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Tag: Duodenal Switch

Don’t lose your Pyloric Valve over a Failed Gastric Sleeve

June 22, 2016 9:32 am

In my opinion, there are very few reasons to lose your Pyloric Valve after sleeve gastrectomy. Recently, I am hearing of people who have had regain due to a failed Sleeve Gastrectomy being revised to Gastric Bypass RNY and then seeking a Duodenal Switch due to regain from Gastric Bypass RNY. A better option is to go from Sleeve Gastrectomy to Duodenal Switch, due to the long term excess weight loss maintenance of Duodenal Switch. The benefit of the pyloric valve can not be taken lightly.

Let’s start by reminding ourselves as to how the Sleeve Gastrectomy has gained popularity. In the quest for a simple solution to the complex problem of obesity, adjustable gastric banding gained popularity only fail to deliver anything close with the results that were promoted and heavily marketed. The focus was then changed to another seemingly simple procedure, laparoscopic sleeve gastrectomy. For some surgeons this is a new procedure. Surgeons that had been doing the duodenal switch operation for decades, sleeve gastrectomy has not been a new procedure. Surgeons that just started doing sleeve gastrectomy as a stand alone procedure started experiencing complications of the sleeve gastrectomy, such as regain and are now looking for another option for these patients. This complication are even more frequent when they’re done following a failed adjustable gastric band procedures due to the metabolic issues after revising one weight loss surgery to another. A similar short sighted approach is also being promoted with SIPS/SADI procedures, which is significantly simpler to perform than the duodenal switch operation.

duodenal-switch
Diagram of Duodenal Switch
Structures of the Stomach
Structures of the Stomach

Laparoscopic sleeve gastrectomy has a predictable profile for weight loss. It will not have as good on the long-term success rate as a duodenal switch operation. Complications of the sleeve gastrectomy including reflux, stricture, fistula, inadequate weight loss which may warrant evaluation and possible intervention. In my opinion, as a surgeon who does the duodenal switch operation routinely, a sleeve gastrectomy requiring revision should almost never be revised to a gastric bypass. I have seen number of patient’s who have had an adjustable gastric banding which was revised to the sleeve gastrectomy then to a gastric bypass. We are contacted for a possible revision to Duodenal Switch operation because of the weight regain. One can argue that the patient should not have had the sleeve gastrectomy or gastric bypass. It is critical that the complexity of the disease of the obesity is clearly appreciated that it purely restrictive procedure will not yield the desirable outcome long-term.

Benefits of the Pyloric Valve:

The pylorus is the valve located at the end of the stomach. It controls the release of the liquid mixture of food from the stomach into the small intestine.

The body naturally regulates the passage of food, so food will stay in the stomach for a certain period of time. We believe it is very important to continue that feeling of fullness in between meals. As a result, one of the principle functions of the pyloric valve is to regulate the amount of food products released into the small intestine where they are absorbed. This helps prevent dumping syndrome and ulceration.

The bodies natural diameter of stomach, pyloric valve and small intestine is left intact. This elevates stretching of the stomas created by RNY Gastric Bypass.

Summary

These failed Sleeve Gastrectomies should be revised to Duodenal Switch unless there are overwhelming health issues that would require another option. I always suggest several opinions from different Bariatric Surgeon’s who do a variety of Weight Loss Surgeries before deciding which type of revision to proceed with.

Is Weight Loss Important Before Weight loss Surgery?

June 21, 2016 7:52 am

The question of “Is a pre operative diet and weight loss important?” No. This is the short answer. In a previous blog, “Weight Loss Before Weight Loss Surgery?” I have gone into further detail about why I don’t require a pre operative diet and weight loss program.

More recently there has been a concerted effort by a number of major health plans to require 3-6 months documented pre operative diet attempt prior to authorization for weight loss surgery. Furthermore, there are surgeons who would mandate a 10% weight loss as a precondition for the patient to have a weight loss surgery, laparoscopic sleeve gastrectomy for example. The overwhelming scientific literature fails to support any direct correlation between preoperative weight loss and the outcome of the weight loss surgery.

