How Does an RNY get Revised to a DS?

[DianaCox]

A proper revision from RNY to DS is an extremely difficult and somewhat risky surgery, with frequent complications - but to most people, worth it in the long run. If by doing just the intestinal part (which really isn't the same thing at all) you mean going from a proximal or medial RNY to a distal or ERNY, what you end up with is the worst of both worlds - the RNY pouch with all its problems, and significant malabsorption with even worse risks of malnutrition, because you don't have the more comfortable VSG, with essentially no limits on the type and texture of foods you can eat - just volume - along with still having a stoma, dumping, no pylorus, no duodenum in the alimentary tract - an unacceptable outcome for many.

A PROPER DS revision involves (ASSUMING the pyloric valve has not atrophied by disuse!) taking down the stoma; putting the transected stomach back together (or removing the staples); and then doing the VSG on the reconstructed restitched stomach; putting the intestine back together and recutting partitioning the duodenum, reconstructing the intestines into the right configuration; putting the Y anastomosis in the right place - it is a horrendously difficult surgery. There are only a handful of surgeons in the US qualified to do it. Which is why we say:

THINK TWICE, CUT ONCE!

 

[Larra]

Actually, what Diana wrote is not quite correct. There is no "recutting" of the duodenum in a revision of gastric bypass to DS because the duodenum was never cut for the gastric bypass. The stomach is cut into 2 pieces to create the tiny pouch (usually 1 oz in size) and the so-called blind stomach. The entire duodenum is bypassed along with the blind stomach and a short length of the proximal jejunum.
Everything else seems correct, and the most important point is that this type of revision is complex, challenging, carries significant risk, and should only be undertaken by a very experienced DS surgeon. There are only a few that do this operation at present, though I am always hopeful that more experienced DS surgeons will do them in the future, to give patients more options for these revisions. The failure rate for gastric bypass is substantial. Some patients are undergoing procedures that have not been shown to be effective for longterm weight loss or resolution of comorbidities, in particular the endoscopic procedures. Others are being subjected to other unproven procedures like band over bypass, which may work for some people (too soon to say, really) but is unlikely to work for most, IMHO. But most are unable to get any kind of revision at all, which is very sad.

Larra

 

[Elizabeth N.]

Are either of you ladies aware of any publications/studies concerning BOB?

 

[DianaCox]

Irani et al.:
Irani K, Youn HA, Ren-Fielding CJ, Fielding GA, Kurian M. Midterm results for gastric banding as salvage procedure for patients with weight loss failure after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2011;7:219-24.

They report on the results of “salvage banding” of 43 patients, resulting in:

12 adverse events: 1 enterotomy requiring band removal; 1 SBO, 1 GI bleed, 3 esophageal dilations resolved with band deflation, 1 minor port leak, 1 port flip, 1 band slip, 1 case of persistent dysphagia, and 2 cases of intragastric band migration
​

If you read that out loud, it kind of makes you want to add "and a partridge in a pear tree."

 

[ShiftedSanity]

The two ladies that i give the utmost respect for their knowledge, advise, and ability to help people suffering with an extremely misunderstood disease. They spent endless time helping me try to sort out what was a rock solid wall set up by a self funded insurance....they helped provide me with strength to continue to move forward ...and trust me as a survivor of two failed trips to mexico and a 12 hour revision surgery to fix all the scarring issues from eroded band and half azzed vsg.... these two wonderful knowledgeable ladies are angels to me....i am so thankful to tap into this bariatric bank... thank you two again...
Shifty out

 

[Spiky Bugger]

Irani et al.:
Irani K, Youn HA, Ren-Fielding CJ, Fielding GA, Kurian M. Midterm results for gastric banding as salvage procedure for patients with weight loss failure after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2011;7:219-24.

They report on the results of “salvage banding” of 43 patients, resulting in:

12 adverse events: 1 enterotomy requiring band removal; 1 SBO, 1 GI bleed, 3 esophageal dilations resolved with band deflation, 1 minor port leak, 1 port flip, 1 band slip, 1 case of persistent dysphagia, and 2 cases of intragastric band migration
​

If you read that out loud, it kind of makes you want to add "and a partridge in a pear tree."

