ABC's of a revision by Eric Schlesinger, MD, FACS

I was digging around on here doing my research and I thought I would post this as it was hella helpful to me.

Even though he is not the surgeon I chose it is still helpful and thought provoking information.


Teena

For the last three weeks we have been setting the stage. We have, hopefully developed a common vocabulary and gained some insight regarding the limitations of different procedures. Our discussion of these limitations could easily go on for weeks. I may not have addressed your specific issue; GERD, the overstuffed esophagus, fistulas, stalled with the sleeve, complications of malabsorption, etc. These can be addressed later. Enough with the preliminaries. On to the main event!

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 dilitation, pre-Stomaphyx upper GI's or endoscopy (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 reconstruced.

This approach carries with it risks that are even greater than Lap-Band over Rny. The stomach is much more unforgivivng 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 is 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.

This is a long post with lots of information. Therefore I will save the discussion of revisions for complications (mechanical, metabolic, and physiologic) for another time.

EVERYBODY DESERVES A SECOND CHANCE!
NEVER GIVE UP!
CLAIM THE SUCCESS YOU DESERVE!

Eric Schlesinger, MD, FACS
AZ Weight Loss Solutions

>>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. <<

This is very wrong information.

If someone slips and the band is surgically repositioned or replaced the person stands a 70% chance of another slip in the near future.  The better revision surgeons are not repositioning or replacing bands.

If someone erodes the studies show, and the band makers state quite clearly, the person should not be rebanded.  If someone erodes once they stand a very high chance of eroding again.

>>The good news is that all WLS options are available to you. The risks for these revisions is minimally increased (if at all) from first time weight loss surgery.<<

This is also dead wrong.

Revising from a band to a WLS with a staple line means triple the chance for leaks, perforations, and bleeding.  I don't see three times the risk as no or minimal risk.  Leaks can be fatal.

Perhaps this is why this doctor has been sued so verrrry many times.

Whether this information is wrong or right I do not know as I am not a surgeon who has performed hundreds of these procedures.

Are you?

Thanks for your opinion stating that information that he wrote (and not me) was wrong.

I only posted what I saw on here as it was written and posted by a doctor that has performed surgery on a lot of patients on this site who are very happy with their results.

I know nothing of this doctor being sued and unless you sued him personally or were involved in the litigation's all you know is here say.

I just see that he is still a doctor listed on this site so I would assume that OH has confirmed his credentials and licensing and if he was not still considered a surgeon in good standing they would have removed him from the site.

Everyone should also know that when picking a doctor that they need to do their own research as well by checking on credentials and licensing .

OH has a disclaimer on all the MD profiles explaining that they do not verify anything.  The doctors with full profiles pay as part of their advertising.  One does not have to be in good standing to advertise on OH.

BTW, here is there disclaimer:

>>Important Disclaimer — Please Read:
The information on this page is presented solely as a tool for public use and contains information supplied by the public. ObesityHelp.com does not monitor or edit this information.<<

The doctor is still with the American Society for Metabolic and Bariatric Surgery (ASMBS) among other organizations,he still has his license, and his practice so he is evidently doing something right.

People like you remind me why I have stayed away from OH for years.

Instead of just agreeing to disagree or ignoring a post that you disagree with people always feel the need to open their mouths and give their two cents.

My post was in no way asking anyone for their opinions or asking if this information is right or wrong.

I just merely just posted what I found,  but leave it to you to dissect it and say it is wrong and then smear the doctor by saying no wonder he has been sued so very many times.

Please go away and leave me alone.

You are very argumentative, negative, obviously love to stir drama, and know everything there is to know let you tell it.

Go do it with someone else because I am not interested.

I'm merely stating the facts, nothing more.  You said OH verifies this information, I showed you they don't.  That's not negative and argumentive, those are just facts and truth.

I never claimed he was or wasn't a member of anything, I never claimed he isn't licensed.  I merely wrote information such as what he provided is probably why he has been sued so many times and he has.  He has at least two more lawsuits coming up in the next few months.

You have edited your post since I responded.

No, I am not a surgeon and I don't need to be a surgeon to read the latest studies and very clear information from the band manufacturers.

It is not "here say" to discuss lawsuits.  It is a matter of public record available by a little research and links.

I never claimed you wrote it.  That explains why you took this so personally.

I agree that people should do their research, that's pretty much my mantra.  Not to believe anything and verify everything.

Hi,

I have to agree with midwestern girl on this one. The information regarding the lapband is definitely all wrong.:

A banded patient who has a slip is NOT a good candidate for a 2nd band and risks a very high rate of a second slippage.

A lapband patient who had an erosion should never have another band. I dont know what the figures are but I think they are greater than 50% of another erosion.

A lapband patient who has to have a band removed risks a very high rate of complication depending on the revision surgeon and how capable they are of doing a one step revision. My revision was 4 and 1/2 hours long and there were tons of adhesions on my stomach, liver and a partial prolapse. IT is true that once a band is taken out and the stomach has a chance to heal, that someone could go back and have a second surgery and revise to something else, but who the hell would want to do that??? You would want to have only one procedure, one time under anesthetic and assurance that you wouldnt be bandless and revisionless which no doc could promise until they look around inside.

I ask anyone *****ads this to attempt to challenge the information that is given out by this surgeon.

Babs

Babs,

Why only ask anyone *****ads this to attempt to challenge the information given out by this surgeon?

There are sooooooo many more other surgeons out there in the world.

WHY ONLY QUESTION INFORMATION THAT IS GIVEN OUT BY THIS SURGEON???

Can you please elaborate as I would love to hear your logic and personal one on one experience with this doctor as that is always beneficial versus heresay or opinions to new people on the board.

Not really sure why, but Midwestern girl deleted her previous posts to my original post, but it is what it is.

I always ask people to challenge the information that is given out by anyone on this board, outside of this board, from their surgeon, and any other surgeons they consult with.

This is your life people and if you do not care about what happens to it who the hell will?

This is not as simple as deciding you want to change your hair color and going to the salon to do the deed.

This is do or die.

Serious business.

Ask questions and more questions and research until you cannot do it anymore.

This should never be taken lightly and if you take it lightly you should seek psychiatric help as you do not fully understand the process that involves the risk versus the gain.