Need expertise...VSG or RNY

I have been planning to have the VSG procedure...hopefully in August. I cannot, however, get the idea that maybe the RNY would be better.  Please read my concerns and questions and provide your best advice.

i had a Lap-band procedure in 2007. Only lost 15 pounds over 5 years but did develop an esophageal ulcer. Lap band was removed in 2012.  Weight has slowly crept up to 280. I have battled GERD for years and Nexium is one of my best friends.  I also have high cholesterol, chronic constipation, and an exorbitant amount of osteoarthritis in my knees and one hip. 

After consulting with my nutritionist she believes my 'stretch resisters' in my stomach don't work properly because I don't get full like most people.

Questions: with already having severe arthritis will lack of calcium absorption following RNY make this worse?

If your body can't absorb calcium and nutrients from food, how can it absorb them from supplements?

Thanks for reading all of this and any advice about which surgery would be most beneficial would be greatly appreciated.

I personally would not have VSG if I had GERD.  VSG often makes GERD worse, though not always.

If you take enough calcium citrate and D3 after RNY, then you will not lack calcium absorption.  And I'm not aware of lack of calcium causing arthritis to get worse, anyway.  Those it does cause osteoporosis.  So make sure you take your calcium citrate and D3.

After RNY, your body CAN absorb calcium and other nutrients from food.  There are a couple of issues with absorption of micronutrients (vitamins and minerals), however.

First, those only get absorbed in specific places in the small intestine.  Some of those places are bypassed in RNY folks.  Like, a normal small intestine has three spots where vitamin D gets absorbed.  After RNY, there is only one spot.  That means you might absorb only 1/3 as much vitamin D as you used to, whether from food or supplements.  So you'll need to take more vitamin D than non-RNY folks in order to be able to absorb enough.

Second, some vitamins and minerals require a fair amount of stomach acid to break them down for absorption, including some types of calcium (including calcium carbonate and the calcium in most foods).  RNY folks have a lot less stomach acid than normal.  Therefore we need to take a calcium supplement to make sure we get enough, and it should be calcium citrate, which doesn't require much stomach acid for absorption.   Same goes for some types of iron.

There is a similar issue with B12, in that it requires something called intrinsic factor in order to absorb it from food or supplements in your stomach/intestine.  RNY folks have very little intrinsic factor.  We need to take B12 supplements, and they need to be in a sublingual form (dissolves under the tongue), a nasal spray or injections.  That way intrinsic factor isn't needed for absorption.

• RNY seems to be the most recommended for patients with GERD, for the sleeve stomach can possibly make it worse.  If pursuing the VSG, ask about a procedure to fix the GERD, too.
• With the calcium question, you simply take more calcium, and take it away from iron, combined with D.  The body does absorb some of the calcium ingested, just not all of it, so you take more.  I also just recently discovered vitamin patches (patchmd.com) that I'm considering trying, thus skipping the digestive process all together.

The RNY will help your GERD but with arthritis you will never be able to take an NSAID  pain reliever again.  NSAIDS will cause ulcers in your remnant stomach.  I think you can still take NSAIDS with VSG.  There are medications for pain that are not NSAIDS.  You should talk to your surgeon about the alternatives for pain relief if you decide to get the RNY.

Thanks for the advice. It does seem that the RNY would be my best option.  Waiting for insurance approval...hopefully within 2 weeks.  

I'm so glad I found this site. 

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I just want to add my reflux went away after the sleeve surgery. Also since you have already had an ulcer you are at higher risk to have another one with the RNY and they can not scope you.

So am I understanding that if you have the RNY you can't ever be scoped?  What do they do if you need that done?

I had the sleeve so not sure what they do. If you research it you can find out I am sure.

Hi bthayes0,

Great advice from our members.  Be sure and post this question on our RNY and VSG forum too.

Roux-en-Y Gastric Bypass Surgery Forum (RNY)

Vertical Sleeve Gastrectomy Forum (VSG)

I have been reading here and on other WLS-related sites for 11 years now.  When I first joined here, almost no one got a Sleeve unless they were planning on getting the intestinal 'switch' added later, for a complete Duodenal Switch. (The DS has the same stomach as the VSG/Sleeve.) Rarely ever did anyone talk about developing GERD after the DS.

Then the stand-alone VSG became popular, but at about 5 years out, people were having some pretty bad regain, so---surgeons started making Sleeves smaller and smaller. And suddenly everyone was saying "Oh, a Sleeve causes GERD!"

In my opinion---a TINY Sleeve causes GERD.  My DS completely cured the GERD I had pre-op, but my 'sleeve' was made to hold 3-4 ounces. I've had extensive arthritis since I was 20, so when at 45 I decided to have WLS, I knew I needed a surgery that would still allow me to take NSAIDs.

With the RNY, there's a tiny little 'pouch' that can be 'scoped, and a huge, blind remnant stomach that can't. It's the danger of getting an ulcer in this remnant stomach that rules NSAIDs out for RNYers.