Category: Uncategorized
Teaching Nursing Students about Duodenal Switch!
October 19, 2015 11:34 am
Dr. Keshishian explaining the different weight loss surgical procedures to nursing students. Including the duodenal switch before cases to a number of nursing students on a board in the operating room. Dr. Keshishian is always willing to educate and draw with a smile but not always with a bowtie!
Cindy Porcell, Surgical tech put the finishing touches on it.
In case you are wondering, surgical scrubs do not have bowties!
Surgical Outcomes
October 02, 2015 10:10 am
In a recent review article published in the September 2015- Volume 42:10 of General Surgery News, the surgical outcomes of different procedures were summarized. There were evaluated based on a number of measures, including re-operation rates. So interesting to note that the re-operation rate of the duodenal switch is the lowest of all surgical procedures.
Adjustable gastric banding had the highest reported re-operation rate. To be noted is the longer the time lapse the higher the need for re-operation for the band.
Original article here.
Shared Success Story- Stephanie U.
September 22, 2015 7:38 am
When I think back as far into my childhood as I can remember my weight was always a problem. I grew up being made fun of and missed out on the simple things that normal kids do growing up because my weight caused limitations.
Even into early adulthood I was still made fun of, but I learned to deal with it. I tried different methods of trying to lose weight. I went to a gym, tried diet pills, followed diets, cut out foods, sodas, alcohol, etc. Sure these things worked (very slowly) for a period of time, but then I would plateau and became discouraged and gain whatever little weight I lost plus some. By the time I was 27yrs old I found myself at my heaviest at 245lbs and I was also pregnant with my first child. I was lucky enough to have a healthy pregnancy. However after I had my daughter, I went up to 265lbs and just couldn’t get it off. I felt the toll the weight was taking on my body. My hips would ache, go numb, my lower back would get stiff, I would become winded just walking upstairs, it was difficult to get up from sitting, my feet would be sore if I was standing too long. I began to realize this was just going to get worse as time went on and as my daughter got older parenting would become more difficult. It became an even bigger concern to be healthier now that I had a little one depending on me and looking up to me.
I decided to explore the option of surgery in late 2013. I knew it was something that my insurance would cover so long as I met the requirements so I set out to find a reputable surgeon in my area.
Surprisingly I reached out into a Facebook group and was overwhelmed with recommendations for Dr. Keshishian (I was originally interested in the DS surgery). I went for my consultation in December of 2013. Upon meeting with Dr. Keshishian I knew I wouldn’t have wanted anyone else to perform this surgery on me. He was very upfront, honest, and straightforward with information regarding what was to come and the effort that needed to be put forth in order for this to work. The Gastric Sleeve was brought up and I decided to go with the sleeve surgery. I pushed forth and the staff at Dr. K’s office began the process of approval which happened to move very swiftly and smoothly.
I ended up having my surgery on 4/11/14 and I weighed 265lbs on the day of. Today, as I write this I am, approaching my 30th birthday healthier than I think I have ever been and I currently weigh 152lbs. The adjustment post-op was not an easy one, but it was well worthwhile. I am much more active, able to keep up and play with my daughter. I feel like I am living a normal life for once. I was scared, nervous, and had so many worries running through my head prior to surgery but now that I have gone through it I would make the same decision all over again in a second’s time.
Revision of a Sleeve Gastrectomy or RNY
August 31, 2015 6:32 am
These are examples of two types of patients referred to us for revision surgery.
The first example is a gastric bypass that we revise to the duodenal switch operation. The upper GI series after the revision, shows a “banana shaped” stomach, the pyloric valve and the duodo-ilesotomy anatomosis component of the duodenal switch.
The second example, images noted below, is that of a sleeve revised to the duodenal switch – both operations done at different institution. Note how the stomach is not a “banana shaped” and more like a funnel with a narrowing at the bottom of the stomach- a stricture.
Internal Hernia And Bowel Obstruction
August 21, 2015 7:49 pm
Whenever there is a bowel resection with anastomosis made there will be a defect in the mesentery (the tissue that holds the blood supply and the nerves etc going to and from the bowel) that needs to be closed. In this particular case, the stitches that were used to close the defect were intact and yet the tissue had separated from it. The result is an internal hernia. This can cause bowel obstruction, where by a loop of the bowel can go through the defect and kink the bowel causing the blockage. In some cases, the internal hernia may reduce itself with intermittent symptoms of the bowel obstruction and in other cases it may require immediate emergent surgery. A CAT scan with oral and IV contrast is needed after Duodenal Switch to visualize the alimentary and bioliopancreatic limbs.
Symptoms may include but are not limited to:
- nausea
- vomiting
- abdominal bloating
- abdominal tenderness
- cramping abdominal pain
- diarrhea, constipation
- feeling of inability to completely empty bowels
- fever
- severe abdominal pain.
Billroth I & II, SIPS, SADI, Loop
July 27, 2015 1:30 pm
In 1881, Dr. Theodore Billroth performed the first successful gastrectomy for pyloric tumor. He removed the distal part of the stomach and tumor of the pyloric region and reconnected the distal end of the transected stomach directly to the segment of the duodenum. This was later renamed as Billroth I procedure. In Billroth I the anastomosis allows the food pathway to stay in the same directional flow with the exception of pyloric valve having been removed. There is, however, increased incidence of bile reflux with the pyloric value removal.
