3rd times arevision is a charm (I hope) RNY gastric by pass revision from proximal to distal...

I am struggling keeping the weight down. I had my first RNY gastric bypass  in 2008 was 303lbs got to 220lbs very slowly and then after about 18 months starting going back up and returned to old eating habits and everything. In 2013 I was back up to 260lbs so got revision because my gastric pouch was 10 cm and my anastomosis was very wide. The pouch and the anastomosis were revised but and I got to 220lbs again then weight loss stopped again. Now it is back up to 260lbs the pouch is at 8 cm and anastomosis is at 25mm. My limbs are 75cm Roux loop, and the 30cm bilio-pancreatic limb.  I am considering revising again to distal gastric bypass and not DS to  get more malabsorption. Any advice???????

When I use to be on this board a lo a few years ago they called the distal RnY the worst of both worlds. Maybe that opinion has changed. 

A distal RNY is probably less risky during the surgery and that's something to definitely consider. I understand Dr Ungson is only doing a distal RNY now rather than a revision to DS. There are good surgeons who do the RNY to DS revision. You might check into Dr Marchesini in Brazil. www.dsfacts.com should have his contact info. Keep us posted, we'll help either way with whatever surgery you choose. 

--gina

How did you hear   that Dr. Ungston is not doing the DS revisions now? When did you hear that?

I think Beemer is spot on about the distal RNY.  I would push for a true DS revision.

Why the DS and not the distal RNY? I understand the DS would cause a reverse of the RNY in order to achieve make  a sleeve which would then be quite risky to inlclude the possibility of leaks. Could I possible just make the limbs longer to get shorter common channel and thus more malabosorption? Will either  result in more sustained weight loss?

There are 2 issues to consider here. First, going from proximal gastric bypass to distal gastric bypass has never been shown to provide much more weight loss. For this to happen, you would need to go to ERNY (extended RNY), which is much more distal, and which will give you a combination of all the issues of both RNY and DS. In other words, you keep the vitamin/mineral malabsorption your RNY gives you, and add to that the malabsorption for the fat solution vitamins that we deal with from the DS. And you still can't take NSAIDs. While there are some people who make a success of this, and yes it's safer than converting RNY to a real DS, it has some significant longterm risks beyond what you would have with a DS.

But second, let's look at your personal, unique situation. How would either a distal or ERNY possibly fix your problems with the stretched out pouch and stoma? Answer: it won't. You will still not have restriction. You will still have food fall straight out of your pouch through your too wide stoma into the small intestine. Nothing changes except a bit of additional malabsorption.

I very much doubt that a bit of malabsorption (you probably have almost no caloric malabsorption at present) will give you the kind of weight loss you want, esp with no restriction at all. I hope you will consult with a surgeon who does RNY to DS revisions for another opinion. Remember, a consultation is a great way to learn more, and doesn't commit you to anything. There are only a few surgeons who do RNY to DS revisions and I don't know where you are so I'm not sure who to recommend.

Larra

I will also be getting the anastomosis smaller and not sure about the pouch because it is not very big but the stoma is. What side effects beyond that of DS is there? Also, what about the malabsorption of the carbohydrates is that possible with either?

There are many advantages of the DS. First, we have a smaller stomach (the sleeve) with normal emptying through the pyloric valve, which allows for regulation of stomach emptying. With the pouch and stoma, there is no valve, so stomach (pouch) emptying isn't regulated. If the stoma is too big there is no restriction and also possible reactive hypoglycemia from rapid passage of food into the small intestine. The pouch is always empty no matter how small it is, which also promotes weight regain. If the stoma is too small it's a stricture, and that isn't good either.

The malabsorption of the DS is mostly selective fat malabsorption - we absorb only about 20% of the fat we consume - and about 40 - 60% protein malabsorption, which means we have to consume plenty of protein. But with the fat malabsorption, we are not limited to lean proteins. We can eat either lean or fatty proteins and not worry about the fat. We can also use most any cooking method. Carbs are well absorbed with either DS or gastric bypass so we still need to be careful about carbs.

I guess now I'm wondering how many times you want to have your stoma worked on. The first two operations have still left you with an excessively wide stoma. Is the third time really going to be the charm?

Larra

I'm in Virginia, who do you recommend? I was advised by Dr. Ungston in Mexicalli that because this is my third time the complications of a leak are highly more likely and other risk are higher. I would have to totally reverse the RNY to get the sleeve when an ERNY I would get all the benefits of a modified DS.. Who did your DS? When? Was it an RNY revision? I wonder if the third tine will be a charm as well???????????????????/