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Tag: revisional weight loss surgery

Shared Success Story: Cyndi E. Had a Gastric Bypass to Duodenal Switch Revision

June 17, 2014 6:29 am

My journey to lose weight has taken most of my life.  Losing weight is not just about food or eating too much, but a combination of genetics, emotions, and habits. My experience began at age 13 and has continued throughout my life.  I have tried everything!  I had a previous RNY Gastric Bypass, and knew something was wrong.  I had seen another Bariatric surgeon who said there is nothing I can do for you because you failed. My primary Doctor asked me “does your husband love you?” Of course, but what does that have to do with me knowing there is something medically wrong with me?  Again, I was brushed off and told to come back in two weeks.  Leaving that day, I knew I was never going back.  I went home and googled, “Bariatric Surgeon”, as I had for the past 3-4 years. Then, through a series of events was put in touch with Barbara Metcalf, a bariatric nurse, who lived in my town.  As I explained my story to Barbara, she shared information with me about Duodenal Switch operation, and gave me names of two surgeons.

Egan-Before
Egan-Before

I contacted Dr. Ara Keshishian, in Glendale, and had a consultation that week.  Meeting “Dr. K” was amazing!  It was the first time a Doctor did not blame me for my weight.  He explained that each weight loss surgery has different measures of success, percentages of weight loss by surgery, and outcomes.   Dr K told me that I may have been a success with the RNY Gastric Bypass, based on the numbers, however it became clear that I did have complications associated with the gastric bypass.  I was scheduled for an Endoscopy the next week, which Dr. K performed. The endoscopy confirmed that I had 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, and causing weight gain.

Dr. Keshishian performed a revision to the Duodenal Switch Surgery on May 31, 2013.  This procedure corrected my anatomy, enabling me to lose weight and regain my health once again.  I have had wonderful success and I have lost 104 pounds.  More importantly, I do not have the complication of the dumping syndrome, episodes of nausea and vomiting and am leading a normal life. I am not prisoner to my weight, what I can and cannot eat or the fear of weight gain.

Egan-After
Egan-After

I contacted Dr. Ara Keshishian, in Glendale, and had a consultation that week.  Meeting “Dr. K” was amazing!  It was the first time a Doctor did not blame me for my weight.  He explained that each weight loss surgery has different measures of success, percentages of weight loss by surgery, and outcomes.   Dr K told me that I may have been a success with the RNY Gastric Bypass, based on the numbers, however it became clear that I did have complications associated with the gastric bypass.  I was scheduled for an Endoscopy the next week, which Dr. K performed. The endoscopy confirmed that I had 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, and causing weight gain.

Dr. Keshishian performed a revision to the Duodenal Switch Surgery on May 31, 2013.  This procedure corrected my anatomy, enabling me to lose weight and regain my health once again.  I have had wonderful success and I have lost 104 pounds.  More importantly, I do not have the complication of the dumping syndrome, episodes of nausea and vomiting and am leading a normal life. I am not prisoner to my weight, what I can and cannot eat or the fear of weight gain.

Sunshine, Water, Rest, Air, Exercise and Diet

May 23, 2014 4:10 pm

Sunshine, Water, Rest, Air, Exercise and Diet

Of course this is over simplified, but we can’t forget the importance of the basics in our general well being. Weight loss surgery and especially Duodenal Switch have distinctive supplement requirements that need to be individualized based on your individual needs.

Sunshine is essential to life. It provides the light that wakes us and helps to regulate wake/sleep cycles and provides us with a feeling of well being. Sunlight is not only the basis of all living things but crucial in boosting the bodies Vitamin D supply. Most Vitamin D deficiencies in the general public are caused by lack of sun exposure. It is important to note that our bodies can not accomplish Vitamin D metabolism if we are wearing sunscreen. Without adequate Vitamin D stores bones will not form properly, muscle strength is impaired and osteoporosis.  Vitamin D 1,25(OH) accumulates in cell nuclei of the intestine, where it enhances calcium and phosphorus absorption, controlling the flow of calcium into and out of bones to regulate bone-calcium metabolism. However, after weight loss surgery this mechanism can be impaired.  Addition supplementation of Vitamin D is usually required based on laboratory studies following weight loss surgery.  Duodenal Switch patients should take a dry “water miscible” type of Vitamin D3 daily. 

