1-818-812-7222 Office Hours: 8:00 AM to 5:00 PM
10 Congress St., Suite #300
Pasadena, CA 91105

Tag: bariatric surgery

Protein Intake

October 14, 2019 7:08 am

Protein intake requirements change over time following weight loss surgery. This is based on the requirements imposed on our body by a number of variables. These include, activity level, muscle mass, over all health condition to name a few.

A very young muscular athletic male with a BMI or 30 will require much higher protein intake (and absorption) that an inactive older Female with the same BMI. The same young athletic male will require much higher protein intake is he is recovering from a surgery than his baseline.

As we have stated in the past, the protein intake, should be adequate and not excessive. High level of protein intake that are not accounted  for based on muscle mass and activity level, will eventually result in weight gain. The best measure of protein intake in a stable weight patient over 3-4 years post op  is their albumin and protein level. Following your yearly laboratory values at a minimum is an important part of weight loss surgery follow up care.

You also need to adjust protein intake when necessary. Protein needs increase depending on physical needs, infection, healing, pregnancy, surgery, age, injury, etc. Plastic surgery requires higher protein needs for appropriate healing.

Information on protein sources and quality here.

The basic formula for protein intake is 1gm/kg of ideal body weight. The calculator below will provide a guide for the protein into based on your stable weight in lbs.

Flagyl

September 25, 2019 9:07 am

Flagyl is sometimes prescribed for excessive gas and diarrhea. It is an antibiotics that works well on certain bacteria that accumulates in the GI tract and contributes to the gas and the bloating. 

These bad bacteria flourish when patients consume significant and excessive fiber and carbohydrates (sugars, salad, pasta etc.) The FIRST line of defense against flatulence, bloating, and diarrhea should be eleminating the culprits in the diet.  This point can not be stressed enough.   Adding a daily dose of yogurt may improve symptoms due to yogurts probiotic benefits. To be beneficial, Yogurt should contain live bacteria cultures, not contain artificial sweeteners or have a high sugar content.

Artificial sweetness also area source of the excessive gas and should be avoided.

The Flagyl eliminates and reduces the bad bacteria. Along with a Probiotic and healthy dietary choices Flagyl can help to significantly improved or eliminate those symptoms of gas and diarrhea.

Before Flagyl is prescribed, it is important that the diet is critically examined to make sure that the carbohydrates and the fiber as source of gas and bloating is minimized or eliminated. Excessive use of medications that may be needed for other infections should be avoided.

Chronic diarrhea should be evaluated to rule out GI infection with C. diff bacteria or other bacteria or parasite.

 

Additional Information on C. Diff (Clostridium Difficile)  and probiotics.

Sleeve And Weight Regain

July 22, 2019 9:50 am

Sleeve gastrectomy has become the most frequently performed operation in the US. Sleeve as a part of the Duodenal Switch or as a stand alone operation has been offered in our practice for nearly 20 years. As a precondition to this, patients’ choosing to have the sleeve, especially with high BMI (>45) and those with metabolic conditions (diabetes, high cholesterol or triglycerides, PCOS, and others) we have always recommended Duodenal Switch as the procedure of choice instead of the Sleeve Gastrectomy due to improved and lasting co-morbid resolution  and weight loss maintenance with Duodenal Switch. It has been know for years that a sizable number of patients having the sleeve will experience weight regain requiring conversion to the duodenal switch or the RNY Gastric Bypass. Majority of the patients having gained weight after sleeve, or experiencing the return of co-morbidities after a transient resolution during the their weight loss phase, should only be revised to the Duodenal switch operation in my opinion. The alternative procedures of SIPS and SADI or similar single anastomosis operation with confusing nomenclature should be avoided, since as of the publication of this blog they are still considered investigational by the American Society for Metabolic and Bariatric Surgery (ASMBS) with no long term data.  The only plausible reason for revision of the Sleeve to the gastric bypass (RNY) would be those patients who are experiencing reflux. Felsernreich et.al. demonstrated that 10 years after sleeve gastrectomy  33% were requiring revisions of their sleeve due to weight regain or reflux. 66% needed revision for weight loss and only 34% for reflux. Those patients who have revision to gastric bypass (in their practice all being revised with two exception) had resolution of their reflux however had no sustained weight loss after the revisions. This supports our position that we have had for years that the those patient who had the sleeve and are experiencing weight regain, recurrence of comorbidities inadequate weight loss ahould all be revised to the duodenal switch operation.

Thyroid Medication Absorption And Weight Loss Surgery

June 10, 2019 8:59 am

Question : “Do I have to take higher dose of thyroid medication after the duodenal switch? ”

Answer : “Maybe”

With all weight loss surgical procedures, there may be changes to absorption of medications. It is easily understood why duodenal switch may results in decreased absorption of fat-soluble medication. What is not as clear is the reduction in absorption of other medication with procedures that do not explicitly change the absorption at the level of the small bowel directly.

The research data is all over on this topic. There is published literature that shows improvement in the thyroid function after gastric bypass and the sleeve gastrectomy.  However, the exact mechanism is not completely understood.

There is research that reports “…decreased postoperative levothyroxine requirements.” Other have shows no correlation between the length of the bowel distal to duodenum to absorption of thyroid medication.

With all this confusing data, the best course would be to always “treat the patient and not the lab results.”

If a patients who has been on medications with stable number and symptoms,  suddenly presents with complaints of hypothyroidism after weight loss surgery, it’s possible the medications should be up adjusted even if the thyroid lab values may not be as defining.

