Tag: BPD/DS
Weight loss Surgery for Treatment of Diabetes
May 25, 2016 7:21 am
New guidelines and recommendation are coming out of the second Diabetes Surgery Summit in the Fall of 2015. One major change is Metabolic or Weight Loss Surgery for the treatment of Diabetes. With all the advances made in newer classes of medication for treatment of diabetes, the majority of patients who are being treated fail to get to achieve the desired results of lowered blood glucose level. This is in contrast where weight loss surgical procedures such as Duodenal Switch can results in >95% cure rate of type II diabetes.
The American Diabetes Association has made the recommendation for weight loss surgical procedures be considered as a treatment option for type II diabetes.
Summarizing their criteria “According to the new Guidelines, metabolic surgery should be recommended to treat type 2 diabetes in patients with Class III obesity (BMI greater than or equal to 40 kg/m2), as well as in those with Class II obesity (BMI between 35 and 39.9 kg/m2) when hyperglycemia is inadequately controlled by lifestyle and medical therapy. It should also be considered for patients with type 2 diabetes who have a BMI between 30 and 34.9 kg/m2 if hyperglycemia is inadequately controlled, the authors agreed. The Consensus S
tatement also recognizes that BMI thresholds in Asian patients, who develop type 2 diabetes at lower BMI than other populations, should be lowered 2.5 kg/m2 for each of these categories. ”
This is a remarkable change in thought and policy on diabetic treatment and long term strategies that can only improve patient outcomes. Stabilization and blood glucose hemostasis can only improve patient health, health care utilization and health care costs.
Minimally Invasive Weight Loss Surgery
May 17, 2016 9:02 am
Minimally Invasive does not mean better, easier, proven outcomes or good excess weight loss. Weight loss surgical patients should be careful of catch phrases such as “less invasive”, “simpler”, “shorter recovery”, “outpatient” and many others that had been used to described procedures with less than optimal outcome. We should not forget the lessons learned from adjustable gastric banding which was also promoted as ” less invasive, simpler to perform, and be done as an outpatient with a short recovery “. We all know how that story has panned out. The overwhelming majority of patients who had an adjustable gastric banding have undergone revision, had it removed or had additional surgeries following the complications which were associated with this simple procedure.
When evaluating outcome data for weight loss surgical procedures, it is important to bear in mind that the long-term success of these procedures will take years to document. More often than not the early weight loss is significantly better than the long-term stable weight loss. This has been clearly documented in the case of the adjustable gastric banding and the gastric bypass and laparoscopic sleeve gastrectomy operation. Duodenal switch , as described by Dr. Hess using the percentage based technique, has the best long-term documented success of all of the weight loss surgical procedures. The scientific data reports 20+ years of successful excess weight loss with a Hess Duodenal Switch procedure. There has been an alternative proposed to Duodenal Switch recently, the SIPS and SADI procedures. As I have already stated in the past, these are not the same as the duodenal switch operation. Any suggestion or innuendos that SIPS/SADI is the same as the Duodenal Switch is deceptive and misleading. We have also seen attempts to use the same catch phrases as described above to promote these unproven procedures. The published data that’s been reported with SIPS/SADI is mostly short-term in small population studies. There are no long-term studies that have documented the efficacy of the SIPS/SADI procedure and “simpler” or minimally invasive does not mean better.
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May 11, 2016 6:07 am
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!
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January 30, 2016 9:19 am
Fluids and Electrolytes After Weight Loss Surgery
January 29, 2016 7:06 am
Fluids and Electrolytes after weight loss surgery are an important part of recovery and lifestyle after undergoing a weight loss surgical procedure. Potassium is an important electrolyte found in higher concentrations within the fluid of the cells. It is important in muscle contraction, heart rhythm, nerve function and co-enzyme function.
Fluids and Electrolytes
The following webinar (link) discusses the balance of fluids and electrolytes with particular attention to post weight loss surgery concerns. Deficiencies can cause heart arrhythmias, muscle weakness and cramping, intestinal paralysis, and neurological deficits.
The Daily Recommended Amount for Potassium is 4,700mg
Here is a list of Lower-carb potassium sources: This is not meant to be in inclusive list. There are many higher carb sources of potassium also.
- Beet Greens- 1/2C 655 mg
- Trout 3oz – 375 mg
- Salmon 719 mg per average filet
- Halibut or Yellowfin Tuna 3oz – 500mg
- Clams 3oz- 534 mg
- Avocados 1 whole- 974 mg
- Squash 1C- 325mg
- Broccoli 1 cup 475m
- Watermelon Radish 3 oz – 233mg
- Sweet Potatoes- one potato 694mg
- Yogurt 1C – 579mg
- Tomato paste 1/4C – 342 mg
- Whole milk 1C – 366 mg
- Chicken breast meat 1 cup chopped – 358 mg
- Cauliflower 1 cup raw– 303 mg
- Peanut butter 2 T – 208 mg
- Asparagus spears 6 – 194 m
- Daikon Radish – 3″ – 280 mg
- Nuts 100-300 mg per 30g / 1 oz serving, depending on the type
- Dark leafy greens 160 mg per cup of raw, 840 mg per cooked
- Kohlrabi 3oz- 98mg
- Mushrooms 1 C- 273 mg
- Spinach – 1 cup 167 mg Potassium
- Walnuts 2 oz-250 mg
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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.