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      A reminder that we have a general set of guidelines that are available at http://www.thinnertimesforum.com/guidelines/. If you have any questions or concerns, you may express them to me or a Community Leader directly. Thank you,
      John Callery

Dr. Callery

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About Dr. Callery

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    Bariatric Surgeon

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  • Gender Not Telling
  • Location San Diego, CA


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Dr. Callery's Activity

  1. Dr. Callery added a post in a topic Aripiprazole (Abilify) and weight gain after sleeve gastrectomy   

    Dear Lori,
    It is extremely important that your bipolar symptoms be well controlled. If aripiprazole (Abilify) works well, you should plan to continue to take it after your sleeve gastrectomy. You and your psychiatrist may need to change the dose depending on how well it is absorbed and how your weight loss changes your response to the drug. It is annoying that Abilify seems to make you gain weight, but hopefully that will not be too big a factor after your surgery. Even if the surgery is not quite as effective with Abilify on board, you still will be much better off overall at a lower weight.
    I've attached an interesting review article that ranks the various newer psychological medications by their tendency to cause weight gain. Fortunately, aripiprazole is relatively low on the list. It causes a lot less weight gain than many other medications.
    Dr. Callery
      Expert Opin Drug Saf. 2015 Jan;14(1):73-96. doi: 10.1517/14740338.2015.974549. Epub 2014 Nov 15. Weight gain and antipsychotics: a drug safety review. Musil R1, Obermeier M, Russ P, Hamerle M. Abstract INTRODUCTION:  Second-generation antipsychotics (SGAs) are widely used in several psychiatric disease entities and exert to a different extent a risk for antipsychotic-induced weight gain (AIWG). As AIWG is associated with an increase in metabolic syndrome or cardiovascular events, knowledge of these risks is crucial for further monitoring and the initiation of counteractive measures.
    AREAS COVERED:  We searched PubMed and Web of Sciences for randomized-controlled trials and naturalistic observational studies published between 2010 and 2014 with sample sizes exceeding 100, including all marketed SGAs apart from zotepine, and providing data on weight increase. We also summarized relevant systematic reviews and meta-analyses of head-to-head comparisons.
    EXPERT OPINION:  Recently published data still support the hierarchical ranking of SGAs already proposed in previous reviews ranking clozapine and olanzapine as having the highest risk, followed by amisulpride, asenapine, iloperidone, paliperidone, quetiapine, risperidone and sertindole in the middle, and aripiprazole, lurasidone and ziprasidone with the lowest risk. Number needed to harm varied considerably in our meta-analysis. Younger patients and patients with a lower baseline body mass index are most vulnerable. The greatest amount of weight gain occurs within the first weeks of treatment. AIWG occurs in all diagnostic groups and is also common in treatment with first-generation antipsychotics; therefore, awareness of this adverse event is essential for anyone prescribing antipsychotics.
  2. Dr. Callery added a post in a topic Older Age and Gastric Surgery   

    Dear Jb,
    As a general rule, age is only a relative factor. Most surgeons think more of "physiological" age than chronological age. In other words, one's general health and ability to tolerate the surgery is the key, and age is just one of many factors to take into consideration. There may be higher complication rates in the elderly, but not to the extent that surgery should not be considered. We have done Lap-Bands, sleeve gastrectomies, and gastric bypasses in patients in their 70's with good results. These patients have all passed careful medical evaluation including cardiac and pulmonary testing.
    I've included the summaries of three journal articles on the subject.
    Dr. Callery
    Obes Surg. 2014 Oct;24(10):1662-9. doi: 10.1007/s11695-014-1247-5. Gastric bypass for obesity in the elderly: is it as appropriate as for young and middle-aged populations? Robert M1, Pasquer A, Espalieu P, Laville M, Gouillat C, Disse E.    
    Abstract BACKGROUND:  Obesity prevalence increases in elderly population. Bariatric surgery has been underused in patients over 60 because of fears of complications and lower weight loss. We postulated worse outcomes in the elderly in comparison to young and middle-aged population 1 year after gastric bypass.
    METHODS:  We retrospectively analyzed gastric bypass outcomes in young (<40 years), middle-aged (40 to 55 years), and elderly (>60 years) patients between 2007 and 2013. Each subject over 60 (n = 24) was matched with one subject of both the other groups according to gender, preoperative body mass index (BMI), surgical procedure, and history of previous bariatric surgery (n = 72).
    RESULTS:  Older subjects demonstrated higher prevalence of preoperative metabolic comorbidities (70 vs 30 % in the <40-year-old group, p < 0.0001). Mean duration of the surgical procedure, mean length of stay, and early and late complication rates were similar between age groups. A trend towards fewer early complications and less-severe complications in the younger groups was noted. One-year weight loss results were similar between young, middle-aged, and elderly patients (percentage of excess BMI loss (EBL%), 74.4 ± 3.5; 78.9 ± 4.5, and 73.7 ± 4.5 respectively, p = 0.69). Age was not predictive of weight loss failure 1 year after surgery. Remission and improvement rates of comorbidities were similar between age groups 6 months after surgery.
    CONCLUSIONS:  Our study confirms weight loss efficacy of gastric bypass in the elderly with acceptable risks. Further studies evaluating the benefit-risk balance of bariatric surgery in the elderly population will be required so as to confirm the relevance of increasing age limit.
    Obes Surg. 2015 Mar;25(3):406-12. doi: 10.1007/s11695-014-1462-0. Advanced Age as an Independent Predictor of Perioperative Risk after Laparoscopic Sleeve Gastrectomy (LSG). Qin C1, Luo B, Aggarwal A, De Oliveira G, Kim JY.    
    Abstract BACKGROUND:  While the safety of many bariatric procedures has been previously studied in older patients, we examine the effect of advancing ageon medical/surgical complications in laparoscopic sleeve gastrectomy, a relatively unstudied procedure but that is trending upwards in use.
    METHODS:  Patients undergoing laparoscopic sleeve gastrectomy (LSG) and laparoscopic gastric bypass (RYGB) were extracted from the National Surgical Quality Improvement Program 2005-2012 database. Pre- and postoperative variables were analyzed using chi-square and student t test as appropriate to determine the comparative safety of LSG to RYGB in the elderly. Multivariate regression modeling was used to evaluate whether age is associated with adverse 30-day events following LSG.
    RESULTS:  Of the patients that met the inclusion criteria, 56,664 (84 %) patients underwent RYGB and 10,835 (16 %) underwent LSG. In the LSG cohort, incidence of overall complications, medical complications, and death significantly increased with increasing age (p < 0.05). No statistically significant differences in rates of 30-day complications, return to the OR, and mortality exist between RYGB and LSG cohorts in patients older than 65 years. The age group of over 65 years independently predicted increased risk for overall and medical complications (OR, 1.748; OR, 2.027). Notably, age was not significantly associated with surgical complications in LSG.
    CONCLUSION:  In this large, multi-institutional study, advanced age was significantly associated with overall and medical complications but not surgical complications in LSG. Our findings suggest that the risk conferred by advancing age in LSG is predominantly for medical morbidity and advocate for improved perioperative management of medical complications. LSG may be the preferable option to RYGB for elderly patients as neither procedure is riskier with regards to 30-day morbidity while LSG has been shown to be safer with regards to long-term reoperation and readmission risk.
    J Am Assoc Nurse Pract. 2015 Mar 4. doi: 10.1002/2327-6924.12235. [Epub ahead of print]
    A review of the safety and efficacy of bariatric surgery in adults over the age of 60: 2002-2013. Caceres BA1, Moskowitz D, O'Connell T. Abstract PURPOSE:  The purpose of this review is to compare outcomes of bariatric surgery in adults over 60 to younger patients. This analysis is important to determine if nurse practitioners (NPs) and other providers should recommend bariatric surgery to obese older adults.
    DATA SOURCES:  This review included 15 studies published between 2002 and 2013.
    CONCLUSIONS:  Although older adults seem to experience less weight loss, bariatric surgery has potential benefits for these patients. Significant improvements in hypertension, diabetes, and, to a lesser extent, dyslipidemia are noted. Mortality and surgical complications in older adults are low, while differences in length of hospital stay are inconclusive.
    IMPLICATIONS FOR PRACTICE:  The risks of bariatric surgery in older adults need to be carefully evaluated based on individual medical condition. Overall the evidence suggests that bariatric surgery can be safely performed in older adults but more research is needed to determine which older adult patients are the best candidates for bariatric surgery. As bariatric surgery among older adults increases, interdisciplinary teams will continue to serve an important role in the management of bariatric surgery patients. NPs must be aware of trends in this emerging population of bariatric surgery patients.
  3. Dr. Callery added a post in a topic 4.5 months post rny   

