ABC's of Revision IV Everybody deserves a second chance!
For the last three weeks we have been setting the stage. We have, hopefully developed a common vocabullary and gained some insight regarding the limitations of different procedures. Our discussion of these limitations could easily go on for weeks. I may not have addressed your specific issue; GERD, the overstuffed esophagus, fistulas, stalled with the sleeve, complications of malabsorption, etc. These can be addressed later. Enough with the preliminaries. On to the main event!
Revisions for Rny'ers
There are two major aspects of a by-pass that may be revised. The restrictive component and the malabsorptive component.
Restriction
As we have discussed, it is common to be able to eat more months to years after your initial surgery. There are many different reasons for this. I will mention only in passing that a small component of this is the skill that you have developed with experience. You have become experts at eating slowly and chewing your food thoroughly. You have learned what "sits" well and what doesn't.
If your pouch wasn't too large when it was constructed, it is prone to "stretch" over time. The same is true for your stoma. This does NOT mean that you did something wrong. In many ways it is as inevitable as the sun rising tomorrow. So your pouch/stoma is dilated, now what?
There are several different approaches to dealing with this.
Stomaphyx is a safe and effective way to decrease the size (volume) of your pouch and its outflow tract. You may have read that Stomaphyx does not "tighten up" the stoma. This statement is misleading. Although no fasteners are place in the stoma, the concentric pleating immediately above the stoma will "tighten up" the out flow from your pouch. Think about your garden hose. Pinching the hose will narrow its opening and restrict the flow of water. Where ever you pinch the hose, this maneuver will have the same effect. So, even though no fasteners are placed in the stoma, properly performed, Stomaphyx will effectively "tighten up" your stoma. Due to its minimally invasive approach, LOW risk and the universality of some degree of pouch and stomal dilitation, pre-Stomaphyx upper GI's or endoscopy (separate anesthesia) are not an absolute prerequisite. Pouches with a volume, capacity of over 250 cc (normal 15-30 cc) are better addressed with procedures other than Stomaphyx. Tubular pouches are better suited for Stomaphyx than globular or spherical pouches. Right sided stomas are better suited for this treatment than left sided stomas. Having said this, I have had excellent results with unfavorable pouches and stomas.
Lap-Band over Rny can result in a dramatic improvement in restriction. Before a Lap-Band over Rny is performed the pouch must be evaluated with either an upper GI (X-Ray) or an upper endoscopy. While relatively small pouches can benefit from Stomaphyx, small pouches will NOT benefit from a Lap-Band. The reason is simple mechanics. If the pouch is too small to be "pinched" by the Band, the Band will serve no purpose. Lap-Band over Rny carries a higher risk than Stomaphyx. As in all weight loss surgery, the procedure chosen must be "matched" to the patient's anatomy, physiology, emotional make up, needs and desires. With the proper match, Lap-Band over Rny will yield excellent results.
The pouch and stoma can be surgically reconstruced.
This approach carries with it risks that are even greater than Lap-Band over Rny. The stomach is much more unforgivivng after it has been operated on once. The risk of a leak is significant. In fact, this risk is the major contributing factor for the reported "high risk" of revisions. Additionally, the surgically revised pouch and stoma is not immune from "stretching" again.
Malabsorption
For the vast majority of patient, a revision which significantly increases the malabsorptive component of their by-pass will result in the greatest weight loss. This increase in malabsorption is achieved by moving the Y further "down stream". This shortens the common conduit (bowel carrying both food and digestive juices)while lengthening the bilio-pancreatic limb (the bowel carrying only the digestive juices). Barring complications, very little if any intestine is removed with this type of surgery.
Much has been written about converting a "classic by-pass" into a DS. While there are indications for this procedure, if one wants to be technically correct, it is very rarely done. To actually convert a "classic Rny" into a DS would require disassembling the connection between the pouch and the intestine, reconstituting the stomach, resecting the left side of the stomach, dividing the duodenum, connecting the Roux limb to the first portion of the duodenum and moving the Y "downstream." It should be obvious that this operation is extensive. It is this type of revision which carries the "high risk" frequently cited in the medical literature.
The revision of a "classic Rny" to a highly malabsorptive operation can be more safely accomplished by revising it into a highly malabsorptive Rny (ERny). This procedure moves the Y downstream. It is the LEAST risky of all the revisions to a highly malabsorptive procedure as neither the pouch nor the stoma is touched. You gain the vast majority of the advantages of revision to a DS with only a small fraction of the risks.
