Category: Uncategorized
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.
Curved Adjustable Gastric Band Discontinued
May 19, 2016 11:19 am
The Curved Adjustable Gastric Band will be discontinued. Johnson and Johnson, the parent company of the Ethicon, is removing the Curved adjustable Gastric Band from its’ product line. This particular band is known as the Realize Band launched by Johnson & Johnson and did not gain much traction. The number of Adjustable gastric band placements have gone down significantly as the data have shown poor outcome over long term and a high complication and re-operative rates.
The following link is a copy of the letter from Ethicon Johnson and Johnson regarding the Curved Adjustable Gastric Bands Discontinuation: Realize Band removed from the Market.
Minimally Invasive Weight Loss Surgery
May 17, 2016 9:02 am
Minimally Invasive does not mean better, easier, proven outcomes or good excess weight loss. Weight loss surgical patients should be careful of catch phrases such as “less invasive”, “simpler”, “shorter recovery”, “outpatient” and many others that had been used to described procedures with less than optimal outcome. We should not forget the lessons learned from adjustable gastric banding which was also promoted as ” less invasive, simpler to perform, and be done as an outpatient with a short recovery “. We all know how that story has panned out. The overwhelming majority of patients who had an adjustable gastric banding have undergone revision, had it removed or had additional surgeries following the complications which were associated with this simple procedure.
When evaluating outcome data for weight loss surgical procedures, it is important to bear in mind that the long-term success of these procedures will take years to document. More often than not the early weight loss is significantly better than the long-term stable weight loss. This has been clearly documented in the case of the adjustable gastric banding and the gastric bypass and laparoscopic sleeve gastrectomy operation. Duodenal switch , as described by Dr. Hess using the percentage based technique, has the best long-term documented success of all of the weight loss surgical procedures. The scientific data reports 20+ years of successful excess weight loss with a Hess Duodenal Switch procedure. There has been an alternative proposed to Duodenal Switch recently, the SIPS and SADI procedures. As I have already stated in the past, these are not the same as the duodenal switch operation. Any suggestion or innuendos that SIPS/SADI is the same as the Duodenal Switch is deceptive and misleading. We have also seen attempts to use the same catch phrases as described above to promote these unproven procedures. The published data that’s been reported with SIPS/SADI is mostly short-term in small population studies. There are no long-term studies that have documented the efficacy of the SIPS/SADI procedure and “simpler” or minimally invasive does not mean better.
Magnesium QuestionsExclusive Member Content
May 11, 2016 6:07 am
Does Your Sleeve Look Like this?
May 10, 2016 9:03 am
The re-shaping of the stomach for weight loss with a Sleeve Gastrectomy can be a technically challenging procedure. There are complications such as stricture, cork-screw stomach, GERD, nausea and vomiting that can lead to further health issues and possibly nutritional issues.
Upper GI pictures of Sleeved Stomach
In the following series of pictures you can visualize that the Sleeve Gastrectomy in the first picture is a hard angled S shape with two stricture points. The second picture points out the two stricture points and the outline the sleeve gastrectomy of a patient referred to our practice for complications of stricture and GERD post sleeve gastrectomy in need of revision. Surgical revision of gastric stricture is highly technical and challenging. It also takes experience in identifying possible options available to the patient.
The outline in light blue depicts the shape a sleeve gastrectomy should follow.
Why are strictures bad? What is the problem with having and living with a stricture? Strictures caused by Sleeve gastrectomy or Duodenal Switch, SIPS/SADI procedure can have detrimental effects. The long-term complications may include, irreversible injury to the esophagus and the stomach above the stricture, Teeth and gum damage, aspiration in addition to nutritional deficits because of the inability to tolerate healthy meals. Additional information regarding complications that can arise from stricture, nausea and vomiting here.
Strictures can not be repaired by dilation in most cases since on one side of the narrowed section is formed by the sample line. These should be addressed surgical by an experienced surgeon. Ideally a a stricture would be avoided at all cost by assuring that the sleeves are not done too tight and narrowed and that there are no sharp angles created when the stomach is divided during these procedures. The repair of these strictures of the stomach in the duodenal switch, sleeve and the SADI/SIPS procedures are complicated since the remnant stomach is removed and the options are limited. Additional information regarding stricture complications and pictures of other stricture types here.
