INCISION-LESS SURGERY: FOR WEIGHT REGAIN AFTER GASTRIC BYPASS

By admin on July 20, 2009 at 10:37 am

I’ve completed my training in a cutting edge technology-and it’s incision-less. Please pardon the pun.  A novel company called USGI has been developing a system to reduce the pouch size from within the pouch itself. It became available in January 2009, and I was selected among a small number of surgeons in the United States to offer this to my patients. I believe it will have a permanent place in the world of weight loss surgery.

I have been performing endoscopy (a lighted scope with camera is inserted into the mouth and guided into the stomach) for over two decades. Through the scope, we have detected peptic ulcers and have treated bleeding, removed polyps as well as large pieces of food that may get stuck, dilated up obstructions with balloons, as well as sealed leaks and perforations with stents. Never before, until now, have we had the opportunity to truly sew within the stomach itself or the gastric bypass pouch.

After several years of performing gastric bypass, we have come to recognize that 5% of our patients may regain some weight. It may not be immediate. Often times it is not apparent until 18 months or several years after surgery. Some patients may only gain a few pounds but some may regain 20 or more pounds. Having the benefit of fluoroscopy (x-ray machine) in the office with the ability to do immediate barium swallows, I have the opportunity to examine these pouches.

Sometimes I find these pouches to be dilated to much larger than when I created it at the time of the original surgery. Because I have often enjoyed an honest relationship with my patients we have shared and discovered the root causes of these dilated pouches. After over thousands of patients, I believe a pouch will dilate in size as a result of three main causes:

• OVEREATING. I ultimately aim to get all patients “full” with 4 oz of food or less. We as human beings sometimes test our limits so we may stretch the pouch out with time. I once had a patient who said she “stops eating when it hurts so much, I can’t stand it”. Eating slowly allows us to listen to our “signals” that we’re full. Thus, chewing our food 25 times and giving ourselves at least 20 minutes to eat. Eating too quickly does not allow us time to listen to these “signals” so we tend to over eat. At the time of surgery, I create a pouch that is 20 cc’s or smaller-that’s about the size of an egg.
• DRINKING AND EATING AT THE SAME TIME. For the same reasons described above.
• DRINKING CARBONATION. Our bodies are 98.6 F or the equivalent of a hot summer day in Dallas. The fizz that we enjoy is carbon dioxide gas or CO2. 98.6 plus CO2 equals a bottle rocket of pressure internally in these pouches causing radial expansion over time.
• POUCH WAS MADE TOO BIG TO BEGIN WITH. This was obviously not the patients fault. I perform a lot of revision surgery and some patients will come to me from other practices with a pouch that was made too big at the original time of surgery.

There are other causes for weight regain such as poor nutrition choices and lack of exercise. That’s why support is important. However, after significant pouch dilation occurs, it will be very difficult to achieve weight loss or maintain your current weight because it may take double the amount of food to feel full. 8 oz meals 3 times a day could lead to tremendous caloric intake that is hard to overcome with proper nutrition and exercise.

For this reason, ROSE was invented. It’s an acronym for Restorative Obesity Surgery. It allows a second chance for patients to shrink down the size of their dilated gastric bypass pouch back to its original size. It will also decrease the size of the opening at the bottom of the pouch, or stoma, as it attaches to the intestine. A dilated stoma can lead to weight regain as well as dumping syndrome. When this becomes dilated, for the 4 above stated reasons, ROSE can shrink or “restore” the size of the pouch and stoma to approach that of its original size. This can allow a patient to start losing weight again.

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As you can see, an endoscope is passed from the mouth into the pouch. All of the operating tools are passed through this scope so the procedure is taking place in the pouch itself with no incisions being made on the surface of the abdomen. Tissue “anchors” made of nitinol create a pleat of stomach tissue the way you create pleats or hemlines in pants. Nitinol is a permanent flexible inert metal. This is the first time a permanent solution has been offered to restore pouch size through a scope. Other operating systems like Stomaphyx came first but did not allow us the ability to take a full thickness “bite” of stomach tissue; thus, our concern that stomaphyx may not lead to permanent pouch reduction.

