Question regarding a revision from a RNY to DS

Hello, I have a question regarding a revision from a RNY done in 2002 to a DS. After the RNY I lost all the weight I needed, got rid of my hypertension, high cholesterol and all other problems that I had. Everything was great until about 3 months ago when I started having pain on the left side of my abdomen after I would eat or drink anything, it went away by itself. But since that I noticed serious weight gain I mean 50 % of what I lost. I always feel hungry even right after I eat. I still exercise, eat a lot of protein. I tried water loading and I notices that I can drink almost 30 oz of water at one time, I don't think that's normal after a gastric bypass. Anyway I have an appointment with doctor Roslin in NYC next week. At this moment my weight is not that bad 180 lbs at 5' 5' but now I'm back on my blood pressure meds and cholesterol is high again. Do you think I'm a good candidate for a switch to DS? Thank you. M. R.

M.R. I am not sure what to say to this post but know that I wanted to send my thoughts and prayers that this works out of you. ~hugs~ I know after you lost weight and have a gain back of any size it really sucks! I wish you the very best hun, keep us posted on how it goes next week. Debra P

Hi M.R. I am no expert by ANY means but here is a question: My Mom had a similar thing happen. After the pain "day", and yes i mean DAY....it was short-lived....she could eat anything and everything....stuff she could not eat for 5 years post-op. The thing is: she had her RNY in 1998 and her surgeon used to do it the same as it's done now *BUT* with the addition of a tiny band where current RNY'ers don't get that. Even her doctor stopped using it. YES, it was a true RNY (not a lap) but the old thinking was to use a band where the new pounch starts where now they use a combination of staples and stitches. After that day, she gained 80 pounds back. By the way: in 1998 she had it done in Florida; it was not nearly as well known as it is now. She met with my surgeon, Dr. Garber, and he is about to embark on a new repairatory procedure to "fix broken" RNY's....and the awesome thing is that is will be done via ENDOSCOPE! (down the throat). No new cutting! He's going to be the first in NY to do it; right now it's only done at Brigham's and Women's Hospital. My Mom met Dr. Garber and is on his waiting list. He expects to start it some time towards the end of 2006. Anyway....again: I am no expert but it's just something to consider before undergoing more surgery. Keep me posted and hugssss, Karen

