC) is an inflammatory bowel disease (IBD), which results in damaging inflammation of the colon and rectum. It effects 700,000 men and women in the United States. As opposed to Crohn’s Disease, UC spreads evenly throughout the colon and rectum only (9). It does not affect the entire GI tract.

Like CD, Ulcerative Colitis occurs through a complex interaction of three factors:

  1. Immune Response: T cells (lymphocyte) mature and function in identifying foreign substances to then defend the body against infection.
  2. Inherited Genes: Variation in genes that protect intestinal function are more likely to respond abnormally to bacteria. Studies show genetic deviation in chromosomes 1 and 12 (11).
  3. Environmental Factors: Factors such as those between the ages of 1-30 yrs. or exposure to isotrentinoin (vitamin A derivative) may be at risk for UC.

Common symptoms of UC include bloody diarrhea, abdominal pain, weight loss, reduced appetite, fatigue, and fever. Inflammation in UC is evenly spread, yet restricted between the colon and rectum (10). Inflammation in the right (ascending), transverse, left (descending), sigmoid colons, and rectum can lead to ulcers that vary in size and depth (red, bloody, swollen). The complications of UC are due to prolonged inflammation, which can lead to:

  1. Increased risk of blood clots
  2. Colon Cancer
  3. Other disorders such as osteoporosis, liver disease, etc.

Antibiotics, anti-inflammatories, corticosteroids, and immunomodulators have been proven to normalize the mechanisms of UC. There is no cure for Ulcerative Colitis, but these treatment options may help regulate it.

It is important to have a coordinated team of medical professionals to develop an ongoing and dynamic treatment plan as well as surveillance for side effects of CD and UC. Patients can lead a productive life regardless of the challenges of CD and UC with appropriate medical treatment.


  1. Westall, F. C. (2006). Integrating theories of the etiology of Crohn’s disease on the etiology of Crohn’s disease: questioning the hypotheses. William M. Chamberlin, Saleh A. Naser Med Sci Monit, 2006; 12 (2): RA27-33. Medical Science Monitor, 12(5), LE5-LE6.
  2. Folwaczny, C., Glas, J., & Török, H. P. (2003). Crohn’s disease: an immunodeficiency?. European journal of gastroenterology & hepatology, 15(6), 621-626.
  3. Braat, H., Peppelenbosch, M. P., & Hommes, D. W. (2006). Immunology of Crohn’s disease. Annals of the New York Academy of Sciences, 1072(1), 135-154.
  4. Canavan, C., Abrams, K. R., Hawthorne, B., Drossman, D., & Mayberry, J. F. (2006). Long‐term prognosis in Crohn’s disease: factors that affect quality of life. Alimentary pharmacology & therapeutics, 23(3), 377-385.
  5. Talbot, R. W., Heppell, J., Dozois, R. R., & Beart, R. W. (1986, February). Vascular complications of inflammatory bowel disease. In Mayo Clinic Proceedings (Vol. 61, No. 2, pp. 140-145). Elsevier.
  6. Eaden, J. A., Abrams, K. R., & Mayberry, J. F. (2001). The risk of colorectal cancer in ulcerative colitis: a meta-analysis. Gut, 48(4), 526-535.
  7. Colitis–Pathophysiology, U. (2003). Inflammatory bowel disease part I: ulcerative colitis–pathophysiology and conventional and alternative treatment options. Alternative medicine review, 8(3), 247-283.
  8. Greenstein, A. J., Janowitz, H. D., & Sachar, D. B. (1976). The extra-intestinal complications of Crohn’s disease and ulcerative colitis: a study of 700 patients. Medicine, 55(5), 401-412.
  9. Lennard-Jones, J. E. (1989). Classification of inflammatory bowel disease. Scandinavian Journal of Gastroenterology, 24(sup170), 2-6.
  10. Gillen, C. D., Walmsley, R. S., Prior, P., Andrews, H. A., & Allan, R. N. (1994). Ulcerative colitis and Crohn’s disease: a comparison of the colorectal cancer risk in extensive colitis. Gut, 35(11), 1590-1592.
  11. Silverberg, M. S., Cho, J. H., Rioux, J. D., McGovern, D. P., Wu, J., Annese, V., … & Barmada, M. M. (2009). Ulcerative colitis–risk loci on chromosomes 1p36 and 12q15 found by genome-wide association study. Nature genetics, 41(2), 216-220.

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)

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.

SupplementsExclusive Member Content

March 19, 2016 11:16 pm

Category :

Pre-Operative Work-Up

March 19, 2016 11:14 pm

Prior to any surgery that involves general anesthesia, a number of diagnostic tests need to be performed. Weight loss surgical procedures are no exception. In fact in most cases a more in-depth and extensive pre-operative evaluation is needed prior to weight loss surgery.

Pre-operative patients will be required to have an EKG, chest x-ray and complete blood work prior to the surgery. The blood work will include a comprehensive evaluation of the patient’s nutritional status by measuring vitamin and mineral levels. Some patient’s may require upper endoscopy and/or upper GI series prior to their surgery to evaluate their anatomy. Based on the patient’s past medical history, some may be required to have a sleep study, while others may require a complete cardiac evaluation.

Our office will coordinate and help you complete the preoperative workup. We have also composed a document to help each patient optimize their pre-opertiave health care status here.

Category :


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.


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?

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?


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.

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