ABC's of Revisions V "Making Choices"
Please pardon the absence of the ABC's of Revisions for the last several weeks. I am certain that all of you can relate to just how crazy life can be.
Weight Loss Surgery is one of my passions; just ask any of my patients. It is criminal the way morbidly obese people are treated. The only people treated worse than someone seeking WLS, are those who are trying to obtain a revision for an operation that "came up short." There is very little that is more disturbing than hearing that one of you has been told, "nothing can be done." Not only is this statement cruel and emotionally devastating; it is blatantly FALSE! There are virtually always options. It is simply a matter of identifying the component of your surgery (restrictve or malabsorptive) that needs to be made more powerful. Clearly there are many things to consider in this decision making process.
What is YOUR goal? The only person who is able to answer this question is you. Do you want to lose the 30 pounds that you regained? Do you want to lose the 100+ that never came off with your initial surgery? Did an orthopedist tell you that you had to lose weight before you could have a hip or knee replaced? Did your PCP tell you that unless you lost more weight you would have to resume taking medication for diabetes? The list of questions and reasons is endless. So, your first task is to identify YOUR GOAL. Once you know exactly what you need and want, you are ready to speak with your surgeon. We have previously looked at some of the requirements that can help you choose your revision surgeon. An essential requirement is that he/she must truly communicate with you. If the surgeon never asks what you are hoping to achieve; find another surgeon.
When you discuss your revision with your surgeon don't fixate solely on the surgical risks. The risks are real and it is important to understand them, but remember to discuss the consequences of each of your options. Listen carefully. It's necessary to have a positive attitude, but don't fall into the trap of failing to seriously consider the consequences. Consequences happen and they can happen to you. Here are just a couple of examples. Ramping up the restriction could result in dilating or stretching your esophagus. Increasing the malabsorption could result in a long, pitched battle with diarrhea. No one expects problems, but they do occur. Will your surgeon be there for you if you run into an unpleasant consequence? It's hard to know for sure, but if he/she cannot or will not engage in a frank dialogue about consequences; it's a safe bet that he/she will be MIA if one should occur.
Each revision patient is unique. I have attempted to cover the major principles that can guide you on your journey. The only way to be certain to address your individual needs is with a personal dialogue. Choosing your revision surgeon is the biggest and most important decision each of you will have to make. Be certain to choose someone who not only provides you with all of your options, but who treats you with the respect, care and concern you deserve. Your revision surgeon must be able to communicate with you in a way that you understand. He/she must be personally invested in your success. Both you and your surgeon must commit to working together for a life-time. Anything less is unacceptable.
As Rev. Jackson stated, it is our responsibility to "keep hope alive." With faith, dedication, hard work, and commitment YOU WILL SUCCEED!
CLAIM THE SUCCESS YOU DESERVE!
ACCEPT NOTHING LESS!
Eric Schlesinger, MD, FACS
AZ Weight Loss Solutions
Weight Loss Surgery is one of my passions; just ask any of my patients. It is criminal the way morbidly obese people are treated. The only people treated worse than someone seeking WLS, are those who are trying to obtain a revision for an operation that "came up short." There is very little that is more disturbing than hearing that one of you has been told, "nothing can be done." Not only is this statement cruel and emotionally devastating; it is blatantly FALSE! There are virtually always options. It is simply a matter of identifying the component of your surgery (restrictve or malabsorptive) that needs to be made more powerful. Clearly there are many things to consider in this decision making process.
What is YOUR goal? The only person who is able to answer this question is you. Do you want to lose the 30 pounds that you regained? Do you want to lose the 100+ that never came off with your initial surgery? Did an orthopedist tell you that you had to lose weight before you could have a hip or knee replaced? Did your PCP tell you that unless you lost more weight you would have to resume taking medication for diabetes? The list of questions and reasons is endless. So, your first task is to identify YOUR GOAL. Once you know exactly what you need and want, you are ready to speak with your surgeon. We have previously looked at some of the requirements that can help you choose your revision surgeon. An essential requirement is that he/she must truly communicate with you. If the surgeon never asks what you are hoping to achieve; find another surgeon.
