The ABC's of Revision A to Z
Welcome to all returning and new future successes!
Over the last couple of months I have made six posts under this title. I hope that those who have been following these posts have found them instructive and helpful. We have covered a great deal of material. Some of you have suggested that having all of the information in one place would be helpful. I have made some corrections, additions, and revisions in combining all of the previous articles.
NEVER GIVE UP!
CLAIM THE SUCCESS YOU DESERVE!
GOOD LUCK!
Eric Schlesinger, MD, FACS
AZ Weight Loss Solutions
The ABC's of Revision
The greatest journey begins with a single step. (Chinese Proverb)
The Basics
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 restrictive 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 "balloon" 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 the "classic" Rny, proximal and distal. The difference between the two is the length 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 intestines 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.
Weight Regain I
Weight regain after a "classic" Rny is NOT unusual. In fact it occurs so frequently that your bariatric surgeon should have discussed this with you at your initial consultation.
Often the first question I am asked by a patient interested in a revision is; "What did I do? How did I break my "tool"?" While these are not unreasonable questions; they are not the correct ones. It is EXTREMELY difficult to "break your tool." Sadly, many surgeons "feel better" if they can blame their patients. I recently saw a young lady who had her Rny performed by another surgeon. She had regained nearly all of the weight she had lost. Her after care left much to be desired. In spite of this, she scheduled an appointment with her bariatric surgeon to learn what could be done. The surgeon entered the exam room. Before this lovely young lady could say a word, her surgeon began scolding her. He rudely declared, "You...Look what you've done to my surgery!" In all my years of practice, I have never heard such a terrible story or a more inappropriate, incorrect response.
Unless this woman had been flagrantly disregarding her nutritional program (she wasn't), her weight regain was NOT her fault. None of us is perfect. Everyone "cheats" from time to time. I tell all of my patients that they are entitled to a treat. Allow yourself a treat from time to time and when you do treat yourself, make it special. While these treats may lessen your weight loss, if they are limited to special occasions, they will not result in significant weight regain.
OK, then why do Rny patients experience weight regain? There are three factors that contribute to this weight regain.
First, the pouch has a tendency to "stretch" over time. Different pouches stretch differently. Pouches based off of the right side of the stomach (lesser curve) stretch less than pouches based off of the left side of the stomach (greater curve).
Second, the stoma (connection between the pouch and small intestine) also has a tendency to enlarge over time.
Third, the body is a miraculous thing. It is constantly adapting and changing. Over time your small intestine adapts to its reduced length by becoming better at absorbing the nutrients that are presented to it. It becomes more efficient.
In summary, through no fault of your own (unless you have been flagrantly abusing yourself and your operation), both the restrictive and malabsorptive components of your by-pass will diminish. That is why a degree of weight regain is the norm; not the exception.
So, what can we do about it? That is the topic for a future posting.
Remember; there are NO failures, only those who have yet to succeed!
Weight Regain II
Let's begin with a few words about surgeons. As a child most of us were told, "A poor carpenter blames his/her tools." Based on behavior, some of us, surgeons, have not yet "grown up." One aspect of this "failure" is that children rarely if ever take responsibility for bad results. This and the purely restrictive nature of the operation place Lap-Banders at jeopardy of an unwarranted verbal assault. If your weight loss has been lagging or you have regained some weight, a "maturity challenged" surgeon may begin by reprimanding you for "eating around" your Band. While a thorough discussion and review of your nutritional program is a vital part of each follow-up visit; accusations are not.
If your behavior won't explain the less than stellar weight loss, the next likely "suspect" he/she may blame is the Lap-Band and/or Port. Mechanical failures of the Band/Port do occur, but are EXTREMELY RARE! Diagnosis should initially be pursued without a scalpel. A "Band-o-Gram" should be the first test to demonstrate or exclude the diagnosis of a "leaky" Band or Port. This is an X-Ray study very similar to having your band adjusted under fluoroscopy. No diagnostic test is 100% accurate, however this is a very good test.
Now that we have dealt with the Doogey Howser MD's. Let's consider more likely causes.
Band Placement.
Was the Band placed in the proper position (15-30 cc upper stomach)? Has the Band "slipped"?
As a first step, a plain abdominal X-Ray will show if the Band is in high in the left upper abdomen; if it is correctly "tipped" (pointing toward the left shoulder). If further diagnostic tests are needed; an upper endoscopy, upper GI series, and an abdominal CT scan with contrast can all provide valuable information. More than one of these tests may be required.
Band Erosion
If your Band has eroded, slightly more common than hen's teeth, this could explain a weight regain. The best way to make this diagnosis is with an upper endoscopy.
