How do u know if u need a revision?

Hello everyone, I haven't been on this board much before.  I had my open rny gastric bypass March 24, 2005.  I weighed 324 when I had surgery. Within the first year I lost down to 160. I was happy. My surgeon was happy.  I loved the new me.  October 8, 2006 we had a car accident.  None of us were hurt too badly but I did have some nerve damage in my hip/back area.  I saw my family doc and got referred to a chiropractor. I can't honestly say he did me any good.  He did tell me that tylenol would not help with the pain from the damaged nerves. He said that I'd need to take Ibprophen, motrin, Advil, etc. NSAIDS.  When I had gastric bypass surgery I heard we weren't supposed to take NSAIDS but my chiro doc said that was pretty much all that would help. It didn't hurt constantly and when it did flare up I'd hobble toward the ibprophen.  I took it regularly for 3-4 months.  It still hurts every now and then but I run for the heating pad now or icy hot.  Last year I started noticing that I had alot of burning in the back of my throat. One night I woke up and my chest was on fire. My family doc says acid reflux.  Could all those ibprophen's I took have done something to the lining in my pouch?  I've never gorged myself. For the first year and a half I maintained. I didn't start gaining till after last spring 07. Now I've gained a total of 50 pounds since last year.  My stomach burns all the time. I don't even feel full anymore. I've called Anthem PPO our new insurance co and told them what was going on. They said just have my doc do the test and submit and it would be no problem to get anything approved.  My aunt just had cancer surgery yesterday and I've put off calling my surgeon, Dr Shina, because I was ashamed of gaining.  Also I want my aunt to be healed and on the road recovery before I start anything. She just had a mass removed from her rectum, colon yesterday and Thank God is doing good.  I guess I need to call my surgeon Monday and I just wanted u're alls input, stories, etc. Thanks and Big Hugs Angela

Angela, My advice is to schedule yourself an upper GI test and then an endoscopy to see what is going on with your stomach.  Those are the first steps and let your doctor take it from there.  If you choose not to see you original surgeon go to a gastroenternologist they will be able to help you with tummy problems.  Good luck.

My Baratric Dr. told me if I need to take  Advil take two 30 mg of Prevacid first to protect our stomachs. I also have regained 29 pounds from my lowest weight. I have not been back to see my surgeron because I am ashamed of the regain, due to my own fault. I still have not got a handle on eating better. I graze way to much.

Hi Angela, I had open RNY in 2001. I lost 135 pounds and have since gained back 50 of it. I know how discouraging this can be. It doesn't help matters when you keep reading that RNy was only meant to keep 50 to 60% of your weight off over time. I am actually considering a revision. I don't think it was you who did anything wrong with your pouch. The pouch will stretch over time. I read a report that claimed after 2 years out, regardless of eating habits, the average size pouch for an RNY patient is anywhere from 6 to 12 ounces in size. I went in for a upper GI last week and go back in to the doc for the results this Friday. While they were doing the test the technician asked if I wake up in the middle of the night with burning in my throat and if it felt like "stuff" was caught in my throat? He showed me where he said I had some reflux going on. So maybe this is also par for the RNY course... I do wake up occasionally with the burning and at times gagging. But at least what he told me now explains it. I won't know until Friday what my PCP is going to suggest doing about it. I never had a problem with reflux before. Although I am discouraged with the weight gain I do remind myself daily that I no longer have diabetes type 2, my heart does not race and act like it is going to beat out of my chest for no apparent reason and I am not dealing with everything else that goes with being obese. I would do it again if I had to do it over again. I wish you luck with your issues and hope there is an easy solution for you. Hang in there.

Hello, welcome and thanks for bringing this up for the board. It is a great topic and reminder for long-term postops and great for newbies and preops as well!
There are several things to consider and one list is not really possible. I will include in this post several articles to further support furthering understanding for those interested in this area.

You may have a serious ulcer I would recommend FAST apt with bariatric surgeon a dear friend of mine had a ulcer that PERFORATED her stomach from NSSAIDS almost costing her her life! Do not delay! PLEASE~ulcers are releived with eating so the increased grazing can account for regain as can not exercising stop it at 50# before it is all regained please!!!!!!!!!!!

1) Avoidance of Nonsteroidal anti-inflammatory drugs (NSAIDs) and oral bisphosphonates (osteoporosis medications) should be avoided since RNYers are at increased risk for ulceration due to the reduced stomach size. Alternatives for pain relief, such as acetaminophen, tramadol, and/or opiates are recommended. Likewise, alternatives for osteoporosis prevention can be used.