MR: Was your orignial surgery open or lap? Do you have the surgical report? (IF NOT GET IT!) we should all have a cop just in case yrs down the road there is an issue and ya know surgeons retired, records get lost, burned in unexpected fires, lawsuits place surgeons out of business and sometimes records are never found again etc). Anyways call hosp. u had surgery at get a release for it and they should send it. As for water/fluids no restriction shuld happen, I can drink/guzzle 4 cups water in a 10 min time, that is normal (from what i havee exp, heard form others told by surgeon) esp at 4 yrs out. Early on itis a different story. WHAT u eat has as much to do w/ rgain and hunger as well (carbs=hunger sooner vs protein=fullness n pouch and less insulin/glucose spike etc) I recommend an upper GI series (scope and xray w/ barium) to see if you have a staple line disruption (*were you transected, the pouch from the unused tummy? *it should say in surgical report) Staple line disruptions are common w/ older surgeries, most surgeons (all lap one due to equiptment.staplers used) transect...Unfort some surgeons still do not, 6 lines of staples can and do fail! In this way you may be eating into old tummy and getting acid in that pouch (ouchie!) and well not malabsorbing and able to eat more. The scope/UGI w barium should tell this, or you could have an ulcer causing the pain, or a gastro-gastro fistula, althogh rare, a connection can form between pouch/distal stomach some small and some larger... again need imaging studies to see... Now regain happens if we stop doing what we always did to lose the wt, erosion of healthy lifeestyle changes (dietary/exercise) regardless of tool people tend to regain at 1-2 or more yrs out. it only takes 100 cal extra a day for a yr to gain 10#! You may just need a transection or the like. But RNY to DS is doable, I WOULD ONLY GO TO A VERY VERY experienced revision bariatric surgeon (like Dr. Gagner in NYC, he was first to do lap DS! and is a guru.ell respected in bariatric community) not saying another surgeon can not be good, but the DS from RNY is serious business and recisions caryy MUCH MUCH higher complications.mortality so nothing should be entered into lightly! This is a document I send to members of my osg off track group to see if they thinkthey need a revision.. also check out the revision sites: ~~~~~~~~~~~~~~~~~ DO I NEED A REVISION? What are your issues/ideas/thoughts on why insufficient wt loss or regain? Solution/recommendations may be different depending on answers.... Three things may be happening independent or together: ü Broken Surgery (tool) ü Behavioral issues (not using tool ü Wrong tool/surgery 1. BROKEN SURGERY: a. WERE YOU Open or Lap? b. Were you transected (pouch and distal unused stomach severed by staples and cut by space?) IF not maybe the issue is a staple line disruption/failure (AKA SLD)...food is going into the old tummy and no malabsorption is happening. Or a fistula ("A gastro-gastric fistula is simply a communication between the new "pouch" and the "old" stomach.)*Same as SLD your getting food into distal stomach and it avoids the bypass. c. Have you had an upper GI endoscopy? (Scope down throat) to see if pouch is intact and how large your stoma is (connection of pouch and intestines). Many have an enlarged stoma allowing them to eat larger quantities w/o feeling full, kind of like a chute. This is usually not patients or surgeons fault but many patients stomas relax on them...Some possible fixes:A lap band may help,or a surgical revision of stoma or a fixed silastic ring, but it isn't always possible. Also many are using sclerotherapy http://www.ingentaconnect.com/content/fd/os/2003/00000013/00000002/art00006 or http://www.drsimpson.com/chattranscript-08-13-2004.php for info. They say for this (inject substance thru upper GI scope into tissue to produce scarring) and there is a new procedure in Boston being done called: Endoscopic pouch repair. http://community.nursingspectrum.com/MagazineArticles/article.cfm?AID=14602 d. Do you get full? How much food? Have you done the cottage cheese test? http://www.digitalhorsewoman.com/pouchrules.htm 2. BEHAVIORAL (not using tool to potential):I am not saying it is behavioral just asking a few questions: a. What do you eat in a given day? Calories track on www.fitday.com % fat/protein/carbs. b. Do you drink with meals? c. Drink calories? d. Soda? e. Do you do protein shakes? (type/number) f. Do you do vitamins? Which ones? Types/amounts/when do you take them? g. When were your last full set of labs/Dexascan? h. Do you exercise? How often? Amount? Type? i. What other meds are you on? Medcial conditions? j. Age, Height? Starting BMI Current BMI. (Basically looking for % of excess you lost) k. Do you follow pouch rules? http://www.digitalhorsewoman.com/pouchrules.htm We can eat more at ~6 months out (quantity/variety), it is also time malabsorbtion of calories decreases for many as body adapts. (intestines can elongate/grow more villi/folds to increase absorbtion) OKAY the above questions are just to help us figure out some potential behavioral issues. Again I am NOT saying the failure of you or anyone is strictly behavioral. It is just one thing. Any surgery can be defeated if the tool isn't used, BUT if the tool is used reasonably it may be broke or may of been the wrong tool (surgery) for you! IF YOU DID NOT CHANGE YOUR LIFESTYLE THER IS NO TOOL THAT WILL WORK! 3 WRONG SURGERY: We do not always know this until after. Some surgeons realize the higher the BMI of the patient the more distal bypassed they should be. Or the type of eater someone is may lend itself to one surgery over another. Some fail to lose wt with a VBG or lap band only to lose well with a RNY or many with a proximal RNY fail to lose wt and do great with a distal RNY or others don't do well with RNY and do fantastic with a BPD/DS...you get my point. One surgeon had this to say about choosing your surgery type for you. (*I am not sure there is any real one size fits all though on deciding!) http://www.alagsa.com/Bariatric_Surgery.htm Some surgeons do a very short 40CM bypass (not near long enough for most of us MO)! Get a copy of your surgical report from the hospital medical records so you KNOW what you have! It is yours according to law! They say 50% of excess wt lost is a 'successful surgery'. I agree *but why accept this? when others lose 75, 80, 90, 100%? I know everyone is different but if there are means to allow most to lost 80+ % why shouldn't everyone have the opportunity? We all have to weigh the pros and cons. Going BPD/DS or more distal has risks, a lap band has risks etc. Many lose 80%+ and regain after 1, 2, 3,5 yrs. Not always behavioral or mechanical,,,,so their body is real good at adapting and hence they probably had wrong surgery.... I hope this helps some and doesn't really confuse you. I have to add, I haven't had a revision. I am here learning with everyone "IN CASE" (I think education is key to success and all I can arm myself with!). It (regain) scares me too! I see/read/hear about wt regain more and more online and read more about revisions. WLS has come a long way, but maybe just maybe some day we'll get the right surgery the first time! One that we can behaviorally adapt to and use and that won't break! ONE CAN DREAM! I think a good revision surgeon is key to lower risks, I wouldn't go to just anyone! And I know many on the group could help u with someone good! Dr Fox and Oh in Washington State. http://www.aboutmso.com/pp/prospectivepatients.cfm http://www.ohtobethin.com/ Dr. Gagner in NYC: http://www.cornellweightlosssurgery.org/ This is a great group http://groups.yahoo.com/group/WLSrevisionsupport/ of people who can definately lead u in the right direction! I also know OH has 2 different Revision Forum. http://www.obesityhelp.com/morbidobesity/amosforums/failed_wls_second_time_around http://www.obesityhelp.com/morbidobesity/surgtype-forums/Revision/ ~~~~~~~~~~~~ Take Care, Jamie Lap RNY 10/9/02 Dr. Singh 320/163 5'9'' (lost 45# before surgery) Plastics 6/9/04 & 11/11/2005 Dr. King http://www.obesityhelp.com/morbidobesity/members/profile.php?N=c1132518510 "Being happy doesn't mean everything's perfect, it just means you've decided to see beyond the imperfections!"

Thank you all for your replies. I had an open RNY and I'm going to get Upper GI tomorrow. As far as the operative report I already called the hospital it takes 10 days. Once again thank you. M.R.