Band Loosening
Just as your trousers/skirt will become loose as you lose weight, so too can your Band. This can be simply determined by a fill.
Band Adjustment
Has your Band ever been tightened to the "Sweet Spot"? If your are able to eat steak (without prior shredding), white bread, sticky rice, etc., you have not had your Band adequately tightened.
Have you been "listening" to your body? Do you stop eating or take a break when you begin to feel that "pressure" sensation under your breast bone? If you haven't been paying attention to the advice that your body has been giving you, you may have stretched your esophagus. If this has happened, you have effectively enlarged your pouch. Your food pipe is now acting as a reservoir. This problem can sometimes be corrected by going back to basics for several months. Adhere strictly to portion size. Solid meals should require no less than 30 minutes to consume. A more aggressive approach to "shrinking" your food pipe would be to revert to a liquid diet. Again, portion control is vital. Neither approach is uniformly successful. If this treatment is going to succeed, it will take months. An upper GI before and after this treatment can document whether or not it has been successful. If your esophagus has returned to normal size, you will find that you are not able to eat as much at any given sitting. You may once again experience that "pressure" sensation.
Was the Band the correct operation? I know that this is a very "touchy" subject and painful question. No one operation is the correct one for everyone. I know that it's late to be considering this question, but... Better late than never.
Revision Operations
Hopefully we have developed a common vocabulary and gained some insight regarding the limitations of different procedures.
Revisions for Rny'ers
There are two major aspects of a by-pass that may be revised. The restrictive component and the malabsorptive component.
Restriction
As we have discussed, it is common to be able to eat more months to years after your initial surgery. There are many different reasons for this. I will mention only in passing that a small component of this is the skill that you have developed with experience. You have become experts at eating slowly and chewing your food thoroughly. You have learned what "sits" well and what doesn't.
If your pouch wasn't too large when it was constructed, it is prone to "stretch" over time. The same is true for your stoma. This does NOT mean that you did something wrong. In many ways it is as inevitable as the sun rising tomorrow. So your pouch/stoma is dilated, now what?
There are several different approaches to dealing with this.
Stomaphyx is a safe and effective way to decrease the size (volume) of your pouch and its outflow tract. You may have read that Stomaphyx does not "tighten up" the stoma. This statement is misleading. Although no fasteners are place in the stoma, the concentric pleating immediately above the stoma will "tighten up" the out flow from your pouch. Think about your garden hose. Pinching the hose will narrow its opening and restrict the flow of water. Where ever you pinch the hose, this maneuver will have the same effect. So, even though no fasteners are placed in the stoma, properly performed, Stomaphyx will effectively "tighten up" your stoma. Due to its minimally invasive approach, LOW risk and the universality of some degree of pouch and stomal dilatation, pre-Stomaphyx upper GI's or endoscopies (separate anesthesia) are not an absolute prerequisite. Pouches with a volume, capacity of over 250 cc (normal 15-30 cc) are better addressed with procedures other than Stomaphyx. Tubular pouches are better suited for Stomaphyx than globular or spherical pouches. Right sided stomas are better suited for this treatment than left sided stomas. Having said this, I have had excellent results with unfavorable pouches and stomas.
Lap-Band over Rny can result in a dramatic improvement in restriction. Before a Lap-Band over Rny is performed the pouch must be evaluated with either an upper GI (X-Ray) or an upper endoscopy. While relatively small pouches can benefit from Stomaphyx, small pouches will NOT benefit from a Lap-Band. The reason is simple mechanics. If the pouch is too small to be "pinched" by the Band, the Band will serve no purpose. Lap-Band over Rny carries a higher risk than Stomaphyx. As in all weight loss surgery, the procedure chosen must be "matched" to the patient's anatomy, physiology, emotional make up, needs and desires. With the proper match, Lap-Band over Rny will yield excellent results.
The pouch and stoma can be surgically reconstructed. This approach carries with it risks that are even greater than Lap-Band over Rny. The stomach is much more unforgiving after it has been operated on once. The risk of a leak is significant. In fact, this risk is the major contributing factor for the reported "high risk" of revisions. Additionally, the surgically revised pouch and stoma is not immune from "stretching" again.
Malabsorption
For the vast majority of patient, a revision which significantly increases the malabsorptive component of their by-pass will result in the greatest weight loss. This increase in malabsorption is achieved by moving the Y further "down stream". This shortens the common conduit (bowel carrying both food and digestive juices)while lengthening the bilio-pancreatic limb (the bowel carrying only the digestive juices). Barring complications, very little if any intestine is removed with this type of surgery.
