RNY to DS Information Wanted
I had RNY back in 2001 and have gained almost all the weight back. I had no complicaations and currently have no health issues, other than being overweight.
I am considering getting a revision to DS. I want to lose about 75lbs and have not been successful losing the weight on my own. I would be a self-pay and would really appreciate some advice.
I want some information from people who have already had this exact revision done.
Healing Time
Open or Lap
Cost
Best Dr.
Pros
Cons
Regrets
Complications
Food Intake
Etc.
(deactivated member)
on 10/12/11 6:36 am
on 10/12/11 6:36 am
On October 12, 2011 at 1:31 PM Pacific Time, Beautywithin wrote:
I had RNY back in 2001 and have gained almost all the weight back. I had no complicaations and currently have no health issues, other than being overweight.
I am considering getting a revision to DS. I want to lose about 75lbs and have not been successful losing the weight on my own. I would be a self-pay and would really appreciate some advice.
I want some information from people who have already had this exact revision done.
Healing Time
Open or Lap
Cost
Best Dr.
Pros
Cons
Regrets
Complications
Food Intake
Etc.
http://www.obesityhelp.com/forums/ds/a,messageboard/board_id,5357/
Hi Beautywithin, I had RNY to DS on 9/26. My doctor did my revision lap, I used the pain medication in the hospital even though I had a prescription for pain meds I didn't need it. My insurance covered my revision. As for doctors, there are only a handful that do RNY to DS revisions, check out www.dsfacts.com there you can find revisions doctors. Since you are on the west coast I would check out Dr. Rabkin and Dr. Ara Keshishian. So far I am 2 weeks post op and I have lost 22lbs. I have had no complication and no regrets. My food intake right now are thick purees.
Also post this on the DS board as the vets will definitely chime in. Good luck to you on your journey.
Best,
Frankie
Also post this on the DS board as the vets will definitely chime in. Good luck to you on your journey.
Best,
Frankie
Hey everyone! I just signed up to this website, and was a lil confused about how to post, so I hope this works!
I had an open RNY done almost 10 years ago. The first year post op was great! Finally, something had worked, and I was losing weight! I started at 246 lbs. at 5'1 tall, and got down to 125 lbs. in exactly one year. I was so happy it worked. Then I started having problems. I had to live off of 300 calories a day to maintain that weight, and excercised 5 days a week. It became too much for me to do, and I turned to amphetamine diet pills to curb the constant hunger and give me energy. I went on and off and back on them again for the next 5 years. Each time I would gain more weight back when I stopped the pills. I finally gave up and went back to somewhat healthy eating habits. I now have two kids, and my weight is almost back to where it was on surgery day! I feel hopeless, and want desperatly to have my surgery re done. I haven't called my old bariatric surgeons office just yet. I'm very nervous I will be told that he won't do revisions and I'll be obese for the rest of my life. I know my insurance won't cover this. Has anyone had it re done because they gained their weight back? Reply if you have any advice or info you want to share
Thanks!
I had an open RNY done almost 10 years ago. The first year post op was great! Finally, something had worked, and I was losing weight! I started at 246 lbs. at 5'1 tall, and got down to 125 lbs. in exactly one year. I was so happy it worked. Then I started having problems. I had to live off of 300 calories a day to maintain that weight, and excercised 5 days a week. It became too much for me to do, and I turned to amphetamine diet pills to curb the constant hunger and give me energy. I went on and off and back on them again for the next 5 years. Each time I would gain more weight back when I stopped the pills. I finally gave up and went back to somewhat healthy eating habits. I now have two kids, and my weight is almost back to where it was on surgery day! I feel hopeless, and want desperatly to have my surgery re done. I haven't called my old bariatric surgeons office just yet. I'm very nervous I will be told that he won't do revisions and I'll be obese for the rest of my life. I know my insurance won't cover this. Has anyone had it re done because they gained their weight back? Reply if you have any advice or info you want to share
Thanks!
Yes, unfortunately, there are many of us that have had to have revisions after regaining after RNY. The malabsorption of the RNY only last for about 18 months, if you are lucky, and then you are on your own with extreme diet and exercise to try and maintain. It is very hard to do. There are those that are able to do it, but I wasn't one of them.
