Tag: bariatric surgery
Should Adjustable Gastric Banding (Lap Band) be done?
October 06, 2024 9:17 pm
The Lap Band was approved in the US in 2001 (BMI> 40). The following studies used only small samples and examined short-term efficacy and safety. They were then performed to consider the utility of the Laob band for patients with lower BMI (BMI 30-40). 
Noe the frequent complications of nausea, difficulty swallowing, pain, and reflux-which may sound familiar to a lot of patients who have had and still have the Lap Band.
Numerous US and international studies have been published over the years, including short-term and long-term studies. The summary outcome has been the same, with only a few exceptions.
- The Lap Band does not result in long-term sustained weight loss.
- Lap band has significant complications, some of which may not be reversible.
- The lap band can be removed, but eroding the banc to the stomach is not easy.
Surgery Bests Lifestyle Changes, GLP-1 for Durable Weight loss
September 11, 2024 9:04 pm
SAN DIEGO-Bariatric surgery far outperforms lifestyle interventions and glucagon-like peptide-1 (GLP-1) medications at maintaining weight loss, according to a meta-analysis presented at the 2024 annual meeting of the American Society for Metabolic and Bariatric Surgery.
With results from six randomized controlled trials, three systematic reviews, and more than 40,000 patients, the study is the first synthesis of its kind.
“The analysis included two systematic reviews of bariatric surgery, one of Roux-en-Y gastric bypass including8,665 patients and one of sleeve gastrectomy including 6,095 patients: a single systematic review or lifestyle interventions including 723 patients; and six randomized controlled trials of GLP-1 medications, including four studies of semaglutide with a total of 11,871 patients and two of tirzepatide with 3,209 patients.
Lifestyle interventions were the least effective treatment, the investigators found, producing a mean total body weight loss of 7.4% at the end of the treatment period, followed by a mean per-month weight regain of 0.14%, with participants reaching their pre-intervention weights within 4.1 years.
GLP-1 medications proved more effective. Weekly semaglutide injections for 20 weeks and tirzepatide for 36 weeks produced a mean total body weight loss of 10.6% and 21.1%, respectively. Roughly half of the weight lost was regained within a year after stopping injections; with continued injections, weight loss plateaued after 17 to 18 months, at 14.9% for semaglutide and 22.5% for tirzepatide.
Outcomes after surgery were significantly better. Gastric bypass surgery and sleeve gastrectomy resulted in a mean total body weight loss of 31.9% and 29.5%, respectively, one year after surgery. Accounting for weight regained in the decade after surgery, both procedures produced a stable total body weight loss of approximately 25%.
While the results demonstrate a striking difference favoring surgery, lead investigator Megan Jenkins, MD, a bariatric surgeon at NYU Langone Medical Center in New York City, emphasized that surgery and medication ought to be viewed not in opposition but through a holistic lens as options and potential complements based on the needs of each patient.
“One of the big benefits of these new medications is that it’s helped us to treat obesity as a chronic disease,” Dr. Jenkins said. “We’ve always treated it that way, but I think the medical field has had trouble truly seeing it as a chronic disease. Like diabetes and high blood pressure, for example, which have always been treated with a combination approach.
Bile Reflux Gastritis
August 02, 2024 10:53 am
Bile Reflux
Bile Reflux is primarily a diagnosis of exclusion. All other possible causes must be ruled out, and bile reflux gastritis is made with the pertinent symptoms. The reason for this is that there is no primary test that can prove the diagnosis. When it comes to treatment, the surgical option requires preventing the bile from coming back to the stomach. The procedure we have performed routinely for bile reflux gastritis is the duodenal switch (without a reduction in the stomach size). This allows the food to go through an intact stomach and pyloric valve with normal stomach physiology (to prevent dumping syndrome). The bile is diverted through 100 cm of the small bowel as the biliary and alimentary limbs to prevent backflow of bile to the stomach (if it’s made too short). The procedure referenced (https://www.americanjournalofsurgery.com/article/S0002-9610(03)00213-7/abstract) is nearly 20 years old. It is rarely, if at all, performed due to its very complex and relatively high-risk nature. Its primary role for a surgeon is to reconstruct the biliary track flow. This operation involved transecting the common bile duct and creating a biliary tree to small bowel anastomosis. This is, at times, done when there is injury, obstruction, or tumor of the bile duct. This anastomosis has its complications, including stricture and sump syndrome. Therefore, hepaticojejunostomy or hepato-duodenostomy anastomosis are reserved for cases with no alternatives.
A-Normal Anatomy
B-Duodenal switch for bile Reflux
C-Hepatojejunostomy for bile relaxation was proposed in a 2003 study.