Much has been written about converting a "classic by-pass" into a DS. While there are indications for this procedure, if one wants to be technically correct, it is very rarely done. To actually convert a "classic Rny" into a DS would require disassembling the connection between the pouch and the intestine, reconstituting the stomach, resecting the left side of the stomach, dividing the duodenum, connecting the Roux limb to the first portion of the duodenum and moving the Y "downstream." It should be obvious that this operation is extensive. It is this type of revision which carries the "high risk" frequently cited in the medical literature.
The revision of a "classic Rny" to a highly malabsorptive operation can be more safely accomplished by revising it into a highly malabsorptive Rny (ERny). This procedure moves the Y downstream. It is the LEAST risky of all the revisions to a highly malabsorptive procedure as neither the pouch nor the stoma is touched. You gain the vast majority of the advantages of revision to a DS with only a small fraction of the risks.
Intermediate in risk between revising a "classic Rny" into a DS and revising a "classic Rny" into a highly malabsorptive Rny is revising a "classic Rny into a BPD. In this revision, in addition to moving the Y down stream, the excluded stomach (distal remnant) is removed. The theoretical advantage of this revision is a greater reduction in grehlin. There are no studies that document that the reduction in grehlin is greater when part of the stomach is removed. There is no information as to how long the reduction in grehlin lasts after any WLS.
Varying the length of the common conduit (bowel with both food and digestive juices) between 50 cm (most malabsorptive) and 100 cm (most conservative) will determine just how malabsorptive the procedure is. This is a decision to be made with your revision surgeon. Not every patient needs the most aggressive operation. This is yet another instance where experience counts.
Each of these revisions to highly malabsorptive procedures can be combined with a procedure that increases the restrictive component of the previous operation. It has been my experience that it is rarely necessary to revise both the restrictive and the malabsorptive components simultaneously.
Revision for Lap-Banders
If you were successful with your Lap-Band until you developed slippage or erosion, you are an excellent candidate for the placement of another Band. However if your initial success with the Band was followed by a weight regain and no "Band complication", you would be best served with a revision to a different procedure. The good news is that all WLS options are available to you. The risks for these revisions are minimally increased (if at all) from first time weight loss surgery. A good experienced WLS revision surgeon should help guide you through the decision making process. As always, be certain that your revision surgery offers you all of your options and LIFE TIME FOLLOW UP.
Setting Goals and Selecting a Surgeon
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 (restrictive 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!
So you've done your research. You feel confident that you are well prepared for the next big step; your consultation with the weight loss surgeon for your revision.
The first thing to remember is that YOU are interviewing the surgeon and the weight loss program. You don't have to go with the first surgeon you see. Just like the first time around, be certain that the surgeon talks to you, not at you. Does he/she speak to you in a courteous fashion with a vocabulary that you understand? Never be reluctant to interrupt if you don't understand.
Here are some things you want to be sure to cover. If your surgeon is thorough, you may not need to ask a ton of questions. The first thing of which your surgeon should be aware is your goal and desires. You must find out what surgical options he/she offers for your revision. Has he/she performed many revision surgeries? Is revisionary surgery one of his/her passions or is just another thing that he/she does? What procedure does the surgeon recommend? Why? What are the pros and cons? Ask not only about complications, but as we discussed last week, ask about the consequences you might expect from the recommended procedure.
If the recommended procedure is not the one that you had in mind, find out why it isn't... Does the surgeon have good reasons why that operation is not your best option? Is he/she persuasive? In other words, do the reasons not to perform that procedure make sense to you?
It is imperative that you know about the entire program. Discuss nutrition. What is the protocol for routine follow-up? How long is long term follow-up? Anything less than life time follow-up is unacceptable.
Let's briefly address investigational procedures such as ROSE, ReSTORE and EROS. I have no objection to investigational procedures and protocols. Without such programs we would still be treating pneumonia with leeches and post partum depressions with purges to rid the body of "black bile." If you choose to participate in an investigational protocol, remember that you may then become a placebo patient, the one who gets a sham procedure. Find out what type of follow-up the protocol is offering. If you were the placebo patient and the investigation demonstrates that the treatment is effective, will you "get" the operation?
The next topic is as close to profanity as I will come in these posts: Insurance. Insurance companies do not care about you or your health. Their goal is to collect premiums and show their investors as large a profit as possible. They are short sighted. The fact that they will save money down the road by treating your obesity means nothing to them. The reason is simple. There is no line item for it in their quarterly profit and loss statement. For some of you, with perseverance, you may succeed in obtaining insurance coverage for your revision. For others, insurance may never pay. They will hide behind the argument that you do not "meet the criteria." Be prepared for a long, pitched battle if you are going to try to have them reverse that denial. If you do not meet their criteria, or if you have an absolute exclusion for weight loss surgery on your policy, you may need to seriously consider alternative means to have your revision.