I had RNY in May 2008. Highest was 300 and got down to 190 with RNY....I am 5'7". I didn't get anywhere near a normal weight. After hitting 190 for about 5 minutes, I started to regain no matter what I did. In 2010 I was back up to almost 250. I consulted with Dr. Henry Buchwald in MN about a revision to DS and had the procedure in April of this year. I am currently back down to 190 and still loosing! I am so happy that I decided to go in and get help.
YOU are NOT a failure! Your surgery failed you. The thing is, there are only a handful of surgeons in the US that do a RNY to DS revision. Dr Ungson (sp?) in Mexico is also highly regarded and the only surgeon in Mexico that can do the revision. Since you would be self pay, it may be a *****eaper in Mexico, but you'll have to consult around.
Post on the DS forum to get more info! Where are you from? There is a surgeon in NJ, IL, MN and a couple in CA. There may be a few more, I can never remember the whole list. Feel free to PM me with any questions, but please post over on the DS forum. Also check out dsfacts.com. Good luck on your journey!
I had RNY in May 2008. Highest was 300 and got down to 190 with RNY....I am 5'7". I didn't get anywhere near a normal weight. After hitting 190 for about 5 minutes, I started to regain no matter what I did. In 2010 I was back up to almost 250. I consulted with Dr. Henry Buchwald in MN about a revision to DS and had the procedure in April of this year. I am currently back down to 190 and still loosing! I am so happy that I decided to go in and get help.
YOU are NOT a failure! Your surgery failed you. The thing is, there are only a handful of surgeons in the US that do a RNY to DS revision. Dr Ungson (sp?) in Mexico is also highly regarded and the only surgeon in Mexico that can do the revision. Since you would be self pay, it may be a *****eaper in Mexico, but you'll have to consult around.
Post on the DS forum to get more info! Where are you from? There is a surgeon in NJ, IL, MN and a couple in CA. There may be a few more, I can never remember the whole list. Feel free to PM me with any questions, but please post over on the DS forum. Also check out dsfacts.com. Good luck on your journey!
RNY to DS Revision 4/29/2011
Dr. Henry Buchwald
"Think twice.....Cut ONCE"
Good morning.
I am fairly new to the RNY to DS lifestyle, but I can tell you that so far things have been going great.
My surgery was performed by Dr. Hilario Juarez on 9/26/11 and was done laprascopically with no complications to speak of. The surgery itself took around 5 hours to complete with about an hour in recovery and then another four days in the hospital. Pain meds were at the ready for the first two days, but as I continued walking around the floor (something the docs strongly urge) I was then given liquid pain meds as needed. I too received a prescription for the same liquid pain med for home use, but quickly found that I didn't much need it after the first week.
Monday will be three weeks post-op and have lost 41 pounds. I have been moved from a full liquid diet to soft foods for the next six weeks and from there I can begin to introduce other solids into my diet.
As far as regrets go: I have none. I look at this as a blesssing. I am regaining my life again and feel every ounce of excited for what the future holds.
I hope this answers some of your questions. Best of luck to you on your weight loss journey.
I am fairly new to the RNY to DS lifestyle, but I can tell you that so far things have been going great.
My surgery was performed by Dr. Hilario Juarez on 9/26/11 and was done laprascopically with no complications to speak of. The surgery itself took around 5 hours to complete with about an hour in recovery and then another four days in the hospital. Pain meds were at the ready for the first two days, but as I continued walking around the floor (something the docs strongly urge) I was then given liquid pain meds as needed. I too received a prescription for the same liquid pain med for home use, but quickly found that I didn't much need it after the first week.
Monday will be three weeks post-op and have lost 41 pounds. I have been moved from a full liquid diet to soft foods for the next six weeks and from there I can begin to introduce other solids into my diet.
As far as regrets go: I have none. I look at this as a blesssing. I am regaining my life again and feel every ounce of excited for what the future holds.
I hope this answers some of your questions. Best of luck to you on your weight loss journey.
Welcome and congratulations on your jouney from RNY to DS. I've copied and pasted my story below. It's good and bad and ugly at times and went on for 18 months. It's important that you count all costs, and not just financial, before you head out on your journey. None of this may happen to you, but it could. Just use it to educate yourself.
I have been asked a lot why I decided to revise from RNY to DS. Truthfully, it was because I was gaining weight. When I had my RNY in 1999 I weighed in at 430 pounds.
