Question:
I need to know the formula used for the amount to bypass

I was bypassed 100 cm distal. I weighed 355 when I was admitted to the hospital the day of surgery. My surgeon did not look to see I had gained 47 pounds since she had first seen me from CHF. This would have raised my BMI almost 9 points. I have lost a total of 85 pounds and no more has come off. My surgeon is now saying she must go in and lengthen my limb for more weight loss. I am told I will have a possibility of diarrhea 3-6 times per day. She told me she had to lengthen because of severe malabsorption. My blood work is fine. I go to see her 8/7/03 and need any help anyone can provide. Thanks!    — amytravis (posted on August 6, 2003)

August 6, 2003
Hi, you're profile is not public so I don't know when you had your surgery, but a loss of 85 pounds is fantastic. How long have you been stuck at the 85 pound loss? It sounds like a plateau. As far as the lengthening of the limb for additional weight loss, this will cause additional malabsorption. You say she says she is lengthening it because of severe malabsorption (like that will fix it). That doesn't sound correct to me. I also could be wrong on this, but I thought 100 cm was considered proximal, not distal. Good Luck.
   — Carolyn M.

August 6, 2003
There is no magic formula. Each surgeon decides what they will do for each patient. In general my surgeon always does a 1/2 ounce pouch and then either bypasses 100cm or 150 cm, which he bases on BMI and other criteria. since you do not have a profile I can't tell what BMI you were originally at. Normally my surgeon uses the 50-55 BMI mark to increase the bypass. He doesn't do longer though because he is concerned of causing too much malabsorption. His experience is that the combo he does will provide long term success if the patient complies with the program. <p>I do not know where your surgeon is coming from with the 3-6 times a day for diarrhea. If she is talking about bypassing you up to a total of 150cm that is very very unlikely to happen. Might have a little problem at first but not for long. I'm thinking she is talking about revising you to a bypass similar to a DS. This is highly unadvisable with an RNY. Your pouch is so small that you will never be able to get in enough food to stay healthy. consequently you will have to live on protein drinks the rest of your life. You will be able to eat real food but most of your protein will come from the drinks. There are very few sugeons in the world that will do an RNY with a bypass similar to a DS, which personally I feel is malpractice to intentionally put a persons health at such risk. If they want to do that long of a bypass then do the DS, because you are left with a significantly larger stomach and normal stomach function. The DS is designed to be matched with the long bypass but the RNY is not. <p>You do not indicate how far out you are either. Unless you are like 18 months out and lost 85 lbs then I would be looking at my eating program to see where I have maybe exceeded it. Are you eating high calorie foods. All of these will affect weight loss. What size pouch were you given? Maybe that was too large from the start. There are so many variable here but before you decide anything you need to fully understand exactly what she plans to do. If she is going to bypass you more than 150cm get another opinion. Maybe it makes more sense to downsize your pouch if it is stretched too much. You need to fully understand the ramifications of what she proposes to do. As an RNY patient who started at 442 and a BMI of 65.3 I would not have let anyone do a bypass longer than 150cm on me as that is the proven surgery that works. Longer than that there is too much uncharted territory to know I would be safe. I know of SMO people who have larger pouches and shorter bypasses and do great and lose most or all of their excess weight. It really comes down to how each person embraces their new life. Please do some honest looking at your eating etc. and see if some or all of this comes from the choices you make. If you know in your heart it does not then I strongly suggest you get a 2nd opinion before doing anything. You may also find that your insurance may not cover this revision, so check everything out. Good Luck!
   — zoedogcbr

August 6, 2003
To answer some of the questions. I am just over 12 months post op. I lost the 85 pounds in the first six months. I have followed the program as I was supposed to as far as eating the amounts and food choices I have made. My pouch started at 1/2 ounce. When my pouch size was checked in May it was 1 1/2 ounce which the surgeon said was perfect. The surgeon has blamed me for the lack of weight loss from the beginning. First, accusing me of stretching my pouch which was proven incorrect. Then, it was blamed on severe malabsorption, which is obviously not the problem considering labs are fine. I am at a loss why a redo to lengthen the bypass is going to help. My research tells me she made me the wrong length by at least 50 cm the first time. I have to wonder if this is why the redo. She has done this same procedure only 6 times. Out of 6 patients, only 1 is willing to talk to others facing the same problem. I am confused. I do not understand. I just need some help to understand.
   — amytravis