Intermediate in risk between revising a "classic Rny" into a DS and revising a "classic Rny" into a highly malabsorptive Rny is revising a "classic Rny into a BPD. In this revision, in addition to moving the Y down stream, the excluded stomach (distal remnant) is removed. The theoretical advantage of this revision is a greater reduction in grehlin. There are no studies that document that the reduction in grehlin is greater when part of the stomach is removed. There is no information as to how long the reduction in grehlin lasts after any WLS.
Varying the length of the common conduit (bowel with both food and digestive juices) between 50 cm (most malabsorptive) and 100 cm (most conservative) will determine just how malabsorptive the procedure is.This is a decision to be made with your revision surgeon. Not every patient needs the most aggressive operation. This is yet another instance where experience counts.
Each of these revisions to highly malabsorptive procedures can be combined with a procedure that increases the restrictive component of the previous operation. It has been my experience that it is rarely necessary to revise both the restrictive and the malabsorptive components simultaneously.
Revision for Lap-Banders
If you were successful with your Lap-Band until you developed slippage or erosion, you are an excellent candidate for the placement of another Band. However if your initial success with the Band was followed by a weight regain and no "Band complication", you would be best served with a revision to a different procedure. The good news is that all WLS options are available to you. The risks for these revisions is minimally increased (if at all) from first time weight loss surgery. A good experienced WLS revision surgeon should help guide you through the decision making process. As always, be certain that your revision surgery offers you all of your options and LIFE TIME FOLLOW UP.
This is a long post with lots of information.Therefore I will save the discussion of revisions for complications (mechanical, metabolic, and physiologic) for another time.
EVERYBODY DESERVES A SECOND CHANCE!
NEVER GIVE UP!
CLAIM THE SUCCESS YOU DESERVE!
Eric Schlesinger, MD, FACS
AZ Weight Loss Solutions
Revisions for Rny'ers
There are two major aspects of a by-pass that may be revised. The restrictive component and the malabsorptive component.
Restriction
As we have discussed, it is common to be able to eat more months to years after your initial surgery. There are many different reasons for this. I will mention only in passing that a small component of this is the skill that you have developed with experience. You have become experts at eating slowly and chewing your food thoroughly. You have learned what "sits" well and what doesn't.
If your pouch wasn't too large when it was constructed, it is prone to "stretch" over time. The same is true for your stoma. This does NOT mean that you did something wrong. In many ways it is as inevitable as the sun rising tomorrow. So your pouch/stoma is dilated, now what?
There are several different approaches to dealing with this.
Stomaphyx is a safe and effective way to decrease the size (volume) of your pouch and its outflow tract. You may have read that Stomaphyx does not "tighten up" the stoma. This statement is misleading. Although no fasteners are place in the stoma, the concentric pleating immediately above the stoma will "tighten up" the out flow from your pouch. Think about your garden hose. Pinching the hose will narrow its opening and restrict the flow of water. Where ever you pinch the hose, this maneuver will have the same effect. So, even though no fasteners are placed in the stoma, properly performed, Stomaphyx will effectively "tighten up" your stoma. Due to its minimally invasive approach, LOW risk and the universality of some degree of pouch and stomal dilitation, pre-Stomaphyx upper GI's or endoscopy (separate anesthesia) are not an absolute prerequisite. Pouches with a volume, capacity of over 250 cc (normal 15-30 cc) are better addressed with procedures other than Stomaphyx. Tubular pouches are better suited for Stomaphyx than globular or spherical pouches. Right sided stomas are better suited for this treatment than left sided stomas. Having said this, I have had excellent results with unfavorable pouches and stomas.
Lap-Band over Rny can result in a dramatic improvement in restriction. Before a Lap-Band over Rny is performed the pouch must be evaluated with either an upper GI (X-Ray) or an upper endoscopy. While relatively small pouches can benefit from Stomaphyx, small pouches will NOT benefit from a Lap-Band. The reason is simple mechanics. If the pouch is too small to be "pinched" by the Band, the Band will serve no purpose. Lap-Band over Rny carries a higher risk than Stomaphyx. As in all weight loss surgery, the procedure chosen must be "matched" to the patient's anatomy, physiology, emotional make up, needs and desires. With the proper match, Lap-Band over Rny will yield excellent results.
The pouch and stoma can be surgically reconstruced.
This approach carries with it risks that are even greater than Lap-Band over Rny. The stomach is much more unforgivivng after it has been operated on once. The risk of a leak is significant. In fact, this risk is the major contributing factor for the reported "high risk" of revisions. Additionally, the surgically revised pouch and stoma is not immune from "stretching" again.
Malabsorption
For the vast majority of patient, a revision which significantly increases the malabsorptive component of their by-pass will result in the greatest weight loss. This increase in malabsorption is achieved by moving the Y further "down stream". This shortens the common conduit (bowel carrying both food and digestive juices)while lengthening the bilio-pancreatic limb (the bowel carrying only the digestive juices). Barring complications, very little if any intestine is removed with this type of surgery.