I really didn't see any possibility of losing 300 pounds or even less than that. RNY was considered "the GOLD standard" and though I had heard about the Duodenal Switch when I asked my surgeon about it his reply was "well, it's just like a distal (now called an eRNY) gastric bypass. I trusted my surgeon and so I didn't do due diligence and I didn't research it like I had researched RNY. I just went with the RNY. So I lost 220 pounds and got to 210 and never lost more weight. My weight just stopped and that was it and where I maintained for about four years after which I started gaining weight and from years 4 to 10 I ended up gaining 92 pounds. To put that in perspective I gained about 48% of the weight that I lost. One thing that the doctor didn't tell me was that Severely Morbidly Obese people gain more like 40-50% of their excess weight loss weight back starting around the forth/fifth year post op. Actually, I was told that I might gain 10-20%. What a lie. Anyway, I wasn't happy with myself and I hated that no matter how much I dieted I still continued to gain weight. In addition to weight gain I really wanted to not dump, which I did frequently.
Me at 430 and then at 210
The following is from my own RNY to DS revision experience. It's long and it might scare you, but use this information to educate yourself in what can happen. It doesn't mean it will, but it just might. You need to count the cost of what could happen to you. I think that many people who want revisions walk around thinking that a revision is a walk in the park and for some it can be, but for many it isn't. Twenty five to thirty five percent of RNY to DS revisions suffer from gastric leaks. That is one in three or one in four people. Revisions are risky and require a skilled and vetted surgeon to perform them. There are only a few in the U.S. that do revisions from RNY and only one in Canada (Dr. Gagner). Dr. Greenbaum in NJ used to do revisions from RNY to DS, but seems to be pushing the eRNY. My personal advice is not to even consider this.
On August 10th, 2009 (Monday) I underwent revision surgery from an RNY to a DS. My original RNY pouch was not transected from my latent stomach, there by making the revision to DS more complicated and greater risk for gastric leaks. There were issues immediately after my surgery. My heart rate was out of control and for some reason my normally low blood pressure was in outer space. I was heavily drugged on pain medication and placed in the critical care unit following my surgery. I was given medication by a cardiology specialist which after a day did bring down my BP and heart rate to more normal levels. My husband brought up to the CCU nurse that my heart rate and BP seemed high. Though nurses had been in and out of the room no one was checking my vitals. I think were it not for my husband checking my vitals I might have had cardiac arrest. After my heart rate and BP were normalized I was sent for an upper GI the next day. I repeatedly failed the GI. The gastrograffin contrast did not exit into my stomach, but rather remained in my esophagus. The next day my bariatric surgeon, Dr. Greenbaum came to visit to me to tell me that I needed to have another operation. I knew something was wrong because I was throwing up old blood, saliva, and the gastrografin contrast. Basically, the contrast nor anything else would go down into my stomach and would remain only in my esophagus I was told and that there was an area in my stomach that had been necessarily over sewn because it was a weak spot along the old RNY staple-line. That area got very swollen and as a result the contrast from the upper GI was not going into my stomach, but rather backing up into my esophagus. The next day (Wednesday) I had a second operation. Sutures were released and my pylorus, which seemed not to be working had to be stretched. I was returned to CCU and in the end I spent 9 days there. I was moved to a regular room on a Wednesday and was to be discharged 2 days later on that Friday, but my incision got red and hot and started leaking sero-sanquenous fluid and had to be opened in two places even though I had two JP drains. My incision was packed daily and dressed. Due to the draining of my incision I was not allowed to leave the hospital until the following Wednesday making my first stay at the hospital 17 days. I came home with a PICC line, a J-tube and home health care nurses to assist with the enteral feedings and thrice daily IV antibiotics as well as dressing changes. I was not allowed to eat anything (NPO), and only allowed small amounts of water and or ice. I was not allowed to eat and allowed only small amounts of ice and water. I had been NPO the entire 17 days I was in the hospital and would continue to be NPO for a total of 55 days. The days that followed my return home the arm I had the Picc line in started to hurt like hell and by Sunday night (home only 4 days) my temperature went up to 102.6. We knew that something bad was going on so I called Dr. Greenbaum's office. His answering service connected me directly with him. He told me to pack a bag and get back to the hospital. It turned out I had a subclavian blood clot (a DVT) caused by the PICC line. The PICC Line was also superficially infected and was removed, but because I needed IV antibiotics at home I had to have another one put in my other (left) arm. I was put on Warfarin and Lovonox while in the hospital. I spent another week in the hospital and was discharged. I came home on Warfarin and again started to settle in. In total I was on blood thinners for 3 months. Four days after I got home I got a visit from the visiting nurse so she could packed and dress my wound. I went to bed later that evening my husband came up a few hours later to hook up my enteral feeding (I had a J-tube) to discover that my night shirt was soaked. He took the dressing off of my incision and discovered white viscous ick (gastric stuff) everywhere.When I raised my head to look ick would come bubbling out of a hole in my incision. Once again I called the doctor the next morning and back to the hospital I went. I ended up getting a gastric leak in the area that had been previously swollen and operated on previously. This in turn caused a fistula which was draining out of the open incision. I spent another week in the hospital again. I came home with a Wound Vacuum pump. Total time in the hospital over Aug. and September was about 27 days.