August 6, 2003
Amy, Thanks for the additional info. Since your surgeon had only done a few RNY's I wonder if there is something else wrong or not ideally done. I would agree that the pouch size sounds okay. However, I wonder since she has so little bariatric experience if her post-op plan she gave you is ideal, which obviously would not be your fault. You followed what you were given. <p>Can you give me an idea of what you typically eat in a day. I'm not trying to pick just trying to see if I can identify anything that might explain the situation. Do you know how many grams of protein, fat and carbs you get in and how many of the carbs are sugar? How much exercise do you do? Have you tried bumping up the protein and water to see if you can kickstart the weight loss again? I've read where people who are further post-op, will go back to square one - liquids on up, to get the weight loss started again. It will help shrink the pouch and kick you into ketosis which should burn the fat some, but make sure you still get the vitamins in. <p>I see from your answer that you have basically been on a plateau for 6 months, which I'm sure is very hard for you to accept. I do understand why you are looking for ideas and options. I would be too! It's not something one normally expects. <p>I wonder if having a leak test or upper GI by another WLS doctor might reveal some tell tale signs. You aren't gaining so obviously what you are eating is keeping your body satisfied and nourished. That is a huge accomplishment in itself, as it would be real easy to console yourself with food when looking at such a long plateau. I would be so afraid to let this surgeon do a revision if that's what you decide. I also question if moving the bypass from 100cm to 150cm will make that much of a difference or if because you are further out and that first section of the small intestine is absorbing again, you need to go longer. But not too long as you do not want to end up malnourished. her comment that you are not losing because of too much malabsorption makes me think she has no clue about this surgery and our bodies. A 100cm bypass is minimal malabsorption and in no way would make you malnourished, so I cannot figure that comment out. Even if she is willing to redo everything for free, which I doubt would cover the hospital costs, I still would get a consult from a 2nd WLS doctor. One who has many years of experience and might be able to figure out what's up. They also might be able to look at your post-op eating plan and see where you were led astray, but I question if that would be the total cause of this situation. I wonder what else she isn't telling you. Maybe a call to her from a lawyer is in order. <p>I'm sorry I don't have any other great words of wisdom, but make sure you find out what is going on before you let the same surgeon go in there again. If she is going to cover everything (including hospital), maybe it would be worth it to pay a WLS surgeon yourself to assist her, if that's even possible. I also would request a copy of the surgery report from the hospital, not the doctor. You will have to sign a release but it is YOUR medical file and you are entitled to have a copy of anything you want. Maybe if another surgeon looked at the surgery report they might find what is wrong. I wonder if she even bypassed the 100cm. Who knows what could be up. At least it's a place to start without having to be cut open for now. Good Luck and let me know what you all find out. This is quite curious. Chris D.
   — zoedogcbr

August 6, 2003
Amy, 100 cm is a proximal and your surgeon is recommending she lengthen it to 150 which is considered distal. The more distal the bypass the more the possibility (not always) of having bowel issues such as daily diahrea. I know that with the DS surgery (not RNY), they bypass so much that DS'ers have this problem (again, not all of them-many have no problems at all!) I think the statement, "she told me that she had to lengthen because of severe malabsorption", perhaps you meant to say that she has to lengthen to CAUSE severe malabsorbtion (hence less absorbed so more weight loss?). I agree with Chris that you should let us know what your daily diet consists of-how many calories/protein grams, how much per meal do you eat, how often do you eat, exercise schedule, water intake first. Lets eliminate the obvious first. 85 pounds in a year is good-but being on a plateau for 6 months is not.
   — Cindy R.