Water comprises 50-60% of our adult bodies.  Water is essential in cell life.  It aids in transporting vitamins, nutrients and minerals to our cells. Chemical and Metabolic reactions rely on water to remove waste products including toxins that the organs’ cells reject and removes them through urine and feces. Our body temperature is regulated by sweating and the evaporation of water on the skin. Also, effectively Lubricating our joints and acting as a shock absorber for our brain, eyes, and spinal cord. Decreased stomach size, after weight loss surgery,  limits the amount of water a person can drink at one time.  It is imperative that patients ingest enough waters and fluids after surgery. We like to see our patients consume a minimum of 64 ounces of fluids a day, more on warmer days.

Rest is something we can all use more of.  Lack of sleep can cause a whole host of health issues ranging from altered levels of hormones involved in metabolism, appetite regulation, stress response to cardiovascular health, insulin resistance, immune function and most importantly post-operatively tissue repair, muscle growth and protein synthesis.  It’s easy to take rest for granted but  do not underestimate the power of sleep.

Air is an obvious essential of life.  It is important in about every function of our cells.  After surgery it is important to lung health and tissue repair. Be aware of the type of air you are breathing.  Pollution and contaminants in the air can impair lung function.  After surgery your breathing and breathing exercises will prevent complications such as pneumonia and atelectasis.  Long term air contaminants can cause asthma and long term lung health. In addition, post surgical patients will need to use their incentive spirometers to combat lung complications.

Exercise’s health benefits can not be denied. Exercise combat health conditions and disease such as stroke, metabolic syndrome, diabetes and cardiovascular disease. It also improves emotional outlook and mood. Physical activity stimulates the brain to release chemicals that involve increasing memory function.  Exercise helps maintain healthy weight, improves energy, promotes better sleep, lowers stress and anxiety.  Needless, to say after surgery exercise is extremely important for all the above reasons but also to ward off complications such as pulmonary embolism and deep vein thrombosis.

Diet is last but definitely not least. Balance along with moderation and eating whole unprocessed foods are best ways to ensure your health.  We derive most our building blocks for cell growth from the nutrients we consume. The quality of the food we put into our bodies is important in lowering health risks such as cardiovascular disease, cancer, and weight control. Protein is crucial in muscle growth, hemoglobin, cell structure and enzymes formation.  It is extremely important after weight loss surgery to remain diligent about protein intake throughout your lifetime.

It is interesting to see how all these elements are so intertwined in their synergy to maintain health.  Most are easily found or done in nature. When engaging in one of these elements,  many of the others are needed or benefited by the doing the first. Exercise requires that you stay hydrated, deep breath, possibly out in the sunlight and therefore you will rest better. Always follow your surgeon’s orders and recommendations based on your individual health status and laboratory studies.

Our First Featured Success Story

May 16, 2014 9:47 am

Patricia Welborn

Screen Shot 2015-04-07 at 1.41.10 PM
In 2002, I weighed 336 lbs. I have been heavy all my life, no matter what diet I did I would gain it all back and more. In 1981 after living on pain pills and shots for my gall bladder, no one wanted to do surgery on me because at the time I weighed 450 lbs. The doctor, besides taking out my gall bladder, also did gastric stapling on me. I did get down to 225 lbs, but never lower.
In 2001 I had a friend tell me about a doctor in Delano that was doing a surgery called Duodenal Switch (DS).  I knew that I could out eat the RNY Gastric Bypass, which is when I met Dr. Keshishian; he gave me all kind of tests and said he believed the Duodenal Switch would help me.
On Jan 7, 2002, I had the surgery that has changed my life forever. When I had the surgery I could barely walk across the street and back without being out of breath. When I got down to 199 lbs I cried with Dr. Keshishian. He asked me what was wrong. I told him I just never believed I would ever weigh less than 200 lbs, considering I was a revision case,  he had told me that I might only lose 100 lbs.
As of this date, I have lost 195 lbs I am smaller than I was in the 8th grade. I really feel if I had not had the DS I would not be alive to meet my 7 beautiful great grandchildren. You are the only one to take care of yourself. This procedure is a tool and if you are not ready to take care of yourself, don’t have the surgery. You will be on vitamins and calcium for the rest of your life. I just know without this surgery I would not be alive today. I could have out eaten any other surgery. As far as I am concerned the DS is the Platinum of weight loss surgeries. What is really neat is Dr.Keshishian will be my doctor for the rest of my life, he cares about his patients. Thank you Dr.Keshishian for giving me my life back!