    Dear Bikewash,
    Revision surgery is always more challenging and carries a higher complication rate than primary surgery. I can only imagine how much scar tissue was present after so many failed fundoplication surgeries. I can't comment about the specifics on your case, but if you are working with a qualified bariatric or general surgeon and gastroenterologist, I'd rely on their advice and encouragement.
    As a rule, there is very little choice this soon after revision surgery but to continue conservative management with endoscopic dilation as needed. Trying to reoperate now may be fraught with danger. If you need nutritional support, a G-tube could be inserted into the bypassed portion of the stomach.
    If you remain nutritionally crippled, at some point your surgeons may consider going back. It might be possible to reverse your gastric bypass, or they might advise removing the remainder  of the gastric pouch and bringing the roux limb up to the esophagus. Either would be difficult and potentially dangerous surgery, but would restore your ability to eat. If the bypass were reversed, you might well have renewed reflux problems, and you would probably regain weight. Patients who have total removal of the stomach maintain weight loss to a greater or lesser extent. If the roux limb is long enough, they usually don't have problems with bile reflux. They can do quite well.
    Best of luck to you with this most challenging problem.
    Dr. Callery
  4. Dr. Callery added a post in a topic Persistent abdominal pain 3 1/2 years post GBP: can't find adequate care.   

    Dear DeeDee,
    As I read your post, you have two problems. The first is abdominal pain of unclear origin, and the second is a systems problem: you can't find a physician to treat you because you are a "gastric bypass patient". I can't give you personal medical advice. I do think you are doing the right thing. Your are being persistent and conscientious by going back to the ER because you are not improving. Any good general surgeon and any good gastroenterologist should be able to help you. There is very little difference between a gastric bypass and a partial gastrectomy other than the bypassed portion of the stomach is left in place with gastric bypass. Having said that, there are some surgeons and some gastroenterologists that duck the care they should provide. (Never assume malice until you rule out ignorance ... or laziness.) If a surgeon or gastroenterologist feels insecure about how to proceed, he or she can always call a bariatric surgeon and ask for advice.
    If you go to your local hospital, and if you need acute care that isn't available locally, you should be transferred to a center that can provide the care. It would be prudent for you to call your insurance company at the time to inform them. If you are an outpatient and can't find local care, call your insurance company and ask them how to proceed. They have the responsibility to see that there is an adequate network of qualified physicians to care for their insured. 
    If you are having trouble getting the care you need at your local hospital, you can contact the chief of the medical staff, the medical director of the hospital, or the chief administrator of the hospital. If your insurance company is not helpful, you can contact your state's  insurance commissioner or department of managed care. 
    Your situation finding a qualified and caring doctor is not unique. The federal government is forcing rapid change on the healthcare system in the name of cost containment. As we go from a fee for service model where at times too many services were provided, we are moving to a rationing system where good care will be less accessible and less timely. I encourage you to stick up for yourself and insist on proper care.
    Dr. Callery
  5. Dr. Callery added a post in a topic Cotinine blood test - smoking cessation   