Postoperatively, the patient is discharged the same day. Sore throat is the most common complaint. Everyone was capable of returning to work the next day, and there were no life threatening complications like perforating the esophagus or stomach in over 120 cases since January 2009.

A patient should know that other options exist for pouch reduction. These include placing a lap band around the dilated gastric bypass pouch as well as surgically cutting the pouch back to a small size and re-creating a small stoma.

If you or someone you know is regaining weight after gastric bypass, make an appointment to see us and examine the options available. We’ll see if you are a candidate for ROSE as well as reviewing your health and considering medical options to weight loss.

Posted in From the desk of Dr. Kim

Exercise Tips from Dr. Kim for Your Weight Loss Journey

By admin on June 8, 2009 at 3:37 pm

Stuck in an exercise rut?

The biggest mistake new exercisers make is to do the same workout over and over for weeks or months at a time.  It is important to change and vary your exercise routine.  Progression of an exercise program is key, if you want to get stronger, fitter and healthier.  Progression is the act of gradually adding to the amount or type of stimulus applied to the muscle during each exercise.  This can be hard or confusing for most.  How do you change your workouts so that they are effective?  One simple way is to try new exercises or vary your current exercise program.

Progression can come in a variety of ways:  change your intensity, speed, duration, repetitions, weight, or exercise.  The key is once you have mastered an activity, you need to do something to make it harder.  More is not better, so do not overdo it especially when starting an exercise program.  This could lead to injuries.  The concept “no pain, no gain” is not true.  If you feel you are straining and not using proper form, then you are doing too much.

Exercisers should start their program slowly and gradually progress to more intensive training levels.  If a problem develops, it is good to stop exercising or to reduce the intensity of training for a few days.  Do not be afraid to experiment with different training practices or techniques to find out what is more comfortable.  If you are doing exercises with weights, first increase the number of repetitions.  Once you can do 3 sets of 10 comfortably, then increase the amount of weight and decrease the number of repetitions.

A general rule may be try and progress an exercise program every two-three weeks.  Interval training, alternating fast bursts of intense exercise with slow easy activity, allows you to increase intensity without overtraining.  For example, if you are walking on a treadmill increase and decrease the speed every 3-5 minutes.

Exercise reminders:

• Warm up and cool down during an exercise session.
• Check your heart rate and know what is a safe range for you.
• Have a variety of exercise programs.
• Check with physician before beginning a new exercise program.

Posted in From the desk of Dr. Kim

Choosing Weight Loss Surgery In Dallas Ft. Worth

By drdkim on April 28, 2009 at 9:17 pm

“Which operation is most appropriate for me?” This is seemingly a logical question. We are often told that, “the doctor knows best” and with a broad scope of bariatric knowledge it would seem logical for a weight loss specialist to choose the best operation for you. Lets flashback to 2003. At that time, I was only performing laparoscopic gastric bypass. The band was only recently released in America, and no significant data had yet been accumulated on the band. In that year, I felt firmly convinced that gastric bypass surgery was the best operation that a weight loss surgeon could offer to patients. Now, if we fast forward to 2009, I currently perform Laparoscopic Gastric Bypass, Lap Band , Realize Band, Laparoscopic Vertical Sleeve Gastrectomy, and Laparoscopic Revision surgery (receiving patients who have had unsuccessful weight loss surgery elsewhere and converting that surgery into a more successful one). In 2009, I still perform a significant amount of gastric bypass surgery, but Lap Band surgery is more popular and occupies more than 50% of the surgeries that I perform. After performimg more than 2000 laparoscopic weight loss surgeries, I feel stongly that in most cases, a patient should decide the operation that is most appropriate for him or her.

Patients are choosing the least invasive way to meet their weight loss goals. This is evidenced by the demographic trends that are occurring in bariatric surgery today. This year, in 2009, it is predicted that Lap Band will overtake gastric bypass in the nation in the sheer number of operations performed in the U.S.
*Marketing facts now reveal that the words “lap band” are Googled (is that a verb?) more often than gastric bypass.

