Telehealth available for follow up as well as new consultations. Please contact us Here.
1-818-812-7222 Office Hours: 8:00 AM to 5:00 PM
10 Congress St., Suite #405
Pasadena, CA 91105

Tag: revisional weight loss surgery

Parathyroid Scan

July 09, 2018 11:48 am

A Parathyroid scan or Sestamibi scan may be needed if the typical weight loss surgical reasons for elevated PTH levels have been addressed. Sestamibi is a small protein which is labeled with the radio-pharmaceutical technetium-99. This very mild and safe radioactive agent is injected into the veins of a patient with overactive parathyroid and is absorbed by the overactive parathyroid gland. If the parathyroid is normal it will not absorb the agent. The scan below shows the uptake of the agent.

Calcium, Vitamin D and Parathyroid hormone are routinely measured on yearly follow up for most post weight loss surgical (WLS) patients. Elevated parathyroid hormone (PTH) may be caused by Vitamin D deficiency or calcium deficiency (most common in post WLS) or by over active parathyroid gland(s). In the latter case, if one of the four glands is overactive then this is knows as a parathyroid Adenoma. If all 4 are over active and are secreting too much PTH, this is known as hyperplasia. Ultrasound of the neck, may identify an enraged parathyroid gland (adenoma) which is located behind the thyroid gland. Given the large area where the parathyroid gland may be located, additional tests are needed to not only identify the location of the gland(s) but also to distinguish between single gland (adenoma) or multiple glands (hyperplasia) cause for the elevated PTH. It is important to investigate all avenues and testing in parathyroid hormone elevation and in some cases, not to rely on one test for your diagnosis. It is also imperative that weight loss surgical patients take their supplements routinely and consistently and have their laboratory studies followed at least yearly.

Parathyroid Scan

Candy Cane Gastric Bypass – RNY

June 21, 2018 1:05 pm

One of the findings following Gastric Bypass is a Candy Cane Gastric Bypass. Nausea and vomiting , upper abdominal pain is a common complaint of patient who have had the Gastric Bypass RNY operation. This is in addition to the high incidence of patients who experience the complications of weight regain and or dumping syndrome.

Quite frequently the symptoms of nausea, vomiting and upper abdominal pain of a patient with history of gastric bypass is evaluated by a primary care, referred to a gastroenterologist. The “routine” work up recommended is X-ray of the abdomen, maybe contrast study (Ct scan or upper GI) and for sure and upper endoscopy. The result quite frequently reported as “…nothing wrong”.

A typical upper GI in a Candy Cane Gastric Bypass situation may look like this:

Anatomy_1
Upper GI

A common and underreported problem may be a Candy Cane finding. The “blind” end of the small bowel anastomosis is too long and this results in food settling in the hook of the candy cane. The symptoms of the nausea, vomiting and upper abdominal pain may be from the residual food and liquids that do not drain from this area.

Flow-2

Candy Cane Gastric Bypass finding

CandyCane_3
Candy

Candy Cane Gastric Bypass cases will require surgical intervention to shorten the length of the blind segment of the small bowel to improve symptoms.

It is my recommendations that any patient with history of weight loss surgery who is having any persistent gastrointestinal symptoms be evaluated by weight loss surgeon.

Revision from failed AGB to Duodenal Switch

January 10, 2018 2:10 pm

A few times a month during consultation for weight loss surgery , I’m ask as to why I do not offer the adjustable gastric banding as an alternative to the patients. As I have said over the years when a patient considers an weight loss surgery the totality of the risk should be considered. This includes the operative, immediate postoperative course, the maintenance and the follow-ups needed. The potential complications of the procedure in addition to the long-term success off each operation should also be taken into account.

Unfortunately, some patients are led to believe that any perceived benefit in the short operative time and the ease of the adjustable gastric banding also translates to a better outcome. This is in fact the opposite of what the published data have shown, a recent study published in April 2017 by Vinzes et.al, shows that 71% of patient lost their band by 10 years out.

Long-term_AGB_outcome-791x1024

What is also interesting that more patients underwent revision from failed AGB to the duodenal switch than the sleeve gastrectomy (Fig 1.). This is what I also recommend.