What we talk about when we talk about drug class is NSAIDS. (NON_STEOIDAL_ANTI_INLFAMMATORY_DRUG_S) the reason NSAIDS are dangerous for us contrary to popular belief, it is not just that they are "pouch burners" it goes much deeper than that. According to an article published in the June 1999 New England Journal of Medicine, NSAIDS, once absorbed into the blood stream cause a chain of chemical reactions that affect the prostaglandins and this in turn reduces the production of mucus in the GI system. The mucus is what lines our GI system and protects our pouch and intestines from damage.

If the mucus production is reduced, this would allow ANYTHING, including eating something with too sharp of an edge or foods that are extremely spicy, to inadvertently begin a marginal ulcer. The best answer is to avoid NSAIDS at all cost. Taking an H2 receptor drug such as Pepcid or zantac or a Proton Pump inhibitor (PPI) such as Prilosec, Prevacid or Nexium is only a band-aid and no guarantee that it will protect you. You are at risk for marginal ulcers any time you take an anti-inflammatory medication. Not to mention the liver, kidney and cardiac issues we now know about w/NSAIDs in anyone! Not the safe drugs we once thought!!!

WARNINGS on most NSAID drugs are:
Gastrointestinal (GI) Effects - Risk of GI Ulceration, Bleeding, and Perforation:
Serious gastrointestinal toxicity, such as inflammation, bleeding, ulceration, and perforation of the stomach, small intestine or large intestine, can occur at any time, with or without warning symptoms, in patients treated with nonsteroidal anti-inflammatory drugs (NSAIDs).