SIPS-SADI and ASMBS
December 31, 2023 1:21 pm
Weight Loss Injection
May 10, 2023 1:06 pm
Semaglutide (Ozempic, Rybelsus, Wegovy, Saxenda) and tripeptide (Mounjaro) treat type II diabetes. They work thru several complex pathways. An observed side effect that has been noted in diabetic patients has been weight loss.
Some have been advocating using the class of medications for weight loss. However, Wegovy is the only medication approved for weight loss in non-diabetic patients.
There is a lot to be discussed here:
1-the use of the medications for weight loss is an off-label use (except Wegovy)- meaning that the FDA did not approve the medication as a weight loss drug.
The practical implication is that the medication’s safety and complication profile in non-diabetic patients looking to lose weight may be unknown and has not been studied.
2-The medication has become available thru compounding pharmacies. It is crucial to appreciate that compounding medications do not meet the same rigor and standards and may, in fact, not be the same formula as the FDA has stated.. This also means that a compounding pharmacy does not approve the medications in several states.
3-The most critical issue for me is the lack of a “long-term plan.” It is not clear what would happen when the patient stopped the medication. Will the patient experience weight regain? Will the patient require higher doses of the medication to maintain the weight loss, or will the medication stop working altogether? Unfortunately, we do not have these answers. For those skeptical about my questions, let me remind you that phentermine has significant side effects, and almost all patients experience weight gain when they have to stop the medication because of the cardiovascular complication of medication.
Pictures For Anesthesia
February 02, 2022 11:57 am
Physical Activity in US
November 28, 2020 1:41 pm
Physical activity in the U.S. varies based on geographic location, socioeconomic status and in comparison to other countries. It is important to know that physical activity is an important component of our well-being. However, this does not mean that going to the gym is the only way to be physically active.
Strain et al. Shows that different populations in different countries get their activity from different sources.
His research showed that the United States population ranked as a high-income country, ranks in the lower 1/3 of the number of countries surveyed with regards to the meeting minutes of moderate-to-vigorous physical activity (MVPA) per week. This may be a contributing factor to the significant rise in obesity in the United States. Individually we should all aim to increase our moderate to vigorous activity significantly.
Sleeve Gastrectomy in Adolescent patients
September 23, 2020 5:44 am
Sleep apnea resolved at the same rate. These early interventions can mean there may be lower long-term risk and associated conditions for these teens as they age.
A recent article was written from several adolescent weight loss surgical patients’ perspectives: This included their feelings of hope for their futures and health.
Zoom Group Meeting
September 21, 2020 7:10 am
We are excited to announce we will be having a Zoom group meeting Tuesday, September 22, 2020 at 7:00 PM PST. We hope to see you online!
Registration is required. Please follow the link to the meeting registration.
Fat Soluble Vitamins
April 26, 2020 10:20 am
Written By: Maria Vardapetyan, Eric Baghdasaryan, Osheen Abnous
Vitamins are chemicals that facilitate many processes in the human body such as blood clot formation, good vision, fight infections etc. There are two classes of vitamins. Water soluble vitamins and fat soluble vitamins. Water soluble vitamins dissolve in water. This makes it possible for them to be absorbed through all mucous membranes. Fat soluble vitamins on the other hand do not dissolve or pass through mucous membranes. Fat-soluble vitamins are absorbed in the intestine along with fats in the diet. These vitamins have the ability to be stored in the fat tissues of the human body. Water-soluble vitamins are not stored in the body and have to be taken in daily with the food and dietary supplements. Solubility of a vitamin is not a function of its physical state. There are fat soluble vitamins that have a liquid form and almost all of the water soluble vitamins come in form of pills or powders.
In this article, we are going to focus on fat soluble vitamins. They are all complex molecules made of carbon, hydrogen, and oxygen in different arrangements (see figures 1, 2, 3 and 4). These fat soluble vitamins are vitamin A, D, E and K.
Vitamin A
Vitamin A has a major role in vision, immune function, cell growth, and maintenance of organs such as heart, kidneys, lungs, etc. It plays a pivotal role in the health of our eyes, specifically the retina1. Rhodopsin protein, a major protein that has the leading role in the process of vision, is found in the retina where it allows us to perceive light. This protein requires vitamin A to function properly. Without vitamin A, rhodopsin cannot sense light and thus cannot initiate the process by which vision occurs.
Figure 1: Chemical structure of Vitamin A molecule
Vitamin D
Vitamin D regulates different chemical reactions that are associated with bones, muscles, and the immune system. The simplified way it does this regulation is it helps absorb calcium from dietary nutrients which in turn strengthens the bones, helps neurons exchange signals to move muscles and helps the immune system to fight against viruses and bacteria2.