Some surgeons require preoperative weight loss as a way to reduce the size of the liver. I’ve personally have never met a liver I couldn’t work around unless it was severely diseased.

Diagram of liver and adjacent organs.
Diagram of liver and adjacent organs.

There is some literature to support this position. However, one has to critically look at all the studies. Almost all the studies have very specific population and procedures that are being looked at. Most often the recommendations had been made for adjustable gastric banding procedures. There are also some that are recommending the same for Lap Sleeve cases only siting the reduction of the liver size as a reason for the Very Low Energy Diet as a precondition to surgery. It is, however, important to remind ourselves that there is no long term studies whatsoever that show any relationship between the preoperative weight loss and the outcome of any weight loss surgery.

Shared Success Story Update- Cyndi RNY to Duodenal Switch

June 06, 2016 6:37 am

Three Years Out Cyndi E … RNY to Duodenal Switch Revision

The Journey to get to the three year mark, has been amazing! And truly, The JOY is in the JOURNEY.

I am a JOYFUL “Third Time’s the Charm Revisionista”…. This is my new title…. And I say this proudly!!

For too many years (like 45! at least) I carried the shame and blame of being overweight and beat myself up on the inside. I tried everything, from age 13. I tried every diet, every program, and yes, I will say it, I have had THREE, yes THREE surgeries. And then, I let others convince me, and I bought into this, that I was a failure… BUT, I am not a failure. Surgery fails. For a long time, I could not say that, again with the SHAME word. BUT, I am done with shame, and I am done with blame. I no longer blame myself and I no longer shame myself or my body, because now, she and I, my body and I, are friends, and we are nice to each other.

Thankfully for me, I was in the right place at the right time, and met Dr. Ara Keshishian… My story with Dr. Keshishian, is simple. Dr. K was the first Doctor that did not blame me for my weight. He explained that each weight loss surgery has different measures of success, and percentages by weight loss surgery and outcomes. He educated me. He did not blame or shame me, he encouraged me. He also did an Endoscopy and found that I has a Gastro-Gastric Fistula. Simply put, this was an abnormal connection between the bypassed stomach and the small pouch created by the RNY Gastric Bypass surgery. Food could travel two ways, thus rendering the Gastric Bypass ineffective causing weight gain.

IMG_3775
Before
After
After
After
After

Dr. Keshishian performed my revision from RNY to Duodenal Switch on May 31, 2013. The procedure corrected my anatomy, enabling me to lose weight and regain my health. I have no complications, no issues post surgery.

Today, being a “Three Year Old” RNY to Duodenal Switch revisionista, I have a better perspective as a relative “newbie”. I am not a prisoner of my weight. I have lost 125-130 pounds, I am 5’12” (6 feet lol) 61 years old and for the first time in my life at a NORMAL WEIGHT! I do not fear, any longer, that I will gain my weight back. I am, however, mindful that I am consistent in my new habits and patterns that I have put in place, that keep me on track. I am also accountable. To myself, also to my Weight Loss Support Group, here in Paso Robles, to some fellow DS girlfriends that

I talk with about challenges, and with Dr. Keshishian. I am not held captive by my limitations, or my weight, and now I live with the possibilities each day brings and the fun challenges I put in front of me to conquer.

To the “newbies” I say, please take your time, treat yourself kindly, with your inner voice. This is not a race, this is a journey. Don’t rush, it’s ok to take it slow, listen to your body. And do not compare your journey to anyone else. You are you! You do you! You can do this well, one day at a time. Listen to the sage advice of those who went before you. We too have learned by trial and error. Be willing to sacrifice in the short term, for the gift of the long term life. Your DS is forgiving, you be forgiving as well!!!