More importantly, The patients who underwent a revision from failed AGB to the duodenal switch operation had the best long term results of all patients (Fig 2.) note the “rBPD” line that is the highest of %EBMIL.

Complication’s were broad and frequent (Table 3.)

Further information on revision from failed AGB to Duodenal Switch or other failed weight loss surgeries can be found here.

New Pasadena Office Map and Parking

August 12, 2017 8:35 am

We’ve created a helpful map and parking diagram for our new Pasadena, CA office location.  It also has a general layout of the Huntington Memorial Hospital Campus and Pre-operative intake and testing area.  We hope that you find it helpful on your next visit to see Dr. Ara Keshishian, General and Bariatric Surgeon.

Map and Parking Dr. Keshishian's office
Map and Parking Dr. Keshishian's office

Dr. Ara Keshishian has performed more than 2,000 Duodenal Switch procedures, thousands of Sleeve Gastrectomies and more than 500 revisions from other Weight Loss Surgeries such as RNY Gastric Bypass, Adjustable Gastric Band, and Sleeve Gastrectomy to Duodenal Switch as well as General Surgical cases over the last 18 years of private practice.

Insurance Appeals And Denials

August 07, 2017 7:08 am

Whenever you are dealing with insurance issues it is important to have a general understanding of insurance ins and outs. The Obesity Action Coalition has a good general guide to the insurance process here.  If you are having issues with out of network, out of area, or insurance appeals and denials for Duodenal Switch, there may be some additional assistance from two individuals who have had the Duodenal Switch procedure themselves. We are grateful that they have provided assistance throughout the years to the Duodenal Switch community. The following is their statement on insurance.

The majority of insurance companies are in the business of making money (for profit). They can deny requests for preauthorization with impunity. These denials are often complexly worded and difficult to comply with and overcome, and are definitely overwhelming to the patient, and the busy surgeon’s office. The vast majority of patients faced with demanding if not impossible to achieve prerequisites, or denial of the request for preauthorization simply give up, and the insurance companies pocket the savings.

If you find yourself  facing impossible pre-op hurdles, or a denial, we urge you to appeal, and to seek assistance in preparing the appeal. You can hire an attorney, of course, but there is an informal and free resource we suggest that you investigate as well.

If you go to BariatricFacts.org (a non-profit, patient-run site), you will find individuals who are long-term DS postops, and patient advocates.  They have been helping patients, pro bono (for free), for over 10 years. They will help you draft your appeal letters, provide supporting medical and legal documentation, and prepare draft letters of medical necessity to be reviewed and signed by your surgeon supporting your appeal. They will not represent you directly, but they will help you best represent yourself.  in many cases it is necessary to exhaust all internal appeals (because the insurance companies are unlikely to overrule themselves), and then file for external review, where independent reviewers often overrule improper denials. If you join and then post on BariatricFacts.org asking for help, you will be connected with them and you can decide if you want their help.

Please note that this is just a suggestion. It is neither legal nor medical advice, nor a guaranty regarding their services, and you should always consider getting legal advice and assistance from an attorney who will represent you directly. The members at BariatricsFacts.org will help you draft your own letters, but will not be your legal or medical representatives; you will be required to do a fair amount of your own work on your appeals, and to sign them yourself.

It is suggested that before or at the same time as you contact the resources suggested at the site, you gather as much of the following information as you can:

  • A copy of your Evidence of Coverage, which is the usually 100+ page insurance contract between your employer and the insurance company, which  you can obtain it from your HR department. If you are self-insured, it will be available directly from your insurance company. Note: it is NOT the Summary of Benefits – it needs to be the contract itself.
  • If your insurance is through an employer, you need to determine whether your plan is self-funded or fully-funded. Your rights are significantly different under the two types of plans.
  • If your insurance company has a separate bariatric surgery policy, provide a copy of that, too.
  • A copy of your surgeon’s request for preauthorization, which provides the ICD-10 and CPT codes submitted.
  • A copy of your denial letter, including the section regarding your appeal rights.

*      It is strongly recommended that you obtain a copy of your surgeon’s LOMN (letter of medical necessity) before it is submitted to your insurer or for external review, so we can assist your busy surgeon in making the strongest possible case for you.

