Had roux-en-y 5 yrs ago and now always hungry
Hi everyone, I had a laparoscopic roux-en-y in 2003 and lost 105 pounds. Things started out really great , however over the last year, I have had a really hard maintaing my weight. I exercise and don't really eat alot. Well, about 2 months ago, I started noticing that I was constantly eating. I am ALWAYS hungry. I can eat a high in protein meal, the right amount, so I'm not "over eating" and 1-2 hours later, I'm hungry again. I have started to gain weight again and am sooooo frustrated. I started researching "revision surgery", thinking my pouch could possibly have stretched. I saw a surgeon yestarday to discuss my options . He sent me for an Upper GI Study this morning. Of course I had to drink that horrible tasting Barium. According to the Radiologst, my pouch was still small, however, the liquid was going straight through it and down into my small intestine. It now made sense why I am always hungry, nothing is staying in my pouch long. I am now wondering if there is some anatomical abnormality with my insides. Any info that you could offer would be appreciated!!!!
Hi, I have the same problem -- my pouch is still small but my stoma is quite enlarged. I had my RNY in 6/03 and lost 170 lbs. In the past 2 years I have been increasinly always hungry and have gained 40 lbs. I'm looking into having a revision. My bypass doc will only offer the band over bypass but reading Dr. Schleisinger's posts (a doctor and revision expert in Arizona) - this would not be good for someone who has a small pouch (you won't have the weight loss needed). So I'm now looking to go for a 2nd opinion. Dr. S. told me the Extended Rny would work (the DS is too extreme for me and not needed). Said I could potentially lose all I gained plus the add'l 40 I had wanted to but never lost. There are many in the same boat. You have to look into revisions and see what would work best for you. Look up Dr. Schleisinger in the member list and read his posts - he has one that's the ABC's of Revisions that has tremendous insight. Good Luck. Let me know what you decide to do! Carolyn
It pretty much depends upon your insurance company and even then a case by case basis. My ins co didn't cover the bypass but that was 5 years ago and now they do. With the revision I don't know if they will. I'm working up the nerve to ask them. I'm hoping they do so I can get it. How about you - did your ins pay for your bypass? Have you called to ask if they cover revisions (and if so, on what conditions)?
On May 16, 2008 at 10:52 AM Pacific Time, Arizonadck wrote:
Hi, I have the same problem -- my pouch is still small but my stoma is quite enlarged. I had my RNY in 6/03 and lost 170 lbs. In the past 2 years I have been increasinly always hungry and have gained 40 lbs. I'm looking into having a revision. My bypass doc will only offer the band over bypass but reading Dr. Schleisinger's posts (a doctor and revision expert in Arizona) - this would not be good for someone who has a small pouch (you won't have the weight loss needed). So I'm now looking to go for a 2nd opinion. Dr. S. told me the Extended Rny would work (the DS is too extreme for me and not needed). Said I could potentially lose all I gained plus the add'l 40 I had wanted to but never lost. There are many in the same boat. You have to look into revisions and see what would work best for you. Look up Dr. Schleisinger in the member list and read his posts - he has one that's the ABC's of Revisions that has tremendous insight. Good Luck. Let me know what you decide to do! Carolyn Here you go - I cut and paste.
Post Date 4/11/08 11:10 am
Topic: 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
Post Date 4/4/08 11:38 am
Topic: ABC's of Revision VI "What's up doc?"
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
Topic: 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
Post Date 4/4/08 11:38 am Topic: ABC's of Revision VI "What's up doc?"
