Tag: sleeve gastrectomy
Bariatric Surgery effects on PCOS
May 17, 2017 11:02 am
Women with Polycystic Ovary Syndrome (PCOS) often feel hopeless and depressed with their diagnosis. Bariatric Surgery improves metabolic syndrome, diabetes resolution, cardiac improvement, quality of life, and increased life expectancy. Bariatric Surgery effects on PCOS are positive in many aspects. However, there isn’t a consensus regarding recommendation for bariatric surgery for PCOS other than morbidly obesity with co-morbities.
PCOS has been shown to effect approximately 10% of women of childbearing age with symptoms of menstrual abnormalities, poly cystic ovaries, and excess androgen (male sex hormone). PCOS should be diagnosed by ensuring there are no other underlying endocrine issues. There are several associated disease processes that seem to be related to PCOS, such as Type 2 Diabetes, higher depression and anxiety, increased cardiovascular risks, stroke, hyperlipidemia, sleep apnea, overall inflammation, and endometrial cancer.
Bariatric surgery can improve several issues related to PCOS such are Type 2 Diabetes, lower weight, sleep apnea, infertility, and hyperlipidemia. Duodenal Switch has the highest rate of Type 2 Diabetes resolution of all weight loss surgeries available at this time. Duodenal Switch also significantly improves hyperlipidemia.Weight loss surgery has been shown to improve and in some cases resolved PCOS in general. A recent meta-analysis of the effects of bariatric surgery in more than 22,000 procedures found an average weight loss of 61%, associated with the complete resolution or improvement of diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea in more than 60% of the patients. Another study looked just at PCOS patients and their metabolic improvement from 47% of the PCOS population to only 21% post Bariatric Surgery.
Several recent article have described how Bariatric Surgery effects PCOS with positive aspects related to fertility. The range of improved fertility in post Bariatric PCOS patients is a wide range of 33-100% with in the literature. It is thought that the loss of fat mass improves hormone levels and insulin resistance in PCOS and has a positive effect on fertility. One study of only 6 omen had a 100% improvement of infertility. American Society of Metabolic and Bariatric Surgery as well as the American College of Obstetricians and Gynecologist have a statement that bariatric surgery is should not be considered a treatment for infertility. The graphic below demonstrates the overlap of some of the symptomatology between PCOS, obesity and metabolic syndrome.
There are several documented positive effects and improvement in co-morbidilties related to PCOS post Bariatric Surgery. These include lipid profile, lower weight, cardiovascular risk, hypertension, and fertility. It is important to note that certain bariatric surgeries have better resolution of these co-morbidities or symptoms of PCOS. Always discuss with your physicians and surgeon what your options are and which treatments may work best for you.
In Summary, PCOS is a metabolic disease condition affecting different organ systems. Weight loss surgery should be considered as a viable treatment option and should be discussed with your OB/GYN and Infertility specialist.
Back on Track 2017 Giveaway
January 10, 2017 10:03 am
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.
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
Review & Update Giveaway!
August 31, 2016 6:27 pm
The Prize winners are Jo and Kimberly! Congratulations ladies and enjoy the Obesity Help National Conference! Thank you to all that participated in the Giveaway!
We are holding a review and update giveaway for two different prizes! Thank you for your
participation!
One Prize and One Grand Prize
Prize: two tickets to Obestiy Help National Conference Sept. 30-Oct 1, 2016
Grand Prize: two tickets to Obesity Help National Conference and one night
hotel stay October 1, 2016
Conference: 11999 Harbor Boulevard Garden Grove, California 92840 Event link here
Hotel Prize: SHERATON GARDEN GROVE – ANAHEIM SOUTH HOTEL
12221 Harbor Boulevard
Garden Grove, California
Official Rules:
How to Enter and eligibility: All entrants and winners must be 18 years of age or older at the time of entry. Up to 5 entries per person.
