Revision to RNY due to acid?

They will do an endoscopy to see if you have any visible damage from reflux. Some people have silent GERD and don't ever feel discomfort. Others suffer with extreme pain. Either way, GERD is not something you want to leave unchecked.

My GERD was obvious. The pain in the chest and throat was awful. I also had trouble swallowing (lump in the throat). I could not bend over without feeling the acid. I also seemed to always have a metallic taste in my mouth.

The endoscopy will be what they use to diagnose the need for a revision. I had to have an open surgery with my revision because my case was very complicated. Many revisions can be done laparoscopically. They will cut the upper part of your sleeve away from the lower part (where the acid is produced) and create a pouch with the upper part. The lower sleeve will remain in place and attached to your intestines. That means the acid will still be able to do it's job further down in your digestive track, but will be unable to get into your esophagus. They will re-route a portion of your intestines to your new pouch and attach it under your duodenum.

Thanks for that explanation! I think I can envision how it would look.

I assume that there's the whole pre-op/post-op diet stuff, just like with a new surgery. Aside from rectifying the acid issues, what sorts of changes did you experience between VSG and revision? Did your eating need to change?

I did not have VSG. I had an old VBG. My situation was unique, to say the least. The diet is basically the same as VSG. You will have to treat it as a new surgery. In my case the GERD was so severe that my revision was immediate relief for me. I woke up from surgery GERD free.

There are a couple of things that you will have to worry about that are different from VSG. The fact that the remnant stomach can not be scoped means that you have to be hyper-vigilant about the no NSAIDS rule. You really don't want to risk an ulcer in your remnant stomach because the only way to see what's wrong would be another surgery. The other would be malabsorption of vitamins. Normally our vitamin absorption takes place in the area that is bypassed (around the duodenum and in the new intestine loop) That means that you will have to pay close attention to your lab work and adjust vitamins accordingly. We also malabsorb fats so any vitamin that is suspended in oil (gel caps, gummies, etc.) will not be effective.

I didn't even know I had acid reflux until my endo before surgery. I was surprised when he showed me pics showing the erosion in the lining of my stomach.

My was pretty "silent".

Ceci

Hi Gwen. I revised to RNY from VSG on 7/1/16. Here are the steps I went through. I first had a barium swallow to see if there was anything anatomically wrong with my sleeve and to see if I had any active reflux. My test came back negative for reflux. I asked my surgeon how that was possible, and he said it's because it was just a moment in time, but that he was pretty sure I had GERD (which I did not have prior to my VSG). He then ordered a mannometry and pH test (which sucked). I that test, that thread a probe through your nose down through your esophagus and into your stomach to test the strength of your Lower Esophageal Sphincter. They have you take 8 swallows of sal****er as the move the probe through various stations in your esophagus. The tone of my LES is so poor that I failed all 8 swallows. They then repeated the test with apple sauce, where I failed all but 2 swallows. The pH testing is a 24-hour test. They remove the larger probe and thread down a smaller sensor which is attached to a computer. It continuously measures your pH levels. They tell you to eat foods that would typically trigger acid. The joy of this test is (1) it's in for 24 hours and you can feel it ever single time you swallow; and (2) you need to be completely off PPis or other acid meds for 5 days prior to the test. My test results came back with a DeMeester Score of 78.95, which translates to an acid level 409% greater than normal. The third test I had was an endoscopy and biopsy of my esophagus. I had two spots that looked suspicious to my surgeon and that sealed the deal. I was scheduled for conversion to RNY.

As Grim was saying there is a gene mutation that affects the rate at which you metabolize PPIs. My PCP tested me for it, and I have it. She said that, for me, taking PPIs was like spitting in the wind. . . they do nothing for me. Which made sense, since none of them offered me any significant relief. The only PPI that offered any relief was Dexilant because it utilizes a different channel through the liver, which adjusts the metabolism rate. Long term Dexilant use wasn't feasible for me, since my Insurance specifically excluded coverage for the med and it would have cost me between 400-600 a month without coverage.

As to your other questions. My acid manifested in a bunch of different ways. It started as pressure in my chest. It felt like I had to pull my bra away from my chest in order to get a good breath. I also had traditional "heartburn" -- burning in my chest and throat. I had bile and acid come up when I slept at night, to the point where I had to sleep sitting up. I'm a runner, and I would have acid bubbling up into my throat and pressure in my chest when I ran. The most concerning to my surgeon was that I developed a cough, which he believed was caused by Microaspirations of acid into my lungs.

The revision itself was super easy. I had an easier recovery from that, than I did my VSG (which was a good recovery). I spent 3 nights in the hospital (mostly because I wanted it to be as expensive for my insurance company as possible . . . a long story). I was up walking the night of surgery, and when my surgeon came to check on me the next morning, they had to go find me, because I was out taking a walk and walked over to the other tower. The worst part of the recovery was that I had to go through the food progression again (his is 1 week clears, 1 week full liquid, 1 week puree and 2 weeks soft foods). Although at my 1 week follow up I complained that I was legit hungry (and not head hunger) and he agreed it was likely because I didn't have much extra for my body to feed on (I was basically at goal when I converted) and he advanced my diet by a few days.