When you discuss your revision with your surgeon don't fixate solely on the surgical risks. The risks are real and it is important to understand them, but remember to discuss the consequences of each of your options. Listen carefully. It's necessary to have a positive attitude, but don't fall into the trap of failing to seriously consider the consequences. Consequences happen and they can happen to you. Here are just a couple of examples. Ramping up the restriction could result in dilating or stretching your esophagus. Increasing the malabsorption could result in a long, pitched battle with diarrhea. No one expects problems, but they do occur. Will your surgeon be there for you if you run into an unpleasant consequence? It's hard to know for sure, but if he/she cannot or will not engage in a frank dialogue about consequences; it's a safe bet that he/she will be MIA if one should occur.
Each revision patient is unique. I have attempted to cover the major principles that can guide you on your journey. The only way to be certain to address your individual needs is with a personal dialogue. Choosing your revision surgeon is the biggest and most important decision each of you will have to make. Be certain to choose someone who not only provides you with all of your options, but who treats you with the respect, care and concern you deserve. Your revision surgeon must be able to communicate with you in a way that you understand. He/she must be personally invested in your success. Both you and your surgeon must commit to working together for a life-time. Anything less is unacceptable.
As Rev. Jackson stated, it is our responsibility to "keep hope alive." With faith, dedication, hard work, and commitment YOU WILL SUCCEED!
CLAIM THE SUCCESS YOU DESERVE!
ACCEPT NOTHING LESS!
Eric Schlesinger, MD, FACS
AZ Weight Loss Solutions
I am going to get anEGD done on 04/07 my Stoma is extremely dialated but my pouch is the size of a large egg still. During the EGD my Dr is wanting to do a partial Cologen fill until I can get lap over rny . I was one of the ones who did great with 0.5-1.0 oz pouch until my pregnancies. My Stoma is dialated to almost the size of a quarter and my stomach I was told is not big enough for a VSG. I am anemic and so I dont need more malobsorbtion. Does Lap over RNY w/ cologen fill sound like a good alternative revision for someone who likes eating 8-10 1oz meals a day ? I dont like to be hungry I like to eat because I have to not because I am hungry. I know I am not typical but my mother is in a similar situation but her stoma is not as bad so she is doing just cologen fill. I love my surgeon rather than insult me for regaining weight he praised me for losing 220 lbs in 1 1/2 years my 1st time. My original Dr just wanted to do BPD and not fix stoma which I felt was avoiding the problem and making nutrition worse for me. So does what my new Dr suggest sound right?
Mary Teresa,
You have posed several questions, but I do not see what your goal and desires are. These questions must be answered before anyone can design the revision that is right for you.
Let's address the questions that you have raised.
There is no good data regarding the use of collagen to decrease the size of a pouch or stoma after Rny. We may gain some insight by looking at the results of collagen fills to diminish or recontour facial wrinkles. Products like Restalyn are only temporary answers. The length or duration of their efficacy depends on several factors. One of the major factors affecting how long the collagen fill will last, is the contraction of the underlying muscles. Without the use of a muscle-paralyzing agent such as Botox, collagen fills will at best "stand up" for only a few months. Your pouch is composed of three layers of muscle, which should be contracting to aid in its emptying. Under these cir****tances, I wouldn't expect the collagen fill to last very long or to be very effective.
How large is your pouch? Are we talking about a "grade A large" chicken egg? What is the shape or configuration of your pouch? Without this information, which would require a review of your upper GI, it is impossible to comment on your anatomic status as a candidate for a "Band Over" procedure.
Why do you "have to" eat 8 to 10 meals a day? Are you having issues with low blood sugar? Are your meals only 1 oz? Have you had an intensive review of your dietary program? Have you investigated biofeedback or some other form of behavior modification?
Has your surgeon explained how the "Band Over" procedure will address your specific issues, behaviors and needs?
Why are you anemic (iron, B12, both)? What has been done to correct your low blood count? What are the rest of the results from your most recent malabsorptive panel?
Without the answer to these questions and several more, it is impossible to offer an informed opinion. This forum is not the appropriate venue to conduct a medical consultation. However, based on the limited information provided, and without a significant change in your dietary behavior, I believe that a "Band Over" procedure may NOT provide you with the results you desire.