I did a quick read..and then another...of the abstract. They call this the "mid-term" report (and mention a previous "short-term" study) but I didn't notice what the time frame was. And, in my experience (as a Lap Band Survivor), the most damning issue with the band is the number of failures over time.

For people who are just now researching wls, the band seems to work really well the first year. And not as well the second. And more reoperations and weight regain in the third year. And so on. Even some of the most vocal band proponents eventually find themselves with big problems.

So for me, how well Band Over Bypass works the first few years is irrelevant. It is more a question of "how long do these poor people expect it will be until their NEXT surgery...this time to remove the band?" And I don't know if these surgeons have published Round Three, the Long-Term Results. But I will guarantee this...the long term results will NOT be as good as the mid-term results and the mid-term are not as good as the short-term (which I haven't seen.)

 

[Spiky Bugger]

The two ladies that i give the utmost respect for their knowledge, advise, and ability to help people suffering with an extremely misunderstood disease. They spent endless time helping me try to sort out what was a rock solid wall set up by a self funded insurance....they helped provide me with strength to continue to move forward ...and trust me as a survivor of two failed trips to mexico and a 12 hour revision surgery to fix all the scarring issues from eroded band and half azzed vsg.... these two wonderful knowledgeable ladies are angels to me....i am so thankful to tap into this bariatric bank... thank you two again...
Shifty out

@ShifterSanity You know they are troublemakers, right?

 

[ShiftedSanity]

@ShifterSanity You know they are troublemakers, right?

 

[ShiftedSanity]

The worst kind...
Female and informed

 

[Elizabeth N.]

The worst kind...
Female and informed

I like you

 

[Larra]

Hey Shifted, so good to see you here!

And regarding that little "salvage banding" study, IMHO those are crappy results - a high rate of complications which increases over time, and which result either in reoperation (meaning a complete failure of the BOB) or band deflation, which is also a failure of the procedure as the patient is at BEST in the same boat as where they were before the BOB and potentially subject to further complications from their bands.
A wise person on another forum said that every band forum eventually turns into a failed band forum. There is less and less success and more and more failure the longer people live with these gadgets. If the complications turned up right after surgery at the same rate the device would not be in use anymore because the high complication rate would be so much more obvious.

I try to be open minded about bariatric operations other than the one I had. I do want people to have options. But I just can't recommend lap band to anyone unless every other option is medically contraindicated.

 

[Charris]

I had a distal bypass. To be honest I didn't really realize how bad I had it except with the dumping. Then around year 10 I realized I was no longer eating any meat bcuz it wouldn't go down and could only eat slider food

 

[ShiftedSanity]

Hey Shifted, so good to see you here!

And regarding that little "salvage banding" study, IMHO those are crappy results - a high rate of complications which increases over time, and which result either in reoperation (meaning a complete failure of the BOB) or band deflation, which is also a failure of the procedure as the patient is at BEST in the same boat as where they were before the BOB and potentially subject to further complications from their bands.
A wise person on another forum said that every band forum eventually turns into a failed band forum. There is less and less success and more and more failure the longer people live with these gadgets. If the complications turned up right after surgery at the same rate the device would not be in use anymore because the high complication rate would be so much more obvious.

I try to be open minded about bariatric operations other than the one I had. I do want people to have options. But I just can't recommend lap band to anyone unless every other option is medically contraindicated.

 

[ShiftedSanity]

Geez how could i not be here...and...
Well you said it was a good source of info....but the bonus is getting to be post op and keeping you and your co-troublemaker up to speed....i mean you know my history with pre op approval all too well....i wanted you two (and any others that may have slightly shifted (mentally) dealing with all the troubles getting to post op stage...
so in two days i will weigh...4 weeks post op.....and in mean time sippy sippy .... and hydrate.....ugh

Shifty out

 

[DianaCox]

Geez how could i not be here...and...
Well you said it was a good source of info....but the bonus is getting to be post op and keeping you and your co-troublemaker up to speed....i mean you know my history with pre op approval all too well....i wanted you two (and any others that may have slightly shifted (mentally) dealing with all the troubles getting to post op stage...
so in two days i will weigh...4 weeks post op.....and in mean time sippy sippy .... and hydrate.....ugh

Shifty out

You're mostly through the worst of it - YAY! And you already sound 1000% better.