    You've asked a pretty straightforward question, so I've posted and answer and some links that will help you get more information. But I'm concerned, because from the sound of your question, I'd guess that you are trying to figure out how best to beat the test. So I've also included some summaries on smoking risks and surgery. I hope you understand that smoking confers increased risk of wound infections and may contribute to other complications as well. It's in your best interest to quit as soon as possible and consider allowing a couple of months to go by before having surgery. A couple of months allows the inflammation in your lungs to quiet so that there are less secretions.
    A cotinine blood, urine, or saliva test will usually be negative after 4 days, but may be positive for up to a week. Second hand smoke will also be reflected in a cotinine level. The denser the exposure, the higher the level, and the longer it will be detectable.
    Wikipedia discussion: http://en.wikipedia.org/wiki/Cotinine
    In depth paper Nicotine Cemistry, Metabolism, Kinetics, and Biomarkers: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2953858/
    Background summaries that you may  find helpful:
    Ann Surg. 2012 Jun;255(6):1069-79. doi: 10.1097/SLA.0b013e31824f632d. Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review. Sørensen LT1. Author information Abstract OBJECTIVE: The aim was to clarify how smoking and nicotine affects wound healing processes and to establish if smoking cessation and nicotine replacement therapy reverse the mechanisms involved.
    BACKGROUND: Smoking is a recognized risk factor for healing complications after surgery, but the pathophysiological mechanisms remain largely unknown.
    METHODS: Pathophysiological studies addressing smoking and wound healing were identified through electronic databases (PubMed, EMBASE) and by hand-search of articles' bibliography. Of the 1460 citations identified, 325 articles were retained following title and abstract reviews. In total, 177 articles were included and systematically reviewed.
    RESULTS: Smoking decreases tissue oxygenation and aerobe metabolism temporarily. The inflammatory healing response is attenuated by a reduced inflammatory cell chemotactic responsiveness, migratory function, and oxidative bactericidal mechanisms. In addition, the release of proteolytic enzymes and inhibitors is imbalanced. The proliferative response is impaired by a reduced fibroblast migration and proliferation in addition to a downregulated collagen synthesis and deposition. Smoking cessation restores tissue oxygenation and metabolism rapidly. Inflammatory cell response is reversed in part within 4 weeks, whereas the proliferative response remains impaired. Nicotine does not affect tissue microenvironment, but appears to impair inflammation and stimulate proliferation.
    CONCLUSIONS: Smoking has a transient effect on the tissue microenvironment and a prolonged effect on inflammatory and reparative cell functions leading to delayed healing and complications. Smoking cessation restores the tissue microenvironment rapidly and the inflammatory cellular functions within 4 weeks, but the proliferative response remain impaired. Nicotine and nicotine replacement drugs seem to attenuate inflammation and enhance proliferation but the effect appears to be marginal.
    ____________________________________________________________________   Can J Anaesth. 2012 Mar;59(3):268-79. doi: 10.1007/s12630-011-9652-x. Epub 2011 Dec 21. Short-term preoperative smoking cessation and postoperative complications: a systematic review and meta-analysis. Wong J1, Lam DP, Abrishami A, Chan MT, Chung F. Author information Abstract PURPOSE: The literature was reviewed to determine the risks or benefits of short-term (less than four weeks) smoking cessation on postoperative complications and to derive the minimum duration of preoperative abstinence from smoking required to reduce such complications in adult surgical patients.
    SOURCE: We searched MEDLINE, EMBASE, Cochrane, and other relevant databases for cohort studies and randomized controlled trials that reported postoperative complications (i.e., respiratory, cardiovascular, wound-healing) and mortality in patients who quit smoking within six months of surgery. Using a random effects model, meta-analyses were conducted to compare the relative risks of complications in ex-smokers with varying intervals of smoking cessation vs the risks in current smokers.
    PRINCIPAL FINDINGS: We included 25 studies. Compared with current smokers, the risk of respiratory complications was similar in smokers who quit less than two or two to four weeks before surgery (risk ratio [RR] 1.20; 95% confidence interval [CI] 0.96 to 1.50 vs RR 1.14; CI 0.90 to 1.45, respectively). Smokers who quit more than four and more than eight weeks before surgery had lower risks of respiratory complications than current smokers (RR 0.77; 95% CI 0.61 to 0.96 and RR 0.53; 95% CI 0.37 to 0.76, respectively). For wound-healing complications, the risk was less in smokers who quit more than three to four weeks before surgery than in current smokers (RR 0.69; 95% CI 0.56 to 0.84). Few studies reported cardiovascular complications and there were few deaths.
    CONCLUSION: At least four weeks of abstinence from smoking reduces respiratory complications, and abstinence of at least three to four weeks reduces wound-healing complications. Short-term (less than four weeks) smoking cessation does not appear to increase or reduce the risk of postoperative respiratory complications.
    Arch Intern Med. 2011 Jun 13;171(11):983-9. doi: 10.1001/archinternmed.2011.97. Epub 2011 Mar 14. Stopping smoking shortly before surgery and postoperative complications: a systematic review and meta-analysis. Myers K1, Hajek P, Hinds C, McRobbie H. Author information Abstract OBJECTIVE: To examine existing smoking studies that compare surgical patients who have recently quit smoking with those who continue to smoke to provide an evidence-based recommendation for front-line staff. Concerns have been expressed that stopping smoking within 8 weeks before surgery may be detrimental to postoperative outcomes. This has generated considerable uncertainty even in health care systems that consider smoking cessation advice in the hospital setting an important priority. Smokers who stop smoking shortly before surgery (recent quitters) have been reported to have worse surgical outcomes than early quitters, but this may indicate only that recent quitting is less beneficial than early quitting, not that it is risky.
    DESIGN: Systematic review with meta-analysis.
    DATA SOURCES: British Nursing Index (BNI), The Cochrane Library database, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Medline, PsycINFO to May 2010, and reference lists of included studies.
    STUDY SELECTION: Studies were included that allow a comparison of postoperative complications in patients undergoing any type of surgery who stopped smoking within 8 weeks prior to surgery and those who continued to smoke.
    DATA EXTRACTION: Two reviewers independently screened potential studies and assessed their methodologic quality. Data were entered into 3 separate meta-analyses that considered all available studies, studies with a low risk of bias that validated self-reported abstinence (to assess possible benefits), and studies of pulmonary complications only (to assess possible risks). Results were combined by using a random-effects model, and heterogeneity was evaluated by using the I(2) statistic.
    RESULTS: Nine studies met the inclusion criteria. One found a beneficial effect of recent quitting compared with continuing smoking, and none identified any detrimental effects. In meta-analyses, quitting smoking within 8 weeks before surgery was not associated with an increase or decrease in overall postoperative complications for all available studies (relative risk [RR], 0.78; 95% confidence interval [CI], 0.57-1.07), for a group of 3 studies with high-quality scores (RR, 0.57; 95% CI, 0.16-2.01), or for a group of 4 studies that specifically evaluated pulmonary complications (RR, 1.18; 95% CI, 0.95-1.46).
    CONCLUSIONS: Existing data indicate that the concern that stopping smoking only a few weeks prior to surgery might worsen clinical outcomes is unfounded. Further larger studies would be useful to arrive at a more robust conclusion. Patients should be advised to stop smoking as early as possible, but there is no evidence to suggest that health professionals should not be advising smokers to quit at any time prior to surgery.
    JAMA Surg. 2013 Aug;148(8):755-62. doi: 10.1001/jamasurg.2013.2360. Smoking and the risk of mortality and vascular and respiratory events in patients undergoing major surgery. Musallam KM1, Rosendaal FR, Zaatari G, Soweid A, Hoballah JJ, Sfeir PM, Zeineldine S, Tamim HM, Richards T, Spahn DR, Lotta LA, Peyvandi F, Jamali FR. Author information Abstract IMPORTANCE: The effects of smoking on postoperative outcomes in patients undergoing major surgery are not fully established. The association between smoking and adverse postoperative outcomes has been confirmed. Whether the associations are dose dependent or restricted to patients with smoking-related disease remains to be determined.
    OBJECTIVE: To evaluate the association between current and past smoking on the risk of postoperative mortality and vascular and respiratory events in patients undergoing major surgery.
    DESIGN: Cohort study using the American College of Surgeons National Surgical Quality Improvement Program database. We obtained data on smoking history, perioperative risk factors, and 30-day postoperative outcomes. We assessed the effects of current and past smoking (>1 year prior) on postoperative outcomes after adjustment for potential confounders and effect mediators (eg, cardiovascular disease, chronic obstructive pulmonary disease, and cancer). We also determined whether the effects are dose dependent through analysis of pack-year quintiles.
    SETTING AND PARTICIPANTS: A total of 607,558 adult patients undergoing major surgery in non-Veterans Affairs hospitals across the United States, Canada, Lebanon, and the United Arab Emirates during 2008 and 2009.
    MAIN OUTCOMES AND MEASURES: The primary outcome measure was 30-day postoperative mortality; secondary outcome measures included arterial events (myocardial infarction or cerebrovascular accident), venous events (deep vein thrombosis or pulmonary embolism), and respiratory events (pneumonia, unplanned intubation, or ventilator requirement >48 hours).
    RESULTS: The sample included 125,192 current (20.6%) and 78,763 past (13.0%) smokers. Increased odds of postoperative mortality were noted in current smokers only (odds ratio, 1.17 [95% CI, 1.10-1.24]). When we compared current and past smokers, the adjusted odds ratios were higher in the former for arterial events (1.65 [95% CI, 1.51-1.81] vs 1.20 [1.09-1.31], respectively) and respiratory events (1.45 [1.40-1.51] vs 1.13 [1.08-1.18], respectively). No effects on venous events were observed. The effects of smoking mediated through smoking-related disease were minimal. The increased adjusted odds of mortality in current smokers were evident from a smoking history of less than 10 pack-years, whereas the effects of smoking on arterial and respiratory events were incremental with increased pack-years.
    CONCLUSIONS AND RELEVANCE: Smoking cessation at least 1 year before major surgery abolishes the increased risk of postoperative mortality and decreases the risk of arterial and respiratory events evident in current smokers. These findings should be carried forward to evaluate the value and cost-effectiveness of intervention in this setting. Our study should increase awareness of the detrimental effects of smoking-and the benefits of its cessation-on morbidity and mortality in the surgical setting.
  6. Dr. Callery added a post in a topic Gastroparesis and gastric bypass   

