Ara Keshishian’s Posts
Topic: RE: Feedback please!!
Hello,
The study that you have quoted talks about the the gastric bypass- long and short limb. The issue has been that the long limb was being done long time ago and then most surgeons stopped doing it because of high complication (mostly nutritional) rates. There has been a resurgence of this operation, since a relatively large % of gastric bypass patients will need revision done. Conversion to Long limb is an easy operation.
There was a very similar set of data that was presented in Las Vegas national meeting a few weeks ago, and essentially echoed the same information that the length of the gastric bypass does not affect the long term weight regain only increases the nutritional complication rate.
Hope this helps.
Ara
The study that you have quoted talks about the the gastric bypass- long and short limb. The issue has been that the long limb was being done long time ago and then most surgeons stopped doing it because of high complication (mostly nutritional) rates. There has been a resurgence of this operation, since a relatively large % of gastric bypass patients will need revision done. Conversion to Long limb is an easy operation.
There was a very similar set of data that was presented in Las Vegas national meeting a few weeks ago, and essentially echoed the same information that the length of the gastric bypass does not affect the long term weight regain only increases the nutritional complication rate.
Hope this helps.
Ara
Topic: RE: BPD,BPD/DS,Distal RNY
Hello
http://www.dssurgery.com/admin/newsletters/dec-5-09.pdf
Hope this helps.
I think it covers two out of the three.
http://www.dssurgery.com/admin/newsletters/dec-5-09.pdf
Hope this helps.
I think it covers two out of the three.
Topic: RE: Revision BOB - pain :-(
Hello Diane,
I would recommend that you see a surgeon that does revisions of gastric bypass frequent enough to be an expert in the field.
I am not clear when did your band come in to play. If you have ulcers then this needs to be treated aggressively, and possibly revised surgically. I am biased for a revision to duodenal switch which will correct the problem with weight gain, pain and the ulcer.
With a RNY there is very little stomach left up there, any bleeding would most probably be from an ulcer.
Hope this helps
Ara
I would recommend that you see a surgeon that does revisions of gastric bypass frequent enough to be an expert in the field.
I am not clear when did your band come in to play. If you have ulcers then this needs to be treated aggressively, and possibly revised surgically. I am biased for a revision to duodenal switch which will correct the problem with weight gain, pain and the ulcer.
With a RNY there is very little stomach left up there, any bleeding would most probably be from an ulcer.
Hope this helps
Ara
Topic: RE: RNY and adding a Lapband?
Hello Shirley,
The use of Band over RNY is tempting because of the perceived ease of placement and maintenance. There are some issues that one has to consider to go with "BOB" (band over bypass).
One is that it is unproven. There are probably less than three articles in all the surgical literature that talk about BOB and its short term results. No one knows where this is going to go in few years down the road, with regards to sustainability, and outcomes. The second issue is the actual outcome of the band itself, that under the best of the cir****tances it results in a 50% EBWL (half of the excess weight).
In your particular case, as a surgeon I would be more concerned about leaving a foreign body in a place where there was a leak in the past (as distant as it is) and have to worry about erosion of the band, than the risk of leak from RNY to DS revision.
Now here are the disclaimers: I do both the DS, banding and Sleeve as primary operation. In my opinion all comers all patient DS is by fat the best option. Do your research, ask questions and expect scientific answers and not anecdotal stories.
Good luck.
Ara
(Joyce here is my response!)
The use of Band over RNY is tempting because of the perceived ease of placement and maintenance. There are some issues that one has to consider to go with "BOB" (band over bypass).
One is that it is unproven. There are probably less than three articles in all the surgical literature that talk about BOB and its short term results. No one knows where this is going to go in few years down the road, with regards to sustainability, and outcomes. The second issue is the actual outcome of the band itself, that under the best of the cir****tances it results in a 50% EBWL (half of the excess weight).
In your particular case, as a surgeon I would be more concerned about leaving a foreign body in a place where there was a leak in the past (as distant as it is) and have to worry about erosion of the band, than the risk of leak from RNY to DS revision.
