If you are considering a revision from RNY to DS you should read this. Think twice, cut once.
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.
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.
On August 10th, 2009 (Monday) I underwent revision surgery from an RNY to a DS. 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 excep****er 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. In the end I had internal and external fistulas (5 in all). In April I was put on TPN (IV nutrition) and made to go NPO once again. This was only supposed to be for a couple of week, however, it it's turned into 6 plus months. In June 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. 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 1/3 of my stomach. I sadly lost my pyloric valve and had to go back to having a 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.
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
Before RNY revision and after on the left. I'm 302 on the right and 160 on the left.
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.
On August 10th, 2009 (Monday) I underwent revision surgery from an RNY to a DS. 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 excep****er 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. In the end I had internal and external fistulas (5 in all). In April I was put on TPN (IV nutrition) and made to go NPO once again. This was only supposed to be for a couple of week, however, it it's turned into 6 plus months. In June 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. 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 1/3 of my stomach. I sadly lost my pyloric valve and had to go back to having a 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.
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
Before RNY revision and after on the left. I'm 302 on the right and 160 on the left.
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"
What an ordeal. You are lucky to be alive! I am very glad that you are on the upswing of things now. You are right, with revision surgery "all bets are off" as my surgeon told me. Most people think complications won't happen to them but they should know that it can.
Band (09/07) removed, revised to sleeve 2/9/12.
Wow, what an ordeal. I am so glad you are on the other side of it.
I am an anomaly, too. To make a long, boring story short, I am a revision, too. My intestines are in the DS configuration according to my surgeon, with a 200 cc, and my stomach is a RNY pouch with the rest of it removed. Why it was removed I have no idea. I wasn't told before hand that it was going to happen and I didn't find out until 6 months later. I wasn't happy about it but there was nothing I could do about it. I am lucky in that I haven't had any issues. I did find out I dumped when I ate some sugar by accident but since The plan is to stay away from sugar anyway it is no big deal. I did go through a period when I increased my calories that I dumped often but fortunately that doesn't happen much anymore. I am also happy that I haven't developed reactive hypoglycemia, although never say never.
Anyway, you are doing great and you look great, too.
I am an anomaly, too. To make a long, boring story short, I am a revision, too. My intestines are in the DS configuration according to my surgeon, with a 200 cc, and my stomach is a RNY pouch with the rest of it removed. Why it was removed I have no idea. I wasn't told before hand that it was going to happen and I didn't find out until 6 months later. I wasn't happy about it but there was nothing I could do about it. I am lucky in that I haven't had any issues. I did find out I dumped when I ate some sugar by accident but since The plan is to stay away from sugar anyway it is no big deal. I did go through a period when I increased my calories that I dumped often but fortunately that doesn't happen much anymore. I am also happy that I haven't developed reactive hypoglycemia, although never say never.
Anyway, you are doing great and you look great, too.
WLS 10/28/2002 Revision 7/23/2010
High Weight (2002) 240 Revision Weight (2010) 220 Current Weight 115.
Your common channel is 200 cm? Wow...not much malabsorption there. Mine is 50, which is the smallest my surgeon would do. Apparently when he did the meausrments (Hess method) it came up with like a 35 cm cc, but he said that was too severe. Apparently I don't have as much intestinal length. Probably because in my first surgery there was a big chunk that was removed. Not certain though. I find it frustrating that I don't know exactly what the hell has gone on inside of me ya know?
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"
I'm with you. I don't have a clue. My surgeon wasn't very good with the DS. I doubt he did 10 when I had mine and he no longer does them, mostly because he had such bad outcomes. I am sure he has a high revision rate. There was zero education and little follow up. Of course this was nearly 10 years ago. I knew almost nothing and most of what I did know was incorrect.
I started out with 100cc and had all kinds of problems. Bacterial overgrowth, constant gas, bloating, pain and diarrhea with many accidents. My diet didn't help. I ate a lot of junk. I haven't had any problems since the day I had my revision. I completely gave up refined carbs, too, so that is part of it I am sure.
Ironically, I don't think I really needed that much malabsorption. I never had problems losing weight when I cut back. I had a big problem with volume and with my first surgery I had pretty much no restriction. I could eat as much as before the surgery pretty early out. I still have some malabsorption because I eat around 2000 + calories a day and I lost a lot of weight, more then I wanted. If I knew then what I know now I might have been better off with just a restrictive procedure but the VSG wasn't even available then as a stand alone procedure and there was no way I was getting a lap band, even then.
It is funny because I regained 100 lbs with 100 cc common channel but that was because I was able to eat so much and my diet was terrible. I just didn't get it then, that I needed to make changes. I really thought WLS was a free ride, and it was for a few years. It just caught up with me. I was a normal weight for the first 5 years and then my weight kept going up. Now I hope I am making the changes I need to but you never know. That person that regained 100 lbs with her first WLS is still here.
I started out with 100cc and had all kinds of problems. Bacterial overgrowth, constant gas, bloating, pain and diarrhea with many accidents. My diet didn't help. I ate a lot of junk. I haven't had any problems since the day I had my revision. I completely gave up refined carbs, too, so that is part of it I am sure.
Ironically, I don't think I really needed that much malabsorption. I never had problems losing weight when I cut back. I had a big problem with volume and with my first surgery I had pretty much no restriction. I could eat as much as before the surgery pretty early out. I still have some malabsorption because I eat around 2000 + calories a day and I lost a lot of weight, more then I wanted. If I knew then what I know now I might have been better off with just a restrictive procedure but the VSG wasn't even available then as a stand alone procedure and there was no way I was getting a lap band, even then.
