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Tag: revisional weight loss surgery

Shared Success- Whitney a RNY to DS revision

June 09, 2015 7:43 am

I was always the big girl, pleasingly plump, chubby. I was put on my first diet at age 12. By the time I graduated High School I had yo-yoed up to 200 pounds at College graduation I was up to close to 300 pounds. In 2002 I had RNY Gastric Bypass surgery. I was 39 and weighted 280 pounds. I was told it was the Gold Standard. The Band was still considered experimental and the Duodenal Switch was never mentioned as an option. In fact, I did not even know it existed.

I lost 110 pounds and was considered a WLS success. I did not have any food restrictions and I felt great and maintained the loss for five years. Then I started to slowly gain weight. In little under 5 years I gained 70 pounds. I developed Dumping Syndrome and my Stoma was stretched out. I joined Weight Watchers and lost 5 pounds in a year. Nothing worked. I developed ulcers, osteoarthritis, planter fasciitis and could barley walk a couple of blocks without pain. I was miserable. I felt like a failure

In 2012 started to research surgical options. A local surgeon wanted to “revamp” my already tiny stomach, put a band around my stoma, and “clean up my intestines”. I asked about revision to Duodenal Switch and was strongly discouraged, but I wasn’t going to settle because that was what he was only capable of doing.

Whitney’s Before DS
Whitney’s Before DS
Whitney’s After
Whitney’s After

I wanted the best. I wanted long term success. So I travelled from Northern CA to Southern CA for a consult with Dr. Keshishian. The only choice for me was to revise to DS. In December of 2012, I had revision surgery of my RNY to Duodenal Switch. One week after surgery, still in the hospital, I went in for a second surgery. Dr. Keshishian found a small leak. I spent an additional two weeks in the hospital. My experience was not the norm and a leak can happen in any surgery involving the stomach.

Recovery was slow but steady. The first 2 weeks Dr. Keshishian called me every three days to make sure I was doing ok. I still have his cell number in my phone. I was back to work 14 weeks after surgery. I could have gone back sooner.

Over the past year I have lost 115 pounds. My BMI is 20, and I feel great. I have my life back. All pre-op issues have been resolved and I am going to start training for a 5K.

My advice for anyone contemplating Weight Loss Surgery is to research all of the options available. Do not settle for a substandard surgery. Get a second or even third opinion. It’s not a decision to be taken lightly. It’s your life fight for it!

Whitney B.

Stricture with Lap Band

May 31, 2015 6:44 am

One of the most common findings with patients seeking revision of the Lap band is the persistent and continuos nausea, vomiting and reflux, even though the band is emptied. The typical presentation is that of a patient who had an adjustable gastric band placed and adjusted. When the weight loss stops any attempt to adjust and tighten the band results in reflux, nausea and vomiting. Unfortunately, there is lack of recognition that even when the band is completely empty, and even if removed, then a patient can still have the symptoms present, if the scar capsule that forms between the band and the tissue is not removed.

It is critical that when a Lap band is removed that time is spent excising the capsule that is present to allow for the tissue beneath the band to return to its normal caliber.

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Note in these images how with the Lap band completely open the tissue underneath is “restricted” by the capsule that has formed under the band. In this case the capsule was also excised and removed along with the band.

Rebanding- A Bad Idea In My Opinion

May 12, 2015 3:42 pm

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There is a wide discrepancy of outcomes for patients who have decided to have weight loss surgery and are experiencing different weight loss, regain and complications primary related to their choice of the procedure. In our practice we see quite a few revisions cases on weekly basis.  More recently there have been a few “Rebanding” patients seeking revision to the Duodenal Switch.

The typical scenario is of a  patient who had an adjustable gastric band placed, and after the initial weight loss (mostly because of the persistent nausea and vomiting) the weight stabilized. The weight loss was never  close to a healthy weight and in most cases their co-morbidities did not resolve but now have added  complications of reflux and abdominal pain  developed. These patients were then recommended to have the band  repositioned to resolve a slipped band causing the above complications.

The scientific evidence for rebranding is not justifiable. I think there continues to be an element of denial that the adjustable gastric banding procedures do not work for the vast majority of the people. In fact, AGB in the  long term will result in some complications that may not be revisable.   The scientific literature shows that there is no benefit to rebranding when it comes to weight loss.