There are incidences where the resected segment is so large that the proximal stomach and the distal duodenal can not be mobilized and brought close to each other to be able to create the Billroth-I anastomosis. Larger resection, where the Billroth I could not be completed Dr. Billroth in 1885 created a procedure call the Billroth II. The Billroth II was performed when the tumor was very large and the continuity of the GI track was created by a loop gastrojejunostomy. This procedure was named Billroth II.
In the Billroth II the bile flow from the small bowel flows toward the stomach, and this results in a much higher incidence of Bile reflux and its associated complication.
The lesson learned from Billroth I and Billroth II was that bile reflux can be a significant problem when creating the continuity of the proximal GI track with exclusion of the pyloric valve. In Bilroth II, there is the additional burden of the bile flowing toward the stomach unlike the Billroth I.
The SADI or SIPS, Loop procedures that are incorrectly promoted as “duodenal switch” employ a loop anastomosis, which results in a biliary flow toward the post pyloric duodenum significantly increasing the chance and the possible incidence of Bile reflux.
All these unknowns about the SIPS, SADI Loop are yet to be investigated.
Alcohol and Weight Loss Surgery Webinar May 20, 2015
July 27, 2015 7:27 am
Shared Success Story- Andrea R.
July 22, 2015 8:00 am
Since I was about 10 yrs old I have struggled with weight. I was always the chubby kid in class, and as I got older I was always the chubby friend. Being overweight didn’t affect me until I hit 220lbs at 15 years old, and as you know, kids can be mean and hurtful. At 18 years old I had my first child, during that time I dropped a little weight then ended up gaining it back and more. At the age of 19 I was sitting at 250lbs.
Fast forward 3yrs, I had my second child and once again, I lost weight just to gain back double what I lost. So now, at the age of 22 I was up to about 290lbs. Every day life became a struggle. I tried my best to stay active, but being overweight made me tired and made me feel like hiding. Over those years I tried everything from low carb diets, to diet pills, to b12 shots, and Weight Watchers; you name it, I tried it. Finally, I was fed up! I couldn’t take it anymore and I was ready to look into different options. I was 26 years old, 5ft 8inches tall, and a mother of 2 who just wanted to be active and healthy for my kids.
I decided that weight loss surgery was what I needed to do. At this point I was morbidly obese and at my highest of 326lbs. I met with Dr. Keshishian, and after going through the consultation we decided the duodenal switch would be the best option for me. On August 26th, 2013, I had my surgery weighing in at 306lbs. Dr. Keshishian is amazing! I didn’t have any complications. I was able to drink and eat small amounts normally.
Since having the surgery, just shy of the 2 year mark, I am now down to 178lbs. My life has changed so much since losing the weight! I honestly can’t describe how grateful I am that I was able to have the surgery withScreen Shot 2015-07-20 at 1.55.13 PM such an amazing Dr. and staff. Anytime I had a question or concern they were willing to hear me out and do whatever they could to assist me. Since losing the weight I am able to be the active mother I wanted to be for myself and my kids. Now I’m taking the steps needed to ensure my kids learn healthy eating habits and helping them understand how important exercise is.
Andrea R.
Informed Surgical Consent
July 18, 2015 9:39 pm
Surgical informed consent is the document that summarizes the discussion that has been carried out between the treating physician and the patient. It also outlines the expectations as well as the potential complications of the treatment being proposed.
An informed consent should mean that the patient is absolutely clear as to the procedure agreed upon and that is reflected on the consent. No abbreviations are allowed on the consent forms. Clearly, there are instances when a physician or surgeon providing service may have to deviate from the proposed plan and agreed upon procedure on the consent because of unexpected findings in the operating room.
Any patient undergoing surgery should be acutely aware of the terminology and the language used. With regards to weight loss surgical procedures, RNY and GB is not acceptable because they are both abbreviations.
Duodenal Switch is a distinct well described procedure with its unique identifiable code (43845 for open procedure) that is recognized by hospitals, insurance companies and the surgical societies.
Duodenal Switch operation is not SADI, SIPS nor a loop Duodenal switch. Any attempt to interchanges these terms or operations is inaccurate the say the least.
A surgical informed consent is signed by the patient ( or the guardian) and the treating physician. This document however is reviewed and confirmed by all those involved in the patient’s care delivered in the hospital. The consent is reviewed by the admission staff when taking the patient for surgery, preoperative nursing and administrative staff, operating room circulating nurse as well as the anesthesia staff. One step most patients may not be aware is initiated after the general anesthesia is induced. The operating room staff, anesthesia staff and the operating physician all go through a set of checklist known as “Time out”.
“Time out” involves confirming the patient’s identification as well as the proposed procedure as the patient had discussed with the staff and confirming the consent.
It is imperative that a patient have complete understanding of their surgical options available to them and critical that they have full knowledge of the type of surgical procedure that has been consented to and performed.
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.
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.