- Write a review of Dr. Ara Keshishian on one or all of the sites below or do an update on your profile on Obesity Help between now and Sept. 8, 2016 at 5:00 PM
2. Take a screen shot of the review or update with your username and date.
3. E-mail the screenshot to contact@dssurgery.com with your contact information (name, phone number, e-mail, and mailing address )
4. Entries must be a verifiable patient of Dr. Ara Keshishian in Glendale, CA.
Promotion Timing:
The Review & Update Giveaway begins September 1, 2016 and ends September 8, 2016 at 5:00pm PST
How Winners are Chosen:
Winners will be chosen by random draw. Odds of winning vary upon the number of entries received for the giveaway.
Winner Notification and the Claiming of Prizes:
Winners will be notified via the email provided at time of entry and also published on our blog comments www.dssurgery.com/blog and on our FaceBook page. The winner will have 72 hours to respond to the winning notification email or the prize will be forfeited. The prizes have no cash value. The prizes are non-transferable and must be accepted as awarded. No changes may be made to the prizes. There is no cash value for the prizes.
General Conditions:
By entering the Giveaway, entrants agree to abide by and be bound by these Official Rules and the decisions of the Sponsor, which are final and binding in all matters relating to the Giveaway, and release and hold harmless Sponsor and its affiliates, directors, officers, employees and assigns from and against any liability, claims, lawsuits, judgments, losses, damages of any kind, injuries, death, property damage, costs and expenses, arising from, resulting from or in connection with the Giveaway, the participation in the Giveaway, or the receipt, possession, use or misuse of any prize. Sponsor is not responsible for lost, late, incomplete, inaccurate, stolen, delayed, misdirected, undelivered or illegible entries or for lost or stolen entry boxes or other errors or difficulties of any kind whether human, mechanical, electronic, typographical, printing or otherwise relating to or in connection with the Giveaway, including, without limitation, errors or difficulties which may occur in connection with the administration of the Giveaway, the processing of entries, the announcement of the prizes, or in any Giveaway-related materials. Sponsor is not responsible for technical, hardware, software or telephone malfunctions of any kind, lost or unavailable network connections, or failed, incorrect, incomplete, inaccurate, garbled or delayed electronic communications caused by the user or by any of the equipment or programming associated with or utilized in the Giveaway. Persons who tamper with or abuse any aspect of the Giveaway or who are in violation of these Official Rules, as solely determined by Sponsor, will be disqualified and all associated entries will be void. The Sponsor reserves the right, at its sole discretion, to cancel, terminate, modify or suspend the Giveaway if, in Sponsor’s opinion, it is not capable of running as planned, including, but not limited to, due to tampering, unauthorized intervention, fraud, technical or phone line failures or any other problems beyond the control of the Sponsor, and select the winners for affected drawing(s) from among all eligible entries timely received for such affected drawing(s) prior to cancellation.
Less Invasive, Easier?
July 20, 2016 11:02 am
There is a continuous desire for a “less invasive”, “easier” procedure for the treatment of obesity and its associated co-morbidities. We have been very clear when discussing the benefits and long term outcome of the procedures. Let’s remind ourselves that “less invasive” does not mean a better option. In almost all cases a less invasive weight loss surgery means less weight loss, lower incidence of resolution of co-morbidities, and in some cases higher complications rate. Have we forgotten the adjustable gastric banding that was advocated to be the cure all for all obesity? All we hear now are the complications, the long term sequel of the reflux, hiatal hernia, irreversible esophageal injury, in addition to inadequate weight loss or weight regain.
Unfortunately, the same is to be said about the Sleeve Gastrectomy. We have said, as supported by the scientific literature, that the long term outcome of the sleeve gastrectomy is not as good as that of the Duodenal Switch procedure. This is true for the amount of weight loss as well as the resolution of the co-morbidities. We see quite a few patients who have gained their weight back after sleeve, never lost enough weight, and/or did not achieve resolution of their co-morbidities, such as diabetes, and are having their procedure revised to Duodenal Switch procedure.
