To Your Health
Hi - I had to share this. I woman whom I respect and admire (she goes by the handle "Vitalady") recently answered my question on the Main Board about the various ways in which the R-en-Y's are performed; I'm trying learn as much as I can so that I can understand why I'm gaining weight - here is her response, it's remarkable how little I knew going into this! I hope this helps:
You know about the partitioning of the stomach to create a small pouch, right? The older procedures just ran a row of staples across to create the division. Of course, by "a row", I mean whatever the doc does, 3 rows, 4 rows, 6 rows, 8 rows, and most docs also oversew. Then intestine is attached to pouch, etc, but we're only talking pouch here, right?
OK, when it's transected, they again do 2 pairs of rows of staples (most of the guns fire 2 rows simultaneously). They cut between the two pairs, so 2 rows hold the pouch side together, 2 rows hold the stomach side together. There is a space between the two stomachs now. My doc sends that hunk between to pathology, but other docs do different things with it.
When it is not transected, it's much like stapling your lips together, slimy fabric to slimy fabric. They never grow together or seal. The staples are holding them together and keeping the partition intact. Staple line disruption can occur at any time (some within 2 weeks, some by 18 months, mine was at 5 yrs) or never. It's a risk.
When it IS transected, you have two adjacent raw edges held together, so they heal to each other and bond. (That applies to both the pouch segment & the stomach segment, of course). If you cut your finger, it is definitely open, but it heals back together invisibly, you know? Raw edge to raw edge. The risk of leak is in the first few days, but then, we are at risk of leak from any of the attachings. And if lea****urs, it will most likely be at one of the intestinal connections. However, once you are past the immediate post-op period, that risk is past.
So, the main benefit of transecting is that you will likely only have ONE surgery. Personally, I still had acid & discomfort before revision, and not much after, but then, I'd guess my staple line was compromised just slightly early on. My doc starred transecting all of them in 96, but I was a 94, my husband a 95, so we were not.
If there is a choice, I'd always recommend transecting. It can be a disaster to have a staple line disruption. It can be painful, as well as the inevitable weight gain, and that general sensation of failure. And what if you do not have the right insurance to fix it?
But that is my very biased opinion.
*****
Let's assume that we all start with 300" of (small) intestine. We don't, but we need to have a figure, so that's it. From the pix you've seen of RNY/gastric bypass, you know there is a left side, right side and tail of the Y. The "junction" of the sides is the determiner if a procedure is proximal or distal.
The original intestine comes out of the old stomach and carries the digestive juices that are manufactured in the old stomach. This piece is called the bileo-pancreatic limb because it carries bile from the gallbladder and pancreatic juice from the pancreas. There is no food here.
This is the LEFT side of the Y. This is the portion that is bypassed.
The alimentary limb connects to the pouch and only carries food, but cannot digest or absorb. This is the RIGHT side of the Y.
The tail of the Y is where both elements mix together and where digestion (if any) and whatever absorption will occur. This is the part that is still in use and is also referred to as the common channel.
If the junction of the Y occurs in near proximity to the stomach, it is said to be proximal. If the junction occurs as a far distance from the stomach, it is said to be distal. That said, neither word describes any actual measurements of anything, so the meaning is in the mind of the person speaking of the procedure. What is proximal to my doctor is considered distal by another.
Generally speaking, ALL RNY people will have to supplement at least the basic 8 elements*, though in varying doses. We are all missing the stomach and its normal digestive function.
Truly distal (with a lot bypassed, and a short common channel) people need to supplement in larger volume, but will achieve and maintain the better weight loss over time. Proximal (less bypassed, longer common channel) people still need to supplement the basics and can reach a reasonable weight, but after 2 years may have to work a little harder to maintain their goal weight.
My doctor measures what is in use, not what is not. So, in my case, I have a 40" common channel, then 60" was used to reach the pouch. The bypassed portion is then ABOUT 200".
Most procedures performed are measured backwards from that. The doctor will bypass 12 to 72", use 60-80" for the right side of the Y, and the common channel will be 100-200".
* the basic 8
protein
iron
calcium
A
D
E
zinc
B12
These need to be supplemented in specific ways to help absorption.