You have many questions that need to be answered before proceeding with any revision. I hope that you find my reply helpful in providing you with some of the questions.
GOOD LUCK!
Eric Schlesinger, MD, FACS
AZ Weight Loss Solutions
I only eat 3 meals a day and due to insatiable hunger from my stomach being always empty I snack. I did really well when I was doing 1oz meals b4 the pregnancies. My pouch looks like a regular stomach except the size of a large egg . I can not get proper hemogoban levels due to my inability to handle meat I take B12 shots and Iron shots keep me at an 8 count but with out those I dropped during my pregnancies to 3.5 and had to get 3 cpacks. As far as the pouch yes it is the size of a large chicken egg. My blood tests showed everything was normal except my Hemogloban iron and it was still at 8. The radiologist said that the Barium just skipped by my stomach didnot even stay in it long enough for him to get the shots hardly I had to drink 2 full glasses of the stuff to get through the test he told me it was my stoma that was the problem. Hope this helps.
Yeah your BACK !!!
Missed reading your postings !!
So I am sure we will be talking in the very near future - I need to ask a questions , What are the questions we all should be asking at our consultations - Some of us have the gift of GAB and get off track . What are the real choices for revision of rny ? , and what research should we be doing ?? before our inital consults ??
I think my major concern is long term and I dont know if there is any data out there in the world wide web. What topic would you suggest to search
Gina,
As usual, excellent questions! Perhaps I will make them the topic for next week's posting. For those of you who cannot wait, read my reply to Mary Teresa. It may provide you with some of the questions.
I look forward to seeing you in the office soon!
Eric Schlesinger, MD, FACS
AZ Weight Loss Solutions
As usual, excellent questions! Perhaps I will make them the topic for next week's posting. For those of you who cannot wait, read my reply to Mary Teresa. It may provide you with some of the questions.
I look forward to seeing you in the office soon!
Eric Schlesinger, MD, FACS
AZ Weight Loss Solutions
I'm so glad to see your post! I spoke with you about a month ago and can't thank you enough for your kindness and positive outlook for those of us who are struggling.I went to my pcp to get the ok for a revison. Because my inusrance is Tricare they sent a referral out for me to be done at a local military hospital and I spoke with a surgeon last week.I originally had a proximal RNY. I am now very worried as his idea of a revision is to go in and redo the whole surgery by making my pouch very, very small he said and enlarging the stoma . Am I not understanding this surgery correctly?That doesn't make any sense to me. I asked about doing a distal and he said absolutely not and he also told me the only reason I was having problems was because I am eating way to much ( even tho he has no clue what I eat-it was never discussed) He said anyone who gains is because they simply eat way to much and don't exercise enough. HELP! I am hoping to get the funds together and pay a visit to AZ WLS!!!
Thak gain forthe great help you offer this board
Sharon A
Dr Schlesinger Thanks so much for taking the time to chat with us, I had a question about revision I was wondering if you could shed any light on! I am having a revision april 9 for blind loop syndrome enlarged pouch and stoma I will be having stomaphyx, fixing the blind loop and bypassing more intestine (open) , regarding recovery do you think this will be more painful / stressful then the actual first surgery? thnaks!
Christine,
It is extremely difficult to predict pain after a procedure. That said, I do not believe that you will have more pain this time around. By the usual criteria, the pain should be less.
Stress and surgery go hand in hand. I know Dr. Overcash well. You are in good hands and he will certainly take good care of you. Let him know your concerns about pain. He will make certain that your pain is well controlled.
GOOD LUCK!
Eric Schlesinger, MD, FACS
AZ Weight Loss Solutions
It is extremely difficult to predict pain after a procedure. That said, I do not believe that you will have more pain this time around. By the usual criteria, the pain should be less.
Stress and surgery go hand in hand. I know Dr. Overcash well. You are in good hands and he will certainly take good care of you. Let him know your concerns about pain. He will make certain that your pain is well controlled.
GOOD LUCK!
Eric Schlesinger, MD, FACS
AZ Weight Loss Solutions
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