It is funny because I regained 100 lbs with 100 cc common channel but that was because I was able to eat so much and my diet was terrible. I just didn't get it then, that I needed to make changes. I really thought WLS was a free ride, and it was for a few years. It just caught up with me. I was a normal weight for the first 5 years and then my weight kept going up. Now I hope I am making the changes I need to but you never know. That person that regained 100 lbs with her first WLS is still here.
WLS 10/28/2002 Revision 7/23/2010
High Weight (2002) 240 Revision Weight (2010) 220 Current Weight 115.
I don't know if they did or not. Somehow it was "inferred" that was done, but to be honest with you I have little memory of who did the suggesting. (Due to a hit and run accident I suffered a tramatic brain injury which affected my memory.) I had a distal bypass in 1999 and I am pretty certain the doctor said something about removing intestine.. Then there was discussion of what my common channel length was when I had my revision. Dr. G said "there wasn't much bowel, which was surprising. I gave you 50 cm cc, but you measured at 35cm, however, that is too short." I think my husband asked why there wasn't a lot of bowel and in my haze (I was in recovery and things were really hazy, fuzzy and dreamlike) there was discussion about it. Words like "removed....prior surgery .... distal.... old way.... blah blah blah..., but honestly, I really don't know.
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"
A. Holt
on 2/14/12 11:06 pm, edited 2/15/12 12:55 am
on 2/14/12 11:06 pm, edited 2/15/12 12:55 am
You look wonderful!
I am sorry that you had all that trouble, man what an ordeal!
I am considering revising my RNY to a DS. I will be self-pay and if I decide to do it, I will use one of 2 doctors in CA.
I have all of my medical records and my stomach was stapled, not transected, which I hear is better in terms of a revision. Is that true?
I am sorry that you had all that trouble, man what an ordeal!
I am considering revising my RNY to a DS. I will be self-pay and if I decide to do it, I will use one of 2 doctors in CA.
I have all of my medical records and my stomach was stapled, not transected, which I hear is better in terms of a revision. Is that true?
I have all of my medical records and my stomach was stapled, not transected, which I hear is better in terms of a revision. Is that true?
No, sadly this is not true. At least that is what Dr. Greenbaum has said. In his experience he feels that a transected stomach actually has less problems post operatively than a non-transected stomach. My stomach was not transected and stapled across. The research suggest that the non transected stomach is tramatized more than the transected stomach when the revision is done. This is what has been told to me.
A transected stomach has had time to acclimate to the reduced blood flow. The pouch has "learned" to adjust to reduced blood flow and has time to recover. When the revision is done the bottom part of the stomach pouch is opened, then the latent stomach is opened and the two pieces put back together. From there the stomach is then tubularized. An omentum patch is placed over the staple line for added strength.
The non transected stomach seems to undergo a much more trauma. The staples across the stomach have to be removed. I do not know how this is done but I suspect they are simply cut away. The pouch, remember still has the blood flow from the lower stomach. From there the two pieces of the stomach are then put back together and then tubularized into the DS configuration. There seems to be a higher incident of gastric leak across the staple line (a weak point) in this type of revision. The blood flow to the pouch is suddenly significantly reduced. An omentum patch (a patch that has blood flow) is placed over the suture line to help strengthen it helps reduce gastric leak, but isn't always successful in doing so.
According to Dr. Greenbaum he has seen a higher complication rate from non-transected stomach pouches which is one reason why he has changed his revision requirements. (there are other reasons I am not privy too, but can speculate about).
If you are having a revision with Dr. K, I'd be certain to discuss this with him in more detail.
Maddie
(I totally don't know how the highlighting got in my post.. I tried to take it out, but not knowing how it got there, I am unable to get rid of it so please ignore it.)
No, sadly this is not true. At least that is what Dr. Greenbaum has said. In his experience he feels that a transected stomach actually has less problems post operatively than a non-transected stomach. My stomach was not transected and stapled across. The research suggest that the non transected stomach is tramatized more than the transected stomach when the revision is done. This is what has been told to me.
A transected stomach has had time to acclimate to the reduced blood flow. The pouch has "learned" to adjust to reduced blood flow and has time to recover. When the revision is done the bottom part of the stomach pouch is opened, then the latent stomach is opened and the two pieces put back together. From there the stomach is then tubularized. An omentum patch is placed over the staple line for added strength.
The non transected stomach seems to undergo a much more trauma. The staples across the stomach have to be removed. I do not know how this is done but I suspect they are simply cut away. The pouch, remember still has the blood flow from the lower stomach. From there the two pieces of the stomach are then put back together and then tubularized into the DS configuration. There seems to be a higher incident of gastric leak across the staple line (a weak point) in this type of revision. The blood flow to the pouch is suddenly significantly reduced. An omentum patch (a patch that has blood flow) is placed over the suture line to help strengthen it helps reduce gastric leak, but isn't always successful in doing so.
According to Dr. Greenbaum he has seen a higher complication rate from non-transected stomach pouches which is one reason why he has changed his revision requirements. (there are other reasons I am not privy too, but can speculate about).
If you are having a revision with Dr. K, I'd be certain to discuss this with him in more detail.
Maddie
(I totally don't know how the highlighting got in my post.. I tried to take it out, but not knowing how it got there, I am unable to get rid of it so please ignore it.)
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"
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