*More lap bands are performed in Dallas/ Ft. Worth than the entire U.S. combined-but I believe the rest of the U.S. is catching up. I believe my practice is mirroring what is going on in the U.S.
*90% of the weight loss surgeries performed in the world consists of Lap Band surgery

By the mere nature that you are on this website is a testament to your dedication for learning about these procedures. Our practice is unique in that, in most cases, I will allow you to choose the operation which is most appropriate for you. Unless I see a medical contraindication, I enjoy a patients participation with surgical selection. I think this is an important first step. My patients are so very successful in many aspects of their lives, other than weight control. They are successful parents, spouses, employees, employers, teachers, coaches, accountants, even doctors….you get the point. My greatest hope and objective is to allow you to gain control of your weight, and in a broader sense, your destiny. I don’t believe this aspect of control can take place if I tell you which operation to have. Likewise, I think it is very important that a patient select a surgeon who can perform all the different types of weight loss surgery and not just one. If a surgeon can only perform one operation, say Lap Band for example, seminars will focus purely on that operation and not provide a non-biased, broad based view of all the operations so that you can truly make an informed decision. As an old saying goes…”If I only sell Ford cars, than Ford becomes the best car out on the street”

I often muse at the entertaining arguments we used to have in the early 2000′s on which was the better operation. At that time, since I performed 100% gastric bypass surgery, I thought this was the best operation. Entire conference rooms full of weight loss surgeons would argue passionately about which was the better operation: Lap Band vs. Gastric Bypass. I think the profession was so divided that eventually it transcended into our patients who also decided to join in this debate, as well. Fortunately for all of us, this debate is over. Conclusively, the data has shown that they are ALL good operations. They become , essentially, “tools” for our patients to use to reach their weight loss goals and in the process, improve their lives. They all work a little differently however. They work at different speeds of weight loss, have different varying degrees of risk, different amounts of follow-up is necessary, and recovery times are different. These are all important factors in the decision making process, so don’t just visit a “Ford Dealer”only.

After more than 2000 surgeries of all types, I truly believe all of these operations are all effective tools. The Lap Band, Realize Band, Gastric Bypass, Vertical Sleeve Gastrectomy, are all surgical tools. And like tools, instructions have to be followed to achieve the maximal result,safely. At the time of surgery, I am basically creating a mechanism in all cases, that will remind you that you will eat differently. They all limit the amount of solid dense food you eat to about 4 ounces and they all help a patient control their appetite. Essentially, behavioral modification takes place. Because hunger is so readily controlled, my patients feel for the first time that weight loss will be sustainable and long lasting. It won’t become another “yo-yo diet”. My patients start to feel better with even an initial 20 pound weight loss, so they can begin to exercise. When a patients’ feet and knees don’t hurt so much, and breathing is easier, they become more inclined to go for a walk. I find that patients who exercise frequently, also eat better. I often hear… I can’t eat that piece of chocolate cake, I walked this morning for 30 minutes and I worked too hard to get this 70 lbs off!”

After you have reviewed this website, take your time and carefully consider your choices. Then , finally, make an appointment and lets talk about the operation that is most appropriate for you. I applaud your courage to improve your health and life. Though these steps may seem slightly intimidating, I think inaction may be the worst option of all.

David Kim, MD FACS, FASMBS

Posted in From the desk of Dr. Kim

Holiday Season

By drdkim on December 1, 2008 at 4:04 pm

Thanksgiving and the holiday season is one of my favorite times of the year. Though I don’t enjoy the hustle and bustle that is often associated with this season, it is often a time to give thanks for the many blessings that we are given. I am thankful to my patients who give me a purpose for why I went to medical school and became a surgeon. I can think of no greater calling than to improve a patient’s health and life while offering hope and optimism for the up-coming year. Bariatric surgery is truly unique with this regard. I am grateful to my office staff. They have a passion to help each patient who walks through the front door. They rejoice in our patient’s successes and offer encouragement when they’re feeling down. I’m proud of each and every one of them. And certainly not least, I am grateful to my family for showing me unconditional love. They are the pillar of my existence and forgive me for my always running late, and understand when I miss events due to unexpected emergencies; parenthood is truly one of life’s greatest pleasures.

I wanted to take this opportunity to introduce Dr. Jane Counts. I have invited Dr. Counts to our blog column. She has a tremendous amount of experience with patients who are about to have weight loss surgery, as well as helping people who may need a friend , whatever the reason, after surgery. Often times, patients may see Dr.Counts not to solve unresolved issues in their lives, but to focus on goals to improve their lives for the future.