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
Hello,
It is been a long time since I visted this site and/or posted. I have my RNY in 2004. I did loose most of my weight but then started to regain. It was found that my stoma was wide open. At that time my surgeon wanted to do a revision...costing more than my original surgery. When I declined I started researching other options. I found that since my stoma was my problem that this could be fixed with a procedure done through endoscopy. Here is one of the web sites that can explain in detail: http://www.liebertonline.com/doi/abs/10.1089/lap.2004.14.223 ;jsessionid=ic8femBQ8Plf
Here is another article I found when researching this:
Abstract:
Background: Dilation of the gastrojejunostomy after gastric bypass may result in weight gain. Many surgical and medical treatments have met with poor results. A feasibility study of endoscopic sclerotherapy (ST) of the gastrojejunostomy was performed, based on the known risk of esophageal stricture in the treatment of esophageal varices.
Methods: From 1991 to 2001, proximal Roux-en-Y gastric bypass (RYGBP) was performed on 685 patients, with a follow-up rate of 60% at 5 years. 20 patients were identified with dilated gastrojejunostomy (DGJ) by gastroscopy (EGD) performed for complaints of weight gain and marked increase in volume tolerance. Sclerotherapy of the gastrojejunostomy was performed during EGD. EGD was repeated 2 months after the sclerotherapy to measure the diameter of the anastomosis and observe any complications. Weight and sense of satiety were also measured, 2 and 6 months after ST. If necessary, the procedure was repeated to achieve a diameter of 10 mm.
Results: Reducing the diameter of the gastrojejunostomy to 9-10 mm was achieved in all patients, with an average of 1.3 treatments per patient. 15 patients (75%) lost weight. The average weight loss was 5.8 kg (ranging from 0.5 to 17.3 kg) in 2 months.
Conclusion: Sclerotherapy successfully restores the desired anatomy of gastric bypass, but exercise and dietary discretion remain critical elements of sustained weight loss.
Keywords: SCLEROTHERAPY; DILATED GASTROJEJUNOSTOMY; GASTRIC BYPASS; BARIATRIC SURGERY; MORBID OBESITY; WEIGHT GAIN
Language: Unknown
Document Type: Research article
DOI: 10.1381/096089203764467162
Affiliations: 1: Department of Surgery, Fletcher Allen Health Care/University of Vermont College of Medicine, Burlington, VT, USA
http://www.ingentaconnect.com/content/fd/os/2003/00000013/00000002/art00006
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Sclerotherapy as tool to revise enlarged stoma:
Also, there is a new procedure call "sclerotherapy", which is a tube placed down at the end of the pouch, to make the opening smaller between that and the small intestine. They first see if the opening has indeed dilated too much, where food escapes too quickly, then they "irritate" the area (inject a substance), which will create swelling for 4 weeks, then create scar tissue. It's for people at least 2 years out I believe, who stopped their weight loss, etc. It's out patient, and they give you a sedative.
This is what I found:
http://www.drsimpson.com/chattranscript-08-13-2004.php
August 13, 2004
Welcome to tonight's chat with Dr. Simpson. Chat starts at 4pm EST/7pm EST. Please type out your questions and hit enter. We will see them and present them to Dr Simpson at the time of chat in the order we receive them. Thank you!
Dr. Simpson, I am 4 years post surgery. I had lost 75 pounds and have been steadily gaining about 10 pounds a year. This means I need to loose 50 pounds again. I think I have busted my staples. What do you do to repair the staples if I have done this?
If you have busted your staples, or if that is a problem then the only thing that can be done is surgery. However, there are a few things to check before you go that route. The first would be to see what your ratio of eating to how many calories you use is that is, you cannot manage what you cannot measure so I suggest you get a band from www.healthwear.com and that will tell you what your calories used vs. what you eat and that gives you some data you can work with if your stoma is enlarged between the stomach and the intestine then sometimes a gastroenterologist can do sclerotherapy and cause some scaring in the area to shrink that stoma so you will keep fuller longer.
I did have this procedure done approx 2 yrs ago. I had to have 3 procedures done at that time. I now have a follow up scheduled for next week to make sure all is still small and if not to redo it. For me it worked great. There is no downtime, no pain, and is done in about 30-45 min. I hope this helps. Feel free to email me if you have any other questions. Lori
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