   

Osteoporosis Medications, Action and Side Effects

May 25, 2019 3:40 pm

Recently I had a short live presentation on the subject of osteoporosis, osteoporosis medications, and the treatment options of this deteriorating bone condition. A patient who has had a bone scan may be diagnosed with Osteopenia and/or Osteoporosis. This information is usually conveyed by the forms of a Low T score. Both of these indicated demineralization of the bones, and the end result is  worsening of the bone structure. This leads to weaker bones and higher chance of fracture due to stress or trauma.

Treatment options should be approached is a global and systemic fashion. It is critical that the nutritional status is at its best possible and optimized for important healthy bone vitamins and minerals. Low protein needs to be corrected. Special attention should be given to nutrients, minerals and vitamins. These include ProteinCalcium, Magnesium, Vitamin D, and Vitamin K1/K2to name a few.

Healthy bones require ongoing and routine force in the form of exercise to remain health. Just as exercise improves muscle strength, it also improves bone health. Exercise is also critical in improving bone structure and density. Ideally, exercise should be weight bearing and resistance.  Examples include: hiking, walking, jogging, climbing stairs, playing tennis, and dancing. Resistance type exercise is weight lifting and resistance bands.  These exercise work by creating a pull or force on the bone either by gravity, movement or weight.  Always check with your physician before beginning an exercise routine, start slowly and building up to longer periods of time.  The ideal goal would be at least 30 minutes a day, every day, if you are able.

We frequently see patients immediately started on osteoporosis medications without checking or improving some of the nutritional markers noted above or without looking at exercise history. In some case, the medication recommended are contraindicated due to nutritional status.

The medications can be grouped in to those  that help with new bone formation (Anabolic agents) or those that help by suppressing the bone breakdown phase (Antiresorptive agents).

Groups of Medication

 

National Osteoporosis Foundation has an exhaustive list (below) of medications for treatment of Osteoporosis.

The table below outlines the side effects and mechanism of the actions of the common medications used for treatment of  osteoporosis which was published by the University Health News Publication on August of 2014.

Mechanism Of Action And Side Effects

 

With all this information, the few points to remember is that the most important factors in healthy bone structure are the nutritional status Protein, Calcium, Magnesium, Vitamin D, and Vitamin K1 levels.

This is an animation of normal bone Metabolism. It shows how bone structures is taken down and rebuilt continuously. This allows for a healthy bone maintainence as we age. The key is the balance of breakdown (osteoclast) and the build up (osteoblast) activity is regulated. Osteoporosis develops when there is more breakdown that build up.

With permission of Dr. Susan Ott of University of Washington.

Additional information available on her site.

Past blogs on Bone Health.

Dr. Facebook

March 22, 2019 8:24 am

We have become reliant on the information that we obtain from the internet, specifically platforms such as Facebook. In our practice we have to continuously correct information that patients have obtained from other patients, unmonitored sites, blogs, and postings. Most of this information is based on individual experiences that has become gospel. “Fat is good for you” is one of them. To clarify, some health fat (olive oil, avocado, Omega 3) is healthy and needed for all patients. We do not recommend “fat bombs” as a part of ones daily dietary intake.

The following article was written on the accuracy of nutritional posts in support groups on Facebook.

Koalall et. all  in  SAORD, December 2018  Volume 14, Issue 12, Pages 1897–1902 published
“Content and accuracy of nutrition-related posts in bariatric surgery Facebook support groups”

The conclusion, as suspected, that “Over half of the posts contained inaccurate content or information that was too ambiguous to determine accuracy..:”

pilot
Pilot by Dr. Ara Keshishian

It is our recommendation before any dietary recommendations are taken from facebook and the like, the source of the information should be verified.  As I have stated in the past, a frequent flier passenger is probably not qualified to fly a

commercial airplane, any more than a previous weight loss surgical patient providing medical and nutritional advice. We realize that there is significant value to the forum for exchange of information and sharing of experiences with other weight loss surgical patients as long as the information is well sourced and verified.

Previous blog with artwork.

by Rina Piccolo https://www.rinapiccolo.com/piccolo-cartoons

Gastric Balloon

March 12, 2019 9:10 am

Here we go again…. There is a new cure for obesity, Gastric Balloon, with minimal to no risk, is an outpatient procedure and/or can be done in the surgeons office with no anesthesia. Have we not similar claimed like this before (Adjustable gastric band) ?

Randomized sham-controlled trial of the 6-month swallowable gas-filled intragastric balloon system for weight loss published  in Surgery for Obesity and Related Diseases 14 (2018) 1876–1889, by Sullivan et. al  reports

“Conclusions: Treatment with lifestyle therapy and the 6-month swallowable gas-filled intragastric balloon system was safe and resulted in twice as much weight loss compared with a sham control, with high weight loss maintenance at 48 weeks.”

This sound very promising, however is very vague and leaves out significant, critical, and pertinent information.

The outcome of weight loss at 24 weeks was reported in Total Body weight loss % (TBWL%), Excess weight % (EWL), weight loss, and BMI change. Of those, the last three were statistically significant changes.

The outcome the weight loss was reported to be at 7% TBWL% at 24 weeks with some weight regain, with the patient employing post REMOVAL life style changes.

It is stated that the Gastric Balloon is temporary device that needs to be removed in 6 months and should  be considered in low BMI patients (<35kg/m2).  It is is important for those patients who are considering this temporary expensive measure for minimal weight loss to entertain the alternative of the same temporary results that may be obtained by lifestyle changes. These results may be maintained by a healthy lifestyle, exercise, and eating without the need for a device.

Adhesions, Internal Hernia And Bowel Obstruction

December 15, 2018 2:35 pm

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

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

Other causes of bowel obstruction:

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

 

Internal Hernia

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

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

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

GI Bleed following Weight Loss Surgery

September 17, 2018 10:28 am

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

Endoscopic Procedures:

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

Normal Anatomy
Normal Anatomy

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

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

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

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