With a commitment to deliver the finest care possible, we have opened a state-of-the-art office. It is a place that our patients will enjoy because of our modern facilities and convenience. Our new address is
35 Veranda Lane Suite 100
Colleyville, Texas 76034

Thank you for visiting our blog section. We will continue to strive to make return visits with us worthwhile. David Kim, MD

Posted in From the desk of Dr. Kim

Lap band fills

By drdkim on October 9, 2008 at 3:16 pm

Thank you for revisiting our blog section and, as promised from my previous blog, I’d like to discuss the hot topic of lap band fills. Today, I would like to discuss what I believe to be the “State of the Art Lap band fill’. Patients undergoing bariatric surgery are often times choosing lap band surgery over other types of weight loss surgeries. In America, 50% of all weight loss surgeries are represented by the lap band. The key to successful weight loss is getting an appropriate amount of saline placed in the band. Let me explain.

When a patient is in my office, they often times look at a chart that has 3 bold colors on it- Yellow, Green, and Red

When a patient is in the yellow zone, there is not enough saline in the band. Patients often times feel hungry and over-eat. Many patients feel as if no operation has occurred at all, because there is inadequate restriction. This often leads to frustration for the patient because in the yellow zone, no weight loss occurs. In other word, Yellow represents proceed with caution to continue to fill the band. In the Yellow Zone, patients often can eat just about anything and as much as they want.

When a patient, is in the Green zone, they feel full with about 3-4 oz. of food. They must chew very slowly, because eating quickly can often lead to vomiting. They often have difficulty with a particular type of food. A common food that gets “stuck” is chicken or bread. This means that a patient is experiencing restriction, and behavioral changes are essential for success. As mentioned above, chewing food thoroughly (I recommend 25 times between bites) and not eating and drinking at the same time become essential to adequate digestion. Patients are very happy in the Green zone because they are losing weight at approximately 1-2 lbs per week and hunger is well controlled .No fills are necessary when a patient is in this zone and and we strive to keep a patient perpetually “in the Green”. Further fills lead to patient discomfort and can actually be harmful. More saline at this point sends the patient into the Red zone.

When a patient has entered the Red zone, there is basically too much saline in the band. Patients have difficulty swallowing almost all solid food and sometimes even liquids. They often experience significant heart burn symptoms and mal-adaptive eating behaviors. It is actually possible to gain weight in the Red zone, because protein dense foods are difficult to swallow. Patients are often so hungry because they have difficulty swallowing healthy foods so they have to resort to liquids which are often high in calories or carbohydrate-rich mush foods (like mashed potatoes). Saline must be removed from the band. Excessive vomiting not only makes a patient feel bad, it can cause a slip.

The concept of keeping a patient in the Green zone sounds simplistic in theory, but I think it is difficult to do without Fluoroscopy (commonly known as “the x-ray machine”). For years, I was giving saline fills “blindly”. Especially with the older band models, these bands had only a 4 cc fill capacity so it was possible to add a 1/2 cc or so at a time because the total fill volume was relatively small. Today’s band models have much higher fill capacities. The new Ethicon Realize band holds 9 cc’s while Allergan’s standard and large bands hold 10 and 14 cc’s respectively. I found that blind fills in lap band patients can be very frustrating for the patient. Let’s illustrate an example. If Gail just had an Allergan AP Standard band placed 6 weeks ago, she would be in my office for her first fill. Lets pretend, for the sake of argument,Gails “sweet spot” or when she enters the Green zone is 6.5 cc’s. Using the blind fill scenario, the doctor would place 1 cc then have her come back each subsequent month to add an additional 1/2 cc. If we do the math, it would take 11 months for Gail’s MD to get her to the sweet spot. Obviously, Gail would be very frustrated if it took 11 months for her to feel like she actually had an operation.

