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Tag: Duodenal Switch

Shared Success Story- Dr. D. Brown

April 13, 2015 11:38 am

I had Roux-en-Y (RNY) gastric bypass surgery in February 2004. I was told it was the “Gold Standard” procedure and it was the only one my insurance would approve (according to the surgeon’s office). I lost around 130 pounds with some minor bounce back. Kept it off for 7 years. I had so much energy; I decided to go back to school to become a doctor.

In medical school I really began to regain, for a total of 75 pounds over 5 years. I tracked food and found that if I ate more than 1300-1400 calories daily, I was gaining. I had absolutely no sugar dumping or satiety or restrictive effects left from the RNY Gastric Bypass, only my metabolism’s memory of starvation mode.

In fact, I never had one incident of dumping syndrome; I only felt satiety for the first 2 years and was able to eat well over 2 cups of food per meal by year 7. Lack of dedicated exercise, extreme stress (time, financial & academic) as well as poor food choices all contributed to my regain. However, the RNY Gastric Bypass surgery only has an average long-term excess weight loss of around 50%, so that still makes my weight regain close to the acceptable range.
Finally, I looked into revision surgery. Not only is surgery always a major decision, but also a revision to a DS is a very technically complicated surgery. I extensively researched all the options to make the right decision. The Duodenal Switch surgery has the best long-term statistics for maintained weight loss in all the medical studies (close to 75% excess weight). The major feature is nutrient malabsorption. The amount is dependent on an individual basis but most fat and some protein calories are not absorbed. There is an initial restrictive component as well. With the nutrient malabsorption also comes vitamin/mineral malabsorption. However, RNY also causes vitamin malabsorption and I was already taking vitamins, so what’s a few more? I am just 4 weeks post-op now and am still in trial-&-error mode, but I have found a safe plan for returning back to work. I really could not have afforded any complications and am so glad that I placed my trust in Dr. Keshishian.
Dr. D. Brown

Starting wt: 274.0

Vitals for 4-16-15 (4 weeks post DS)
wt = 249.0
T = 97.7
P = 88
BP = 108/80

Evaluations of Gallbladder Disease And Function

April 11, 2015 7:03 am

Gallbladder disease can include both anatomical and functional condition. We are familiar with gallstones. Bile acids, Lecithin (a phospholipid), and cholesterol are present in the Bile. When the proportional percentage of each one of them is outside a very narrow range, gallstones are formed. Approximately 75% of the gallstones are formed because of the supersaturation of the content of the gallbladder with cholesterol which results in cholesterol stone formation.  The rest are pigmented stones.

Gallstones are usually identified by ultrasound and they are seen as shadows.

Gallstone
Gallstone

There are patients that have a normal gallbladder ultrasound result   that  continue to have signs and symptoms of gallbladder disease, such as abdominal pain in the right upper quadrant, nausea and vomiting with fatty meals, and bloating to name a few. These patients should be evaluated by a dynamic HIDA scan.

A dynamic HIDA scan study evaluates the function of the gallbladder, by creating a movie of the gallbladder, where as an ultrasound takes pictures of the gallbladder.

In a dynamic HIDA scan, and contractility of the gallbladder is reported in form of ejection fraction (%EF). This represent the amount of gallbladder contraction in response to the stimulation  by a fatty meal mediated thru cholecystokinin (CCK).  A normal EF is greater that 35%. Anything less than than with the sign and symptoms of gallstones, should be highly suspect for acalculous cholecystitis. Calculus because there is no stone.

(The bright white collection represents the filling of the gallbladder)

This short movie represents the uptake of the radio nuclear material in the gallbladder and its normal secretion in the small bowel.

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These are the static images before the injection of CCK.

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Following the injection, digital subsection of the images measure the amount of nuclear activity of the gallbladder before and after contraction and an Ejection Fraction is calculated.

Vitamin K1

April 08, 2015 7:16 pm

Vitamin K1 is a found in dark green leafy vegetables, asparagus, brussels sprouts, some grains,  olive oil, prunes, soy bean oil, and canola oil.  The body has limited storage capacity for Vitamin K and uses a recycle system to reuse it.

Vitamin K1 is a fat-soluble vitamin that after Duodenal Switch is not as easily absorbed due to the limiting contact of the food product with the bile until the common channel.  Bile is needed to absorb fatty acids and fat-soluble vitamins.

Duodenal Switch patients in need of Vitamin K1 supplements should take “Dry” or water miscible type of Vitamin K1, such as Biotech brand.  The patients laboratory studies will determine if a patient requires Vitamin K1 supplement. Duodenal Switch patients should  have laboratory studies drawn and evaluated at least on a yearly basis. Vitamin K works in a delicate balance with other supplements and should be monitored by a physician,  in at risk people.

vitamink3
vitamink3
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Vitamin K1 is most know for it’s coagulation effect and the clotting cascade.  Vitamin K1 works with calcium and proteins in order to accomplish coagulation synethesis. Care should be taken with Vitamin K supplementation and anti-coagulation (blood thinners) therapy.  Please see your physician regarding any supplementation of Vitamin K and blood thinner medications.