Here is a recent publication that discusses this.
Along with the same argument, this is why I caution patients when having the SIPS or SADI procedures. There is a chance that when the long term data for SIPS/SADI is available there may be some benefits procedure. However, as it stands at this point in time, these procedures are not the same as the Duodenal Switch procedure. So in short, less invasive, easier isn’t better.
Don’t lose your Pyloric Valve over a Failed Gastric Sleeve
June 22, 2016 9:32 am
In my opinion, there are very few reasons to lose your Pyloric Valve after sleeve gastrectomy. Recently, I am hearing of people who have had regain due to a failed Sleeve Gastrectomy being revised to Gastric Bypass RNY and then seeking a Duodenal Switch due to regain from Gastric Bypass RNY. A better option is to go from Sleeve Gastrectomy to Duodenal Switch, due to the long term excess weight loss maintenance of Duodenal Switch. The benefit of the pyloric valve can not be taken lightly.
Let’s start by reminding ourselves as to how the Sleeve Gastrectomy has gained popularity. In the quest for a simple solution to the complex problem of obesity, adjustable gastric banding gained popularity only fail to deliver anything close with the results that were promoted and heavily marketed. The focus was then changed to another seemingly simple procedure, laparoscopic sleeve gastrectomy. For some surgeons this is a new procedure. Surgeons that had been doing the duodenal switch operation for decades, sleeve gastrectomy has not been a new procedure. Surgeons that just started doing sleeve gastrectomy as a stand alone procedure started experiencing complications of the sleeve gastrectomy, such as regain and are now looking for another option for these patients. This complication are even more frequent when they’re done following a failed adjustable gastric band procedures due to the metabolic issues after revising one weight loss surgery to another. A similar short sighted approach is also being promoted with SIPS/SADI procedures, which is significantly simpler to perform than the duodenal switch operation.
Laparoscopic sleeve gastrectomy has a predictable profile for weight loss. It will not have as good on the long-term success rate as a duodenal switch operation. Complications of the sleeve gastrectomy including reflux, stricture, fistula, inadequate weight loss which may warrant evaluation and possible intervention. In my opinion, as a surgeon who does the duodenal switch operation routinely, a sleeve gastrectomy requiring revision should almost never be revised to a gastric bypass. I have seen number of patient’s who have had an adjustable gastric banding which was revised to the sleeve gastrectomy then to a gastric bypass. We are contacted for a possible revision to Duodenal Switch operation because of the weight regain. One can argue that the patient should not have had the sleeve gastrectomy or gastric bypass. It is critical that the complexity of the disease of the obesity is clearly appreciated that it purely restrictive procedure will not yield the desirable outcome long-term.
Benefits of the Pyloric Valve:
The pylorus is the valve located at the end of the stomach. It controls the release of the liquid mixture of food from the stomach into the small intestine.
The body naturally regulates the passage of food, so food will stay in the stomach for a certain period of time. We believe it is very important to continue that feeling of fullness in between meals. As a result, one of the principle functions of the pyloric valve is to regulate the amount of food products released into the small intestine where they are absorbed. This helps prevent dumping syndrome and ulceration.
The bodies natural diameter of stomach, pyloric valve and small intestine is left intact. This elevates stretching of the stomas created by RNY Gastric Bypass.
Summary
These failed Sleeve Gastrectomies should be revised to Duodenal Switch unless there are overwhelming health issues that would require another option. I always suggest several opinions from different Bariatric Surgeon’s who do a variety of Weight Loss Surgeries before deciding which type of revision to proceed with.
Stricture after Sleeve Gastrectomy Duodenal Switch
May 01, 2016 9:45 pm
According to the American Society of Metabolic and Bariatric Surgery sleeve gastrectomy has become the most commonly performed operations in 2012. Sleeve gastrectomy became popular because of the high failure rate of the adjustable gastric banding and the issues with RNY pouch. The Sleeve Gastrectomy was performed many years prior to 2012 as a part of the Duodenal Switch procedure. Stricture is a complication occurring post Sleeve Gastrectomy and Duodenal Switch.