    Dear Sandrawilder,
    Gastroparesis is a condition wherein the stomach does not empty properly. Food builds up in the stomach making the subject feel bloated, have abdominal pain, often have heartburn, and sometimes vomit. Stomach paralysis occurs when the nerves that regulate stomach functioning are damaged by disease or surgery or if the stomach itself is disordered. Diabetes is a prime cause. "The cumulative proportions developing gastroparesis over a 10-year time period were 5.2% in type 1 DM, 1.0% in type 2 DM, and 0.2% in controls."(see summary at end of this post.) Other causes include Parkinsons disease and multiple sclerosis. Amyloidosis and scleroderma can affect the stomach directly. Medications such as narcotics and some of the antidepressants can also decrease the peristalis or emptying of the stomach.
    Treatment includes medications, gastric pacing, and gastric surgery. Since morbidly obese patients with diabetes often benefit from gastric bypass, gastric bypass may serve a dual purpose of weight loss and treating gastroparesis symptoms.
    We have treated two patients with gastroparesis due to severe diabetes successfully with gastric bypass. I did a literature search and reprinted the following articles from the National Medical Library database. There is relatively little written about the surgical treatment of gastroparesis in the severe diabetic. I also included the summary of an article that describes gastroparesis after gastric bypass. The causes of post op gastroparesis were not described in the summary. We have not yet seen such a case in our clinical practice.
    I hope you find this information useful.
    Dr. Callery
    Gastric bypass surgery as treatment of recalcitrant gastroparesis.
      Papasavas PK1, Ng JS2, Stone AM2, Ajayi OA3, Muddasani KP4, Tishler DS2. Author information Abstract  
    Few treatments for idiopathic and diabetic gastroparesis exist beyond symptom management, and no study has described gastric surgery for gastroparesis in obese and morbidly obese patients. The objective of this study was to describe treatment of recalcitrant gastroparesis in obese adults with Roux-en-Y gastric bypass (RYGB) surgery.
    A retrospective review was conducted of adult patients who underwent laparoscopic RYGB. Clinical data pre- and postsurgery and at a follow-up of up to 2 years were reviewed. Total symptom scores for gastroparetic symptom severity and frequency were compared presurgery and at follow-up using paired t tests.
    Seven obese and morbidly obese patients (body mass index [bMI] = 39.5, range = 33-54; 6 women) with idiopathic or diabetic gastroparesis reported marked symptom improvement, and total symptom scores significantly decreased after RYGB. All 4 patients who were taking prokinetics preoperatively no longer required their medication after surgery. Three patients required prolonged treatment with antinausea medications in the postoperative period. Mean BMI change was 9.1 units and mean percent excess weight lost was 71.6 lbs. No perioperative complications were experienced. Two required readmissions due to various concerns (dysphagia, nausea, anastomotic ulcer).
    In our cohort, no patients required the use of prokinetics after surgery and everyone experienced significant improvement in symptoms. Importantly, we found that RYGB is a safe surgical treatment for gastroparesis in obese patients. Our results indicate that gastroparesis, primarily believed to result in being underweight, can present in morbid obesity and can be markedly improved with RYGB.
    Copyright © 2014 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.
    Gastroparesis; Roux-en-Y gastric bypass
    Comment in
    Comment on: gastric bypass surgery as a primary treatment of recalcitrant gastroparesis. [surg Obes Relat Dis. 2014]
    Surg Endosc. 2013 Jan;27(1):61-6. doi: 10.1007/s00464-012-2407-0. Epub 2012 Jun 30.
    Minimally invasive surgical approach for the treatment of gastroparesis.
    Zehetner J1, Ravari F, Ayazi S, Skibba A, Darehzereshki A, Pelipad D, Mason RJ, Katkhouda N, Lipham JC.
    Author information
    Gastroparesis is a chronic disorder resulting in decreased quality of life. The gastric electrical stimulator (GES) is an alternative to gastrectomy in patients with medically refractory gastroparesis. The aim of this study was to analyze the outcomes of patients treated with the gastric stimulator versus patients treated with laparoscopic subtotal or total gastrectomy.
    A retrospective chart review was performed of all patients who had surgical treatment of gastroparesis from January 2003 to January 2012. Postoperative outcomes were analyzed and symptoms were assessed with the Gastroparesis Cardinal Symptom Index (GCSI).
    There were 103 patients: 72 patients (26 male/46 female) with a GES, implanted either with laparoscopy (n = 20) or mini-incision (n = 52), and 31 patients (9 male/22 female) who underwent laparoscopic subtotal (n = 27), total (n = 1), or completion gastrectomy (n = 3). Thirty-day morbidity rate (8.3% vs. 23%, p = 0.06) and in-hospital mortality rate (2.7% vs. 3%, p = 1.00) were similar for GES and gastrectomy. There were 19 failures (26%) in the group of GES patients; of these, 13 patients were switched to a subtotal gastrectomy for persistent symptoms (morbidity rate 7.7%, mortality 0). In total, 57% of patients were treated with GES while only 43% had final treatment with gastrectomy. Of the GES group, 63% rated their symptoms as improved versus 87% in the primary gastrectomy group (p = 0.02). The patients who were switched from GES to secondary laparoscopic gastrectomy had 100% symptom improvement. The median total GCSI score did not show a difference between the procedures (p = 0.12).
    The gastric electrical stimulator is an effective treatment for medically refractory gastroparesis. Laparoscopic subtotal gastrectomy should also be considered as one of the primary surgical treatments for gastroparesis given the significantly higher rate of symptomatic improvement with acceptable morbidity and comparable mortality. Furthermore, the gastric stimulator patients who have no improvement of symptoms can be successfully treated by laparoscopic subtotal gastrectomy.
    PMID: 22752276 [PubMed - indexed for MEDLINE]
    Am J Gastroenterol. 2013 Jan;108(1):18-37; quiz 38. doi: 10.1038/ajg.2012.373. Epub 2012 Nov 13.   Clinical guideline: management of gastroparesis.
    Camilleri M1, Parkman HP, Shafi MA, Abell TL, Gerson L; American College of Gastroenterology. Author information  
    This guideline presents recommendations for the evaluation and management of patients with gastroparesis. Gastroparesis is identified in clinical practice through the recognition of the clinical symptoms and documentation of delayed gastric emptying. Symptoms from gastroparesis include nausea, vomiting, early satiety, postprandial fullness, bloating, and upper abdominal pain. Management of gastroparesis should include assessment and correction of nutritional state, relief of symptoms, improvement of gastric emptying and, in diabetics, glycemic control. Patient nutritional state should be managed by oral dietary modifications. If oral intake is not adequate, then enteral nutrition via jejunostomy tube needs to be considered. Parenteral nutrition is rarely required when hydration and nutritional state cannot be maintained. Medical treatment entails use of prokinetic and antiemetic therapies. Current approved treatment options, including metoclopramide and gastric electrical stimulation (GES, approved on a humanitarian device exemption), do not adequately address clinical need. Antiemetics have not been specifically tested in gastroparesis, but they may relieve nausea and vomiting. Other medications aimed at symptom relief include unapproved medications or off-label indications, and include domperidone, erythromycin (primarily over a short term), and centrally acting antidepressants used as symptom modulators. GES may relieve symptoms, including weekly vomiting frequency, and the need for nutritional supplementation, based on open-label studies. Second-line approaches include venting gastrostomy or feeding jejunostomy; intrapyloric botulinum toxin injection was not effective in randomized controlled trials. Most of these treatments are based on open-label treatment trials and small numbers. Partial gastrectomy and pyloroplasty should be used rarely, only in carefully selected patients. Attention should be given to the development of new effective therapies for symptomatic control. [Ed note: this is a medical perspective.]
    J Gastrointest Surg. 2007 Dec;11(12):1669-72. Epub 2007 Sep 29.   Refractory gastroparesis after Roux-en-Y gastric bypass: surgical treatment with implantable pacemaker.   Salameh JR1, Schmieg RE Jr, Runnels JM, Abell TL. Author information  
    BACKGROUND: Gastroparesis is a rare complication of Roux-en-Y gastric bypass. We evaluate the role of gastric electrical stimulation in medically refractory gastroparesis.
    Patients with refractory gastroparesis after gastric bypass for morbid obesity were studied. After behavioral and anatomic problems were ruled out, the diagnosis of disordered gastric emptying was confirmed by radionuclide gastric emptying. Temporary endoscopic stimulation was used first to assess response before implanting a permanent device.
    Six patients, all women with mean age of 42 years, were identified. Two patients ultimately had reversal of their surgery with gastro-gastrostomy, while another had a total gastrectomy with persistence of symptoms in all three. Five of the patients evaluated had insertion of a permanent gastric pacemaker, with pacing lead implanted on the gastric pouch (2), the antrum of the reconstructed stomach (1), or the proximal Roux limb (2). Nausea and emesis improved significantly postoperatively; mean total symptom score decreased from 15 to 11 out of 20. There was also a persistent improvement in gastric emptying postoperatively based on radionuclide testing.
    If medical therapy fails, electrical stimulation is a viable option in selected patients with gastroparesis symptoms complicating gastric bypass and should be considered in lieu of reversal surgery or gastrectomy.
    Am J Gastroenterol. 2012 Jan;107(1):82-8. doi: 10.1038/ajg.2011.310. Epub 2011 Nov 15.
    Risk of gastroparesis in subjects with type 1 and 2 diabetes in the general population.
    Choung RS1, Locke GR 3rd, Schleck CD, Zinsmeister AR, Melton LJ 3rd, Talley NJ.
    Author information
    In patients with diabetes mellitus (DM) and upper gastrointestinal symptoms, a diagnosis of diabetic gastroparesis is often considered, but population-based data on the epidemiology of diabetic gastroparesis are lacking. We aimed to estimate the frequency of and risk factors for gastroparesis among community subjects with DM.
    In this population-based, historical cohort study, the medical records linkage system of the Rochester Epidemiology Project was used to identify 227 Olmsted County, MN residents with type 1 DM in 1995, a random sample of 360 residents with type 2 DM, and an age- and sex-stratified random sample of 639 nondiabetic residents. Using defined diagnostic criteria, we estimated the subsequent risk of developing gastroparesis in each group through 2006. The risk in DM, compared with frequency-matched community controls, was assessed by Cox proportional hazards modeling.
    The cumulative proportions developing gastroparesis over a 10-year time period were 5.2% in type 1 DM, 1.0% in type 2 DM, and 0.2% in controls. The age- and gender-adjusted hazard ratios (HRs) for gastroparesis (relative to controls) was 33 (95% confidence interval (CI): 4.0, 274) in type 1 DM and 7.5 (95% CI: 0.8, 68) in type 2 DM. The risk of gastroparesis in type 1 DM was significantly greater than in type 2 DM (HR: 4.4 (1.1, 17)). Heartburn (HR: 6.6 (1.7, 25)) at baseline was associated with diabetic gastroparesis in type 1 DM.
    Gastroparesis is relatively uncommon in patients with DM, although an increased risk for gastroparesis was observed in type 1 DM.
  7. Dr. Callery added a post in a topic almost 14 years out and gained weight back and having stomach issues   