A discovery of Vitamin K dependent proteins has led to research on Vitamin K1 in bone health.  Bone matrix proteins, specifically osteocalcin, undergo gamma carboxylation with calcium much the way coagulation factors do; this process also requires Vitamin K. Osteocalcin is a Gla-protein that is regulated by Vitamin D.  The calcium binding ability of osteocalcin requires several Vitamin K carboxylations to exert it’s effects on bone mineralization.

vitamin-2Bk
vitamin-2Bk

In adults, the causes of Vitamin K1 deficiency include the following :

Chronic illness
Malnutrition
Alcoholism
Multiple abdominal surgeries
Long-term parenteral nutrition
Malabsorption
Cholestatic disease
Parenchymal liver disease
Cystic fibrosis
Inflammatory bowel disease
Medications:  Antibiotics (cephalosporin), cholestyramines, warfarin, salicylates, anticonvulsants, Cefamandole, cefoperazone, salicylates, hydantoins, rifampin, isoniazid, barbiturates, and certain sulfa drugs, higher Vitamin E can antagonized Vitamin K)
Massive transfusion
Disseminated intravascular coagulation (DIC) – Severe
Chronic kidney disease/hemodialysis

Additional information: https://lpi.oregonstate.edu/infocenter/vitamins/vitaminK/

Intake of Vitamin K1 and K2 and bone fracture risk

As always, discuss with your physicians and/or surgeon any changes in medications and supplements.  This is not meant to be an all inclusive discussion of Vitamin K.

First Duodenal Switch Patient- Dr. Hess

April 05, 2015 3:35 pm

I had the opportunity to be in a meeting with Dr. Hess in November of 2004. He presented a lecture about the history of the Duodenal Switch and his collaborative work with Dr. Scopinaro, the pioneer surgeon of the Biliopancreatic Diversion. The BPD was the the foundation of the Duodenal Switch operation.  The first patient ever to have had the Duodenal Switch was a revision from a failed vertical banded March of 1988 by Dr. Douglas Hess.  At the time of this particular meeting (in 2004), the patient was 17.5 years post op.

Hess
First Duodenal Switch Patient by Dr. Hess

This is a copy of the slide that he shared with the surgeons present at the Duodenal Switch meeting  on November 21, 2004.

Gall Bladder- Should the Gall Bladder Be Removed During Duodenal Switch?

February 16, 2015 1:17 pm

The indication for concurrent cholecystectomy (gall bladder removal) with weight loss surgery is not clear. There is some scientific literature that recommends against cholecystectomy at the time of the Gastric Bypass RNY operation. To the best of my knowledge, there is no such studies looking specifically at the indication of cholecystectomy with duodenal switch operation.

My rationale for doing a cholecystectomy with every Duodenal Switch patient is that there is not only higher incidence of asymptomatic cholecystitis present but also due to limited access to the biliary tree. The transection of the duodenum and removal of the greater curvature of the stomach both limit access to the biliary tree. Additionally, the patient recovering from weight loss surgery, may not be in the best nutritional status to undergo a subsequent operation for gallbladder removal. A second surgery could add to nutritional issues due to protein needs for healing, risk of infection, hernia formation, etc.

From a technical aspects, in Duodenal Switch operation, the liver and the gall bladder need to be elevated in order to expose the anterior surface of the duodenum where the transection of the duodenum is performed. Doing a cholecystectomy at the time of the duodenal switch operation, more often than not only add a few minutes to the operation. In the majority of patients, long-term this saves them the potential need for a subsequent operation at a later date should they develop gallstones or gall bladder attack.

When I perform a Sleeve Gastrectomy the duodenum is not transected or dissected, and thus I do not remove the gall bladder when doing sleeve gastrectomy. I do, however, remove the gall bladder when doing primary Duodenal Switch for revision from a Gastric Bypass RNY to the Duodenal Switch operation.

Optimizing Pre-operative Health Status

November 12, 2014 1:23 pm

The outcome of any weight loss surgery is dependent not only on the operation but also the extend and depth of preparation before surgery and adherence to the post operative recommendation. The operation should be considered a planned injury to the body. We should enter the operating room in the best physical and mental condition possible to secure the best possible outcome. Optimizing your Pre-operative health status is the best plan for going into surgery in the best shape possible. Here are some basic steps to maximize the odds for a good outcome. Physical preparation:
  • Maintaining a healthy diet
  • Cessation of ALL tobacco and alcohol use
  • Do not use NSAIDS prior to surgery or after surgery until cleared by surgeon
  • Getting plenty of rest
  • Staying Hydrated
  • Pulmonary embolus prevention exercises such as ankle circles and point and flex toes
  • Maintaining or starting a regular activity level. Any amount of increase in activity will benefit you after surgery. Walking, squats, lifting weights with arms
  • Full laboratory blood studies and vitamin levels as ordered by the surgeon
  • Start and optimize your vitamins, calcium and other mineral and supplements. Vitamin D deficiency increases surgical complications. (Another Vitamin D article)
  • Manage preexisting health conditions (diabetes, sleep apnea, high blood pressure etc..) Follow instruction in regards to what medication to stop or continue before surgery i.e. Aspirin, blood thinners, medications that interfere/interact with anesthesia, etc.
  • Two forms of Birth Control if indicated.