Enhanced Cognitive Function after Bariatric Surgery
March 18, 2016 6:51 am
The adverse effects of obesity reduce the body’s natural potential of optimal physical, mental health and cognitive function. Obesity is associated with a greater risk of health problems such as hypertension, stroke, diabetes, and sleep apnea. These issues attribute to an increased risk of dementia and cognitive dysfunction.
Glucose homeostasis plays a key role in the neural mechanisms of the brain. Insulin signals nutrients by circulating within the body in proportion to body fat mass. In addition to other regulatory mechanisms, this allows the brain to control feeding behavior by stimulating energy storage and metabolic homeostasis. Metabolic imbalances modify insulin sensitivity and lead to impaired glucose output inhibition [Qatanani and Lazar et al., 2007 (1)].
Free radicals are formed when weak molecular bonds are split. Their instability causes them to attack neighboring stable molecules and lead to a chain reaction of disturbing living cells. Antioxidants, such as vitamins C and E, defend the body from the damaging effects of free radicals by acting like scavengers. They protect cells from tissue damage that can potentially lead to disease.
Moreover, insulin resistance links oxidative stress, which is the continuous imbalance between free radical production and the body’s antioxidant defenses to detoxify its harmful effects. Enhanced oxidative stress is a result of accumulated fat, which impairs the secretion of insulin and damages glucose uptake in muscle and fat. Increased oxidative stress is the underlying cause of pathogenesis in vascular cell walls that lead to the development of cardiovascular problems, plaque formation. Data suggests, in a study conducted by Dr. Convit (2) in 2002, that management of blood sugar levels may enhance memory and possibly decrease the risk of Alzheimer’s disease.
In congruence with these findings, added stress due to excess weight can negatively affect the anatomy and physiology of the body. A study in 2010, led by Dr. Thompson (3), concluded that obesity is associated with “atrophy in brain areas targeted by neurodegeneration: hippocampus, frontal lobes, and thalamus” [Raji et al., 2010 (3)]. These brain regions play a critical role in the maintenance of memory, executive function, and sensory interpretation, respectively.
Central respiratory function is also disrupted by the mechanical effects of obesity. Reduced lung expansion is especially destructive during sleep. Obstructive sleep apnea is a disorder where breathing stops for brief periods because of an obstructed upper airway. Excess weight and increasing body mass index (BMI) restricts expansion of the chest wall and increases airway resistance, which decreases lung volume [Zammit et al. 2010 (4)]. This boosts respiratory muscle workload for consistent breathing. Complications of sleep apnea include fatigue, heart problems, metabolic syndrome, and more.
Cognitive impairments lead to deficits in executive function, response, reflex time, planning, and memory [Spitznagel et al. 2013 (5)]. Blood sugar levels, oxidative state, respiration and other mechanisms influence our cognitive abilities. Weight loss from bariatric surgery may reduce the comorbidities of an obese patient. The primary outcomes are improvements with diabetes, blood pressure, glucose levels, sleep apnea, BMI, and excess weight resolutions.
Weight loss surgery reverses the stressors of the body to permit the development and preservation of cognitive function. By improving anatomical aspects of physical health, the overall mental well-being of patients is remarkably enhanced.
A number of studies have looked at the short [Gunstad 2011(6)] and intermediate [Alosco 2013, (7)] term improvement in memory function after weight loss surgery
Thank you to Contributor: Mariam Michelle Gyulnazaryan
References for Cognitive Function
- Qatanani M, Lazar MA. Mechanisms of obesity-associated insulin resistance. Genes & Dev. 2007; 21: 1443-1455.
- Convit A, Wolf OT, Tarshish C, de Leon MJ. Reduced glucose tolerance is associated with poor memory performance and hippocampal atrophy among normal elderly. PNAS. 2013; 100 (4): 2019-2022.