For 60 days I wore the wound vac pump while it sucked out ick from my stomach and helped close my incision. In mid October the J-tube was removed and I was put on full liquids. The PICC line was removed at the beginning of October. I had been moved from being NPO except water to clear liquids to full liquids to actually eating. Unfortunately when I did eat anything that wasn't pudding or yogurt consistency I threw up. From October to April 10 I was moved back and forth from full liquids to soft foods. I had a lot of food intolerance. Most meats were impossible for me to eat. Most of my protein came from cottage cheese, Greek yogurt, and protein drinks.
For a total of 17 months I dealt with the now chronic gastric leak and fistula and ever present pain. In the end I had internal and external fistulas (5 in all). In April of 2010 I was put on TPN (IV nutrition) and made to go NPO once again after my gastric leak started leaking everything I ate or drank. TPN was supposed to be for a couple of weeks, however, it it's turned into 6 plus months. In June 2010, I got sepsis from the tunneled PICC which was in my jugular vein and being used to infuse the TPN. That PICC was removed and a Groshong cath was inserted into my subcavian vein just above my left breast and was there from June to December. In September I underwent a Enterocutaneous Gastric plug procedure. The plug was supposed to plug up the fistula and the gastric leak, however, it the procedure failed and didn't work for me. Frankly, at this point and knowing what I know, the plug never had a chance since I had so many internal fistulas and a leak that in no way was filled by the plug. In October I went back to the GI surgeon who I had been referred to by Dr. Greenbaum. He said that surgery was the next step, but told me that I potentially could come out of the surgery without a stomach. Even though the potential outcome could mean a total gastrectomy I decided to have surgery. December 15th, 2010 I underwent another surgery to excise out the gastric leak. While the surgeon was inside of me he discovered three additional blind fistulas. One that went from my stomach to my colon, which had to be repaired as well. The other two were tributary fistulas and were causing internal abscesses which had to be cut out. I had two external fistulas (fistulas that went from my stomach to the outside of my body) that were cut out as well. I ended up having a lot of strictures around the lower portion of my stomach that was causing poor blood flow to my lower stomach. I had a stricture around my pyloric valve that was so tight that the tip of a pen could not have penetrated it. This was why I was throwing everything up that wasn't pudding consistency. In the end I lost another 2/3 of my stomach. I sadly lost my pyloric valve and had to go back to having something like pouch. Some of my intestine had to be cut out however, my intestines are still a DS configuration.
As a revision I am an anomaly, but you should know that sometimes things do not always go the way we think they will. You must count the cost of having a revision. It bears repeating; think twice, cut once.
So, in the end I have lost (this time) 145 pounds so far. I'm close to being at my goal of 150 and close to being at my surgeons goal of 140 pounds.
Me at 302 on the right and now around 160.
I'm able to eat now and rarely throw up anymore. I have no more medical appliances in my body. It's been a long year and a half and there were times when I wondered if I was going to make it to the next day, however, I'm finally at a place where I am enjoying my DS.
Peace,
Maddie
I have been asked a lot why I decided to revise from RNY to DS. Truthfully, it was because I was gaining weight. When I had my RNY in 1999 I weighed in at 430 pounds.