Now here are the disclaimers: I do both the DS, banding and Sleeve as primary operation. In my opinion all comers all patient DS is by fat the best option. Do your research, ask questions and expect scientific answers and not anecdotal stories.
Good luck.
Ara
(Joyce here is my response!)
Topic: RE: Revision - Molina Band to VSG
Hello,
I have done these revisions.
The scar tissue between the band the the native stomach may be very thick and hard needing a "chisel" to remove it.
I am sure your surgeon is experienced and you will do fine. I do however tell my patients that there may be a situation that I may not be able to revise it and it would need to be done in a staged format of removing the band and let it heal and then go back and complete the surgery.
Good luck.
Ara
I have done these revisions.
The scar tissue between the band the the native stomach may be very thick and hard needing a "chisel" to remove it.
I am sure your surgeon is experienced and you will do fine. I do however tell my patients that there may be a situation that I may not be able to revise it and it would need to be done in a staged format of removing the band and let it heal and then go back and complete the surgery.
Good luck.
Ara
Topic: RE: Band Revision-Hiatal Hernia
Hello,
I am assuming that you have a symptomatic Hiatal Hernia, with reflux, etc.
The safest thing is to remove the band, repair the hiatal hernia and revise to another operation.
Gastric bypass not my first choice. I am in favor of the duodenal switch. Do your research.
Te reason for removing the Band is that if you fill the band to loose weight, you make the reflux worse, which could damage your esophagus. It is why you want an operation that does not result in any significant restriction.
Thanks
Ara
I am assuming that you have a symptomatic Hiatal Hernia, with reflux, etc.
The safest thing is to remove the band, repair the hiatal hernia and revise to another operation.
Gastric bypass not my first choice. I am in favor of the duodenal switch. Do your research.
Te reason for removing the Band is that if you fill the band to loose weight, you make the reflux worse, which could damage your esophagus. It is why you want an operation that does not result in any significant restriction.
Thanks
Ara
Topic: RE: A question for Dr Keshishian
Hello Kerry,
The duodenal switch operation (DS, GRDS, BPD-DS) has one specific part that makes it the DS (duodenal switch). More specifically what this means is that
1-the pyloric valve stay in the path of the food, and regulates the flow, and
2-The blio-pancreatic secretions are redirected so that they are mixed with the food (that has gone thru the pyloric valve) lower down stream to limit the absorption.
You need to have this two elements to call it duodenal switch. Any thing else is false and misleading.
The specific answers to your question:
1-I would call it distal gastric bypass, because if the pouch is intact, and the pyloric valve is not in the path of the food, then it is a gastric bypass. If the junction of the two small bowel where the food and the bilio-pancreatic is further down stream then it would be distal. These definitions are pretty well set.
2-I am not sure if there are any advantages to the distal gastric bypass.
3-SIgnificant malabsorption, more so that the DS. This is on top of the fact that the patient has much more limited ability to eat and digest food, because of the exclusion of the parts of the stomach and the pyloric valve.
4- A gastric bypass to Duodenal switch is done carefully ! It can be done in the case of the distal gastric bypass as well.
5-Yes in the case of revision to DS.
6- Not to be picky, but I am not sure what you mean by full DS. There is only one DS, and that is the one that includes the two components as described above. Anything else is barely a look alike.
Not too long ago I described some of these points on our website at:
http://www.dssurgery.com/newsletters/dec-5-09.pdf
No problem, and sorry for not getting back to you sooner.
Ara
Ara Keshishian, MD, FACS, FASMBS
[email protected]
www.dssurgery.com
The duodenal switch operation (DS, GRDS, BPD-DS) has one specific part that makes it the DS (duodenal switch). More specifically what this means is that
1-the pyloric valve stay in the path of the food, and regulates the flow, and
2-The blio-pancreatic secretions are redirected so that they are mixed with the food (that has gone thru the pyloric valve) lower down stream to limit the absorption.
You need to have this two elements to call it duodenal switch. Any thing else is false and misleading.
The specific answers to your question:
1-I would call it distal gastric bypass, because if the pouch is intact, and the pyloric valve is not in the path of the food, then it is a gastric bypass. If the junction of the two small bowel where the food and the bilio-pancreatic is further down stream then it would be distal. These definitions are pretty well set.