In my opinion when a patient encounters problem with the adjustable gastric band,  Duodenal Switch operation represent the best option because it has the best long term outcome of all weight loss surgical procedures.

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GERD, Nausea and Vomiting- Don’t ignore it!

April 28, 2015 11:30 am

Gastroesophageal Reflux Disease is a serious matter and should not be left untreated. It is know as heartburn or reflux and if you are experiencing more than twice a week you should be evaluated by a physician to investigate the cause. Listed below are some of the causes and end results of not treating GERD.

Esophagitis – An irritant that can be acid, bile, food and digestive enzymes coming back up the esophagus can cause irritation and swelling in the esophagus. If left untreated, it can damage the lining of the esophagus to the point of erosion and scarring. Bile Reflux may also be a cause of esophagitis and Duodenogastroesphogeal reflux (DGER). Bile Reflux information here.

Esophageal Stricture – Scar tissue can cause the lumen of the esophagus to become smaller and narrow.  This stricture makes it difficult or painful to swallow foods. If a stricture is narrow enough food may become stuck and require intervention for removal and treatment.  This can also put a person at risk for choking. The treatment includes ballon dilation with an endoscope and in cases where it recurs surgery may be required.

Esophageal Ulceration– If GERD is left untreated it can progress to actual ulcerations in the esophagus.  Patients may cough up or vomit blood or see it in their stool as dark tarry or coffee ground type stool.

Gastric Stricture– After weight loss surgery such as sleeve gastrectomy, RNY Gastric Bypass, Duodenal Switch, SADI/Loop,  Adjustable Gastric Banding, or other gastric surgeries a narrowing of the inner opening of the stomach can result from scar tissue forming.  This will require a surgical procedure to rectify.  The symptoms can be food intolerance, full feeling, nausea and/or vomiting. (See pictures below)

Hiatal Hernia– An anatomical weakening or enlargement of the opening of the diaphragm muscle where the esophagus meets the stomach.  This defect can allow a portion of the stomach to slide or roll into the chest cavity. This then causes reflux of gastric juice and content.  Hiatal Hernia’s can also form on weight loss surgical patients.  There are several examples within this blog here.

Breathing Difficulties– The acid aspiration while sleeping can make asthma and other breathing difficulties worst and can cause coughing and other issues.

Dental Issues – The acid, food, digestive enzymes backing up into the esophagus and mouth can cause dental issues such as erosion and tooth decay.  In regards to dental issues after weight loss surgery there are also other vitamin and mineral deficiencies that can cause oral health issues. Dental Issues after WLS here.

Lower Quality of Life– GERD can affect a person’s quality of life.  If you are in discomfort from acid reflux or having food intolerance it can make life difficult.  It can also alter food choices and impact nutrition.

Barrets Esophagus– Pre-cancerous changes in the bottom portion of the esophagus due to long term acid exposure from gastric reflux. Diagnosis requires and endoscopic procedure (EGD) and biopsy.

Esophageal Cancer– There is a significant rise in the western world in esophageal adenocarcinoma. The main risk factors are alcohol use, smoking, untreated GERD, and poor diet.

Reflux and difficulty with swallowing caused by stricture is not normal. These problems are quite frequently encountered as complication of Adjustable gastric banding, with slipped band or a band that is too tight and scarred in placed resulting is belt effect. This results in the esophagus not being able to empty and propel the food down. The end result is significant reflux, with difficulty swallowing, nausea, vomiting etc.  Similar problems are seen with Gastric bypass where the anastomosis between the stomach pouch and the small bowel RNY limb is too narrow. In Gastric Sleeve and Duodenal Switch operations, is the sleeve is made too narrow, or misshaped (hour glass, funnel, cork screw) it will result in the patient having reflux and symptoms of stricture. One specific problem with the new operation of SADI is the concern for  risk of bile reflux, similar to the BillRoth I procedure.