Finally, listen to your "gut." Trust your impressions. If you feel good about the surgeon, the recommended revision, and the follow-up care; GO FOR IT! If you don't have these positive feelings, then look for another surgeon.
NEVER GIVE UP!
CLAIM THE SUCCESS YOU DESERVE!
Eric Schlesinger, MD, FACS
AZ Weight Loss Solutions
Over the last couple of months I have made six posts under this title. I hope that those who have been following these posts have found them instructive and helpful. We have covered a great deal of material. Some of you have suggested that having all of the information in one place would be helpful. I have made some corrections, additions, and revisions in combining all of the previous articles.
NEVER GIVE UP!
CLAIM THE SUCCESS YOU DESERVE!
GOOD LUCK!
Eric Schlesinger, MD, FACS
AZ Weight Loss Solutions
The ABC's of Revision
The greatest journey begins with a single step. (Chinese Proverb)
The Basics
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 restrictive 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 "balloon" 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 the "classic" Rny, proximal and distal. The difference between the two is the length 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 intestines 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.
Weight Regain I
Weight regain after a "classic" Rny is NOT unusual. In fact it occurs so frequently that your bariatric surgeon should have discussed this with you at your initial consultation.
Often the first question I am asked by a patient interested in a revision is; "What did I do? How did I break my "tool"?" While these are not unreasonable questions; they are not the correct ones. It is EXTREMELY difficult to "break your tool." Sadly, many surgeons "feel better" if they can blame their patients. I recently saw a young lady who had her Rny performed by another surgeon. She had regained nearly all of the weight she had lost. Her after care left much to be desired. In spite of this, she scheduled an appointment with her bariatric surgeon to learn what could be done. The surgeon entered the exam room. Before this lovely young lady could say a word, her surgeon began scolding her. He rudely declared, "You...Look what you've done to my surgery!" In all my years of practice, I have never heard such a terrible story or a more inappropriate, incorrect response.
Unless this woman had been flagrantly disregarding her nutritional program (she wasn't), her weight regain was NOT her fault. None of us is perfect. Everyone "cheats" from time to time. I tell all of my patients that they are entitled to a treat. Allow yourself a treat from time to time and when you do treat yourself, make it special. While these treats may lessen your weight loss, if they are limited to special occasions, they will not result in significant weight regain.
OK, then why do Rny patients experience weight regain? There are three factors that contribute to this weight regain.
First, the pouch has a tendency to "stretch" over time. Different pouches stretch differently. Pouches based off of the right side of the stomach (lesser curve) stretch less than pouches based off of the left side of the stomach (greater curve).
Second, the stoma (connection between the pouch and small intestine) also has a tendency to enlarge over time.
Third, the body is a miraculous thing. It is constantly adapting and changing. Over time your small intestine adapts to its reduced length by becoming better at absorbing the nutrients that are presented to it. It becomes more efficient.
In summary, through no fault of your own (unless you have been flagrantly abusing yourself and your operation), both the restrictive and malabsorptive components of your by-pass will diminish. That is why a degree of weight regain is the norm; not the exception.
So, what can we do about it? That is the topic for a future posting.
Remember; there are NO failures, only those who have yet to succeed!
Weight Regain II
Let's begin with a few words about surgeons. As a child most of us were told, "A poor carpenter blames his/her tools." Based on behavior, some of us, surgeons, have not yet "grown up." One aspect of this "failure" is that children rarely if ever take responsibility for bad results. This and the purely restrictive nature of the operation place Lap-Banders at jeopardy of an unwarranted verbal assault. If your weight loss has been lagging or you have regained some weight, a "maturity challenged" surgeon may begin by reprimanding you for "eating around" your Band. While a thorough discussion and review of your nutritional program is a vital part of each follow-up visit; accusations are not.
If your behavior won't explain the less than stellar weight loss, the next likely "suspect" he/she may blame is the Lap-Band and/or Port. Mechanical failures of the Band/Port do occur, but are EXTREMELY RARE! Diagnosis should initially be pursued without a scalpel. A "Band-o-Gram" should be the first test to demonstrate or exclude the diagnosis of a "leaky" Band or Port. This is an X-Ray study very similar to having your band adjusted under fluoroscopy. No diagnostic test is 100% accurate, however this is a very good test.