Now, let’s imagine Gail entering my office for her first fill 6 weeks after surgery with the aid of fluoroscopy. To visualize this sweet spot, I ask our patients to swallow barium (it’s not as yucky as it sounds-it’s strawberry flavored). Under x-ray vision, we can see if the band is in the proper position. We follow the rate of barium exiting the lap band pouch. By adding saline to the band port, we slow down the rate of emptying of barium. Conversely, withdrawing saline, allows the barium to empty faster. By visualizing this rate of barium emptying, Gail will be in the green zone immediately. This allows her to start losing weight immediately, and avoids 11 months of frustration. Both Gail and I are happy with her steady weight loss progress.

All bariatric surgeries require wise dietary choices and moderate daily exercise. The lap band requires an experienced caring team under the direction of the physician to adjust the band with precision. This precision can only come about using fluoroscopy while the patient is swallowing barium. Safe lap band surgery is needed to place this tool within the patient. This tool will remind patients of the changes that are necessary at meal time. Safe surgery will only take a patient so far however; accurate timely fills with education and compassion allows one to lose 1-2 lbs per week. Depending on a patients starting weight, a patient will reach their target goal in 2 to 3 years. Our office is so committed to the care of lap band patients, we often accept patients who have had surgery elsewhere in the U.S. and Mexico who wish to transfer their care to us.

There is one last bit of advice I’d like you to heed. If you choose lap band surgery, please choose a program that is a Center of Excellence (COE designation) because these programs have been deemed by the American Society of Metabolic and Bariatric Surgery to have complete programs with the highest degree of success. These COE designated centers are supposed to help the consumer/patient identify the best programs for the bariatric patient.

Until next time, stay well. David Kim, MD FACS

Posted in From the desk of Dr. Kim

The Realize Band

By drdkim on September 4, 2008 at 7:57 am

Welcome to our blog section, and thank you spending some time with us to further increase your bariatric education. I wanted to write to you today about a new bariatric surgical device, called the Realize band. This device works like the lap band, in that it decreases the amount of food you can eat at meal time. This is a term, we call restriction. It is inserted via minimally invasive surgery. Using a scope and 5 very small incisions, the Realize band is inserted. A small egg sized pouch is created by gently compressing the top part of the stomach with the band. This pouch is easily filled with less than 4 ounces of food helping a patient feel satisfied and full. The rate of emptying of food from this upper pouch into the lower part of the stomach can be adjusted by adding saline into a port which connects with tubing to the band. The band itself is made of plastic bio-compatible materials. The inside of the port is essentially a soft inner tube which is a reservoir for the saline. The port is implanted on top of the muscle, underneath the skin, so it can’t be seen. This surgery typically takes about 30 minutes to perform. It is performed under general anesthesia and the patient is discharged later the same day.

The Realize band is approximately 10 years old and was first used in Europe. It was actually the first adjustable restricting device, and was originally known as the Swedish Adjustable Gastric Band. Over 100,000 of these bands have been implanted world-wide. It is a very safe and durable device and it has been very effective in helping patients lose significant amounts of weight. I was selected to be among the first surgeons in the U.S. to be trained to insert the Realize band and have inserted numerous bands since they were introduced to our country. I have been impressed with the weight loss and my patients have been very happy with the progress they have made. As a result of utilizing x-ray guided band fills, patients will lose 1-2 pounds per week.

When considering weight loss surgery, we have to carefully review the risks of the procedure, the benefits of weight loss and the risks of living with the disease of obesity. Morbid obesity (defined as a Body Mass Index of 35 or greater) is a dreaded disease. Patients with morbid obesity have a 400% greater chance of developing Diabetes Type II than non-obese individuals. They also have a 300% greater chance of developing heart disease, a 167% chance of suffering a stroke, a 50% greater chance of developing breast cancer and other types of cancer than individuals who do not have a weight problem. This equates to a shorter life and a diminished quality of life.

Risks with this surgery are very low. This type of surgery does not involve cutting or stapling so it is 10x less risky than gastric bypass surgery. Recovery is much faster, in most cases, people return to work in a matter of days. For patients who do not have insurance coverage, it is half the price of gastric bypass so many patients finance this procedure for around $200/month. With success rates so high after surgery, patients are immensely satisfied. If we look at just the cure rates of Diabetes alone after banding, 85% of patients are cured. I also believe depression is a dreaded disorder that impacts in the every day lives of my patients. 90% of morbidly obese patients suffer from depression compared to 10% of the general population. When depression is related to a person’s weight, after surgery we often see complete or significant improvement in a patient’s depression.

