HELP>>>>>

I have a friend who had surgery performed with Dr. Rubstein in Patchogue New York. She states that she was supposed to have an OPEN RNY and has only lost 50 lbs. She is interested in having a revision? She went to see Dr.Cooperstone who told her he does not do Revisions? Does anyone have a name of a Doctor that does revisons in the Long Island/ New York city area? She was given a name of a Doctor in New Jersey , but that is too far for her? ANy help would be appreciated. Thanks, Nina

Try NY Bariatric Group, the surgeons are Dr.Shawn Garber and Dr.Spencer Holover, ph# 516-616-5500 Good luck

Hi, Why is she looking for a revision? Is there something mechanically wrong w/her bypass? That is the only reason any surgeon would consider doing one. Maybe it is a behavior problem that is going on? Dunno. I wish her well though. I see your had your surgery by Dr. Cosgrove? I know who that is. He used to be an attending general surgeon at North Shore last year. When did he start doing the bypass? Wishing your friend well! Tavia

Nina: First here is my thoughts, following is an article I have: DO I NEED A REVISION? What are your issues/ideas/thoughts on why insufficient wt loss or regain? Solution/recommendations may be different depending on answers.... Three things may be happening independent or together: ~Broken Surgery (tool) ~Behavioral issues (not using tool ~Wrong tool/surgery 1. BROKEN SURGERY: a. WERE YOU Open or Lap? b. Were you transected (pouch and distal unused stomach severed by staples and cut by space?) IF not maybe the issue is a staple line disruption/failure (AKA SLD)...food is going into the old tummy and no malabsorption is happening. Or a fistula ("A gastro-gastric fistula is simply a communication between the new "pouch" and the "old" stomach.)*Same as SLD your getting food into distal stomach and it avoids the bypass. c. Have you had an upper GI endoscopy? (Scope down throat) to see if pouch is intact and how large your stoma is (connection of pouch and intestines). Many have an enlarged stoma allowing them to eat larger quantities w/o feeling full, kind of like a chute. This is usually not patients or surgeons fault but many patients stomas relax on them...Some possible fixes:A lap band may help,or a surgical revision of stoma or a fixed silastic ring, but it isn't always possible. Also many are using sclerotherapy http://www.ingentaconnect.com/content/fd/os/2003/00000013/00000002/art00006 or http://www.drsimpson.com/chattranscript-08-13-2004.php for info. They say for this (inject substance thru upper GI scope into tissue to produce scarring) and there is a new procedure in Boston being done called: Endoscopic pouch repair. http://community.nursingspectrum.com/MagazineArticles/article.cfm?AID=14602 d. Do you get full? How much food? Have you done the cottage cheese test? http://www.digitalhorsewoman.com/pouchrules.htm 2. BEHAVIORAL (not using tool to potential):I am not saying it is behavioral just asking a few questions: a. What do you eat in a given day? Calories track on www.fitday.com % fat/protein/carbs. b. Do you drink with meals? c. Drink calories? d. Soda? e. Do you do protein shakes? (type/number) f. Do you do vitamins? Which ones? Types/amounts/when do you take them? g. When were your last full set of labs/Dexascan? h. Do you exercise? How often? Amount? Type? i. What other meds are you on? Medcial conditions? j. Age, Height? Starting BMI Current BMI. (Basically looking for % of excess you lost) k. Do you follow pouch rules? http://www.digitalhorsewoman.com/pouchrules.htm We can eat more at ~6 months out (quantity/variety), it is also time malabsorbtion of calories decreases for many as body adapts. (intestines can elongate/grow more villi/folds to increase absorbtion) OKAY the above questions are just to help us figure out some potential behavioral issues. Again I am NOT saying the failure of you or anyone is strictly behavioral. It is just one thing. Any surgery can be defeated if the tool isn't used, BUT if the tool is used reasonably it may be broke or may of been the wrong tool (surgery) for you! IF YOU DID NOT CHANGE YOUR LIFESTYLE THER IS NO TOOL THAT WILL WORK! 3 WRONG SURGERY: We do not always know this until after. Some surgeons realize the higher the BMI of the patient the more distal bypassed they should be. Or the type of eater someone is may lend itself to one surgery over another. Some fail to lose wt with a VBG or lap band only to lose well with a RNY or many with a proximal RNY fail to lose wt and do great with a distal RNY or others don't do well with RNY and do fantastic with a BPD/DS...you get my point. One surgeon had this to say about choosing your surgery type for you. (*I am not sure there is any real one size fits all though on deciding!) http://www.alagsa.com/Bariatric_Surgery.htm Some surgeons do a very short 40CM bypass (not near long enough for