Don’t be deterred by a denial. It is unfortunately more common than it should be, but it can often be overcome if you meet the requirements for bariatric surgery, if you get help navigating the process.

Shared Success- Samantha had a Sleeve to Duodenal Switch Revision

July 14, 2017 9:30 am

After struggling with obesity for most of my life I was finally fed up. I had heard about weight loss surgeries before but was always under the common misconception that it was for people who wanted the “easy” way out of a hard situation. I had been working out and reducing calories and tried every popular diet and trainer you could think of. I was still huge and each time I would stop one of these extreme programs I would only end up larger than I was before.

My husband’s cousin had the sleeve surgery and she raved about it. Watching her success is what started to open my mind to surgery, but I was only considering the sleeve gastrectomy. I went to a center in another state that offers Duodenal switch, lapband, RNY and the sleeve. The surgeon I met with strongly suggested RNY to me, but I was stuck on the sleeve. I didn’t want my intestines touched period. I had the sleeve surgery on October 9, 2013.

My high weight was 402 lbs and I weighed 343 on the day of my sleeve surgery. I actually did well with the sleeve and was able to get down to 218 as my lowest. However it was still much like dieting. It was so stressful. After a while my body wouldn’t drop the weight regardless of how little I ate and exercised. I was eating 800-1200 calories a day and low fat meals and working out and kept slowly gaining weight. I was frustrated  and honestly I gave up. My reflux wouldn’t go away so I visited a bariatric surgeon in my area who suggested that we essentially re-do the sleeve surgery to make my sleeve small again so that I would eat less and lose weight again. I got a second opinion and that surgeon suggested I revise to RNY. I went to obesity help’s website to explain my situation and a lot of people with much more experience than me HIGHLY urged me to see Dr Keshishian before making a decision. He was said to be an expert in revision weight loss surgery. I almost cancelled my appointment and didn’t have hope with this doctor either, but since I was in a dead end I went anyway. Dr Keshishian told me it wasn’t my fault. WHAT!? I had never heard that before. I usually get the shame from doctors who assume I must not be trying or that I am secretly eating something wrong. He ordered tests and told me it was “simply science” and I just LOVED him! I had a stricture in my Sleeve that needed to be repaired so since I needed surgery anyway I decided to go ahead and revise to a surgery that has the highest success rate, Duodenal Switch.

Before Sleeve to Duodenal Switch revision
Before Sleeve to Duodenal Switch revision
after Sleeve to Duodenal Switch revision
after Sleeve to Duodenal Switch revision

I was so scared of my intestines being cut and Dr. Keshishian eased my fears. I wish I had went that route the first time but then I might not appreciate it like I do now. Duodenal switch is the ONLY surgery I would recommend to anyone. As Dr K says it’s simple numbers. It’s the surgery with the highest percent of excess weight lost and kept off. I was 252 before my revision from Sleeve to Duodenal Switch and I am just at a year out and today I weigh in the low 190’s and I am still losing. Dr K’s goal for me was about 180. My goal is about 175.  I eat more fat now than I ever did even when I was 400 lbs. I enjoy what I eat and I enjoy exercising and most of all I get to enjoy seeing results from my hard work. Food no longer causes me stress and anxiety. I know with 100% certainty that I made the right decision. Thank you Dr. K for your great skill and I don’t mean just with the knife but with the way you are able to make a high anxiety situation seem like no big deal.

 

After Sleeve to Duodenal Switch Mud Run
After Sleeve to Duodenal Switch Mud Run
After Duodenal Switch Mud Run
After Duodenal Switch Mud Run

Back on Track 2017 Giveaway

January 10, 2017 10:03 am

back-on-track-2017-keshishian
back-on-track-2017-keshishian

Let’s get back on track 2017 after the holiday season! The holidays were wonderful but if you find yourself with a few extra souvenirs don’t feel alone. The average American gains between 1-8 pounds during the holiday season and I am no exception. Let’s get back on track 2017 together.

Time to clear out the kitchen! Disposing of temptations and high trigger foods is the first step to getting back on track. If the food isn’t easily acquired then it is less likely to be consumed.