Figure 2: Chemical structure of Vitamin D molecule
Vitamin E
Vitamin E acts as an antioxidant. Antioxidants are naturally occurring chemicals that neutralize toxic byproducts of many chemical reactions in the human body. When food is consumed and digested, the human body converts it into energy. As a result of metabolism free radicals (toxic byproducts) are formed and are neutralized with the help of vitamin E. In addition, free radicals are also in the environment. Furthermore, vitamin E stimulates the immune system to fight against bacteria and viruses3.
Figure 3: Chemical structure of Vitamin E molecule
Vitamin K
Vitamin K can be obtained from food and dietary supplements. There are two forms of vitamin K: phylloquinone (Vitamin K1), which is found in spinach, kale and other greens and menaquinone-4 (Vitamin K2), which is found in animal products. Vitamin K1 is involved in blood clotting, and Vitamin K2 is involved in bone tissue building. Vitamin K1 is the main Vitamin K in human diet (75-90% of all vitamin K consumed), however, it is poorly absorbed in the body4,5.
Figure 4: Chemical structures of Vitamin K1 and K2 molecules
Absorption of fat soluble vitamins
Polarity describes the inherent charge(positive or negative) or lack of charge for any given substance or molecule. Molecules that are charged are referred to as “polar”, while those that lack charge are “nonpolar”. When discussing solubility, it is important to remember the phrase “like dissolves like”. That means polar (charged) substances like to interact with a polar environment like water, since water contains a slight negative charge. Hence, charged substances are water-soluble. Nonpolar substances on the other hand readily interact with nonpolar environments such as fat, which contains no charge. Therefore, molecules that lack a charge such as vitamins A, D, E, and K are referred to as fat soluble.
Due to their water fearing nature, these fat soluble vitamins cannot simply be absorbed directly into the bloodstream (which is mostly water) like the sugars and amino acids in our diet. As their name suggests, these fat soluble vitamins like to be embedded in fatty droplets, which facilitate their absorption in the following way. Fat soluble vitamins group together with other fat molecules to form fatty droplets, effectively reducing the amount of interaction with the watery environment of the intestines. Therefore, without an adequate amount of fat in your diet, your body is unable to effectively absorb these fat-soluble vitamins. This may be true in an intact anatomy, however, post weight loss surgical patients can not increase their fat soluble vitamin levels by increasing their fat intake. This is due to the fact that a high fat diet causes excessive bowel movement which in turn washes away any vitamins taken by mouth. DS limits fat absorption (thus the great weight loss) which can cause vitamin A and D deficiency that can not be easily corrected with oral supplementation.
As mentioned before, fat soluble vitamins are hydrophobic and nonpolar, which means they are also fat loving or lipophilic. Excess fat soluble vitamins can be stored in the liver and fat tissue. Therefore, these vitamins do not need to be eaten every single day since stores of these vitamins can sustain a person for some time. It may take several weeks or months for our body to deplete these stores of fat soluble vitamins which is why it generally takes a longer amount of time for fat soluble vitamin deficiencies to manifest themselves. The ability to store these fat soluble vitamins in tissues can also lead to vitamin toxicity – marked by an excess of vitamin stores in our body.
Clinical manifestations of A, D, E, K deficiency
| Vitamin | Clinical Deficiency manifestations |
| Vitamin A | Vision Problems
Dryness of the eye |
| Vitamin D | Softening and weakening of the bones
Bone shape distortion Bowed legs (generally in children) Hypocalcemia |
| Vitamin E | Damage to red blood cells
Tissue/organ damage due to inability to supply enough blood Vision problems Nervous tissue malfunction |
| Vitamin K1 | Excessive bruising
Increased bleeding time Small blood clots under nails Increased bleeding in mucous membrane |
| Vitamin K2 | Weak bones
Increased plaque deposits along gumline Arterial calcification |
References
- Office of Dietary Supplements – Vitamin A. NIH Office of Dietary Supplements. https://ods.od.nih.gov/factsheets/VitaminA-HealthProfessional/#. Accessed April 26, 2020.
- Office of Dietary Supplements – Vitamin D. NIH Office of Dietary Supplements. https://ods.od.nih.gov/factsheets/VitaminD-Consumer/. Accessed April 26, 2020.
- Office of Dietary Supplements – Vitamin E. NIH Office of Dietary Supplements. https://ods.od.nih.gov/factsheets/VitaminE-Consumer/. Accessed April 26, 2020.
- Vitamin K. The Nutrition Source. https://www.hsph.harvard.edu/nutritionsource/vitamin-k/. Published July 2, 2019. Accessed April 26, 2020.
- Beulens JWJ, Booth SL, van den Heuvel EGHM, Stoecklin E, Baka A, Vermeer C. The role of menaquinones (vitamin K₂) in human health. The British journal of nutrition. https://www.ncbi.nlm.nih.gov/pubmed/23590754. Published October 2013. Accessed April 26, 2020.