most of us MO)! Get a copy of your surgical report from the hospital medical records so you KNOW what you have! It is yours according to law! They say 50% of excess wt lost is a 'successful surgery'. I agree *but why accept this? when others lose 75, 80, 90, 100%? I know everyone is different but if there are means to allow most to lost 80+ % why shouldn't everyone have the opportunity? We all have to weigh the pros and cons. Going BPD/DS or more distal has risks, a lap band has risks etc. Many lose 80%+ and regain after 1, 2, 3,5 yrs. Not always behavioral or mechanical,,,,so their body is real good at adapting and hence they probably had wrong surgery.... I hope this helps some and doesn't really confuse you. I have to add, I haven't had a revision. I am here learning with everyone "IN CASE" (I think education is key to success and all I can arm myself with!). It (regain) scares me too! I see/read/hear about wt regain more and more online and read more about revisions. WLS has come a long way, but maybe just maybe some day we'll get the right surgery the first time! One that we can behaviorally adapt to and use and that won't break! ONE CAN DREAM! I think a good revision surgeon is key to lower risks, I wouldn't go to just anyone! And I know many on the group could help u with someone good! Dr Fox and Oh in Washington State. http://www.aboutmso.com/pp/prospectivepatients.cfm http://www.ohtobethin.com/ Dr. Gagner in NYC: http://www.cornellweightlosssurgery.org/ This is a great group http://groups.yahoo.com/group/WLSrevisionsupport/ of people who can definately lead u in the right direction! I also know OH has 2 different Revision Forum. http://www.obesityhelp.com/morbidobesity/amosforums/failed_wls_second_time_around http://www.obesityhelp.com/morbidobesity/surgtype-forums/Revision/ ~~~~~~~~~~~~~~ EVALUATION FOR WEIGHT LOSS FAILURE Evaluating a patient who is progressively regaining weight can be relatively simple - or difficult. The first principle is to determine that the gastric pouch is anatomically intact. If it is not intact, it should be made intact by a revision procedure. Only when the surgeon can be reassured that the pouch in intact does the complex part begin - evaluating how and why the patient is not using the pouch/tool properly, and/or getting a reasonable amount of exercise. We need to know three things about the small gastric pouch. First, is the staple line intact; second, is the outlet intact; and third, is the pouch reasonably small in size. The upper GI series is the basic tool for evaluating intactness of the staple line and the outlet. If the pouch has been stapled in continuity with the rest of the stomach (non-transected), we must confirm that the staple line remains intact. A disruption of the staple line will create two gastric outlets leading to rapid pouch emptying, early loss of satiety, and thus early return of hunger. The upper GI series can usually give the bariatric surgeon a reliable view of the diameter of the gastric outlet also. A diameter of over 18-20 mm is usually associated with weight regain. Outlet failure, like a staple line disruption, causes rapid emptying of the pouch and early loss of satiety, and early return of hunger. On the other hand, weight regain can occur as a result of an outlet diameter under 7-8 mm which can lead to persistent vomiting of solid foods and gradual persuasion of the patient towards the Soft Calorie Syndrome with resultant rapid pouch emptying, early loss of satiety, early return of hunger, and regain. The upper GI series is less effective for evaluating pouch volume because of the fact that barium is very much of a liquid. To assess pouch volume, you must turn to the patient's history of the size of the meal that he/she can consume within a short five to fifteen minute time frame, and/or the Cottage Cheese Test. Cottage Cheese Test: Measure out a couple 1/2cup servings of cottage cheese. See how much cottage cheese you can eat until you are full (Eat it at a regular pace. It should only take a short time.) The amount you eat until just full is approximately the size of your pouch. Up to 4-6 ounces should be considered average. (1/2 C equals 4 ounces) In the patient whose gastric pouch seems to be anatomically intact and yet he/she is still regaining weight, the evaluation becomes more complex. The usual finding is that the patient is not following the principles of the use of their pouch/tool and/or is exrtremely inactive physically. There are four problems that occur with some frequency: · The patient has never been taught/ or does not understand how to use the tool. · The patient is significantly depressed. · Loss of contact with a bariatric practice or other bariatric patients and a gradual erosion of following the principles. · The patient is truly noncompliant and will not take responsibility for his/her own behavior. PATIENT DOESN'T