I really didn't see any possibility of losing 300 pounds or even less than that. RNY was considered "the GOLD standard" and though I had heard about the Duodenal Switch when I asked my surgeon about it his reply was "well, it's just like a distal (now called an eRNY) gastric bypass. I trusted my surgeon and so I didn't do due diligence and I didn't research it like I had researched RNY. I just went with the RNY. So I lost 220 pounds and got to 210 and never lost more weight. My weight just stopped and that was it and where I maintained for about four years after which I started gaining weight and from years 4 to 10 I ended up gaining 92 pounds. To put that in perspective I gained about 48% of the weight that I lost. One thing that the doctor didn't tell me was that Severely Morbidly Obese people gain more like 40-50% of their excess weight loss weight back starting around the forth/fifth year post op. Actually, I was told that I might gain 10-20%. What a lie. Anyway, I wasn't happy with myself and I hated that no matter how much I dieted I still continued to gain weight. In addition to weight gain I really wanted to not dump, which I did frequently.
Me at 430 and then at 210
The following is from my own RNY to DS revision experience. It's long and it might scare you, but use this information to educate yourself in what can happen. It doesn't mean it will, but it just might. You need to count the cost of what could happen to you. I think that many people who want revisions walk around thinking that a revision is a walk in the park and for some it can be, but for many it isn't. Twenty five to thirty five percent of RNY to DS revisions suffer from gastric leaks. That is one in three or one in four people. Revisions are risky and require a skilled and vetted surgeon to perform them. There are only a few in the U.S. that do revisions from RNY and only one in Canada (Dr. Gagner). Dr. Greenbaum in NJ used to do revisions from RNY to DS, but seems to be pushing the eRNY. My personal advice is not to even consider this.
On August 10th, 2009 (Monday) I underwent revision surgery from an RNY to a DS. My original RNY pouch was not transected from my latent stomach, there by making the revision to DS more complicated and greater risk for gastric leaks. There were issues immediately after my surgery. My heart rate was out of control and for some reason my normally low blood pressure was in outer space. I was heavily drugged on pain medication and placed in the critical care unit following my surgery. I was given medication by a cardiology specialist which after a day did bring down my BP and heart rate to more normal levels. My husband brought up to the CCU nurse that my heart rate and BP seemed high. Though nurses had been in and out of the room no one was checking my vitals. I think were it not for my husband checking my vitals I might have had cardiac arrest. After my heart rate and BP were normalized I was sent for an upper GI the next day. I repeatedly failed the GI. The gastrograffin contrast did not exit into my stomach, but rather remained in my esophagus. The next day my bariatric surgeon, Dr. Greenbaum came to visit to me to tell me that I needed to have another operation. I knew something was wrong because I was throwing up old blood, saliva, and the gastrografin contrast. Basically, the contrast nor anything else would go down into my stomach and would remain only in my esophagus I was told and that there was an area in my stomach that had been necessarily over sewn because it was a weak spot along the old RNY staple-line. That area got very swollen and as a result the contrast from the upper GI was not going into my stomach, but rather backing up into my esophagus. The next day (Wednesday) I had a second operation. Sutures were released and my pylorus, which seemed not to be working had to be stretched. I was returned to CCU and in the end I spent 9 days there. I was moved to a regular room on a Wednesday and was to be discharged 2 days later on that Friday, but my incision got red and hot and started leaking sero-sanquenous fluid and had to be opened in two places even though I had two JP drains. My incision was packed daily and dressed. Due to the draining of my incision I was not allowed to leave the hospital until the following Wednesday making my first stay at the hospital 17 days. I came home with a PICC line, a J-tube and home health care nurses to assist with the enteral feedings and thrice daily IV antibiotics as well as dressing changes. I was not allowed to eat anything (NPO), and only allowed small amounts of water and or ice. I was not allowed to eat and allowed only small amounts of ice and water. I had been NPO the entire 17 days I was in the hospital and would continue to be NPO for a total of 55 days. The days that followed my return home the arm I had the Picc line in started to hurt like hell and by Sunday night (home only 4 days) my temperature went up to 102.6. We knew that something bad was going on so I called Dr. Greenbaum's office. His answering service connected me directly with him. He told me to pack a bag and get back to the hospital. It turned out I had a subclavian blood clot (a DVT) caused by the PICC line. The PICC Line was also superficially infected and was removed, but because I needed IV antibiotics at home I had to have another one put in my other (left) arm. I was put on Warfarin and Lovonox while in the hospital. I spent another week in the hospital and was discharged. I came home on Warfarin and again started to settle in. In total I was on blood thinners for 3 months. Four days after I got home I got a visit from the visiting nurse so she could packed and dress my wound. I went to bed later that evening my husband came up a few hours later to hook up my enteral feeding (I had a J-tube) to discover that my night shirt was soaked. He took the dressing off of my incision and discovered white viscous ick (gastric stuff) everywhere.When I raised my head to look ick would come bubbling out of a hole in my incision. Once again I called the doctor the next morning and back to the hospital I went. I ended up getting a gastric leak in the area that had been previously swollen and operated on previously. This in turn caused a fistula which was draining out of the open incision. I spent another week in the hospital again. I came home with a Wound Vacuum pump. Total time in the hospital over Aug. and September was about 27 days.
