The ABC's of Revision A to Z

Deanne,
The hypoglycemia that you and others experience is the result of an overactive pancreas. It is continuing to churn out large amounts of insulin. When you were larger, your body was unable to react to insulin in a normal fashion. You needed very high insulin levels for your body to respond to the insulin and drive the glucose into your cells. As you get smaller, your body responds to lower levels of insulin. Unfortunately, your pancreas is slow in recognizing this. Most individuals will eventually have their pancreas "slow down". A few unfortunate souls will continue to be plagued by this problem for extended periods of time.
So, what can you do about it. The single most important thing you can do to minimize these wild swings in your blood sugar is to avoid high glycemic index carbohydrates. These type of carbs stimulate your pancreas to release a "ton" of insulin, which results in your blood sugar "bottoming out." Remember your "Golden Ratio", three bites of a high quality protein to every bite of low glycemic index carbohydrate. When your sugar gets low, correct it with low glycemic carbs, like an apple or pear. It will take longer to get your blood sugar up than hard candy or fruit juice, but it will mute the rebound hypoglycemia (low blood sugar).
The ERny may for a time accentuate the hypoglycemia. As you lose more weight and your body may become even more responsive to insulin. Just remember to eat some apple, pear, or other low glycemic index carbohydrate.
I hope that answers your question.

Eric Schlesinger, MD, FACS

Hi Dr. I just want to take this opportunity to thank you and other medical people who have given so much of their time and expertise..Thankyou thankyou thankyou!!!!!! Patsy

Dear Dr. Schlesinger, I had a VBG done in 1996 and was 279 lbs at that time. I am 5'2". I lost down to 170 lbs the first year. I regained to 210-215lbs range over the years and have stayed in that area. I had started having progressive difficulty eating normal foods, and felt things weren't going down, developed horrible reflux, and recurrent vomiting of undigested food. Last year my original surgeon did an endoscopy and found everything to appear intact except for undigested debris in my pouch. He did a dilation even though he saw no problem and for approximately 2-3 months things seemed to improve. The problem got progressively worse and I can only tolerate ice cream, cottage cheese, baked potatoes without skin, some cheeses, on occasion some salad, but still vomit these items at times.  I cannot eat even a scrambled egg without being ill for several hours before I end up vomiting. I returned to my surgeon for another endoscopy with dilation two days ago. He found my pouch filled with food and liquid after 12 hours fasting and now believes I have gastroparesis and my only option is total reversal since my pouch is non-functioning. This time the dilation seems to have not helped. I return to him on July 7 to decide. He feels that since the pouch is a problem conversion to gastric bypass is not an option. I would be interested in your impression, as I am highly stressed over making this decision. I am terrified of regaining to where I started 12 years ago. I am now 46 years old, and although not thin, I have a quality of life that I never had at that time.  I am diabetic also which may explain the gastroparesis. Thank you for any help you can give. Kim C.

Kim,
Reversal is NOT your only option. I would need more information and more studies before I could venture any definite opinion.
What's going on in the rest of your stomach?
You need a gastric emptying study. In order to study the lower portion of your stomach, a tube, placed through your nose under X-Ray guidance, could be used to put the "tracer" in the lower part of the stomach.
You could possibly be a candidate for a DS or an ERny with a generous pouch and/or a large stoma. You owe it to yourself to have a thorough work-up before deciding how you want to proceed.

NEVER GIVE UP!

Eric Schlesinger, MD, FACS

Dr. Schlesinger, Thank you so much for your reply. It has given me hope. I have not had a gastric emptying study, my doctor had wanted to do a esophageal motility study last year and the insurance would not approve it as being necessary.  I am nervous about trading one type of wls for another that may have other possible complications. But I have read other patient's stories that are able to eat normal foods, and still lose weight, and envy them. I would love to be able to eat some protein for a change. I already have hereditary hair thinning, so the hair loss also worries me, but considering the little protein intake I have, it could improve!  I have Tricare prime insurance, and not even sure what I can get approved. I know with my co-morbidities and the weight I am at for my height I am still obese. I wish you were in Kentucky, I would gather up everything and switch doctors! Thank you again and if you have anything to add, feel free to share. Kim C.

Dear Dr Schlesinger, I thought of another question, after I had posted my reply. Why would I have the ERny? I am not as familiar with this surgery, I realize it is described as a highly malabsorptive surgery, but what is the different from regular rny? Would I keep the pouch that is there from my vbg? I had open surgery and had other abdominal surgeries, so is a closed procedure even an option? Thanks again. Kim C.

Dear Dr. Schlesinger, I returned to my surgeon today and I am now having an esophageal motility study and a gastric emptying study scheduled. My surgeon has now changed his opinion after this endoscopy I just had and feels the band is my problem. I had asked him about having the gastric sleeve done and he feels because of the vbg that it is not an option. I am considering gastric bypass revision after the further testing. I do have polyps in my big stomach, and he said that the nexium has caused it that I take for the GERD. I know that the bypass should resolve the reflux, at least that is what I have read, but I am now concerned about this blind stomach which is left after bypass. Should I be more concerned since I already have polyps? Also I am a little confused about the length of bypass. What number is considered a conservative bypass, and what is considered the extreme? I don't want to have massive malabsorption problems, or have too much or too little. I am 46 years old and don't want to make a decision that could be life threatening in old age. Thank you so much for any insight you can provide. Kim C.

Kim, I would assume that your surgeon is planning a "classic" Rny, either proximal or distal, and not an ERny. In general, I think that a distal is a better option for most people. That however is a decision for you and your surgeon who knows you better and has all the information. If the polyps are benign and also not adenomatous, then I wouldn't worry about the distal remnant. Once again, this is decision best made by you and your surgeon who has a complete picture. I am delighted that you have made so much progress in your quest for a revision and that your surgeon is working with you to achieve your goals! GOOD LUCK! Eric Schlesinger, MD, FACS

Dear Dr. Schlesinger,
I had written to you previously. I have a 12 yr out vbg with complications. I have now had a gastric emptying study which shows "sluggish". I also had an esophageal motility study which shows I have mild achalasia. My surgeon feels this indicates I am not a candidate for conversion to rny.
I have seen this listed as a co-morbidity for some rny preops. Will a pouch and stoma instead of a pouch with banding help this problem? I have recurrent vomiting, so could this have caused the achalasia? Would the slow emptying stomach combined with it be ill advised?
Thank you for any insight you can give.
Kim Cameron

Kim,
The delayed gastric emptying is not problematic. The achalasia may be of greater concern. Without further information, I cannot offer any real insights. Your's is not a simple problem. None the less, there are options.
Eric schlesinger, MD, FACS