2-I am not sure if there are any advantages to the distal gastric bypass.
3-SIgnificant malabsorption, more so that the DS. This is on top of the fact that the patient has much more limited ability to eat and digest food, because of the exclusion of the parts of the stomach and the pyloric valve.
4- A gastric bypass to Duodenal switch is done carefully ! It can be done in the case of the distal gastric bypass as well.
5-Yes in the case of revision to DS.
6- Not to be picky, but I am not sure what you mean by full DS. There is only one DS, and that is the one that includes the two components as described above. Anything else is barely a look alike.
Not too long ago I described some of these points on our website at:
http://www.dssurgery.com/newsletters/dec-5-09.pdf
No problem, and sorry for not getting back to you sooner.
Ara
Ara Keshishian, MD, FACS, FASMBS
[email protected]
www.dssurgery.com
Topic: RE: RNY revision to DS question- common channel length?
Hello Scott,
Longer common Channel= less weight loss, and less chance of certain vitamin deficiency and less chance of protein malnutrition, less chance of significant loose bowel movements, and less chance of significant flatus issues.
The opposite is clear.
The key is not to start comparing lengths. (i.e., mine is this long how long is yours) because the lengths of the bowel should be taken in context of the total length of the bowel.
What this all means, as a surgeon, I have to balance the desire for maximum weight loss, with the significant nutritional deficiencies. It is my opinion, that it is much safer to be 10-15lbs over weight than the same underweight.
Hope I did not confuse the issue.
Ara
Hello Scott,
Longer common Channel= less weight loss, and less chance of certain vitamin deficiency and less chance of protein malnutrition, less chance of significant loose bowel movements, and less chance of significant flatus issues.
The opposite is clear.
The key is not to start comparing lengths. (i.e., mine is this long how long is yours) because the lengths of the bowel should be taken in context of the total length of the bowel.
What this all means, as a surgeon, I have to balance the desire for maximum weight loss, with the significant nutritional deficiencies. It is my opinion, that it is much safer to be 10-15lbs over weight than the same underweight.
Hope I did not confuse the issue.
Ara
Topic: RE: Advice (DS) VS. (RNY) totally cluess
Hello,
43848 code is a revision of a RNY code. I think anything passed this I would refer you to a billing expert, that I am not.
I would however tell you that I asked out biller in our office and I was told that she does not use that code when I do the RNY revision to the DS.
It is also very hard to predict what insurance companies will and will not do.
Hope this all helps.
Ara
43848 code is a revision of a RNY code. I think anything passed this I would refer you to a billing expert, that I am not.
I would however tell you that I asked out biller in our office and I was told that she does not use that code when I do the RNY revision to the DS.
It is also very hard to predict what insurance companies will and will not do.
Hope this all helps.
Ara
Topic: RE: sleeve revision not done???????
Hello,
It is always a possibility, but very rare. Unless you have a necrotic stomach, or a completely eroded band, a Sleeve gastrectomy can be done. I am assuming that studies have been done to rule both of these out.
Hope this helps.
Ara
It is always a possibility, but very rare. Unless you have a necrotic stomach, or a completely eroded band, a Sleeve gastrectomy can be done. I am assuming that studies have been done to rule both of these out.
Hope this helps.
Ara
Topic: RE: Cross Post from DS Forum -- Input Appreciated
Hello Nannette,
The indication for weight loss surgery revision is divided to:
1-complication of the original surgery
2-inadequate weight loss or weight regain
Different surgeons may have a different way of outlining this.
Here how I have done it on our website.
http://www.dssurgery.com/ourprogram/revision_surgery.php
Investigate all your options. As you have already noted, probably stay away from unproven "new" procedures.
Dr. Greenbaum is a very good surgeon.
Good luck.
Ara
The indication for weight loss surgery revision is divided to:
1-complication of the original surgery
2-inadequate weight loss or weight regain
Different surgeons may have a different way of outlining this.