Now that we have dealt with the Doogey Howser MD's. Let's consider more likely causes.
Band Placement.
Was the Band placed in the proper position (15-30 cc upper stomach)? Has the Band "slipped"?
As a first step, a plain abdominal X-Ray will show if the Band is in high in the left upper abdomen; if it is correctly "tipped" (pointing toward the left shoulder). If further diagnostic tests are needed; an upper endoscopy, upper GI series, and an abdominal CT scan with contrast can all provide valuable information. More than one of these tests may be required.
Band Erosion
If your Band has eroded, slightly more common than hen's teeth, this could explain a weight regain. The best way to make this diagnosis is with an upper endoscopy.
Band Loosening
Just as your trousers/skirt will become loose as you lose weight, so too can your Band. This can be simply determined by a fill.
Band Adjustment
Has your Band ever been tightened to the "Sweet Spot"? If your are able to eat steak (without prior shredding), white bread, sticky rice, etc., you have not had your Band adequately tightened.
Have you been "listening" to your body? Do you stop eating or take a break when you begin to feel that "pressure" sensation under your breast bone? If you haven't been paying attention to the advice that your body has been giving you, you may have stretched your esophagus. If this has happened, you have effectively enlarged your pouch. Your food pipe is now acting as a reservoir. This problem can sometimes be corrected by going back to basics for several months. Adhere strictly to portion size. Solid meals should require no less than 30 minutes to consume. A more aggressive approach to "shrinking" your food pipe would be to revert to a liquid diet. Again, portion control is vital. Neither approach is uniformly successful. If this treatment is going to succeed, it will take months. An upper GI before and after this treatment can document whether or not it has been successful. If your esophagus has returned to normal size, you will find that you are not able to eat as much at any given sitting. You may once again experience that "pressure" sensation.
Was the Band the correct operation? I know that this is a very "touchy" subject and painful question. No one operation is the correct one for everyone. I know that it's late to be considering this question, but... Better late than never.
Revision Operations
Hopefully we have developed a common vocabulary and gained some insight regarding the limitations of different procedures.
Revisions for Rny'ers
There are two major aspects of a by-pass that may be revised. The restrictive component and the malabsorptive component.
Restriction
As we have discussed, it is common to be able to eat more months to years after your initial surgery. There are many different reasons for this. I will mention only in passing that a small component of this is the skill that you have developed with experience. You have become experts at eating slowly and chewing your food thoroughly. You have learned what "sits" well and what doesn't.
If your pouch wasn't too large when it was constructed, it is prone to "stretch" over time. The same is true for your stoma. This does NOT mean that you did something wrong. In many ways it is as inevitable as the sun rising tomorrow. So your pouch/stoma is dilated, now what?
There are several different approaches to dealing with this.
Stomaphyx is a safe and effective way to decrease the size (volume) of your pouch and its outflow tract. You may have read that Stomaphyx does not "tighten up" the stoma. This statement is misleading. Although no fasteners are place in the stoma, the concentric pleating immediately above the stoma will "tighten up" the out flow from your pouch. Think about your garden hose. Pinching the hose will narrow its opening and restrict the flow of water. Where ever you pinch the hose, this maneuver will have the same effect. So, even though no fasteners are placed in the stoma, properly performed, Stomaphyx will effectively "tighten up" your stoma. Due to its minimally invasive approach, LOW risk and the universality of some degree of pouch and stomal dilatation, pre-Stomaphyx upper GI's or endoscopies (separate anesthesia) are not an absolute prerequisite. Pouches with a volume, capacity of over 250 cc (normal 15-30 cc) are better addressed with procedures other than Stomaphyx. Tubular pouches are better suited for Stomaphyx than globular or spherical pouches. Right sided stomas are better suited for this treatment than left sided stomas. Having said this, I have had excellent results with unfavorable pouches and stomas.
Lap-Band over Rny can result in a dramatic improvement in restriction. Before a Lap-Band over Rny is performed the pouch must be evaluated with either an upper GI (X-Ray) or an upper endoscopy. While relatively small pouches can benefit from Stomaphyx, small pouches will NOT benefit from a Lap-Band. The reason is simple mechanics. If the pouch is too small to be "pinched" by the Band, the Band will serve no purpose. Lap-Band over Rny carries a higher risk than Stomaphyx. As in all weight loss surgery, the procedure chosen must be "matched" to the patient's anatomy, physiology, emotional make up, needs and desires. With the proper match, Lap-Band over Rny will yield excellent results.