Stock up on high protein and whole, unprocessed foods that are low carbohydrate and nutrient dense. When quality foods are easily available we are more likely to stay on track with the types of foods we should be eating. Simple sugars/carbohydrates are the biggest culprit of holiday weight gain. We need to go back to the basics of hydration, high protein, low carbohydrate/sugar, vitamin/mineral supplements and exercise. Simple sugars and carbohydrates are easy for our bodies to use and absorb and cutting them back can jump start your weight loss. Each individual needs to identify the daily carbohydrate intake that works for them. Some people stay under 50 grams of carbohydrates daily. You may also need to look at your protein and fat intake. All excess nutrients absorbed have the potential to turn into fat mass and inhibit weight loss. Metabolism video.

Hydration is an important ways to start getting back on track. Water is essential to life functions. The brain is 85% water, blood is 80% and muscle is about 70% water. Hydration aids in digestion, eliminating waste, byproducts and toxins. It also can decrease the feeling of hunger. Lack of hydration can increase fatigue which can lead to craving high carbohydrate foods to increase energy.

Protein’s importance in almost every bodily function and muscle mass can not be ignored. High quality complete Protein sustains muscle mass during weight loss, aids immunity, antioxidant function, and enhances leptin and insulin function. Filling up on protein first will help with carbohydrate carvings and give a sustained satisfied feeling. A prior blog post gives additional information on the importance of protein and the effects of protein malnutrition. WLS makes daily protein intake important but especially after Duodenal Switch, protein is a necessity of daily life.

Vitamins, minerals and supplements will ensure the body has the nutrients it needs to function adequately and can keep cravings at bay. Deficiencies in vitamins and minerals can cause cravings for foods. Vitamin and minerals are essential to muscle function, red blood cell production, bone health, and numerous other physiologic functions. We may all slack off on our supplements occasionally but now is the time to get back into the habit of daily vitamins and mineral supplements. A daily vitamin, mineral, and supplement routine is a lifetime commitment after Duodenal Switch or any WLS. Here is a list of commonly used supplements.

Exercise can increase weight loss, overall well being, mental well being, mood, alertness, improve digestion, improve sleep, and increases energy levels. Exercise does not have to be a daunting task. Simply adding 15-30 minutes of activity can give added benefits. Yoga, walking, dancing, lifting weights, hiking, and sports activities can be included or added to more traditional forms of exercise. There are many free online videos for all types of exercise available.

Finding a new hobby can keep both your hands and mind busy, curbing the unconscious eating of foods that are high in sugar and carbohydrates. Adult coloring books, drawing, painting, knitting, crocheting, sewing, dance lessons, gardening, learning to play an instrument and many others are great ways to use your time and expand your quality of life and brain function. New hobbies can also help establish new coping skills.  Our previous post on Coping Skills After Bariatric Surgery can be found here.  There are a whole host of online videos for “how to” on new hobbies.

Teaming up with others can also help increase weight loss and compliance. Support from friends, family and other groups will assist you. There is a whole gamut of support group online and in person. If you have fallen out of the habit of attending our support group or webinars get back to them. You can find our schedule and announcements regarding webinars here. Our Central Valley Bariatric Facebook page also gives daily inspirational messages, protein recipes and articles and any new information or research available. There is also our Duodenal Switch Facebook Group. Anything that increases accountability is a benefit and motivates us to stay on track.

Experiment with new recipes and flavors that are bariatric friendly and within your dietary needs.  There are so many options for quick and easy meals.  We have several recipes on our page for all stages following weight loss surgery and Duodenal Switch. However, there are endless option on the internet in Paleo, low carb, and high protein type recipes.

In the spirit of new starts and getting back on track 2017, we are having a giveaway with the basics to get back into the swing of things. This year we are looking for before and after weight loss surgical journeys.  Share your weight loss journey! Don’t be shy, your journey can inspire others and/or motivate yourself. To enter the Back on Track 2017 Giveaway, please submit your weight loss surgical journey with before and after pictures to contact@dssurgery.com or you can also post your before and after pictures on our Facebook page. You will also need to sign a release for the use of your story on our website. We will draw 2 names from those that enter by announcing it on our FaceBook page or by e-mail on January 31, 2017. You must submit your mailing information to contact@dssurgery.com in order to claim the prize.

give-2Baway
give-2Baway

Please check with your physician before starting a new supplement and follow laboratory studies for adjustments in supplements. Vitamin information here. Mineral information here.