For 60 days I wore the wound vac pump while it sucked out ick from my stomach and helped close my incision. In mid October the J-tube was removed and I was put on full liquids. The PICC line was removed at the beginning of October. I had been moved from being NPO except water to clear liquids to full liquids to actually eating. Unfortunately when I did eat anything that wasn't pudding or yogurt consistency I threw up. From October to April 10 I was moved back and forth from full liquids to soft foods. I had a lot of food intolerance. Most meats were impossible for me to eat. Most of my protein came from cottage cheese, Greek yogurt, and protein drinks.
For a total of 17 months I dealt with the now chronic gastric leak and fistula and ever present pain. In the end I had internal and external fistulas (5 in all). In April of 2010 I was put on TPN (IV nutrition) and made to go NPO once again after my gastric leak started leaking everything I ate or drank. TPN was supposed to be for a couple of weeks, however, it it's turned into 6 plus months. In June 2010, I got sepsis from the tunneled PICC which was in my jugular vein and being used to infuse the TPN. That PICC was removed and a Groshong cath was inserted into my subcavian vein just above my left breast and was there from June to December. In September I underwent a Enterocutaneous Gastric plug procedure. The plug was supposed to plug up the fistula and the gastric leak, however, it the procedure failed and didn't work for me. Frankly, at this point and knowing what I know, the plug never had a chance since I had so many internal fistulas and a leak that in no way was filled by the plug. In October I went back to the GI surgeon who I had been referred to by Dr. Greenbaum. He said that surgery was the next step, but told me that I potentially could come out of the surgery without a stomach. Even though the potential outcome could mean a total gastrectomy I decided to have surgery. December 15th, 2010 I underwent another surgery to excise out the gastric leak. While the surgeon was inside of me he discovered three additional blind fistulas. One that went from my stomach to my colon, which had to be repaired as well. The other two were tributary fistulas and were causing internal abscesses which had to be cut out. I had two external fistulas (fistulas that went from my stomach to the outside of my body) that were cut out as well. I ended up having a lot of strictures around the lower portion of my stomach that was causing poor blood flow to my lower stomach. I had a stricture around my pyloric valve that was so tight that the tip of a pen could not have penetrated it. This was why I was throwing everything up that wasn't pudding consistency. In the end I lost another 2/3 of my stomach. I sadly lost my pyloric valve and had to go back to having something like pouch. Some of my intestine had to be cut out however, my intestines are still a DS configuration.
As a revision I am an anomaly, but you should know that sometimes things do not always go the way we think they will. You must count the cost of having a revision. It bears repeating; think twice, cut once.
So, in the end I have lost (this time) 145 pounds so far. I'm close to being at my goal of 150 and close to being at my surgeons goal of 140 pounds.
Me at 302 on the right and now around 160.
I'm able to eat now and rarely throw up anymore. I have no more medical appliances in my body. It's been a long year and a half and there were times when I wondered if I was going to make it to the next day, however, I'm finally at a place where I am enjoying my DS.
Peace,
Maddie
HW (pre RNY) 430 / HW (pre DS) 302 / SW 288 /
Lowest weight 157 / CW 161 / GW 150
"I'm just one stomach flu away from my goal weight"
Thanks so much for enlightening me on things that can happen. I have been reseaching revision from RNY to DS. I am so sorry you had to go through so much but thank God you are doing better now.
I had RNY in 2000 lost 137lbs but have gained 70 back, so you can see why I am seeking a revision.
Good luck with your health and your journey to reach your goal.
Marianna
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