GERD, VSG and RNY

I've been seeing some posts about people who have had VSG and now have GERD. I had VSG almost 10 years ago and, while I have had some regain, I am still considered at a good BMI and not overweight. Problem is, I have really bad heartburn most days even with medication, and some days I have actual serious pain in my stomach. I have been tested and treated for an ulcer and have gone through more than 1 endoscopy.

I have seen that RNY surgery is usually done to correct GERD in VSG patients, but my concern is that I will lose too much weight if I get another surgery. I could afford to lose probably 20 pounds, but more than that and I would be very underweight.

Does anyone have any advice? I have seen some recent treatments for GERD such as the Links and fundoplication. Does anyone have experience with either of these?

Conversion from sleeve to RNY for gerd is very common. You shouldn't keep suffering the way you have from the acid. And long term PPI use has horrid side effects, not to mention the esophogeal cancer risks from the acid.

You won't lose too much weight. It's possible to gain weight after RNY, so wether you lose, gain, or maintain is all on you.

They can't do a Nissen fundoplication on anyone who has had a VSG. They need much more stomach for that procedure thgan what you have left.

What do your endoscopy(s) show, and that possibly along with and upper GI imaging, will lead towards the answer. Yes, an RNY revision is often done to correct intransigent GERD, though it isn't the only solution - that depends on the specific cause and the skill and knowledge of the surgeon. Some docs will diagnose you virtually over the phone (you have a VSG, heartburn, therefore you need an RNY revision...) while others will look at your EDG and upper GI, curse under their breath - twenty years of doing RNYs and they think that they know how to do a sleeve... - then they will explain the problem and the possible solutions. It might be an RNY, or it might be a re-sleeve to correct some shaping issues, or maybe a Nissen (yes, it can be done on a VSG, though not all surgeons can to do it) or other method to correct a hiatal hernia.

When it comes to revisions, they are inherently more complex than a virgin WLS - both in cause and in solution - which puts a premium on finding the right surgeon for the job. Second and third opinions are essential. As with any profession, within the qualified ranks, there are the majority who are functionally competent practitioners who do the everyday jobs well (the 'B' students), the artists and gifted practitiioners who seem to do everything well (the 'A' students) and then those who scraped by with a 'C'. Look through the surgeons' CVs on this site or others, and they all do revisions because they have converted lapbands to VSGs or RNYs, but you need someone a cut above that, and that is the hard part. One proxy for the appropriate skill is to look for a surgeon who has been doing the duodenal switch for some time. As the DS is based upon the sleeve, they tend to have longer and deeper experience in dealing with them, and as it is a fairly complex procedure, that tends to weed out the 'C' and most of the 'B' surgeons.

As to excessive weight loss, you probably will lose a bit too much at first, as it is difficult to "only lose" 20 lb with these procedures. However, deviating from classic WLS rules and diets can help - drinking calories is a good thing when you are trying to avoid losing weight. Likewise common advice in this cir****tance is to go with a high fat, low carbohydrate diet (a la keto or paleo) as the high caloric density of the fats helps keep the calories up, and the low carb helps to avoid classic RNY problems like dumping and reactive hypoglycemia. Also, if going the RNY route, consider carefully the temptation to minimize malabsorption weight loss via shorter limb lengths, as that can promote bile reflux in exchange (always those compromises!)

To perform a Nissen fundoplication, a surgeon takes excess stomach from just below the esophagus (the fundus), and they wrap it around and stitch it. Think of a shirt sleeve way too big for your arm, wrap it around, and sew it tight.

After a VSG, your stomach is the size of a sharpie in diameter. Maybe a hilighter, if it's on the large side. There is no excess stomach to wrap around and stitch. A Nissen is not possible.

I've seen some folks have multiple surgeries to change the shape of their sleeve, sew their esophagus tighter, look for hernias-- all sorts of things. And they still have acid.

Get a couple of opinions from good surgeons. Listen to them.

Grim, you might want to drop a note to Dr. Keshishian explaining why he can't do what he does. (Hint - our stomachs don't remain the size of a Sharpie, just as a pouch doesn't stay the same size as a shot glass.) He says that he can usually get about 3/4 of a wrap done with an average sleeve.

DR K is brilliant from what I heard. He is one of a very very few who actually could attempt to do that and really help the patient.

I converted to VSG to RNY because of GERD 10 days ago. My acid was quite bad, but I have not had any GERD trouble since coming home from the hospital.

Per my surgeon, most people don't lose nearly as much weight after a conversion surgery, and when they do it's much slower. My goal is to lose only 50lb, and the doctor says he's had people with much lower goals-- or even people who just wanted to maintain after changing the surgery.

I did look into the alternatives as well. Fundoplication is not an option for us, as we do not have any excess stomach to use for the procedure. Outcomes for the LINX are not nearly as good; research shows that about 75% of patients see their GERD mostly/totally resolved, whereas RNY is 90 - 95%. Plus there may be some complications with it; I recall reading that the implant makes it physically impossible to throw up, which seems problematic.

Good luck!