    Dear Browneyedgirl67,
    I've found that an upper GI series with food can be very helpful in this situation. I'll ask the patient to bring a chicken salad sandwich, and I'll meet the patient at the radiology department. I'll work with the radiologist when the study is done. We'll have the patient drink some barium to get the general anatomy and function of the esophagus, gastric pouch, gastrojejunostomy, and Roux limb. Then we'll put some barium paste on the sandwich and have the patient eat the sandwich. The patient can watch with us as the sandwich goes down. We can all see if there is a problem with passage of the sandwich material. If the patient develops pain, we can all see what's causing it.
    Not all surgeons recommend this study. Many are not aware how helpful it can be. Some aren't able or aren't interested in going to the radiology lab. But I'd discuss it with your surgeon and see if he or she thinks it is worthwhile in your case. If he or she can't make it to the lab, he or she can still call the radiologist to discuss the goals of the study or send written instructions.
    Dr. Callery
  8. Dr. Callery added a post in a topic Lapband with having a previous pulmonary embolism   

    Dear Stacymeyer1,
    Let your surgeon know about your recent pulmonary embolism and the NuvaRing. He or she will take your history and decide if any additional studies are needed to determine if you have a tendency to form blood clots now that you no longer use the NuvaRing. Most surgeons administer preventative anticoagulation at the time of weight loss surgery. He or she will determine how much to give and how long to continue the medication based on your history and any other testing that may be indicated.
    You should stop smoking at least 6 weeks prior to surgery to clear your lungs effectively. Some people develop more secretions in the first few weeks after quitting, so waiting a little longer allows the inflammation from the smoking to completely settle down.
    Dr. Callery
    From Wikipedia:
    "NuvaRing is the trade name for a combined hormonal contraceptive vaginal ring manufactured by Merck (formerly Schering-Plough, formerly Organon) that is available by prescription. It is a flexible plastic (ethylene-vinyl acetate copolymer) ring that releases a low dose of a progestin and estrogen over three weeks. It is currently used by approximately 1.5 million women worldwide.[2]
    A recent study found that users of vaginal rings with ethinyl estradiol and etonogestrel have a 6.5 times increased risk of venous thrombosis compared to non-users.[3] This is commensurate to the risk of thrombosis due to the use of combined oral contraceptive pills, which in studies ranged between 2.9 times to 13.7 times the risk.[4]"
  9. Dr. Callery added a post in a topic Upper Gi Results- Confused   

    Dear Jailin,
    I can understand why you would be confused from that report. I also find it very hard to understand some of the radiology readings. The readings vary according to the experience of the radiologist and on the ability of the radiologist to describe the findings in clear English.
    When a patient comes to my practice for consultation I ask that they bring a copy of the images of the upper GI so that I can put them up on my computer and look at them. That way I can look at them for myself. If the study has been done well, that's all I need. If the study has been poorly done or poorly recorded, I'll have the study repeated at my hospital. I'll attend the study so I can actually see what's happening. I'll request additional views as needed to get the complete story.
    As you can understand, that I can't do justice to your study just be reading the report. So I'd rather not comment on the meaning of the report.
    If your surgeon was dismissive, I'd get a second opinion from another bariatric surgeon. Get a disc of the images from the radiology lab or hospital where you had the study done and take it with you to your visit. Your second opinion surgeon can then explain what the study shows.
    Dr. Callery
  10. Dr. Callery added a post in a topic Concerned abour absorption of my regular high dose of Methadone after bypass   