Here how I have done it on our website.
http://www.dssurgery.com/ourprogram/revision_surgery.php
Investigate all your options. As you have already noted, probably stay away from unproven "new" procedures.
Dr. Greenbaum is a very good surgeon.
Good luck.
Ara
Topic: RE: erny revisions
Here is the description:
http://www.dssurgery.com/newsletters/dec-5-09.pdf
The ERNY is a very potent operation when it comes to the weight loss and as a result it had the most dramatic and significant malnutrition, when it comes to al weight loss surgical procedures.
Investigate all your options.
Ara
http://www.dssurgery.com/newsletters/dec-5-09.pdf
The ERNY is a very potent operation when it comes to the weight loss and as a result it had the most dramatic and significant malnutrition, when it comes to al weight loss surgical procedures.
Investigate all your options.
Ara
Topic: RE: statistics on lap-band revisions to DS?
Hello,
There is no published reports of Lap Band to DS revisions.
From my own professional experience, it is an easier revision to do, than a patient that had a Lap Band revised to RNY, and not is getting it revised to DS.
I would suggest that you research procedures on their own rather than the revision data.
Good luck
There is no published reports of Lap Band to DS revisions.
From my own professional experience, it is an easier revision to do, than a patient that had a Lap Band revised to RNY, and not is getting it revised to DS.
I would suggest that you research procedures on their own rather than the revision data.
Good luck
Topic: RE: a vsg redo??
Hello,
I am not sure if malfunction is the word, more like a possible complication. The very top part of the stomach can stretch, and if you had a funnel type stomach, then that would be the cause.
The hiatal hernia repair, if it incorporates the top part of the stomach will cause restriction.
Thanks
Ara
I am not sure if malfunction is the word, more like a possible complication. The very top part of the stomach can stretch, and if you had a funnel type stomach, then that would be the cause.
The hiatal hernia repair, if it incorporates the top part of the stomach will cause restriction.
Thanks
Ara
Topic: RE: a vsg redo??
If the upper part of the hour glass is large, it can be used for the nissen repair of the hiatal hernia. This will depend what is found in the OR, and if the top part of the stomach has blood supply intact.
Thanks
Ara
Thanks
Ara
Topic: RE: Your advice appreciated!
The cause (s) of reactive hypoglycemia is not clear. I have read speculation about the balance of glucagon and insulin being off. There is also a theory that epinephrine may be elevated. The issue seems to be around the fact that for whatever reason there is an imbalance between the food entering the bowel and the relative amount of the insulin and glucagon ( which can be though of anti insulin- causes increase in sugar). The stored glycogen is stored in the liver and with excessive weight loss, and inability to eat large (larger than RNY) diet, rea*****omplex carbohydrates and protein, there is no reserve of glycogen left to regulate the ups and downs of the blood sugar between meals. That is why the recommendations are for frequent small meals to avoid reactive hypoglycemia.
I am not aware of any scientific research, but my personal experience has been that patients that have had this complication for years tend to be slow with recovering from it.
Hope this helps.
Ara
I am not aware of any scientific research, but my personal experience has been that patients that have had this complication for years tend to be slow with recovering from it.
Hope this helps.
Ara
Topic: RE: Your advice appreciated!
Yes. It however depends as to how long have you been having the reactive hypoglycemia etc.
Ara
Ara
Topic: RE: Proximal RNY to Distal RNY (Xpost)
Hello,
The nutritional requirements for distal RNY, long limb RNY or ERNY are more stringent than those of the DS patients. The length of the bowel for the common channel does play a role on the short end. The shorter the common channel the better the weight loss, the worst the diarrhea and the nutritional deficiencies (vitamin, minerals and protein) The longer the common channel the worst the weight loss, the less diarrhea, and the less incidence and severe the nutritional deficiencies.
I do not recommend any distal bypass because of its significant nutritional deficiencies that it has.
I was laso asked about the Distal RNY and DS. from another post. After reading the post I got so confused
that I had to sit down and write about it.