Remember: WATER, PROTEIN, SUPPLEMENTS, EVERYTHING ELSE, EAT CLOSE TO THE DIRT, ELMO DIET

With JOY, Cyndi

Cyndi’s first Shared Success Story here.

Shared Success Story- Heidi

June 02, 2016 7:59 am

My name is Heidi and this is my weight loss journey. I had been struggling with my weight for years and was actively researching different surgical procedures available. I was also trying everything to lose the weight on my own. My wake up call to take action was one night when my husband said, “I’m worried about you and want you around for a long time.” I knew I had to do something. If someone loved me that much I needed to love myself enough to change.

before image back
Before Duodenal Switch
before image side
Before Duodenal Switch
After Duodenal Switch Imaga
After Duodenal Switch with my beautiful son

So the very next day I made an appointment with my Primary Care Physician who recommended Dr. Ara Keshishian. That afternoon I called Dr. Keshishian’ office, scheduled a consultation and began what was about to be one of the greatest journeys of my life. I was approved within a month and ready to go.

In 2012, I had my Duodenal Switch with the great Dr. Keshishian. I was hopeful post op and determined to succeed. I knew with my husband’s and family’s love and support I could do it. I wanted to lose the weight for me, my husband and our future children so they had the healthy, happy mom they deserved. My Surgery weight was 220 ( Started at 230) I reached my goal at 10 months post op at 125lbs. Since having my DS I have had 1 (almost 2) amazing son’s. Duodenal Switch made this possible. I have my older son and I am currently 8 months pregnant with my 2nd son. Duodenal Switch did not just allow me to lose the weight that kept me from living life but it allowed me to get healthy and live life to the fullest. I am grateful everyday for my DS, my amazing husband, my boys, and Dr. Keshishian.

I am simply blessed. Would I do it again? In a heart beat.
Starting weight- 230
Surgery weight- 220
Goal Weight- 125
Current-130

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

diabeties control post WLS
Diabetes controls post weight loss surgery

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.

Inadequate Weight loss and Weight Regain

May 24, 2016 7:56 am

There were numerous causes for the inadequate weight loss and or weight regain after weight loss surgery.

These factors may include:
1-Type of the surgery: Duodenal Switch, RNY, Adjustable Gastric Banding, Intragastric Balloon, etc.
2-Patients metabolic state (age, activity level, hormones state etc)
3-Co-morbidities
4-Patient compliance
5-Other

Each and every one of these may be an independent factor or may be a contributing cause.

In our experience, patients non-compliance is not as common as others believe. Frequently, we see patients in our office where they have been told that the poor outcome of the surgery is “their fault”
We see this with RNY, and Band patients as well as some of the duodenal switch patients who are seeking advice for weight regain or inadequate weight loss.

I would like to talk about the issues of inadequate weight loss or regain post Duodenal Switch specifically. Duodenal switch operation as described by Dr. Hess, outlined the division of the small bowel lengths to be proportional to each and every patients own total bowel lengths. This meant that two patients with the same BMI and weight will end up with two different lengths for common and alimentary limbs if there total length of the bowel is different. Unfortunately, too often patients are given a “standard”  or “set” ( not clear what that word means, since there is no established standard in the literature) length for common channels and alimentary  channels regardless of the total small bowel length. In some patients, those lengths may result in acceptable weight loss. However, quite frequently a patient with a preselected length for the common and alimentary limbs will end up either loosing too much weight and have nutritional problems or not loose adequate weight. As with all practices, we have over the years had patients who have had nutritional deficiencies and excessive weight loss or have had inadequate weight loss. Looking at the raw numbers however, we have had more patient from other practices that have come to us for revisions and corrections of lengths of the bowel lengths from other practices that our own patients have required.

Another level of the confusion is the improper interchanging of the “SIPS and SADI” procedures with the duodenal switch operation. As I have said in the past repeatedly, SIPS and SAID are not the same as the duodenal switch- and attempt to call these different procedures the same is misleading to say the least.