Off-Limit Medication
REMEMBER after surgery Non-Steroidal Anti-inflammatory Drugs are no longer an option for use. DO NOT TAKE THEM. The chemical composition of this medication is very irritating to the esophagus and stomach lining. Chronic use will result in bleeding, ulceration of gastric lining, and eventually form scar tissue. Medications in this category are:
GENERIC BRAND
Flurbiprofen Ansaid
Fenoprofen Nalfon
Nabumetone Relafen
Ibuprofen Motrin, Advil, Nuprin
Ketoprofen Orudis, Oruvail
Piroxicam Feldene
Naproxen Naprosyn, Anaprox, Aleve
Indomethacin Indocin
Sulindac Clinoril
Tolmetin Tolmetin
Meclofenamate Meclomen
Etodolac Lodine
Ketorolac Toradol
Diclofenac Voltaren
Oxazoprin Daypro
Celecoxib Celebrex
Rofecoxib Vioxx
~~~~~~~~~~~~~~~~~~~~~~~~~~~~
DO I NEED A REVISION?
What are your issues/ideas/thoughts on why insufficient wt loss or regain?
Solution/recommendations may be different depending on answers.... Three things may be happening independent or together:
ü Broken Surgery (tool)
ü Behavioral issues (not using tool)
ü Wrong tool/surgery

1. BROKEN SURGERY:
a. WERE YOU Open or Lap?
b. Were you transected (pouch and distal unused stomach severed by staples and cut by space?) IF not maybe the issue is a staple line disruption/failure (AKA SLD)...food is going into the old tummy and no malabsorption is happening. Or a fistula ("A gastro-gastric fistula is simply a communication between the new "pouch" and the "old" stomach.)*Same as SLD your getting food into distal stomach and it avoids the bypass. Have you had an upper GI endoscopy? (Scope down throat) to see if pouch is intact and how large your stoma is (connection of pouch and intestines). Did a little more research on the Upper GI stuff....(scope vs xray with contrast) Upper GI endosopy can see at least 3x more pathology than upper GI radiographic series Upper GI contrast radiography can however best detect small gastro-gastric fistulas which can often be missed with an upper GI endoscopy. Also it can be extremely helpful to radiologically study the anatomic upper GI configuration of potential re-operative bariatric surgery candidates, as these films provide a "road-map" prior to operation which can be particularly valuable. An upper GI radiologic study often misses several 'culprits' responsible for wt regain after bariatric surgery such as: SLD (pouch reunion with stomach), partially or total eroded gastric ring or band, dilated stoma or enlarged gastric pouch. So both studies (scope and x-rays) are important in investigating bariatric surgical patients complaints of excessive wt regain. There are exceptions to every rule and it is preferable that each patient is evaluated independently, using sensible clinical judgment. So depends what is being sought/presenting problem as to what is done.From UPDATE: SURGERY FOR THE MORBIDLY OBESE PATIENT by: Mervyn Deitel ISBN 0-9684426-1-7 ©2000
c. Many have an enlarged stoma allowing them to eat larger quantities w/o feeling full, kind of like a chute. This is usually not patients or surgeons fault but many patients stomas relax on them...Some possible fixes:A lap band may help,or a surgical revision of stoma or a fixed silastic ring, but it isn't always possible. Also many are using sclerotherapy and now stomaphyx http://www.stopobesityforlife.com/StomaphyX.html or http://www.endogastricsolutions.com http://www.ingentaconnect.com/content/fd/os/2003/00000013/00000002/art00006 or http://www.drsimpson.com/chattranscript-08-13-2004.php for info. They say for this (inject substance thru upper GI scope into tissue to produce scarring) and there is a new procedure in Boston being done called: Endoscopic pouch repair. http://community.nursingspectrum.com/MagazineArticles/article.cfm?AID=14602
d. Do you get full? How much food? Have you done the cottage cheese test? http://www.digitalhorsewoman.com/pouchrules.htm

2. BEHAVIORAL (not using tool to potential):I am not saying it is behavioral just asking a few questions:
a. What do you eat in a given day? Calories track on www.fitday.com % fat/protein/carbs.
b. Do you drink with meals?
c. Drink calories?
d. Soda?
e. Do you do protein shakes? (type/number)
f. Do you do vitamins? Which ones? Types/amounts/when do you take them?
g. When were your last full set of labs/Dexascan?
h. Do you exercise? How often? Amount? Type?
i. What other meds are you on? Medcial conditions?
j. Age, Height? Starting BMI Current BMI. (Basically looking for % of excess you lost)
k. Do you follow pouch rules? http://www.digitalhorsewoman.com/pouchrules.htm

We can eat more at ~6 months out (quantity/variety), it is also time malabsorbtion of calories decreases for many as body adapts. (intestines can elongate/grow more villi/folds to increase absorbtion)

OKAY the above questions are just to help us figure out some potential behavioral issues. Again I am NOT saying the failure of you or anyone is strictly behavioral. It is just one thing. Any surgery can be defeated if the tool isn't used, BUT if the tool is used reasonably it may be broke or may of been the wrong tool (surgery) for you! IF YOU DID NOT CHANGE YOUR LIFESTYLE THER IS NO TOOL THAT WILL WORK!

3 WRONG SURGERY:
We do not always know this until after. Some surgeons realize the higher the BMI of the patient the more distal bypassed they should be. Or the type of eater someone is may lend itself to one surgery over another. Some fail to lose wt with a VBG or lap band only to lose well with a RNY or many with a proximal RNY fail to lose wt and do great with a distal RNY or others don't do well with RNY and do fantastic with a BPD/DS...you get my point. One surgeon had this to say about choosing your surgery type for you. (*I am not sure there is any real one size fits all though on deciding!) http://www.alagsa.com/Bariatric_Surgery.htm Some surgeons do a very short 40CM bypass (not near long enough for most of us MO)! Get a copy of your surgical report from the hospital medical records so you KNOW what you have! It is yours according to law!

They say 50% of excess wt lost is a 'successful surgery'. I agree *but why accept this? when others lose 75, 80, 90, 100%? I know everyone is different but if there are means to allow most to lost 80+ % why shouldn't everyone have the opportunity? We all have to weigh the pros and cons. Going BPD/DS or more distal has risks, a lap band has risks etc. Many lose 80%+ and regain after 1, 2, 3,5 yrs. Not always behavioral or mechanical,,,,so their body is real good at adapting and hence they probably had wrong surgery....

I hope this helps some and doesn't really confuse you. I have to add, I haven't had a revision. I am here learning with everyone "IN CASE" (I think education is key to success and all I can arm myself with!). It (regain) scares me too! I see/read/hear about wt regain more and more online and read more about revisions. WLS has come a long way, but maybe just maybe some day we'll get the right surgery the first time! One that we can behaviorally adapt to and use and that won't break! ONE CAN DREAM! I think a good revision surgeon is key to lower risks, I wouldn't go to just anyone! And I know many on the group could help u with someone good! Dr Fox and Oh in Washington State.
http://www.aboutmso.com/pp/prospectivepatients.cfm
http://www.ohtobethin.com/
Dr. Gagner in Florida now not sure his site?
This is a great group http://groups.yahoo.com/group/WLSrevisionsupport/ of people who can definitely lead u in the right direction!
I also know OH has a different Revision Forum.
http://www.obesityhelp.com/forums/revision/

2 articles FYI
http://www.bariatrictimes.com/displayArticle.cfm?articleID=article207
Revisional Surgery Article:
Bariatric Revisional Surgery
- by Rodrigo Gonzalez, MD; Scott F. Gallagher, MD; and Michel M. Murr, MD, FACS
EVALUATION FOR WEIGHT LOSS FAILURE
http://home.comcast.net/~muzicluvr777/Eval.htm

Wow, thank u so much for taking the time to do this for me. It's very informative.......Thanks so much.

U R Welcome email me off list anytme! [email protected]