The link is attached:
http://www.dssurgery.com/newsletters/dec-5-09.pdf
Hope this helps
Ara
The nutritional requirements for distal RNY, long limb RNY or ERNY are more stringent than those of the DS patients. The length of the bowel for the common channel does play a role on the short end. The shorter the common channel the better the weight loss, the worst the diarrhea and the nutritional deficiencies (vitamin, minerals and protein) The longer the common channel the worst the weight loss, the less diarrhea, and the less incidence and severe the nutritional deficiencies.
I do not recommend any distal bypass because of its significant nutritional deficiencies that it has.
I was laso asked about the Distal RNY and DS. from another post. After reading the post I got so confused
that I had to sit down and write about it. The link is attached:
http://www.dssurgery.com/newsletters/dec-5-09.pdf
Hope this helps
Ara
Topic: RE: Your advice appreciated!
Hello,
I have no idea how the insurance issues work, I am not smart enough for that complicated matter. I would suspect that if there are no surgeons offering the services, then they will make the option available to have it done in a neighboring state.
Ara
I have no idea how the insurance issues work, I am not smart enough for that complicated matter. I would suspect that if there are no surgeons offering the services, then they will make the option available to have it done in a neighboring state.
Ara
Topic: RE: Blood Thinners
The blood thinner that are used peri-operative are all short acting. Their effect is gone within 12-24 hours of the last dose (depending on what you were being given). The exception to this would be if you were on coumadin, plavix or Aspirin.
More likely than not, you had a nasogastric tube place in the operating room, and with dry air of an oxygen nasal cannula you have injured nasal mucosa. This is all good news.
My only warning would be to be mind full that you can loose a lot of blood from a nose bleed. Seek medical care it if is ongoing.
Ara
More likely than not, you had a nasogastric tube place in the operating room, and with dry air of an oxygen nasal cannula you have injured nasal mucosa. This is all good news.
My only warning would be to be mind full that you can loose a lot of blood from a nose bleed. Seek medical care it if is ongoing.
Ara
Topic: RE: a vsg redo??
Hello,
Yes it is possible to do a redo gastrectomy, only after an upper GI (contrast x-ray studies) shows that the fundus of the stomach is large. This means either inadequate resection at the time of the first operation, or stretching of part of the stomach. As a surgeon I have done this many times. I am not a big fan of the sleeve gastrectomy, since on one hand if you make it too small patients have problem with reflux, and on the other hand the patients do not loose a lot of the weight long term. (At the present time there are only a few mid term studies that talk about efficacy of the sleeve gastrectomy-The jury still out on it.)
I would recommend completion of the DS regardless of the findings with the upper GI series. If you have a large stomach then your surgeon, experienced with DS should be able to redo the sleeve, without making you have reflux for the rest of your life.
Hope this helps
Good luck.
Ara
Yes it is possible to do a redo gastrectomy, only after an upper GI (contrast x-ray studies) shows that the fundus of the stomach is large. This means either inadequate resection at the time of the first operation, or stretching of part of the stomach. As a surgeon I have done this many times. I am not a big fan of the sleeve gastrectomy, since on one hand if you make it too small patients have problem with reflux, and on the other hand the patients do not loose a lot of the weight long term. (At the present time there are only a few mid term studies that talk about efficacy of the sleeve gastrectomy-The jury still out on it.)
I would recommend completion of the DS regardless of the findings with the upper GI series. If you have a large stomach then your surgeon, experienced with DS should be able to redo the sleeve, without making you have reflux for the rest of your life.
Hope this helps
Good luck.
Ara
Topic: RE: Your advice appreciated!
Hello,
I promise not to lecture, since there is nothing to lecture about.
I am believer that an ideal weight loss surgical procedure should allow a patient to eat a normal meal, without any one around them know that they had a weight loss surgery. In your support, nut against what you believe I would propose that your weight gain had very little to do with what you did or did not do, and more with the fact that all weight loss surgical procedures had a very well documented, predictable weight loss over time. This means that you can look at the scientific data and be able to say what percentage of patient will loose what percent of their excess weight and keep it off. Once again, you are not at fault of you weight gain, only a function of the operation that you had.
Additionally I would propose to day that Your Iron deficiency is a complication of the gastric bypass operation. It is a common problem post gastric bypass because of exclusion of the duodenum that is the principal area of iron absorption.