The pouch and stoma can be surgically reconstructed. This approach carries with it risks that are even greater than Lap-Band over Rny. The stomach is much more unforgiving after it has been operated on once. The risk of a leak is significant. In fact, this risk is the major contributing factor for the reported "high risk" of revisions. Additionally, the surgically revised pouch and stoma is not immune from "stretching" again.
Malabsorption
For the vast majority of patient, a revision which significantly increases the malabsorptive component of their by-pass will result in the greatest weight loss. This increase in malabsorption is achieved by moving the Y further "down stream". This shortens the common conduit (bowel carrying both food and digestive juices)while lengthening the bilio-pancreatic limb (the bowel carrying only the digestive juices). Barring complications, very little if any intestine is removed with this type of surgery.
Much has been written about converting a "classic by-pass" into a DS. While there are indications for this procedure, if one wants to be technically correct, it is very rarely done. To actually convert a "classic Rny" into a DS would require disassembling the connection between the pouch and the intestine, reconstituting the stomach, resecting the left side of the stomach, dividing the duodenum, connecting the Roux limb to the first portion of the duodenum and moving the Y "downstream." It should be obvious that this operation is extensive. It is this type of revision which carries the "high risk" frequently cited in the medical literature.
The revision of a "classic Rny" to a highly malabsorptive operation can be more safely accomplished by revising it into a highly malabsorptive Rny (ERny). This procedure moves the Y downstream. It is the LEAST risky of all the revisions to a highly malabsorptive procedure as neither the pouch nor the stoma is touched. You gain the vast majority of the advantages of revision to a DS with only a small fraction of the risks.
Intermediate in risk between revising a "classic Rny" into a DS and revising a "classic Rny" into a highly malabsorptive Rny is revising a "classic Rny into a BPD. In this revision, in addition to moving the Y down stream, the excluded stomach (distal remnant) is removed. The theoretical advantage of this revision is a greater reduction in grehlin. There are no studies that document that the reduction in grehlin is greater when part of the stomach is removed. There is no information as to how long the reduction in grehlin lasts after any WLS.
Varying the length of the common conduit (bowel with both food and digestive juices) between 50 cm (most malabsorptive) and 100 cm (most conservative) will determine just how malabsorptive the procedure is. This is a decision to be made with your revision surgeon. Not every patient needs the most aggressive operation. This is yet another instance where experience counts.
Each of these revisions to highly malabsorptive procedures can be combined with a procedure that increases the restrictive component of the previous operation. It has been my experience that it is rarely necessary to revise both the restrictive and the malabsorptive components simultaneously.
Revision for Lap-Banders
If you were successful with your Lap-Band until you developed slippage or erosion, you are an excellent candidate for the placement of another Band. However if your initial success with the Band was followed by a weight regain and no "Band complication", you would be best served with a revision to a different procedure. The good news is that all WLS options are available to you. The risks for these revisions are minimally increased (if at all) from first time weight loss surgery. A good experienced WLS revision surgeon should help guide you through the decision making process. As always, be certain that your revision surgery offers you all of your options and LIFE TIME FOLLOW UP.
Setting Goals and Selecting a Surgeon
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 (restrictive 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!
So you've done your research. You feel confident that you are well prepared for the next big step; your consultation with the weight loss surgeon for your revision.
The first thing to remember is that YOU are interviewing the surgeon and the weight loss program. You don't have to go with the first surgeon you see. Just like the first time around, be certain that the surgeon talks to you, not at you. Does he/she speak to you in a courteous fashion with a vocabulary that you understand? Never be reluctant to interrupt if you don't understand.
Here are some things you want to be sure to cover. If your surgeon is thorough, you may not need to ask a ton of questions. The first thing of which your surgeon should be aware is your goal and desires. You must find out what surgical options he/she offers for your revision. Has he/she performed many revision surgeries? Is revisionary surgery one of his/her passions or is just another thing that he/she does? What procedure does the surgeon recommend? Why? What are the pros and cons? Ask not only about complications, but as we discussed last week, ask about the consequences you might expect from the recommended procedure.
If the recommended procedure is not the one that you had in mind, find out why it isn't... Does the surgeon have good reasons why that operation is not your best option? Is he/she persuasive? In other words, do the reasons not to perform that procedure make sense to you?
It is imperative that you know about the entire program. Discuss nutrition. What is the protocol for routine follow-up? How long is long term follow-up? Anything less than life time follow-up is unacceptable.
Let's briefly address investigational procedures such as ROSE, ReSTORE and EROS. I have no objection to investigational procedures and protocols. Without such programs we would still be treating pneumonia with leeches and post partum depressions with purges to rid the body of "black bile." If you choose to participate in an investigational protocol, remember that you may then become a placebo patient, the one who gets a sham procedure. Find out what type of follow-up the protocol is offering. If you were the placebo patient and the investigation demonstrates that the treatment is effective, will you "get" the operation?