The other category of weight regain or inadequate weight loss includes medications and new health issues.  Discussed in a previous blog, there are many medications that can influence weight gain.  It is important to work with your health care provider to find medications that have a positive effect on symptoms without added side effects whenever possible.

In summary, weight re-gain or inadequate weight loss can have many facets.  However, surgical technique can provide an advantage.  Each aspect should be addressed and identified.

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)
Exercise

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.

Stricture after Sleeve Gastrectomy Duodenal Switch

May 01, 2016 9:45 pm

According to the American Society of Metabolic and Bariatric Surgery sleeve gastrectomy has become the most commonly performed operations in 2012.  Sleeve gastrectomy became popular because of the high failure rate of the adjustable gastric banding and the issues with RNY pouch. The Sleeve Gastrectomy was performed many years prior to 2012 as a part of the Duodenal Switch procedure. Stricture is a complication occurring post Sleeve Gastrectomy and Duodenal Switch.

Stricture:

Sleeve gastrectomy may appear to be a simple procedure under the surface; however, it is fraught with very unique and challenging complications. These may include, but are not limited to, staple line failure resulting in leak,  injury to the spleen,  stricture,  and even a rare and under diagnosed portal vein thrombosis.  Technique is important in avoiding short and long-term complications. Strictures can be caused by making the sleeve stomach too narrow or by stapling in a fashion where the corkscrew stomach.

Some surgeons create a very narrow sleeved stomach in an attempt to maximize weight loss by increasing restriction.   This can result in significant GERD in patient with  no long-term benefit. Re-sleeving is another incidence were strictures can become an issue. These strictures are debilitating and almost all the time require surgical intervention.  Balloon dilation by an endoscopy method is frequently unsuccessful.  The patient who has a stricture should seek the attention of an experienced revision surgeon for surgical repair.   Strictures are usually a short narrow segment of the stomach.  The reason why sleeve gastrectomy strictures do not respond well to balloon dilatation is because of  the staples line that is present on one side of the  tube of the stomach that cannot be stretched.

Stricture after Sleeve Gastrectomy Duodenal Switch
Stricture after Sleeve Gastrectomy Duodenal Switch
Stricture after Sleeve Gastrectomy Duodenal Switch

Some surgeons create a very narrow sleeved stomach in an attempt to maximize weight loss by increasing restriction.   This can result in significant GERD in patient with  no long-term benefit. Re-sleeving is another incidence were strictures can become an issue. These strictures are debilitating and almost all the time require surgical intervention.  Balloon dilation by an endoscopy method is frequently unsuccessful.  The patient who has a stricture should seek the attention of an experienced revision surgeon for surgical repair.   Strictures are usually a short narrow segment of the stomach.  The reason why sleeve gastrectomy strictures do not respond well to balloon dilatation is because of  the staples line that is present on one side of the  tube of the stomach that cannot be stretched.

Stricture after Sleeve Gastrectomy Duodenal Switch
Stricture after Sleeve Gastrectomy Duodenal Switch

An increasingly more complicated problem is when the stricture  is caused by a spiraling of the staple line.  This is quite frequently seen where the stapling of the stomach was started on the  greater curvature of the stomach and rotated anteriorly causing a corkscrew effect of the stomach.  A long segment stricture of the stomach cannot be corrected by balloon angioplasty and would require surgical intervention.

I have been involved with numerous repairs of strictures on sleeve gastrectomies and Duodenal Switch  stomach from other institutions.  In  my opinion, repeated endoscopy and balloon dilatation only complicate  further care  by compromising the tenuous tissue of a strictured stomach due to scaring and blood supply.   As above-stated earlier it is critical that a patient who is experiencing significant reflux, changes in nausea and vomiting, suspected stricture or narrowing, or has a corkscrew stomach to be seen by an experienced surgeon for surgical repair.  See the following Blog for health issues that can occur or progress with strictures.

Sleeve Gastrectomy specimen picture.