Weight regain, inadequate weight loss, complication of the surgery (iron deficiency anemia, dumping syndrome, marginal ulcer etc) are all indication for revisional surgery. Please make sure that no one tries to tell you that dumping is god for you and it will prevent you from dumping since it is not true.
As far as surgical distal gastric bypass (ERNY) it is well documented that it has the most severe set of complications. It is interesting to me that as a surgeon, as recently as 5 years ago, this procedure was being done less and less, because of its significant metabolic problems, yet with the increasing incidence of failed RNY this procedure is being offered. Please do your objective research about all the procedures. These should include revision of your pouch, band over RNY, distal bypass, and the Duodenal switch. Needless to say that I am biased in favor of DS.
Good luck.
Ara
I promise not to lecture, since there is nothing to lecture about.
I am believer that an ideal weight loss surgical procedure should allow a patient to eat a normal meal, without any one around them know that they had a weight loss surgery. In your support, nut against what you believe I would propose that your weight gain had very little to do with what you did or did not do, and more with the fact that all weight loss surgical procedures had a very well documented, predictable weight loss over time. This means that you can look at the scientific data and be able to say what percentage of patient will loose what percent of their excess weight and keep it off. Once again, you are not at fault of you weight gain, only a function of the operation that you had.
Additionally I would propose to day that Your Iron deficiency is a complication of the gastric bypass operation. It is a common problem post gastric bypass because of exclusion of the duodenum that is the principal area of iron absorption.
Weight regain, inadequate weight loss, complication of the surgery (iron deficiency anemia, dumping syndrome, marginal ulcer etc) are all indication for revisional surgery. Please make sure that no one tries to tell you that dumping is god for you and it will prevent you from dumping since it is not true.
As far as surgical distal gastric bypass (ERNY) it is well documented that it has the most severe set of complications. It is interesting to me that as a surgeon, as recently as 5 years ago, this procedure was being done less and less, because of its significant metabolic problems, yet with the increasing incidence of failed RNY this procedure is being offered. Please do your objective research about all the procedures. These should include revision of your pouch, band over RNY, distal bypass, and the Duodenal switch. Needless to say that I am biased in favor of DS.
Good luck.
Ara
Topic: RE: RNY to Band or DS
Hello,
DS will not cause the return of the hearth burn.
The other issue is if a revision is needed for 50-60lbs weight gain. That depends as to what the BMI is at that weight. If a patient is gaining weight after RNY, I would much rather operate when they have gained little ( and still meet the NIH guidelines based on the BMI) rather than weight till a lot of weight is gained.
Duodenal switch operation as a revisional operation is a proved procedure. It outcomes that are very predictable.
Seek a surgeon who is experienced with revisions.
Good luck.
DS will not cause the return of the hearth burn.
The other issue is if a revision is needed for 50-60lbs weight gain. That depends as to what the BMI is at that weight. If a patient is gaining weight after RNY, I would much rather operate when they have gained little ( and still meet the NIH guidelines based on the BMI) rather than weight till a lot of weight is gained.
Duodenal switch operation as a revisional operation is a proved procedure. It outcomes that are very predictable.
Seek a surgeon who is experienced with revisions.
Good luck.
Topic: RE: Revision of VSG
The only logical revision should to be Duodenal switch.
Do your research. You already have half of the surgery done. If he is unable, unwilling to offer or do it, get other opinions. Also, please note that Duodenal switch is not "like" distal gastric bypass, that some patients are getting done.
Hope this helps.
Do your research before so that you can ask the correct questions:
examples:
1-what are the long term outcomes data with VSG, DS, RNY, distal RNY and AGB?
2-what about the same with revision data?
Good luck
Do your research. You already have half of the surgery done. If he is unable, unwilling to offer or do it, get other opinions. Also, please note that Duodenal switch is not "like" distal gastric bypass, that some patients are getting done.
Hope this helps.
Do your research before so that you can ask the correct questions:
examples:
1-what are the long term outcomes data with VSG, DS, RNY, distal RNY and AGB?
2-what about the same with revision data?
Good luck
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