The next topic is as close to profanity as I will come in these posts: Insurance. Insurance companies do not care about you or your health. Their goal is to collect premiums and show their investors as large a profit as possible. They are short sighted. The fact that they will save money down the road by treating your obesity means nothing to them. The reason is simple. There is no line item for it in their quarterly profit and loss statement. For some of you, with perseverance, you may succeed in obtaining insurance coverage for your revision. For others, insurance may never pay. They will hide behind the argument that you do not "meet the criteria." Be prepared for a long, pitched battle if you are going to try to have them reverse that denial. If you do not meet their criteria, or if you have an absolute exclusion for weight loss surgery on your policy, you may need to seriously consider alternative means to have your revision.
Finally, listen to your "gut." Trust your impressions. If you feel good about the surgeon, the recommended revision, and the follow-up care; GO FOR IT! If you don't have these positive feelings, then look for another surgeon.
NEVER GIVE UP!
CLAIM THE SUCCESS YOU DESERVE!
Eric Schlesinger, MD, FACS
AZ Weight Loss Solutions
I am interested to know if you can give us any real information on the Stomaphyx proceedure. Like how many people have had this proceedure, and how are are they doing now? How long has it been for them, say from 1 year out down to a month out? What percentage seem to be losing a substantial amount of their excess or regained weight? How many are not having much sucess losing?
If RNYers are in normal range for their labs, would a more malabsorptive proceedure be better than Stomaphyx? What sort of guidelines do you use to determine suitability for Stomaphyx, or increasing malabsorption? To become more distal, does one have to be eligible for WLS in general, as in 35 BMI with co-morbs, or 40 BMI without? For Stomaphyx, is a stretched pouch or enlarged stoma the only requirement, since insurance doesn't pay as of yet? If one was self-pay, would your own judgement be the deciding factor?
Thank you for answering these questions. I am sure these are on everyone's minds.
Edited to add: What type of revision could a Dser get? Stomaphyx would reduce the stomach, I assume. If the common channel is short, what would the Dser do in the event of weight regain?
Losing Sally,
I am awaiting the next set of data from EndoGastric Solutions. The results with Stomaphyx have been variable. This is not the result of the procedure as much as it is the result of patient selection. Patients expecting to be able to "lean heavily" on the procedure are poor candidates. Patients who are "carboholics" are poor candidates. "Grazers" are poor candidates. Interestingly, when I have studied patients who were not as successful as they had hoped, I found that the procedure had done exactly what it was designed to do. Their pouches and stomas were significantly smaller and "tighter". Motivated patients who do not fall into any of the aforementioned groups are averaging 15 to 20% excess body weight loss at 3 months. As with any other WLS, patient compliance has a significant impact on the degree of success they achieve. As I have stated previously, I believe that Stomaphyx is an excellent option for those whose goal is to lose 50 lbs or less and do not fall into any of the categories listed above.
For Rny'ers the choice of revision depends on their status and goals. If a patient's labs are not in the normal range, the first objective is to correct any deficiencies. Once accomplished these individuals would have a full array of options available to them. A highly malabsorptive revision is a very powerful tool with dramatic results and the potential for significant consequences. The decision as to what type of revision is performed must be tailored to each individual. It is a decision made by the patient. After I have evaluated the patient, I will present him or her with their options. We cover the pro's and con's. I do my best to inform them and to help guide them to a choice that is best suited to their needs and desires.
If your question is will insurance cover a revision to a malabsorptive procedure for someone with a BMI under 35; the answer is no.
Eric Schlesinger, MD, FACS
AZ Weight Loss Solutions
I am awaiting the next set of data from EndoGastric Solutions. The results with Stomaphyx have been variable. This is not the result of the procedure as much as it is the result of patient selection. Patients expecting to be able to "lean heavily" on the procedure are poor candidates. Patients who are "carboholics" are poor candidates. "Grazers" are poor candidates. Interestingly, when I have studied patients who were not as successful as they had hoped, I found that the procedure had done exactly what it was designed to do. Their pouches and stomas were significantly smaller and "tighter". Motivated patients who do not fall into any of the aforementioned groups are averaging 15 to 20% excess body weight loss at 3 months. As with any other WLS, patient compliance has a significant impact on the degree of success they achieve. As I have stated previously, I believe that Stomaphyx is an excellent option for those whose goal is to lose 50 lbs or less and do not fall into any of the categories listed above.