Stricture:
Sleeve gastrectomy may appear to be a simple procedure under the surface; however, it is fraught with very unique and challenging complications. These may include, but are not limited to, staple line failure resulting in leak, injury to the spleen, stricture, and even a rare and under diagnosed portal vein thrombosis. Technique is important in avoiding short and long-term complications. Strictures can be caused by making the sleeve stomach too narrow or by stapling in a fashion where the corkscrew stomach.
Some surgeons create a very narrow sleeved stomach in an attempt to maximize weight loss by increasing restriction. This can result in significant GERD in patient with no long-term benefit. Re-sleeving is another incidence were strictures can become an issue. These strictures are debilitating and almost all the time require surgical intervention. Balloon dilation by an endoscopy method is frequently unsuccessful. The patient who has a stricture should seek the attention of an experienced revision surgeon for surgical repair. Strictures are usually a short narrow segment of the stomach. The reason why sleeve gastrectomy strictures do not respond well to balloon dilatation is because of the staples line that is present on one side of the tube of the stomach that cannot be stretched.
Some surgeons create a very narrow sleeved stomach in an attempt to maximize weight loss by increasing restriction. This can result in significant GERD in patient with no long-term benefit. Re-sleeving is another incidence were strictures can become an issue. These strictures are debilitating and almost all the time require surgical intervention. Balloon dilation by an endoscopy method is frequently unsuccessful. The patient who has a stricture should seek the attention of an experienced revision surgeon for surgical repair. Strictures are usually a short narrow segment of the stomach. The reason why sleeve gastrectomy strictures do not respond well to balloon dilatation is because of the staples line that is present on one side of the tube of the stomach that cannot be stretched.
An increasingly more complicated problem is when the stricture is caused by a spiraling of the staple line. This is quite frequently seen where the stapling of the stomach was started on the greater curvature of the stomach and rotated anteriorly causing a corkscrew effect of the stomach. A long segment stricture of the stomach cannot be corrected by balloon angioplasty and would require surgical intervention.
I have been involved with numerous repairs of strictures on sleeve gastrectomies and Duodenal Switch stomach from other institutions. In my opinion, repeated endoscopy and balloon dilatation only complicate further care by compromising the tenuous tissue of a strictured stomach due to scaring and blood supply. As above-stated earlier it is critical that a patient who is experiencing significant reflux, changes in nausea and vomiting, suspected stricture or narrowing, or has a corkscrew stomach to be seen by an experienced surgeon for surgical repair. See the following Blog for health issues that can occur or progress with strictures.
Sleeve Gastrectomy specimen picture.
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.
Hiatal Hernia Treatment
February 13, 2016 4:45 pm
Hiatal Hernia may be one reason for developing symptoms of GERD (Gastroesophageal reflux disease). As we have discussed previously, the treatment for reflux should not be long-term use of the “purple pill”, or all PPI’s, as advertised on TV. There is a large population who are delaying definitive care and probably increasing their chance of esophageal cancer by taming the symptoms of the reflux with over the counter or prescription medication. However, it is important to note that taming the symptoms isn’t necessarily stopping the effects. Be proactive and request to be sent to a surgeon to fix any issues if you are being recommended to “….take the medication and come back again for another endoscopy again ….”
Types of Hiatal Hernia:
This is an example of a patient who had been told to take the medication and just keep and eye on it with repetitive endoscopies. He had to have hiatal hernia repair with Nissen fundoplication for progressively worsening symptoms even on maximum treatment.
This is another example of a hiatal hernia repair procedure of a patient with a previous history of sleeve gastrectomy. In this patient, mesh had to be placed in order to fix the hiatal hernia.
NSAIDS Use After Duodenal SwitchExclusive Member Content
January 30, 2016 9:19 am