We also malabsorb SOME fats/oils and complex carbs.
We never, ever malabsorb sugar.
Some will have to supplement potassium or magnesium, but not everyone.
You know about the partitioning of the stomach to create a small pouch, right? The older procedures just ran a row of staples across to create the division. Of course, by "a row", I mean whatever the doc does, 3 rows, 4 rows, 6 rows, 8 rows, and most docs also oversew. Then intestine is attached to pouch, etc, but we're only talking pouch here, right?
OK, when it's transected, they again do 2 pairs of rows of staples (most of the guns fire 2 rows simultaneously). They cut between the two pairs, so 2 rows hold the pouch side together, 2 rows hold the stomach side together. There is a space between the two stomachs now. My doc sends that hunk between to pathology, but other docs do different things with it.
When it is not transected, it's much like stapling your lips together, slimy fabric to slimy fabric. They never grow together or seal. The staples are holding them together and keeping the partition intact. Staple line disruption can occur at any time (some within 2 weeks, some by 18 months, mine was at 5 yrs) or never. It's a risk.
When it IS transected, you have two adjacent raw edges held together, so they heal to each other and bond. (That applies to both the pouch segment & the stomach segment, of course). If you cut your finger, it is definitely open, but it heals back together invisibly, you know? Raw edge to raw edge. The risk of leak is in the first few days, but then, we are at risk of leak from any of the attachings. And if lea****urs, it will most likely be at one of the intestinal connections. However, once you are past the immediate post-op period, that risk is past.
So, the main benefit of transecting is that you will likely only have ONE surgery. Personally, I still had acid & discomfort before revision, and not much after, but then, I'd guess my staple line was compromised just slightly early on. My doc starred transecting all of them in 96, but I was a 94, my husband a 95, so we were not.
If there is a choice, I'd always recommend transecting. It can be a disaster to have a staple line disruption. It can be painful, as well as the inevitable weight gain, and that general sensation of failure. And what if you do not have the right insurance to fix it?
But that is my very biased opinion.
*****
Let's assume that we all start with 300" of (small) intestine. We don't, but we need to have a figure, so that's it. From the pix you've seen of RNY/gastric bypass, you know there is a left side, right side and tail of the Y. The "junction" of the sides is the determiner if a procedure is proximal or distal.
The original intestine comes out of the old stomach and carries the digestive juices that are manufactured in the old stomach. This piece is called the bileo-pancreatic limb because it carries bile from the gallbladder and pancreatic juice from the pancreas. There is no food here.
This is the LEFT side of the Y. This is the portion that is bypassed.
The alimentary limb connects to the pouch and only carries food, but cannot digest or absorb. This is the RIGHT side of the Y.
The tail of the Y is where both elements mix together and where digestion (if any) and whatever absorption will occur. This is the part that is still in use and is also referred to as the common channel.
If the junction of the Y occurs in near proximity to the stomach, it is said to be proximal. If the junction occurs as a far distance from the stomach, it is said to be distal. That said, neither word describes any actual measurements of anything, so the meaning is in the mind of the person speaking of the procedure. What is proximal to my doctor is considered distal by another.
Generally speaking, ALL RNY people will have to supplement at least the basic 8 elements*, though in varying doses. We are all missing the stomach and its normal digestive function.
Truly distal (with a lot bypassed, and a short common channel) people need to supplement in larger volume, but will achieve and maintain the better weight loss over time. Proximal (less bypassed, longer common channel) people still need to supplement the basics and can reach a reasonable weight, but after 2 years may have to work a little harder to maintain their goal weight.
My doctor measures what is in use, not what is not. So, in my case, I have a 40" common channel, then 60" was used to reach the pouch. The bypassed portion is then ABOUT 200".
Most procedures performed are measured backwards from that. The doctor will bypass 12 to 72", use 60-80" for the right side of the Y, and the common channel will be 100-200".
* the basic 8
protein
iron
calcium
A
D
E
zinc
B12
These need to be supplemented in specific ways to help absorption.
We also malabsorb SOME fats/oils and complex carbs.
We never, ever malabsorb sugar.
Some will have to supplement potassium or magnesium, but not everyone.
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