Much has been written about converting a "classic by-pass" into a DS. While there are indications for this procedure, if one wants to be technically correct, it is very rarely done. To actually convert a "classic Rny" into a DS would require disassembling the connection between the pouch and the intestine, reconstituting the stomach, resecting the left side of the stomach, dividing the duodenum, connecting the Roux limb to the first portion of the duodenum and moving the Y "downstream." It should be obvious that this operation is extensive. It is this type of revision which carries the "high risk" frequently cited in the medical literature.
The revision of a "classic Rny" to a highly malabsorptive operation can be more safely accomplished by revising it into a highly malabsorptive Rny (ERny). This procedure moves the Y downstream. It is the LEAST risky of all the revisions to a highly malabsorptive procedure as neither the pouch nor the stoma is touched. You gain the vast majority of the advantages of revision to a DS with only a small fraction of the risks.
Intermediate in risk between revising a "classic Rny" into a DS and revising a "classic Rny" into a highly malabsorptive Rny is revising a "classic Rny into a BPD. In this revision, in addition to moving the Y down stream, the excluded stomach (distal remnant) is removed. The theoretical advantage of this revision is a greater reduction in grehlin. There are no studies that document that the reduction in grehlin is greater when part of the stomach is removed. There is no information as to how long the reduction in grehlin lasts after any WLS.
Varying the length of the common conduit (bowel with both food and digestive juices) between 50 cm (most malabsorptive) and 100 cm (most conservative) will determine just how malabsorptive the procedure is.This is a decision to be made with your revision surgeon. Not every patient needs the most aggressive operation. This is yet another instance where experience counts.
Each of these revisions to highly malabsorptive procedures can be combined with a procedure that increases the restrictive component of the previous operation. It has been my experience that it is rarely necessary to revise both the restrictive and the malabsorptive components simultaneously.
Revision for Lap-Banders
If you were successful with your Lap-Band until you developed slippage or erosion, you are an excellent candidate for the placement of another Band. However if your initial success with the Band was followed by a weight regain and no "Band complication", you would be best served with a revision to a different procedure. The good news is that all WLS options are available to you. The risks for these revisions is minimally increased (if at all) from first time weight loss surgery. A good experienced WLS revision surgeon should help guide you through the decision making process. As always, be certain that your revision surgery offers you all of your options and LIFE TIME FOLLOW UP.
This is a long post with lots of information.Therefore I will save the discussion of revisions for complications (mechanical, metabolic, and physiologic) for another time.
EVERYBODY DESERVES A SECOND CHANCE!
NEVER GIVE UP!
CLAIM THE SUCCESS YOU DESERVE!
Eric Schlesinger, MD, FACS
AZ Weight Loss Solutions
Dr. Schlesinger,
I am a revision patient. I had lapband 12/28/05. It slipped 5/2/06. I had gatric bypass 12/17/2007. My weightloss as of today is only 20lbs. I was told that revision patients is alot slower. I just want to know why???? I don't want to be a failure at the rny too. I feel like I can eat alot. Is my pouch the right size for me?
Ebony_Teaches
highest life time weight 330lbs/// lowest life time weight without surgery 217lbs
weight pre band 292lbs /// lowest weight with band 232lbs
pre op weight w/ gastric bypass 252lbs
current weight with RNY 195lbs
"Everything is possible for him who believes."
Mark 9:23
Ebony,
First and foremost, you are NOT a failure.
Revision WLS patients do lose weight more slowly than "newbies". This may in part be due to metabolic changes resulting from the dietary changes adopted after the first operation.
Patients who are placed on a strict dietary regimen for six months or more prior to their first WLS lose weight more slowly than those who are not. How many calories are you taking? Has your body gone into a starvation metabolism mode?
Given your weight, a 20 lbs. weight loss in the 2 months since your revision to Rny is fine. Keep up the good work! Remember that this is not a sprint; it's a marathon. The race does not always go to the swiftest.
I cannot intelligently comment on the size of your pouch without more information. Keep a dietary journal. Are you able to eat "large" portions with all types of food? How much is a lot?
Think positive thoughts! Stick with your nutrition and exercise program. Make certain your surgeon and his/her program are following you closely. Go to support groups. Continue to use OH as the valuable resource it is. Claim the success that you deserve!
Eric Schlesinger, MD, FACS
AZ Weight Loss Solutions
First and foremost, you are NOT a failure.
Revision WLS patients do lose weight more slowly than "newbies". This may in part be due to metabolic changes resulting from the dietary changes adopted after the first operation.