    Dear Perserverane,
    Your absorption of methadone may decrease somewhat after weight loss surgery whether it be bypass of sleeve gastrectomy. You'll need to work closely with your prescribing physician to adjust the dose as needed over time. Same is true for your other medications. You seem thoughtful, aware, and careful, so I don't think you'll have any problem.
    Dr. Callery
  11. Dr. Callery added a post in a topic Biliopancreatic diversion with duodenal switch (VSG/DS) vs. Gastric bypass   

    Dear Lemise,
    The sleeve gastrectomy with duodenal switch (VSG/DS) is the procedure that I think you are referring to as "BPD with dodenal switch". (Click on the first thumbnail of the VSG/DS is pasted below.) The BPD, biliopancreatic diversion, on the other hand is not used in this country much. BPD involves removing the lower half of the stomach and then creating a long limb gastric bypass. (Click on the second thumbnail below.) Both the VSG/DS and the BPD feature a smaller stomach and a short common digestive channel. Both cause decreased absorption of protein, fats, and carbohydrates. Both are associated with greater weight loss and more nutritional complications than gastric bypass.
    The big question that your surgeon is asking you is, "is the additional weight loss worth the nutritional consequences?" Advocates for VSG/DS argue yes. They say nutritional consequeces can be minimized by careful management. Gastric bypass advocates say no. They say you get the most benefit from the initial weight that you lose, and less benefit from the added weight loss that the VSG/DS confers. They also say that VSG/DS is very risky since many so many patients don't follow up on nutritional recommendations. These people can develop severe vitamin deficiencies, oxalate kidney stones, and protein/calorie malnutrition.
    So it's a cost/benefit argument. If you undergo a VSG/DS it is absolutely essential that you be committed to long term metabolic follow up. You'll need to accept that you may develop oxalate kidney stones. Finally you may have significant problems with multiple daily bowel movements and seriously foul smelling intestinal gas.
    If you do decide to have a VSG/DS, go to a surgeon who has a team committed to the long term metabolic management of your new anatomy. Don't rely on your primary care physician or a gastroenterologist.
    By the way, many surgeons would argue in favor of a two step approach. Have a sleeve gastrectomy first. If you don't lose enough weight to achieve your health goals AND if you are actually very compliant with the dietary regimen, then consider a duodenal switch or gastric bypass as a second step.
    There is one randomized prospective trial comparing VSG/DS and GBP.  At one year the weight loss is greater for DS. Long term side effects can't be evaluated because the length of follow up is too short. (First abstract pasted below.) There is another article that compares the two procedures, but in a non-randomized fashion. Again weight loss is greater for the VSG/DS group, but metabolic complications are also higher. (Second abstract below.)
    Someday we may see a randomized prospective trial comparing DS and GBP for patients with a BMI greater than 50 with longer follow up. Until such time we all are going to have to rely on relatively low level scientific evidence and our best common sense.
    Br J Surg. 2010 Feb;97(2):160-6. doi: 10.1002/bjs.6802. Randomized clinical trial of laparoscopic gastric bypass versus laparoscopic duodenal switch for superobesity.
    Søvik TT1, Taha O, Aasheim ET, Engström M, Kristinsson J, Björkman S, Schou CF, Lönroth H, Mala T, Olbers T. Author information Abstract BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic biliopancreatic diversion with duodenal switch (LDS) are surgical options for superobesity. A randomized trial was conducted to evaluate perioperative (30-day) safety and 1-year results.
    METHODS: Sixty patients with a body mass index (BMI) of 50-60 kg/m(2) were randomized to LRYGB or LDS. BMI, percentage of excess BMI lost, complications and readmissions were compared between groups.
    RESULTS: Patient characteristics were similar in the two groups. Mean operating time was 91 min for LRYGB and 206 min for LDS (P < 0.001). One LDS was converted to open surgery. Early complications occurred in four patients undergoing LRYGB and seven having LDS (P = 0.327), with no deaths. Median stay was 2 days after LRYGB and 4 days after LDS (P < 0.001). Four and nine patients respectively had late complications (P = 0.121). Mean BMI at 1 year decreased from 54.8 to 38.5 kg/m(2) after LRYGB and from 55.2 to 32.5 kg/m(2) after LDS; percentage of excess BMI lost was greater after LDS (74.8 versus 54.4 per cent; P < 0.001).
    CONCLUSION: LRYGB and LDS can be performed with comparable perioperative safety in superobese patients. LDS provides greater weight loss in the first year.
    Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
    Surg Obes Relat Dis. 2010 Jul-Aug;6(4):408-14. doi: 10.1016/j.soard.2010.03.293. Epub 2010 Apr 8. Laparoscopic biliopancreatic diversion/duodenal switch or laparoscopic Roux-en-Y gastric bypass for super-obesity-weight loss versus side effects. Laurenius A1, Taha O, Maleckas A, Lönroth H, Olbers T. Author information Abstract BACKGROUND: Laparoscopic biliopancreatic diversion/duodenal switch (LDS) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the main surgical options for super-obese patients (body mass index >50 kg/m(2)).
    METHODS: We performed a medium long-term evaluation of 13 super-obese patients who had undergone LDS compared with a control group of 19 patients who had undergone LRYGB. The patients were assessed 31 months (range 17-38) and 34 months (range 26-62) after LDS and LRYGB, respectively, for body mass index changes, relief of co-morbidities, nutrition, quality of life, postoperative bowel function, and accumulated healthcare consumption.
    RESULTS: The mean body mass index decreased from 54.9 to 30.0 kg/m(2) in the LDS group and 57.8 to 39.8 kg/m(2) in the LRYGB group (P = .005). The hemoglobin A1c level was lower in the LDS group than in the LRYGB group (3.8 +/- .31% versus 4.3 +/- .43%, respectively; P = .01). The LDS patients reported greater energy intake than the LRYGB patients (3132 +/- 1392 kcal versus 2014 +/- 656 kcal, respectively; P = .021). The number of stools daily was 4.1 +/- 3.3 in the LDS group and 1.9 +/- 1.1 in the LRYGB group, P = .0482). Of the 12 patients in the LDS group, 6 reported fecal incontinence or soiling compared with 2 of 16 in the LRYGB group (P = .034). The number of outpatient visits was 5.6 +/- 4.6 for the LDS group and 2.0 +/- 1.9 for the LRYGB group (P = .016), and the number of telephone consultations was 5.0 +/- 5.6 and 1.4 +/- 1.6 for the LDS and LRYGB groups, respectively (P = .043).
    CONCLUSION: LDS resulted in greater weight loss than LRYGB in super-obese patients. However, the LDS patients in our series had more frequent gastrointestinal side effects, required greater doses of calcium and vitamin supplementation, and required more postoperative monitoring. Patient satisfaction was high in both groups.

