Your advice appreciated!

Hi,

I am looking for information from people who have had a revision due to regain after WLS. I would love to hear your story or information you have to share (if you personally didn't have a revision for this reason, but have good stuff to share too).

A little about me...
I had an open RNY in April 2002. My weight at the time of surgery was 274 and I had a total loss of approximately 109 lbs. I got pregnant with my second child in February 2003, had only a little bit of a gain (and an otherwise healthy pregnancy, delivery via c-section and baby). I then returned to my pre-pregnancy weight.

I kept the bulk of the weight off for approximately 5 years, but then started regaining in 2007. Slowly at first, but now I'm up to about 240lbs again.
 
I am not sure what type of RNY I had (distal, etc). I have only had minor dumping issues and can otherwise tolerate most foods.

I definitely do not have the same appetite I had pre-surgery...but I think I must have stretched my pouch because of a bizarre cauliflower addiction (I only like it raw and could literally go through 2-3 heads a week if I bought that much). Please please please do not lecture me about how foolish I was for eating such a bulky type of food in such high volumes. When i say an "addiction" it feels literally like that (my mouth salivates when I see it/am about to eat it and I honestly thought consuming such a healthy food would ultimately be good and not bad for me). I obviously know now I shouldn't have done it. And I didn't gain weight from eating too much cauliflower, I have gained weight because of drinking iced coffee with cream for too long (I have since switched to skim milk, but that was only within the last year...and it's been hard core to skim ever since) and also as I mentioned I think my stretched pouch can now accomodate higher volumes of food all around.

I have experienced iron-deficiency anemia. On occasion, but not often, I have felt light-headed but never passed out. I have also experienced a weird 'knot' in my abdomen -- which I could best describe as feeling like my smal intestine is crimped/bent (like when you bend a garden hose so water won't flow through). This doesn't happen often, and usually occurs if I sit up from a lying position. Having described this to my primary care physician -- she ordered an upper GI and a colonoscopy a year or so ago (to check for any issues in my abdomen as well as see if I had any reasons other than WLS for my iron deficiency anemia -- ie internal bleeding). They also did an ultrasound of the abdominal region.  Nothing unusual was found.

I am in the process of scheduling an appointment with my original surgeon and want to be prepared for the discussion. He has ordered an endoscopy for the same day -- I think he probably wants to check my stoma/pouch, etc.

So my questions...

How does a surgeon decide if a revision is needed and how does one decide what type of WLS to select?

Are there any important issues you think I should consider?

Thank you in advance for any insight and advice you can share!

Hello,
I promise not to lecture, since there is nothing to lecture about.
I am believer that an ideal weight loss surgical procedure should allow a patient to eat a normal meal, without any one around them know that they had a weight loss surgery.  In your support, nut against what you believe I would propose that your weight gain had very little to do with what you did or did not do, and more with the fact that all weight loss surgical procedures had a very well documented, predictable weight loss over time. This means that you can look at the scientific data and be able to say what percentage of patient will loose what percent of their excess weight and keep it off. Once again, you are not at fault of you weight gain, only a function of the operation that you had.

Additionally I would propose to day that Your Iron deficiency is a complication of the gastric bypass operation. It is a common problem post gastric bypass because of exclusion of the duodenum that is the principal area of iron absorption.  
Weight regain, inadequate weight loss, complication of the surgery (iron deficiency anemia, dumping syndrome, marginal ulcer etc) are all indication for revisional surgery.  Please make sure that no one tries to tell you that dumping is god for you and it will prevent you from dumping since it is not true.

As far as surgical distal gastric bypass (ERNY) it is well documented that it has the most severe set of complications. It is interesting to me that as a surgeon, as recently as 5 years ago, this procedure was being done less and less, because of its significant metabolic problems,  yet with the increasing incidence of failed RNY this procedure is being offered. Please do your objective research about all the procedures. These should include revision of your pouch, band over RNY, distal bypass, and the Duodenal switch. Needless to say that I am biased in favor of DS.
Good luck.
Ara 

Thank you so much for your very detailed and thoughtful response. I very much appreciate it.

I agree with you that the Iron-deficiency anemia is a complication or the RNY. Does that issue tend to be resolved with a revision to DS?

I have a Massachusett-based HMO and have looked at their updated WLS protocol/approved/denied policy document and a BP DS is covered. Unfortunately, if I understand correctly, there aren't any doctors currently doing the DS in Massachusetts or New Hampshire.

While I'm not opposed to a self-pay option -- should it become necessary, I want to be sure to exhaust my insurance options (if I have any) before taking a self-pay route.

Thank you again for sharing all of the information! 

 Hello,
I have no idea how the insurance issues work, I am not smart enough for that complicated matter. I would suspect that if there are no surgeons offering the services, then they will make the option available to have it done in a neighboring state.
Ara

I just wanted to let you know that there is a doctor doing the DS in Massachusetts.  I can't recall his name but he came from CA and had worked with Dr. Crookes.  He is located at the Lahey Clinic in Burlington, MA. 
Please post on the DS Board as the lady that just had it done this week down there posts there and she is from NH.

Thank you Valerie!!!

Revisions carry more risk than virgin surgeries. Look at DSfacts.com, and there is a great list of surgeons there that can do the DS, and surgeons capable of doing revisions. Many of us had to travel for the surgery, but you may not have to go as far as you think.

Of course I like the DS for many reasons, but one is that I think life is easier if you have a surgery that works with the foods that you crave. Cauliflower is a great food, so having a fully functioning stomach with the pyloric valve would enable you to eat it without worry of it getting stuck or stretching anything.

I have a thing for avocados, but used to avoid them like the plague (as well as flavored olive oil, and nuts) because I was afraid of the fat calories. It's a shame to avoid healthy foods for such reasons. I had the DS in part so I could eat a normal, healthy diet, with no odd restrictions. No one that I dine with would know I had surgery, if I didn't tell them. They'd think I was a light eater, but without restrictions, or anything that causes problems.

If you are considering the DS, I recommend coming over to the DS board, as there are many revisions there to DS from RNY and band.

Does DS revisional surgery STOP reactive hypoglycemia?

 Yes. It however depends as to how long have you been having the reactive hypoglycemia etc.
Ara

Why is that?

I have been a reactive hypo since 2005... about 18 months post RNY.