For Rny'ers the choice of revision depends on their status and goals. If a patient's labs are not in the normal range, the first objective is to correct any deficiencies. Once accomplished these individuals would have a full array of options available to them. A highly malabsorptive revision is a very powerful tool with dramatic results and the potential for significant consequences. The decision as to what type of revision is performed must be tailored to each individual. It is a decision made by the patient. After I have evaluated the patient, I will present him or her with their options. We cover the pro's and con's. I do my best to inform them and to help guide them to a choice that is best suited to their needs and desires.
If your question is will insurance cover a revision to a malabsorptive procedure for someone with a BMI under 35; the answer is no.
Eric Schlesinger, MD, FACS
AZ Weight Loss Solutions
Hi, I just today had a procedure done to reduce the size of my stoma and is called scleratherpy, the Dr. actually went down the throat to see if my pouch had increased in size but it had not, so while he was already in there done this procedure to reduce the size of the stoma and he said it is far less invasive than the stomaphyx and of course Insurance will pay for it , he injects whatever it is to cause a scar tissue to make the stoma smaller, and he said this is by far better than the stomaphyx and they have had better results with this procedure, so that is what I done so I am now back on the puddings and protein drinks and jello, I ask why it had gotten increased in size he said he did not but sometimes it happens with no reason you see I had not lost any thing for about a year now and the problem was my food was going thru too fast and not saying in my stomach long enough I had really not gained anything but I was not losing any either, he did say that I might have to have it repeated by if that is what I need I will do it again in a heartbeat. And the insurance does pay for it my supplement and also medicare paid for it . And my Drs. office says when you have medicare it does not have to have an approval from medicare for the WLS, they just do it and medicare pays for it but of course you need to know if your Dr. accepts medicare for this procedure of WLS first. When My Dr. started accepting medicare he did a lot of medicare patients and I heard with my own ears that all you have to do is turn in your paperwork to the Dr. and Medicare will pay for WLS that is also if you meet some of the criteria you have have wrong with you as to why you are wanting the surgery to start with I know all of this because my friend had the medicare approval and there was no waitng at all
Patsy,
Both procedures are what is referred to as natural oriface surgeries. ROSE employs sutures whereas Stomaphyx uses fasteners. To the best of my knowledge, no data has yet been published regarding the ROSE procedure. Due to the nature of the ROSE instrument, the pouch must be large enough to accomodate its manipulation. The Stomaphyx can be employed on smaller pouches. The ROSE procedure tighten the pouch's outflow by suturing the stoma. The Stomaphyx tightens the pouch's outflow tract by narrowing the pouch immediately above the stoma. Pouch reduction is achieved in a similar manner with both instruments. Each creates a pleating effect. Further discussion gets highly technical. In selected individuals, I have had gratifying results with the Stomaphyx procedure.
Eric Schlesinger, MD, FACS
AZ Weight Loss Solutions
Both procedures are what is referred to as natural oriface surgeries. ROSE employs sutures whereas Stomaphyx uses fasteners. To the best of my knowledge, no data has yet been published regarding the ROSE procedure. Due to the nature of the ROSE instrument, the pouch must be large enough to accomodate its manipulation. The Stomaphyx can be employed on smaller pouches. The ROSE procedure tighten the pouch's outflow by suturing the stoma. The Stomaphyx tightens the pouch's outflow tract by narrowing the pouch immediately above the stoma. Pouch reduction is achieved in a similar manner with both instruments. Each creates a pleating effect. Further discussion gets highly technical. In selected individuals, I have had gratifying results with the Stomaphyx procedure.
Eric Schlesinger, MD, FACS
AZ Weight Loss Solutions
Thank you for the clarification on both procedures. I have been researching both and I am leaning toward the stomaphyx procedure. I do have a question about what happens to the flaps, as I understand the fuse together which can take up to 12 months? My concern is food getting caught inbetween. Could you elaborate a bit on this? Thanks, Cindy
Ms. Cin,
The basic principles of wound healing indicate that the pleats or flaps should be healed in 4 to 6 weeks. When I complete a Stomaphyx procedure, there is no space in between the pleats or the rows of pleats for food to "get caught." None of my patients has ever had a problem with food being retained in between the pleats.
Eric Schlesinger, MD, FACS
AZ Weight Loss Solutions
The basic principles of wound healing indicate that the pleats or flaps should be healed in 4 to 6 weeks. When I complete a Stomaphyx procedure, there is no space in between the pleats or the rows of pleats for food to "get caught." None of my patients has ever had a problem with food being retained in between the pleats.
Eric Schlesinger, MD, FACS
AZ Weight Loss Solutions
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