The Realize band also has some interesting features on the web site. You can track your own weight with their software program. It allows you to enter daily food diaries to measure the calories, grams of protein, fats, and carbs. Some of my patients have found this to be an attractive feature that helps them to choose the realize band. If you desire, I as your bariatric surgeon, can follow your progress too, as the software allows me to do this-only with your permission of course!

We at the Live Life Again Center are a committed team of professionals whose only mission is to see you succeed. Utilizing education for sound nutritional principles and state-of -the-art- band fills performed in the office, we achieve high success rates and a safety record that has resulted in the distinguished “Center Of Excellence” designation. This award was presented by our national weight loss society, known as the ASMBS. Once again, thank you for visiting our web site and our blog section. Our next blog topic will be one that I am passionate about, “The State Of The Art Band Fill”. I think you’ll enjoy it.
Sincerely, David Kim, MD FACS

Posted in From the desk of Dr. Kim

A Wonderful Time to Consider Bariatric Surgery

By drdkim on August 5, 2008 at 9:56 pm

Welcome to our blog section of the website. My staff and I will hopefully find an interesting topic relative to bariatric surgery and we will write a new blog every other week. It also gives us a medium to speak directly to you in a format that is not in a support group or seminar. Thank you for taking the time to visit with us again.
” A Wonderful Time To Consider Bariatric Surgery” by David D. Kim FACS,
Center of Excellence Surgeon
I have had the privilege of being a surgeon since graduating from medical school in 1986. Dare I say , “In the Olden Days”, we believed in maximally invasive surgery. We were trained to make the incisions as long as possible to increase our exposure. Pain was an expected side effect from these surgeries. It often took 3 months for patients to recover and just return to work. Patients would often spend 1-2 weeks in the hospital routinely just to gain enough strength to return home. Our patients spent much of the time in bed. I performed my first bariatric operation in 1988 and because we routinely made such lengthy incisions, the poor lady didn’t (couldn’t) get out of bed for 5 days! I was thinking today of the marvels of modern medicine and surgery. Diseases such as breast cancer that often took the lives of so many women, as well as leaving them disfigured twenty years ago, today, can often lead to cures while leaving a woman’s dignity intact. In these past 22 years I have performed thousands of operations and have had the opportunity to see the amazing advancements in surgery as well. As a result of laparoscopic surgery, I present the argument that no other sub-group of patients have benefited more than my weight loss surgery patients. Twenty years ago, the same treatments we offer today would have been accomplished from a 10-inch incision and a week in the hospital on a regular basis.Today, I perform these surgeries through a series of 5 separate little incisions that are a 1/2-inch to 1 inch long. A scope is inserted that is attached to a camera. this image is projected to a high definition TV screen. Skinny, long instruments are introduced through the little incisions so my hands don’t even enter the body. There is a gentle manipulation of tissues that lead to far less pain than traditional methods of surgery. Wound infections and hernias are drastically reduced since lengthy incisions are avoided. Pain is tolerated so well after laparoscopic bariatric surgery, that in the case of my Lap Band patients, they go home the same day on minimal amounts of liquid pain medicine. Patients usually return to work in one week if they work in an office type setting. I’ve had Lap Band patients return to work as short as 2-3 days after surgery. Pain can also be reduced with removable pain pumps that trickle topical anesthetics through skinny catheters. Because I recognize the value of laparoscopic surgery, reducing pain and complications, I try to operate through the scope for all of my weight loss surgery patients. In well over 1500 bariatric surgeries, I have yet had to convert a Lap Band patient into an “open patient”. Of my gastric bypass patients, 99% have laparoscopic surgery. With gastric bypass, adhesions involving the small intestines usually account for the 1% of the open patients who elect to have this type of surgery. Not only are these operations minimally invasive and intrusive, but most importantly they work! They are tools for you to use and if you are committed to making a lifestyle change, you can achieve your weight loss goals. It truly is a great time in surgical history to consider weight loss surgery. It would truly be a privilege for us to help you accomplish these goals.

Posted in From the desk of Dr. Kim