UNDERSTAND HOW TO USE THIS TOOL Patient needs teaching on use of pouch/tool and proper eating habits after gastric bypass surgery. Also attendance at a good bariatric support group is extremely important DEPRESSION Depression is a powerful inhibiter of success after bariatric surgical procedures. A small but significant number of patients have been doing well following surgery only to drop out of sight for a time and then reappear with a significant weight regain. Upon evaluating these patients, it would appear that in many instances they seemingly deliberately reverse all of their learned principles of the use of their pouch/tool: grazing and snacking through much of the day, drinking high calorie liquids, drinking liquids with meals, and stopping their exercise, even when they are intellectually aware that exercise in itself releases numerous vasoactive substances which act like antidepressants. What can be done when a bariatric patient obviously is depressed and regaining weight? Obviously, the most important thing is to steer them to professional counseling, if they are not already in counseling. Then, be encouraging. We can encourage them to continue to use the tool as best as they can; we can encourage them to return to exercise which will improve their spirits and reassure them that the improvement is "deserved," because they really are a good person and deserve to feel better..." Most of all, they need to be reassured that the pouch/tool is not ruined by this overeating and gradual weight regain. When they are ready once again to use their pouch/tool, it will be there for them, and they will be able to once again lose weight without being hungry. EROSION OF THE USE OF THE PRINCIPLES In a third subset of weight maintenance failure patients, a subtle weight creep can occur in patients who are otherwise compliant, non-depressed, and have intact pouches. The patient will see it as "struggling" with his/her weight, and by definition, he/she will not have seen their bariatric surgeon for followup visits, and will have usually lost contact with a support group or other bariatric surgical patients. There seems to be a progressive erosion of following the principles of the pouch/tool. This may be due to denial as seen in diabetic patients, or it may be due to the influence of their peer group and the fact that some of the principles of the use of the pouchtool, especially fluid management, are counter-intuitive and counter to behavior of their peer group. The patient will often not come back for evaluation because "I know what I'm doing is wrong!" (meaning that he/she is eating the wrong things and too often), and these patients will internalize their "failure" with an increasing sense of guilt which itself acts as an inhibition to coming back to their surgeon's office or support group for help. These patients are in need of a "refresher course" in the use of the principles of the pouch/tool. In the first three examples of reasons for failure - lack of teaching, depression, and gradual erosion of the use of their tool, weight once regained can be lost once again if the pouch is anatomically intact and the patient decides to use it, or learn how to use it or relearns how to use it. In these three examples we are working with compliant, reasonably responsible persons who, when they can, are willing to take responsibility for their own behavior. TRUE NON-COMPLIANCE The most difficult problem is determining, and being comfortable with that determination, when a patient is being fundamentally noncompliant and obstructive. This type of individual may leave his/her surgeon's care and go to others complaining about a "personality conflict", or perhaps even that the surgeon has not given them the time and attention that they need and deserve. Inexplicably, some will actually stay with their surgeon. In this instance, when the patient tends to return perhaps even more frequently than usual, depression will be more likely the underlying mechanism rather than noncompliance. It can be difficult to be reasonably sure of what is going on in one or two visits. The truly noncompliant patient will very likely end up with multiple revisions and/or a reversal due to weight regain or complications. This is not to say that someone with multiple revisions and/or a reversal necessarily is noncompliant. The kind of patient who is truly noncompliant is often quite resistant to counseling, but no other management option offers much hope for success. Luckily, this type of patient represents a very small minority of patients. ~~~~~~~~~~~~ Take Care, Jamie Lap RNY 10/9/02 Dr. Singh 320/163 5'9'' (lost 45# before surgery) Plastics 6/9/04 & 11/11/2005 Dr. King http://www.obesityhelp.com/morbidobesity/members/profile.php?N=c1132518510 "Being happy doesn't mean everything's perfect, it just means you've decided to see beyond the imperfections!"