Mental preparation:

  • Have a clear understanding of the procedure
  • Study all information provided to you regarding your surgery
  • Remember that surgery is one of many tools to assist in weight loss and improved health. It does not fix other issues.
  • Realistic expectation of the outcome of surgery
  • The role of family involvement for support
  • Be prepared with all the purchases for the post operative diet, vitamin and mineral supplements.
  • There is also a number of other variables that will improve the long term outcome of the weight loss surgery:
  • Investigate Protein Supplements for the highest bioavailability
  • Try and eat whole, unprocessed foods
  • Read labels on all food items
  • Look for high protein recipes
  • Network with supportive people who will provide a positive influence
  • Long term success also depends on:
  • Maintain daily protein requirements
  • Maintain daily vitamins, calcium, minerals and other supplements
  • Routine follow up with your bariatric surgeon.
  • Routine laboratory studies to surveil vitamin and mineral levels.
  • Get your medical advice from your surgeon.
  • Get suggestions from other patients. Do not confuse this with medical advice.
Weight loss surgical procedures are not an easy way out. On the contrary, weight loss surgical procedures are complex operations, from technical, metabolic, nutritional and psychologic perspective. A patient has to be prepared to deal with all aspect of the surgery for the best possible longterm outcome.

Telogen Effluvium: Hair Loss After WLS (Weight Loss Surgery)

September 14, 2014 12:56 pm

Telogen Effluvium is the premature pushing of the hair root into a resting state and can be chronic or acute. It is usually brought on by a shock to your body such as high fevers, childbirth, severe infections, severe chronic illness, severe psychological stress, major surgery or illnesses, over or under active thyroid gland, crash diets with inadequate protein, and a variety of medications. Most hair loss from medications, is this type of hair loss, and the related medications include retinoids, beta blockers, calcium channel blockers, antidepressants, and NSAIDS (including ibuprofen). Supplements that can also cause or increase telogen effluvium are higher doses of iron and Vitamin A.

hair-2Bcycle
Hair cycle

The hair begins to fall out in differing amounts and can start weeks to months after the initial shock to the body or medication initiation. The hair loss can continue up to 6 weeks and typically slows at 8 weeks after the start of the hair loss.

Weight loss surgical patients experience this due to the stress of surgery and the low protein state directly after surgery. Although there is no specific treatment for Telogen Effluvium, there are steps that can be taken to potentially slow the hair loss and help support the new hair growth.

The most important steps to take are to maintain your protein supplementation at a minimum of 80-100 grams of protein daily and hydration (at least 64 ounces daily) after weight loss surgery.

Hair loss pattern from telogen effluvium
Hair loss pattern from telogen effluvium

Protein, particularly L-lysine, are the building blocks of hair and nails, without adequate protein your body will forgo making hair and nails to maintain critical muscle mass. Also hydration is important to flush the body of toxins, due to fat breakdown in the liver during the rapid weight loss phase, that will prevent further new hair growth.

Vitamin B6 and B12 deficits can also contribute to hair loss. Multivitamin supplementation is essential to maintaining the required levels of these vitamins. The recommended multivitamin supplementation is two multivitamins daily that are equivalent to Centrum brand multivitamin.

Some people add Zinc supplements to increase hair production. However, if you are adding Zinc it is advised to also add a Copper supplement as they compete with each other for absorption. Copper is important for red blood cell production and a copper deficiency can exacerbate iron deficiency anemia. Inactivity can also decrease zinc levels, therefore exercise/activity will naturally maintain zinc levels.

Biotin is also a B vitamin that can be helpful in new hair growth.

Folicure is a supplement tablet that contains many vitamins and minerals that some people find helpful for hair re-growth. They also manufacture a shampoo that can be used.

There are many shampoos and topical treatments that people use and report satisfaction in their results. However, it is important to note that a topical treatment may make your hair appear thicker but the hair regrowth will only be supported by internal nutritional maintenance. Minoxidil is a liquid vasodilator medication applied to the scalp that is the exception to this rule and can help with hair regrowth. However, Minoxidil will not work to it’s optimal level in the absence of adequate nutritional status.

We always go back to our basics after weight loss surgery of hydration, protein and exercise to maintain health of body and hair.