ABC's of Revision

    Reading the posts on the Revision Forum, it has become clear that there is a great deal of confusion regarding revisions. It is my goal to eliminate this confusion. Over the next several weeks I will discuss revisionary WLS from A to Z. I am aware that this is an enormous project. In order to enable you to fully digest all of this information, I will provide you a managable "bite" each week.                          The greatest journey begins with a single step. (Chinese Proverb)     The best place to begin our journey is a review of the principles of  WLS. These principles are every bit as pertinent to revisions as they were to your initial procedure. With the exception of "the sleeve" (VSG), all WLS procedures reside along a spectrum. At one end of the spectrum are the essentially resrictive procedures and at the other end of the spectrum are the highly malabsorptive operations.          Restrictive operations work by severely limiting the amount of food your are able to eat at a given meal. The most commonly performed essentially restrictive procedure is the Lap-Band. The Lap-Band is a silicon ring that is placed around the upper portion of the stomach. The "pouch" created in this procedure is the upper portion of the stomach. Ideally the Lap-Band "pouch" should have a volume of 1/2 fluid ounce or 15 cc. "Pouch" sizes up to 1 fluid ounce (30 cc) are acceptable. Anything larger is not sufficiently restrictive. The Lap-Band is currently the only procedure which is adjustable without another operation. The outlet of the "pouch" can be tightened by inflating the "ballon" on the inside of the band with sal****er (saline). Tightening the Lap-Bang increases the restriction by narrowing the outlet of the "pouch".     Highly malabsorptive operations create a very short common conduit, thereby preventing you from absorbing much of the nutrients in the food you eat. The common conduit is the part of the intestine which sees both food and digestive juices. Classic malabsorptive procedures have a common conduit of between 50 cm and 100 cm. The shorter the common conduit, the less nutrients your body is able to absorb. Highly malabsorptive procedures are the duodenal switch (DS), extended Roux-en-Y (ERny), and the less commonly performed bilio-pancreatic diversion (BPD). In the ERny nothing is removed. In the DS and BPD a large portion of the stomach is removed at surgery. The  "Dumping Syndrome" will likely occur after the ERny or BPD, but not the DS.      In between the essentially restrictive procedures (Lap-Band) and the highly malabsorptive operations (ERny, DS, and BPD) is the "classic" gastric by-pass (Rny). Rny's are excellent restrictive operations. The Rny "pouch" is constructed to be able to hold between 1/2 and 1 fluid ounce. The stoma (pouch outlet)  should be  about 12 mm in diameter. There are two basic varieties of  ther "classic" Rny, proximal and distal. The difference between the two is the lenth of small intestine which is excluded from "the food stream". The proximal Rny excludes 150 cm of the small bowel or less. The distal Rny excludes 150 cm  or more of small bowel (classically no more than 250 cm). Excluding more small intestine  from the food stream increases the malabsorptive component of the Rny. Neither the proximal or "classic" distal Rny is a highly malabsorptive procedure.      The "sleeve" (VSG) works in two ways. There is a restrictive element to the VSG. However the restriction created by this operation is insufficient to explain its successful results. Part of the efficacy of the "sleeve"  is due to the reduction in grehlin levels caused by removing a large portion of the stomach. To date it is not known how long this reduction in grehlin will persist.     These principles will not only give you a clearer "picture" of your initial operation; they will enable you to better understand revisionary surgery.  Armed with this information you will be able to actively and intelligently participate in any discussion of your revision. Now that we are all speaking the "same language"; let the dialogue begin.     Next week: Why do Rny patients commonly experience a weight regain? Until my next post, remember; There is NO profit in pessimism! Claim the success you deserve! NEVER GIVE UP! Eric Schlesinger, MD, FACS AZ Weight Loss Solutions

Thank you so much for your informative post.  