- Raji CA, Ho AJ, Parikshak N, Becker JT, Lopez OL, Kuller LH, Hua X, Leow AD, Toga AW, Thompson PM. Brain structure and obesity. Hum Brain Mapp. 2010; 31(3): 353-364.
- Zammit C, Liddicoat H, Moonsie I, Makker H. Obesity and respiratory diseases. Int J Gen Med. 2010; 3:335-343.
- Spitznagel MG, Alosco M, Strain G, Devlin M, Cohen R, Paul R, Crosby RD, Mitchell JE, Gunstad J., Cognitive function predicts 24-month weight loss success following bariatric surgery. Surg Obes Relat Dis. 2013; 9(5): 765-770.
- John Gunstad, Gladys Strain, Michael J. Devlin, Rena Wing, Ronald A. Cohen, Robert H. Paul, Ross D. Crosby, James E. Mitchell, 2011, ‘Improved memory function 12 weeks after bariatric surgery’, Surgery for Obesity and Related Diseases, vol. 7, no. 4, pp. 465-472
- Michael L. Alosco, Mary Beth Spitznagel, Gladys Strain, Michael Devlin, Ronald Cohen, Robert Paul, Ross D. Crosby, James E. Mitchell, John Gunstad, 2013, ‘Improved memory function two years after bariatric surgery’, Obesity, vol. 22, no. 1, pp. 32-38
- Furukawa S, Fujita T, Shimabukuro M, Iwaki M, Yamada Y, Nakajima Y, Nakayama O, Makishima M, Matsuda M, Shimomura I. Increased oxidative stress in obesity and its impact on metabolic syndrome. J Clin Invest. 2004; 114(12): 1752-1761.
- Mitchell JE, de Zwaan M. Psychosocial assessment and treatment of bariatric surgery patients. 2011;6: 103-109.
- Nguyen JCD, Killcross AS, Jenkins TA. Obesity and cognitive decline: role of inflammation and vascular changes. Front Neurosci. 2014; 8: 375.
- Chan JSY, Yan JH, Payne VG. The impact of obesity and exercise on cognitive aging. Front Aging Neurosci. 2013; 5: 97.
Shared Success Story – Albert L.
March 07, 2016 10:46 am
Lose weight, eat smaller portions, eat healthy, go to the gym, don’t eat bread, don’t eat starches, try this diet try that diet….. on and on.
It is so easy for dietitians, nutritionists, cardiologists, family members to speak these words. Being the one with the weight issue, it would drive me crazy hearing all the smart advice everyone had for me. I tried it all without success! Some for one day, some for longer, the results were always the same. I would lose a few pounds and in the end I would gain more. I imagine that the advice givers really didn’t understand the fatigue and appetite that comes with the extra pounds. At 39 years old, 245lbs, on blood pressure and cholesterol meds, all I could see was a life of diabetes and heart disease. Oh, the days I spent in department stores looking at designer clothes I couldn’t wear, talking to women who wouldn’t see past my belly, being the guy at the pool with his shirt on and most of all facing a very rocky future.
The day I walked into Dr Keshishian’s office was the day my life changed. He looked me in the eyes and told me it’s all going to be better. I had my surgery in June and my recovery was unusually fast. The pounds were dropping daily and within 6 weeks my cardiologist took me off my blood pressure and cholesterol medications. At eight months after surgery, I am so close to my goal of 180lbs. I have to admit that I would have reached my goal months ago. But a trip to Australia, wining and dining my new fiancé put me off track. But I’m happy to say I’m well on my way to success. Because I am feeling so much healthier, I have joined a gym. Since surgery, I don’t have a huge appetite so I am eating smaller and healthier portions. The future is looking very very bright. Thank you Doc.”
-Albert L.
Metabolic Processes In Different TissuesExclusive Member Content
February 11, 2016 8:29 am
Introduction to Metabolism
February 05, 2016 10:34 am
Informative and simplified Introduction To Metabolism.
My recorded Webinar on Metabolism and weight loss surgery.
This animations are being used with the permission of the copyright holder:
NSAIDS Use After Duodenal SwitchExclusive Member Content
January 30, 2016 9:19 am