Iron Deficiency Anemia

May 13, 2014 8:38 am

Iron Deficiency Anemia is a common problem in society and weight loss surgical patients. Anemia is usually easily treatable, although requires adequate surveillance and diligence in treatment. Microcytic/hypochromic (small pale colored red blood cells) erythrocytes indicate some inadequacy of structural matter, usually, not enough hemoglobin. This is most commonly due to an inadequate dietary supply of iron. In fact, iron deficiency anemia is the most common of all anemias.

Determining the cause of the iron deficiency is of pivotal importance in selecting appropriate therapy. Microcytic/hypochromic erythrocytes may also be seen in anemia of chronic disease, in thalassemia and in the sideroblastic anemias.

Microcytic Red Blood Cells
Microcytic Red Blood Cells
Normal Red Blood Cells

Symptoms of iron deficiency include:

  • Being tired and feeling weak
  • Getting frequent infections
  • Feeling cold all the time
  • Having swelling in the tongue
  • Struggling to keep up at school or work
  • Restless legs syndrome
  • In children, having delayed mental development
Symptoms of too much iron can include:
  • Feeling tired and weak
  • Joint pain
  • Abdominal pain

Possible Causes other than the above:

Blood loss is the most common cause of iron deficiency. Menstruation is the most likely reason in women ages 15 to 45 years. Iron deficiency anemia in adult men and postmenopausal women is most likely due to chronic gastrointestinal blood loss. Such losses are usually secondary to ulcerating lesions [peptic ulcer disease, mucosal trauma (hiatal hernias), drug ingestion (aspirin, nonsteroidal anti-inflammatory drugs, steroids, potassium), parasitic infections, inflammatory bowel disease and malignancy.

Undergoing several surgeries within a short time frame is also a source of blood loss. Frequently Duodenal Switch (DS) patients become anemic after their panniculectomy, breast reductions, arm or thigh lifts because of the short interval between operations. Also pregnancy after weight loss surgery can increase chances of developing iron deficiency anemia. After consecutive surgeries it is important to monitor your Iron, Ferritin and Transferrin, Total Iron Binding Capacity levels. Any drop in Ferritin or Transferin levels should be discussed with your DS surgeon. It is important to keep your levels with in normal limits because it can be challenging to bring these levels back up.Lack of dietary iron may cause anemia in infancy when the daily need for iron is not met by milk alone. This is why iron supplements are given to infants. Iron deficiency is a major cause of anemia in pregnancy.

Malabsorption of iron is a rare cause of iron deficiency in the general public but is seen in patients who have had a partial gastrectomy,  RNY Gastric Bypass, or who have a surgical malabsorption, such as Duodenal Switch.  Iron is absorbed through the duodenum and the first part of the jejunum. After DS there is only a small section (approximately 5cm) of the duodenum that comes into contact with the iron source in the GI tract. The remainder of duodenum and the jejunum after DS is now the biliopancreatic limb. There is an area of small intestine in the ileum that also absorb iron to a lesser degree in normal anatomy.

The following are definitions of Iron Deficiency Anemia diagnostic laboratory studies:

Ferritin is in essence an “iron buffer”, taking up excess iron or releasing iron as needed. Small amounts of ferritin, derived from iron stores, circulate in the plasma.
The amount of serum ferritin closely reflects iron stores, thus providing a readily measured assessment of body iron stores.

1) ferritin increases in chronic inflammation;
2) ferritin is increased in hepato-cellular disease
3) ferritin may be increased in malignancy.