  12. Dr. Callery added a post in a topic Medication caused weight gain   

    Dear Scarlet,
    You've raised a common concern. As you know, there are many medications that tend to make people hungrier. Presumably you and your docs have found a combination of meds that work well to stabilize your mood. Stabilizing your mood is essential to your functioning and sense of wellbeing. Now the hard part, how to prevent or manage weight gain.
    I gather from your post that you are contemplating surgery, and you wonder if surgery can successfully help you lose weight if you are taking these medications. We have many patients who are on these meds who do lose weight successfully after surgery. I haven't done and haven't read of any research that compares weight loss in people on and off meds such as yours, so I can't give you a more informed answer.
    The same general rules regarding weight loss and weight management hold for people who are on meds like yours. The meds are unfortunately a factor that it make it tougher to comply.
    You can make the most of the situation following these steps:
         Accept responsibility for your eating and activity. Don't blame externals: drugs, people, genes.
         Set goals for calorie intake and activity level.
         Eat healthy foods.
         Monitor your success at following your goals.
         Monitor your weight a couple of times a week.
         Make family, friends, and coworkers part of your team.
         Try to make your efforts as fun as possible.
         Get help for personal issues with good psychological counceling.
         Look to any spiritual resources that you may have for guidance and support.
         Remember that each meal and each day give you another chance to be successful.
         Don't give up easily. Have faith.
    Best of luck,
    Dr. Callery
  13. Dr. Callery added a post in a topic Diarrhea, malnutrition 6 years after gastric bypass   

    Dear Mz_D,
    I understand that you had a GBP in 2008, did well with good weight control and normal digestion until early 2014, and for the past several months have faced unwanted weight loss, diarrhea after meals, and signs of malnutrition.
    First, what you're facing is clearly not "normal". It seems to me that you need to have a workup by a really knowledgeable FP, internist, or gastroenterologist. There are lots of causes for chronic diarrhea: dietary/food intollerance, infectious, inflammatory, and due to malignancy. The type of gastric bypass that most surgeons perform (with 15 - 40 cm bilioenteric limb and 100 - 150 cm Roux limb) may be associated with dumping syndrome or rapid gastro-colic reflex (early bm after meals), but not the type of diarrhea and malnutrition that you are describing, and certainly not starting new after several successful years.
    One possible explanation for late post gastric bypass diarrhea is the development of bacterial overgrowth in the excluded portion of the stomach or rarely in the remnant of jejunum that may extend beyond the gastrojejunostomy in a few patients. Such bacterial overgrowth can cause diarrhea and is treated with antibiotics.  If there is a long remnant of jejunum past the gastrojejunostomy (identified on upper GI series x-ray), it can be removed surgically.
    If your PCP is unfamiliar with GBP and doesn't feel up to speed with a malnutrition/diarrhea work up, I'd get a referral to a gastroenterologist. That's your best bet to have a speedy workup and find a solution to your problem.
    Dr. Callery
  14. Dr. Callery added a post in a topic Stomach spasms/cramping after sleeve gastrectomy   

    Dear Blueswede,
    As you point out, I can't give personal medical advice. If you don't feel that you are doing well get in touch with your surgeon or his on call counterpart. If you can't reach him/her go to the ER and be evaluated.
    As a general rule, I've found that sleeve patients have a tougher time than gastric bypass patients during the first three weeks after surgery. A sleeve is long narrow tube whereas gastric bypass is a shorter, somewhat fatter tube with an opening into the jejunum. Liquids often clear the stomach more quickly after a GBP than a VSG especially early on. We've noted more nausea and retching in the first 24 hours after VSG than GBP. Usually by the second day, 95% of both VSG and GBP patients are doing well and are ready to go home. More VSG patients than GBP patients need to stay a third day.
    We did upper GI series on the second post op day on our first 50 sleeve patients for quality control, to help rule out a leak, and to correlate what the patient was feeling when they swallowed with what the patient and I saw on the fluoroscope (x-ray tube). In most cases the fluid passed through without symptoms or difficulty. In a few patients there appeared to be some spasm of the sphincter muscle between the esophagus and the sleeve. In these cases there was some pain and some reflux when the contrast material hit the sphincter muscle. Patients had to swallow two or three times to get fluid down. In other cases, patients experienced some pain when fluid hit the upper part of the sleeve and caused distension of the sleeve. We had one case where the sleeve seemed to zigzag at first. The patient was initially obstructed, but over three days the zigzag disappeared and the sleeve straightened out. Finally, we had a case where there was some initial narrowing about half way down the sleeve that caused a backup of liquid. We think it was due to swelling since it resolved after a couple of days. In all of these problematic cases the upper GI was helpful to improve our understanding of the symptoms.
    Staying well hydrated can be a real problem for both sleeve and bypass patients. Signs of dehydration are weakness, rapid heart rate, and concentrated urine output. Dehydration can occur in a few days and can cause damage to the kidneys. Sometimes just getting couple of liters of IV fluid in the ER does the trick. Sometimes an overnight stay or admission is needed.
    Pain with swallowing is often due to problems like the ones I mentioned above, but it can also be associated with more severe complications like a staple line leak, a kink or twist of the sleeve, or a point of significant narrowing of the sleeve. These complications may require aggressive treatment.
    The reason why trying to self-diagnose is a very bad idea is because dehydration may be worse than you think, and it is just one of the problems that can cause these symptoms. Bleeding, a staple line leak with infection, or an abscess can show up with the same symptoms. While most patients with a leak or infection have a fever and chest or shoulder pain, some don't. It can sometimes be tricky even for a surgeon to diagnose the problem. By going to the contacting your doctor and/or going to the ER you can have a blood tests, x-rays or CT scan, and consultation with a qualified surgeon.
    I haven't tracked exact statistics, but I think that about 10% of my sleeve patients have fairly rough going in the first three weeks or so. A few patients are challenged for the first 3 months. Need for rehydration is uncommon and readmission is rare. But adjusting to liquids, not eating food, experiencing some difficulty swallowing, and wondering why the heck you had the surgery are all part of the process. The good news is that after the early phase you'll be losing some serious weight, you'll be feeling much stronger, your medical problems will subside, and you'll know that is was all worthwhile.
    I hope this post has given you an overview of some of the problems with dehydration, early sleeve challenges, and why being evaluated professionally is so important.
    Good luck, and I hope you have a speedy recovery,
    Dr. Callery
  15. Dr. Callery added a post in a topic Cymbalta [duloxetine] and Neurontin [gabapentin] after gastric bypass or sleeve gastrectomy?   