Patients who are placed on a strict dietary regimen for six months or more prior to their first WLS lose weight more slowly than those who are not. How many calories are you taking? Has your body gone into a starvation metabolism mode?
Given your weight, a 20 lbs. weight loss in the 2 months since your revision to Rny is fine. Keep up the good work! Remember that this is not a sprint; it's a marathon. The race does not always go to the swiftest.
I cannot intelligently comment on the size of your pouch without more information. Keep a dietary journal. Are you able to eat "large" portions with all types of food? How much is a lot?
Think positive thoughts! Stick with your nutrition and exercise program. Make certain your surgeon and his/her program are following you closely. Go to support groups. Continue to use OH as the valuable resource it is. Claim the success that you deserve!
Eric Schlesinger, MD, FACS
AZ Weight Loss Solutions
Have you seen many RNY patients with reactive hypoglycemia? Mine started when I was at goal about 18 mos. post-op. I have found eating pretty much continuously really helped! So much so, that I have re-gained about 40 lbs. I know several OH members who have frequent, severe, hypoglycemic attacks whi*****lude seizures. Through research I have found that it may be due to food dumping out of the stomach into the intestine too fast and too much insulin being produced. Do you know of any surgical solutions to this? Maybe making the stoma smaller or revising the pouch/stoma to a sleeve/pyloric valve (if still there?) Hope you can help. Thanks. Laurie
Laurie,
Your condition is not unique. Before you lost your weight, your body was insulin resistant. It was not responding to the insulin your pancreas was making. Your pancreas responded by making more and more insulin, until your body responded to the higher "dose". Your body now responds to insulin in a much more normal fashion. Unfortunately, your endocrine system hasn't reset.
There are a number of surgical interventions that have been tried. None have been particularly successful. These options should be your last resort.
Are you getting the support and follow up you need and deserve? Have you tried dietary manipulations. Avoid sugars and limit your carbohydrate intake at meals. When eating fruit, try apples and pears. Avoid bananas, grapes, etc. Push the protein and fluids. Keep a "juice box" in your purse. Drink from it when you start to get the symptoms, but drink slowly and take only enough to correct the symptoms. Work closely with your dietician and surgeon. See an endocrinologist. Try not to graze.
If you would like to discuss the specifics of your condition in the privacy you deserve, call my office at 480-419-2280.
Be persistent. Be your own best advocate and friend. Demand the treatment that you require! This is but one reason why a life long comprehensive follow up program is essential to all WLS patients.
Eric Schlesinger, MD, FACS
AZ Weight Loss Solutions
Hi Dr. Schlesinger,
I was evaluated for the RESTORe clinical trial several weeks ago. I went to John Hopkins for my EGD and was told that my anatomy was incorrect and that my pouch was 8x9cm in size. They were unable to measure the aastomsis due to the angle of the stoma. The surgeon drew the pouch and stated that a usual pouch is much smaller and my line was much lower. So, I am unsure what my options are at this point. I contacted the research coordinator for the ROSE procedure and actually have an appointment in Richmond, VA which is about 3 hrs from where I live. But, it would seem if I was anatomically incorrect for the RESTORe procedure then this would still be an issue for me now. I had a proximal gastric bypass with 150cm roux retrocolic limb in 2003 which was done as a open procedure. I have gained about 60lbs and am at a lost what to do now. Could you provide me some guidance? I am just not sure whether I should get involved in this other clinical trial to spend both time and money and be told that I won't qualify. I have followed your reponses to all of the many questions and you seem to really care about what you do and those of us *****ally need guidance. Thank you so much for being there for each of us.
I hope you have a great weekend and take care.
Kathy
Katchal,
While I cannot speak for those involved with the clinical trail for ROSE, I think that your skepticism is well found. I would be surprised if you were included in their study. If you decide to go, be ready to try to negotiate a procedure "outside" of the trial. This basically means that the data from your procedure would not be included in their report. If they truly believe in ROSE and are compassionate; they might say yes. Don't count on it.
If you would like to discuss this in greater detail, then a more private setting would be more apropos. If you would like, call my office @ 480-419-2280.
Good luck!
Eric Schlesinger, MD, FACS
AZ Weight Loss Solutions
While I cannot speak for those involved with the clinical trail for ROSE, I think that your skepticism is well found. I would be surprised if you were included in their study. If you decide to go, be ready to try to negotiate a procedure "outside" of the trial. This basically means that the data from your procedure would not be included in their report. If they truly believe in ROSE and are compassionate; they might say yes. Don't count on it.
If you would like to discuss this in greater detail, then a more private setting would be more apropos. If you would like, call my office @ 480-419-2280.
Good luck!
Eric Schlesinger, MD, FACS
AZ Weight Loss Solutions
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