Ferritin is in essence an “iron buffer”, taking up excess iron or releasing iron as needed. Small amounts of ferritin, derived from iron stores, circulate in the plasma. The amount of serum ferritin closely reflects iron stores, thus providing a readily measured assessment of body iron stores.

iron transport
The iron cycle
Transferrin, the major iron transport protein, is synthesized by the liver and macrophages (type of blood cell). Each molecule of transferrin can bind two at- oms of iron. Usually about one-third (25 – 45%) of the total transferrin is bound to iron (referred to as % saturation)Transferrin carries iron via plasma to cells throughtout the body, though the most important site of delivery is to the mar- row erythroblast. Non-heme iron (mainly Fe +++(Iron) ) is stabilized by gastric HCl; bound to mucin and then transferred to a mucosal cell surface receptor.

Most heme iron is catabolized to Fe ++ (Iron) and tetrapyrrole in the mucosal cell. In the mucosal cell the iron is bound to mobilferrin, transported through the cell to the submucosal capillary network where the iron is oxidized to Fe+++, bound to transferrin and delivered via the blood to the marrow and other tissues. Note that some iron is stored or “trapped” as ferritin in the mucosal cell. This “trapped” iron plays only a minor role in regulation of iron intake/loss as it is readily overwhelmed by ingestion of inorganic iron.

Total Iron Binding Capacity approximates a measure of transferrin. Serum iron is a measure of Fe bound to transferrin. Normally 25 – 45% of transferrin is bound to iron, ie. The % saturation of transferrin. In inflammatory and malignant conditions transferrin is decreased possibly due to macrophage degradation. Iron is decreased due to decreased release of iron from macrophages into the plasma. Iron deficiency is best screened for with serum ferritin levels (serum ferritin levels correspond to marrow stores). A serum ferritin of 12-307 ng/ml is the normal range.

The definitive test for iron deficiency is a Prussian blue stained bone marrow. The upper image demonstrates an absence of iron in the bone marrow macro-phages of an individual with iron deficiency.

bone-marrow-biopsy
Lacking iron stores in bone marrow
Prussian blue staining of RBC
Prussian blue staining of iron stores in bone marrow

Compare the upper image with the lower image of a normal bone marrow stained with Prussian blue and demonstrating coarse granular storage iron in macrophages.

Normal Iron Ranges:

Normal results of iron testing may be different for men, women, and children. Iron and TIBC are measured in micrograms per deciliter (mcg/dL). Normal results for iron are:

  • 65 to 175 mcg/dL for men
  • 50 to 170 mcg/dL for women
  • 50 to 120 mcg/dL for children

Normal results for TIBC are 250 to 450 mcg/dL for men and women.
The diagram below shows the normal uptake, storage and loss of iron within the cell.  An excellent explanation of iron transport physiology can be found here: https://sickle.bwh.harvard.edu/iron_transport.html

iron-kinetics
iron-kinetics

Iron is continually conserved and recycled for use in heme and non-heme enzymes. About 1 to 2 mg of iron are lost each day to sloughing of skin and mucosal cells of the gastrointestinal and genitouretal tracts. This obligate iron loss is balanced by iron absorption from the gastrointestinal tract. Only a small fraction of the 4 grams of body iron circulate as part of transferrin at any given time. Body iron is most prominently represented in hemoglobin and in ferritin.

Treatment:

There are different oral iron formulations available. I recommend heme iron instead of ferrous sulfate or ferrous fumarate. After 3 months of therapy it is necessary to repeat laboratory blood levels to determine the next course of action.  Iron supplements along other medications should be stored away from children in “child proof” containers. Your pharmacist will be able to instruct you with the correct way of taking the iron supplements, and possible interference with other medications that you may be taking.

In severe anemia and/or iron deficiencies  anemias resistant to oral iron supplementation, it may be necessary to have iron injections or infusions intravenously.  If you have any questions please contact us either by email or phone.

In summary, iron deficiency anemia develops gradually. It also takes a great deal of time to build iron levels  back up again.  The importance of continued surveillance of laboratory studies is crucial after weight loss surgery. In addition, the treatment of iron deficiency anemia requires diligence in taking the iron supplement or reacting to the inability to absorb oral iron supplements by using iron infusions. Please contact our office if you have not had your yearly lab work or you may have your primary care physician order these studies.