    Dear Laura,
    You’ve asked if Duloxetine [Cymbalta] or gabapentin [Neurontin] cause weight gain when used to treat painful peripheral neuropathy (presumably diabetic neuropathy). Great question. Diabetic neuropathy is a real problem for many bariatric patients, and it may persist after significant weight loss.
    Let’s start with the following three summaries from Wikipedia:
    “Duloxetine (sold under the brand names Cymbalta, Ariclaim, Xeristar, Yentreve, Duzela, Dulane) is a serotonin-norepinephrine reuptake inhibitor (SNRI) manufactured and marketed by Eli Lilly. It is prescribed for major depressive disorder and generalized anxiety disorder (GAD). Duloxetine also has approval for use in osteoarthiritis and musculoskeletal pain. It can also relieve the symptoms of painful peripheral neuropathy, particularly diabetic neuropathy,[1][2] and it is used to control the symptoms of fibromyalgia.”
    “Gabapentin (Neurontin) is a pharmaceutical drug, specifically a GABA analog. It was originally developed to treat epilepsy, and currently is also used to relieve neuropathic pain. It is recommended as a first line agent for the treatment of neuropathic pain arising from diabetic neuropathy, post-herpetic neuralgia, and central neuropathic pain.[3]
    “Pregabalin [Lyrica] is an anticonvulsant drug used for neuropathic pain and as an adjunct therapy for partial seizures with or without secondary generalization in adults.[1]
    I found two really relevant articles by doing a search of PubMed, the National Medical Libarary database of medical journal articles. The first article by Gaynor states that patients with diabetic peripheral neuropathy had net weight loss after 12 – 15 months.
    The second article, by Irving, states that in a 12 week randomized trial, patients with diabetic peripheral neuropathy treated with pregabalin [Lyrica] gained weight while patients treated with duloxetine [Cymbalta] or duloxetine plus gabapentin [Neurontin] lost weight.
    I also included an article about pregabalin [Lyrica] since it is sometimes used in conjuction with other meds for peripheral neuropathy. 1/7 patients treated with pregabalin gained significant weight at one year of treatment.
    I’m sure that there is quite a bit of individual variability, but on average, it doesn’t seem that you should be overly concerned in trying Cymbalta or Neurontin. I would monitor your appetite carefully, eat mindfully, and check the scale at least a couple of times a week. It would seem to me that the symptom relief that you might enjoy from the medications would outweigh the weight gain risks. If you have less neuropathic pain you’ll probably be more active. As you know, activity relieves stress, and it may make you less likely to eat for the wrong reasons.
    Int J Clin Pract. 2011 Mar;65(3):341-9. doi: 10.1111/j.1742-1241.2011.02635.x.
    Weight change with long-term duloxetine [Cymbalta] use in chronic painful conditions: an analysis of 16 clinical studies.
    Gaynor P1, McCarberg B, Zheng W, Shoemaker S, Duenas H.
    Report weight change baseline up to 12-15 months in duloxetine-treated patients during clinical trials of chronic painful conditions of diabetic peripheral neuropathic pain (DPNP), fibromyalgia, chronic low back pain (CLBP) and chronic knee pain as a result of osteoarthritis.
    Weight change data from 16 duloxetine studies in chronic painful conditions were pooled by pain condition and duration, creating 10 datasets. Datasets included placebo-controlled, open-label and routine-care-controlled designs. Assessments included mean weight change from baseline, baseline body mass index category, potentially clinically significant (PCS) weight change and weight-related treatment-emergent adverse events.
    Total number of patients was 5111 with mean baseline weight ranging from 70 to 97 kg. All duloxetine groups had significant mean weight loss compared with placebo at acute phase completion (p ≤ 0.001). In studies > 3 months, patients from fibromyalgia and CLBP studies had overall mean weight increase (up to 1.1 kg), whereas patients in DPNP studies had overall mean weight loss (-0.33 to -1.7 kg) at end-point. Overall, the percentage of patients with PCS weight gain was 0.4-16% and PCS weight loss was 2.5-9.9%.
    Weight change data in clinical trials of patients with fibromyalgia or CLBP treated with duloxetine for up to 15 months were consistent with data reported in 10 clinical trials of patients with major depressive disorder (MDD) using duloxetine up to 52 weeks. Patients with DPNP had weight loss at end-point.
    Mean weight changes and percentages of patients with PCS [potentially clinically significant] weight loss and weight gain observed in DPNP, fibromyalgia and CLBP with long-term duloxetine treatment were consistent with those reported previously for MDD studies.
    Int J Clin Pract. 2014 May 18. doi: 10.1111/ijcp.12452. [Epub ahead of print]
    Comparative safety and tolerability of duloxetine vs. pregabalin vs. duloxetine plus gabapentin in patients with diabetic peripheral neuropathic pain.
    Irving G1, Tanenberg RJ, Raskin J, Risser RC, Malcolm S.
    The safety and tolerability of three treatments for diabetic peripheral neuropathic pain (DPNP) were compared.
    A 12-week, randomized, open-label study confirming the non-inferiority of duloxetine (N = 138) vs. pregabalin (N = 134) and the combination of duloxetine plus gabapentin (N = 135) as the primary outcome was previously published. Patients had an inadequate pain response to a stable dose of gabapentin (≥ 900 mg/day) for ≥ 5 weeks prior to study enrolment. Data from that study were assessed in this current analysis for a detailed report of safety and tolerability.
    Completion rates did not differ significantly between the groups. Discontinuation because of adverse events was significantly greater in the duloxetine (19.6%) vs. pregabalin group (10.4%; p = 0.04); no differences emerged between the duloxetine vs. duloxetine plus gabapentin (13.3%) groups (p = 0.19) or pregabalin vs. duloxetine plus gabapentin groups (p = 0.57). Adverse event rates varied: nausea, insomnia, hyperhidrosis and decreased appetite were reported significantly more often in patients treated with duloxetine vs. patients treated with pregabalin (each p ≤ 0.01); insomnia significantly more in patients treated with duloxetine vs. duloxetine plus gabapentin (p = 0.01); peripheral oedema significantly more in patients treated with pregabalin vs. duloxetine and duloxetine plus gabapentin (p ≤ 0.001 each) and nausea, hyperhidrosis, decreased appetite and vomiting significantly more in patients treated with duloxetine plus gabapentin vs. pregabalin (each p ≤ 0.05). At end-point, weight change differed significantly among treatment groups: patients in the pregabalin group on average gained weight (1.0 ± 0.04 kg); while, patients in the duloxetine and duloxetine plus gabapentin groups on average lost weight (-2.39 ± 0.04 and -1.06 ± 0.04 kg, respectively) (pregabalin vs. duloxetine, p ≤ 0.001; pregabalin vs. duloxetine plus gabapentin, p ≤ 0.001; duloxetine vs. duloxetine plus gabapentin, p = 0.01).
    Duloxetine, pregabalin and duloxetine plus gabapentin were generally safe and tolerable for the treatment of DPNP.
    ___ Curr Med Res Opin. 2012 Jun;28(6):1027-37. doi: 10.1185/03007995.2012.684044. Epub 2012 May 3.
    Characterizing and understanding body weight patterns in patients treated with pregabalin.
    Cabrera J1, Emir B, Dills D, Murphy TK, Whalen E, Clair A.
    We examined patterns of weight change among patients treated with pregabalin for up to 1 year.
    Patients with ≥1 pre-treatment weight measurement, ≥2 measurements in Period 1 (day 2-56), and ≥2 during Period 2 (day 57-356) were identified from pooled data of 106 studies including 43,525 patients. Seven patterns were developed and used for exploratory 'change point' analyses (day on-treatment when weight-change trend changed from initial trajectory) and to assess patterns of weight change by baseline weight/body mass index (BMI).
    A total of 3187 patients (from 41 studies) were eligible. 98.9% of patients were described by three of the seven patterns. The majority of patients (2607/3187 [81.8%]) remained within ±7% of baseline weight ('Pattern 4'). Fewer patients (463/3187 [14.5%]) were 'delayed weight gainers' (exceeded 7% weight gain in Period 2 but not Period 1 ['Pattern 6']), fewer still (82/3187 [2.6%]) were 'early weight gainers' (exceeded ≥7% baseline weight in Period 1 and remained above 7% or continued to gain weight in Period 2 ['Pattern 7']). Overall weight gainers (Patterns 6, 7) experienced 1-year weight gain (median [% change]) of +6.20 kg [+9.12%] and 5.46 kg [+13.9%] vs. 2.22 kg [+2.10%] for non-weight gainers (Pattern 4). Average baseline weight/BMI was lower for weight gainers (Patterns 6, 7) versus other patterns. Early weight gainers (Pattern 7) had change point day at day 40 versus day 54 for Pattern 4 and day 69 for Pattern 6. Use of concomitant medications and influence of comorbid conditions on weight should be considered as inherent variables when interpreting the study.
    The majority of patients treated with pregabalin (150-600 mg/day) for 1 year maintained weight within ±7% baseline weight. One in six patients gained ≥7% weight from baseline, and generally exceeded 7%, 2-12 months after treatment onset.