Kaiser ok'd for RNY, but not DS (mostly yay!)

I had my appointment with the Bariatric Surgeon at Kaiser's South Sacramento location today.

There was some confusion about having paperwork, and upon my confused expression they clarified that it should be in my "binder." I explained that I had never been given such a thing, and they figured out since I was asking about a revision, I apparently got to skip a lot of the initial stuff, including this mythical green binder.

I spoke with my surgeon for about 30 minutes. He asked me a lot of timing and history questions. When was my first surgery, where, when did I have my gallbladder removed, why (emergency surgery for stones), am I still taking anti-depressants, am I still taking my anti-nausea meds? How frequent are nausea and vomiting episodes? Describe your acid reflux, when did that start, how severe, etc.

Ultimately, he said that he recommended gastric bypass revision to correct my initial surgery's complications. I asked when we discuss which procedure and he said he recommended Roux-en-Y. I asked about he Duodenal Switch, citing my reasons why I was interested in that procedure. He countered with he only recommends that surgery for people with an extremely high BMI of like 60 or more. He said because of the long term nutritional deficiencies blah blah blah it's less than ideal. He also mentioned that he was less concerned about future weight loss and more concerned with doing a revision to correct the severe acid reflux symptoms.

He told me to lose 10 pounds and attend a two-hour nutrition class. Once I did that, call back and they'd schedule a psych eval. Until then, he ordered an endoscopy to look at the damage done by the years of reflux and some blood work.

I walked into my appointment with my metaphorical boxing gloves, but in the end I didn't want to turn a pleasant and easy conversation going mostly in my favor into a fight. I had studies showing that losing weight before a medically-necessary weight loss surgery had no merit and was not supported by anything anywhere. I was armed with stats on long term results of VSG, RNY and DS and studies declaring the DS as the best all around option for people in my situation. I came armed with IMR decisions finding that DS for patients with a BMI greater than 50 had no better or worse results than in people with BMIs under 50... and in the end I didn't pull out any of those points. Did I chicken out or was discretion the better part of valor here?

I am going to research RNY vs. DS more in-depth, but I really feel DS is the right option for me. At what point do I start my fight for the procedure I actually want, without throwing down too early and they just take away what they've already offered to do?

If GERD is an issue, the DS isn't going to fix that.  You keep your sleeved stomach.  I agree with your doc that the RNY is a better option for you, not because of your weight or statistics, but because GERD is a dangerous thing to have, on top of being downright painful.

How does RNY resolve GERD in a way that DS doesn't? At the upper part of the stomach the surgeries leave the anatomy in the same way. Virgin RNYs leave a remnant stomach which my VSG already removed, so if it has something to do with that, it's a moot point in my case. My understanding was that GERD involved a weakening of the sphincter between the esophagus and the stomach... why would RNY help and DS not?

Other than the short and long-term weight loss, my primary problem with RNY is the hole (stoma) that gets.  punched right into the stomach wall allowing food and acid to freely flow into the unsuspecting and alkaline intestine. The bypassing of the duodenum and pyloric valve concern me quite a bit and I think would cause more problems than it's worth. I'd rather keep that regulator in place. 

The rny bypasses the pyloric valve at the bottom of the stomach and instead  food exits through the stoma. 

The food exits more easily and this usually helps or resolves gerd. Doctors recommend that patients with pre-existing gerd not get the vsg or ds for this reason. And if you do a search of oh about revisions from vsg to rny, you'll find that many of the revisions were to resolve gerd. 

Wouldn't rampid acid problems be more of a problem in the intestine, causing ulceration and bleeding??? The small intestine is an alkaline environment and can't handle stomach acid. 

Your doctor could address that question better than me.   But rny is used as a cure for gerd and reflux and I've never heard about problems with the small intestine with the rny generally. 

I agree with the above poster.  If the reason you are having a revision is because of GERD than you absolutely don't want a DS.  You would keep your sleeved stomach and that is what is causing the problems.

I had the DS with the sleeve and I had horrible reflux.  I would wake up at night choking on acid.  I took several PPIs and none helped.

I did not have my revision due to the GERD but it completely cured my reflux issues.  I have not taken a PPI since I finished the 90 day course my surgeon had me take as a precaution.  I don't know what the science is behind it but I know that for me and others it has been a cure.

If you fill a balloon with water it will build up pressure.  If you punch a hole in the bottom it will let the pressure and water out.

Your sleeve is small and builds a lot of pressure.  The pyloric valve keeps the pressure in.   RNY's stoma will give that pressure a quick escape point.  With the pressure relieved you won't be creating all the acid anymore.

Sure, but it's not.    water that's sliding effortlessly into the small intestine, its food and stomach acid. Marginal ulcers become a concern, and those don't resolve on their own. They require more surgery after god knows how much pain and dysfunction. Also the RNY takes NSAIDs off the table which will not work for my situation. I'll settle for the RNY as a last resort, but I have considered what you said here and the rest of the research I've been doing, and I'm still all-ahead go on the DS.

You are always in your rights as a patient to: 1) present research to a physician and advocate for yourself.  2) explain your understanding and ask their opinion on it.  Qualify what you say with your research.  Qualify it with research, concrete yet brief examples, and come prepared with notes and questions.  Pull these out first so the doctor sees you holding them and is prepared.  I have a medical background even though I work in a non-physician specialty (counseling) and even I do this if only to stay organized and on top of things.

I have a wee bit of experience as I'm going through a similar revision situation.  I have the sleeve and also have GERD caused by the sleeve, but also by pressure pushing upward.  When we are obese, pressure pushes upward towards our lungs and stomach.  This doesn't help the fact we have a high-pressure system from the gastrectomy.  GERD from the sleeve is sometimes resolved with further weight loss.  Of course, this isnt always the case.  I have talked to many DS patients (over two dozen so far) whose GERD resolved, or significantly improved, with further significant weight loss.  I have also spoken to several RNY patients whose GERD did not improve.  Of course, this is purely anecdotal, and not a scientific observation.  It is not clear-cut that revision to RNY improves GERD across the board. In fact, some insurance companies will not cover revision to RNY for this purpose - mine actually does not. 

At any rate the reason we all decided to opt for the DS over the RNY is that the excess weight loss will relieve the pressure causing the GERD on the high pressure system.  I also drastically reduced the GERD with diet changes - eliminating whey and dairy, and also all gluten possible made it very much improved.  I also added probiotics, changed eating times, and other tweaks.  I am very grateful to Hala helped me a lot with this.  After talking to several doctors, I also likely have bile rather than acid reflux, so the DS would help tremendously.

The reason DS is indicated for BMI 50+ is that higher BMIs are harder to get to a lower/typical BMI.  It can be just as effective in patients with a lower BMI as a second stage, too.

I made the personal decision to get the DS because, while the RNY is an excellent surgery and very effective, I wanted as much malasorption as possible for as long as possible, which biochemically the DS provides more than any other procedure, SADI/SIPS possibly included. If I could not choose I would get the RNY in a heartbeat.  If the DS doesn't work out for whatever reason (I may be getting a new job) I will do the RNY for sure.  However if I have the availability to do the DS with some of the best surgeons in the country, (which I do as they are just 30m away) it makes more sense for my situation.  

So yeah, definitely consider the RNY for no other option, but don't hesitate to advocate for the DS if it's best for you.