Anatomically, he drew me a picture of what the revision entails and I'd be happy to share it with you. I do have the remnant stomach. The only downside for me so far (7 months post) is that I dump . . . big time . . . on everything. And I mean everything. Dumping for me on non sugar or fats equals heart palpitations, sweating and fatigue. Dumping on sugar involves all of the above, and includes GI issues and sweat pouring from every pore in my body (I don't mean glistening, I mean rivers of sweat). I'm currently working with my surgeon and an endocrinologist to work on that issue.

One more thing to look into is a procedure called Stretta. It is done through an endoscopy and utilizes RF waves to strengthen the LES. My surgeon likened it to lifting weights . . . you irritate the muscle and when it repairs, it grows bigger and stronger. The theory is a stronger LES prevents the acid from splashing back up the esophagus. My insurance denied coverage for it and we were in the process of appealing to the State Insurance Board when we decided that the damage to my esophagus warranted conversion. I was bummed that I couldn't do it, because I loved my sleeve, just hated that it was trying to kill me with acid, and thought that Stretta was a good approach.

Sorry for the length of this response. I'd be more than happy to answer any specific questions you have or to share my drawing with you. I'm all about paying it forward and am happy to share my experience.

Wow! Thank you for all of this information! So the testing sounds like a drag, but it is what it is, I suppose.

The dumping though.. eek? I wonder what's going on there. Did you know that might be an issue pre-op? What are your docs doing to try to figure things out?

Stretta sounds interesting - I'll definitely ask about it if I have an issue with acid!

Right now I'm still wondering what's going on. Am I being paranoid? I'm trying to think of changes I've made in my diet and I did switch to chewable calcium and the primary "other ingredient" is fructose which I have issues with, so I'm considering cutting that out for a few weeks and dealing with swallowing the HUGE pills instead to see if it changes anything.

Seriously, though, ARGH. I really don't want to have to have a revision.

How soon post-VSG did you start having problems?

I didn't want a revision either. Ask anyone on here who knows my story. I had the perfect sleeve. I got to 100% EWL. I could eat anything. I run 1/2 marathons and was able to "carb load" the week before (with my surgeon's approval. He's a runner and developed a fueling plan for me to follow) I knew that dumping was a possibility with RNY and the possibility was one of the reasons I was so against revision, but when my insurance denied Stretta and then specifically amended my policy mid-year to exclude coverage for Dexilant, I knew I had no choice but to revise. At the time, I did not know dumping would (or could) be an issue to the extent that I have it. I thought if I stayed away from sugar and high fat food, I'd be fine. When I first started to complain (about 4 months after my revision), my surgeon had me track my food intake and heartrate (I had to check my pulse before eating and then 20 and 30 minutes after). My rate typically increased by 15-20 beats a minute. He told me it must feel like I'm dying. He also made me eat a 100% protein meal and then check my blood sugar, 20 minutes before eating then every 20 minutes after eating for 2 hours. Repeat with a meal with more carbs than I usually consume. He's working with an endocrinologist (who is mostly a researcher. She focuses her practice on Dumping Syndrome and RH - and is currently involved in 2 studies funding by the NIH). I'm going today to have a continuous glucose monitor implanted which will check for trends in my blood sugar to see if there is a correlation between food consumption, exercise and my dumping. I had an endoscopy yesterday to check for any anatomical issues. The only thing he found is that my pouch is still small (he made it small because larger pouches tend to have more issues with acid and he wanted to resolve that issue). He feels the small size may be contributing to my dumping because my pouch fills very quickly, but empties very quickly. We had a discussion after the test, but I'm waiting to talk to him again, since I was still foggy when we talked.

As far as vitamins go, I'm a big believer in doing what my Dr. requires, but I asked him at the beginning of February if I could switch to the patch and he said my levels were good enough that he was fine with it. You may want to consider it, particularly if you think something in your vitamins is causing the reflux.

I began having problems with acid around the 1 year mark. I know you're farther out than that, but it started about 9 months post surgery and got progressively worse. I converted 2 years and 2 months post VSG

If you're interested, I can tell you what the genetic marker test is called. If you think you can be controlled by PPIs it might be worth it, because then you can custom determine which medication would work best for you. It's a simple blood test. Let me know if you have any other questions or want to chat. I did ALL the research on revision, stretta, medications, etc. and would be happy to share my knowledge.

Stacy, whenever any information on those NIH studies on dumping and RH come out, I'd love to know about it.

Will do. I know they're still ongoing as I received an email from my surgeon (sent to all his patients) asking if we would be interested in participating in the study. I am participating by default as one of her patients. I'm getting my continuous glucose monitor installed (implanted???) today.

Wow. Big brother really is watching.