Gastric bypass patient with stricture at the gastro-jejunostomy before and after balloon dilation. Fig A

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After balloon dilation. Fig B

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Fig. C : Lap band Patient with stricture where the band as removed at another facility and the scar tissue formed around the GE junction was not taken down. The patient had to be taken back to the operation room after his symptoms persisted even though the band had been removed 3 months prior.

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A corkscrew stomach of a Duodenal Switch done at another facility, with the patient presented with persistent reflux, nausea and vomiting for years after surgery.     Fig. D

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This is not an inclusive discussion of GERD and the treatment.  Please see your healthcare providers if you are experiencing any symptoms pertaining to GERD or any other health care issue.

Adjustable Gastric Band Removal & Hiatal Hernia Repair

April 21, 2015 6:30 pm

As it is a recurrent theme, a patient presents with a band that was placed years ago with marginal weight loss over a short period of time. Multiple office visits to the same center for band adjustments, which only results in worsening nausea, vomiting and reflux to the point of having difficulty with taking fluids in. The irony was that the patient was being blamed for the symptoms as to “…eating the wrong food, …eating too much, etc” The patient presented to the Emergency Room and was taken to the Operating Room within few hours for a partially slipped band and a Hiatal Hernia was also identified. The adjustable gastric band was removed and the Hiatal hernia was repaired.

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The band in place and after being taken down

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The dissection of the wrap over the band that shows erosion

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Part of the hiatal hernia repair.

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The band and the port removed.

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

Shared Success Story- Odessa D.

April 07, 2015 10:20 am

My name is Odessa D. I am going to talk about my weight loss journey with the lap band which started in 2006. At my heaviest I weighed 270 pounds and was a size 24 waist. I had high blood pressure, was a border line diabetic, had lower back pain, I had no energy, I was tired all the time, and I had sleep apnea.

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My family doctor had suggested weight loss surgery but I was hesitant because I was afraid of surgery. Until one night my 8 year old daughter found me not breathing in my sleep. I made the decision to go through with the surgery.

Prior to surgery I did as much research as I could about the lap band. At the time I felt it was the right decision. On the day of the surgery everything went well. The first few months were great. I was losing weight, feeling good, feeling happy, and healthier then I have in years.

Then it began, all the symptoms of a slipped band. I started vomiting, nausea, acid reflux, and I was having trouble drinking and eating on a daily basis. My doctor confirmed it was a slipped band. We decided to replace the band because I was still overweight. On day of surgery I weighed 210 lbs.

After a month I started having symptoms of a slipped band. My doctor performed x-rays but everything looked fine. After 2 years with these symptoms and numerous doctor visits and x-rays I just gave up and learned to live with it. In 2 years I lost 4 lbs. My high blood pressure and sleep apnea came back. I finally decided to get the lap band removed. I wanted my life back and if that meant gaining the weight back that I lost then I was willing to make that sacrifice.

Dr. Keshishian was referred to me by 2 of his past patients. From the moment I walked into his office I was already at ease. When I first met Dr. Keshishian, I knew I was in good hands and I knew he could help me. He confirmed I had another slipped band and a detached port. At this point we discussed removing the lap band and switching to the Sleeve Gastrectomy. Finally everything was going to be fixed and everything was going to be right.

I can’t express how much my life has improved since removing the second band and switching to the sleeve. I have lost 46 pounds in 9 months. I now weigh 160 pounds and wear a size 8 waist. Now I look forward to each and every day with joy and pleasure knowing I don’t have to deal with a bad band and all the horrible symptoms that came with it.

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Since the surgery and losing more weight I have been very active. I go hiking almost every weekend. I have literally climbed a mountain! I did my first 5k mud obstacle course in which my second 5k is in October. I even have a purple Mohawk! I have 100% confidence in myself and in everything that I do. My life has greatly improved since the sleeve. All thanks to Dr. Keshishian. It has been a very bumpy road with my weight loss journey but Dr. Keshishian has smoothed out the bumps and I plan on traveling the distance with many adventures along the way.

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I would like to leave a huge “Thank You” to Dr. Keshishian and his staff. Thank you for making me feel welcomed, being friendly, making me feel comfortable, and especially for giving my life back to me. I can’t wait to see what the future holds for me and my family!

Thank you Dr. Keshishian and staff!

Odessa D.