Thank you for that informative post Dr. Schlesinger.  That was more information than most of us knew, and a good refresher for others.  Many will be anxiously awaiting your next installment on weight regain after Rny.  Whether we're having some type of revision, StomaphyX, or the RESTORe procedure, we're all grapling with various degrees of disordered eating issues that returned after our initial successes with WLS (dilations of pouch and stoma aside).  Thanks for taking the time to educate us. Betsy (current in the RESTORe study in Baltimore)

Hello Dr. Schlesinger, It is so refreshing to see a physician that is willing to provide us education regarding these issues.  I was evaluated for the RESTORe procedure but was told during the endoscopy that they were unable to measure my stoma because of my anatomy and that my pouch was 8-9cm in size.  I contacted the surgeon who was going to do the procedure and he wants to evaluate me for the Stomaphyx procedure.  I also have been looking at the ROSE procedure which seems to be very similiar to the RESTORe procedure.  My question is: If my anatomy is incorrect, then how can any of these procedures be completed?  I don't want to waste money on Stomaphyx if it will not be successful.  Have you got any suggestions for me?  Thanks Kathy

Kathy, Your concerns are appropriate and extremely important. You should pose these questions to your treating physician. The discussion regarding your possible revision should include malabsorption as well as restriction. Be certain to communicate your desires and expectations to any surgeon with whom you consult. A surgeon who is unwilling to discuss ALL of your options or is unable to adequately answer your questions in a way you understand is the WRONG surgeon for you. Eric Schlesinger, MD, FACS AZ Weight Loss Solutions

Excluding more small intestine from the food stream increases the malabsorptive component of the Rny.Neither the proximal or the "classic" distal Rny is a highly malabsorptive procedure. Could you please answer a question on this statement please ?  If the rny proximal and distal are not highly malabsoptive then why are they done ?How much malabsorption is there ? I have a 2mt bypass and that is why I ask ? Regards  Susie

Susie, The "classic" Rny employs excellent restriction with a mild to moderate component of malabsorption. "Classic" Rny's (proxomal and distal)rely more on restriction than malabsorption to achieve their results. This avoids some of the consequences/risks (vitamin deficiencies, mineral deficienies, protein deficiency) of highly malabsorptive procedures. As a rule of thumb "classic" Rny patients do not need to take as many supplents as ERny, DS, or BPD patients. Avoiding some of these consequences/risks make these patients easier to manage and follow. In todays environment, where more and more bariatric surgeons have chosen not to personally provide their patients with lifetime follow-up, avoiding highly malabsorptive procedures decreases some of the patient risks and enables these bariatric surgeons to avoid the liability that results from not continuing to care for these "at risk" patients. In fairness, some bariatric surgeons believe that the risks of highly malabsorptive procedures are unacceptable. Those of us who perform highly malabsorptive operations know that the risks are acceptable and the consequences can be avoided or corrected. Every bariatric patient deserves expert, competent lifetime care; none more so than those with a highly malabsorptive procedure. Patients with highly malabsorptive procedures must be even more compliant than other bariatric patients. The responsibility is a shared one. Eric Schlesinger, MD, FACS AZ Weight Loss Solutions

What is your approximate cost of a revision from proximal to distal RNY and do you do DS revision and if so how much.  I realize every case is different but an approximate cost would be nice.  One more question, are your revisions from proximal to distal done open or are you able to do some lap?

Cheryl, Each case is different. If you would like, you may call my office at 480-419-2280. You could then privately provide us with the details of your situation. With this additional information we would be delighted to discuss your options and answer all of your questions. I look forward to hearing from you. Eric Schlesinger, MD, FACS AZ Weight Loss Solutions

Dr Schlesinger :  what is considered normal stretching for stoma and pouch for a post-op?  A recent EGD provided me with a guesstimate of the size of my pouch (4-5 cm in length) and stoma (20-24 mm).  I know it is an inexact process to measure both, but this gives me a rough idea of what size I currently have at 4+ years post-op.  My original pouch was 30 cc and I am not sure how to translate that to a length measurement and my stoma was originally 12 mm.   Thank you. Sandra B