Weight Gain after Gastric Bypass

January 04, 2017 9:12 am

Weight loss surgical procedures have different long term results and some procedures have more dramatic weight loss than others. Some procedures also result in much more sustained and long term weight loss. Unfortunately, what may be not obvious is that the patient has very little control over the outcome of the surgery in most cases. IT is very easy to blame the patient for weight regain after weight loss surgery. However, it is important to remind ourselves that the long term data reporting outcomes of the surgical procedures in most cases, includes all patient population. All these studies include the most compliant and not so compliant patients. Comparison chart of outcomes of weight loss surgical procedures.

regain-ad-graphic
regain-ad-graphic

A larger percentage of gastric bypass patients will require revision for weight regain, or other problems. There is no evidence that the size of the pouch or the anastomosis between the pouch and the small bowel changes the weight regain outcomes. Yet, quite frequently I will see patient who have had gastric bypass revision for weight regain, by reducing the size of the pouch or the anastomosis. Here are some publications that support the notion that other than extreme dilation, the size of the pouch and the size anastomosis does not predict the outcome of the surgery. There is some correlation with the site of the pouch, anatsmosis and weight loss, but there is no correlation between the size of the pooch, the opening and the failure rate. This means that patient with smaller pouch do not have better long term outcome that the ones with larger pouch, only that the patient with smaller pouch or anatsmaosis will loose more weight.

“Influence of pouch and stoma size on weight loss after gastric bypass”

“Impact of gastrojejunostomy diameter on long-term weight loss following laparoscopic gastric bypass: a follow-up study”

Weight regain after RNY Gastric Bypass may also be caused by a Gastro-gastric fistula, which is a new connection between the pouch and the remnant stomach. Here is further information on Weight Loss Surgery Revisions.

When considering a primary weight loss surgical procedure, be informed.  Investigate all your options and consider the long term outcomes.  This may mean investigating different weight loss surgical procedures on your own.

Standard Common Channel In Duodenal Switch Will Result In Weight Regain.

December 16, 2016 1:57 pm

Stéfane Lebel, M.D.*, Geneviève Dion, M.D., Simon Marceau, M.D., Simon Biron, M.D., M.Sc., Maud Robert, M.D., Laurent Biertho, M.D. earlier this year released a research article comparing patients undergoing standard common channel of 100cm and standard common channel 200cm. The conclusion of this article was: “In this population, BPD-DS with a 200-cm common channel offered similar remission rate of co-morbidities compared with standard BPD-DS. It was associated with similar weight loss at nadir, followed by a more significant weight regain. It might yield a lower rate of nutritional complications. Long-term randomized data are needed to detect other potential advantages.”

Our Experience:

One of the most dreaded outcomes of any weight loss surgical procedure is weight regain. This is assuming that initial adequate weight was lost to result in resolution of the co-morbidities in the first place.  As the weight loss surgical field has changed over the years so has been the cases of regain that we have seen.

There was a time when Lap bands were being revised for inadequate weight loss and weight regain. Not to mention the complications of reflux, difficulty swallowing and persistent Nausea and vomiting. Then as more Gastric bypass procedures “aged” the number of patients that started looking for revision for weight regain increased. The latest fad is the Vertical Sleeve Gastrectomy that are done with false sense of expectation and results. The long term outcome of Vertical Sleeve Gastrectomy is no where close to that of the Duodenal Switch, independent of the size of the sleeve. In fact, more surgeons are trying to get a little more weight loss by making the sleeve too tight. All they are doing is creating a significant and debilitating set of problems such as reflux, nausea, and solid intolerance.

The ideal revisional procedure for these patients should be the Duodenal Switch. Some surgeons, however, have started advocating “single anastomosis” knock off the duodenal switch. Others do “standard length common channel” rather than a Hess method Duodenal Switch. I have always performed a traditional Hess method Duodenal Switch.  The Hess method Duodenal Switch has held the largest and longest excess weight loss maintenance for 28 years, going into 29 years.  Here is a past blog regarding small bowel length.

The predetermined standard common channel results in weight regain. Study