Reving for the third time possible RNY to DS???

[cboone]

Hi my name is Tee. My apologies for not brining my "A" game to this forum. If I may start again. I am struggling getting and keeping my weight under 200ibs at age 45. I had my first RNY gastric bypass in 2008 with Dr. Isaac Newton in Iowa City. I started at 303lbs got to 220lbs very slowly and then after about 18 months starting going back up and returned to old eating habits etc. In 2013 I was back up to 260lbs so I got an RNY revision in Mexicali by Dr. Aceves (my he rest in peace). My gastric pouch was revised from 10cm to 7cm. The anastomosis was measured in endoscopy last week at approximately 25mm. It was too restricted in 2009 shortly after my first RNY and they dilated it twice to approximately 20mm. After the 2013 revision of the pouch I got back to the 220lbs again then weight loss stopped again. Now I'm back up to 260lbs the pouch is at 7cm and anastomosis is at 25mm. My limbs are 75cm Roux loop, and the 30cm bilio-pancreatic limb.

Dr. Ungson advised that I get an ERNY (gastric bypass) revision and not the DS for more mal-absorption and thus weight loss. He stated that it is too risky and complicated to get revise to the DS and refused my request to revise to the DS. From all the readings I have some to the conclusion that he does not do RNY to DS revisions. In fact I love the Mexicali team but they do not appear to be the best for any revisions. He suggested making the Roux loop and the bilo-pancreatic limbs longer thus shortening the common channel. The length of the common channel would depend on the length of the small intestine. He also suggested that he may or may not revise the two wide anastomosis because of the condition of the tissues and there may not be enough blood flow to the upper area because it has been worked on twice and thus not enough blood flow means no healing and leaks. I was scheduled for tomorrow (Nov 13, 2014) and finally decided to start reading obesity help and met Laura who directed me to this website.

I was driven here out of desperation to make a more informed decision and to let the third and final time be a charm. After much reading (still reading though) and chats I delayed my procedure in Mexicali and consulted so far with Dr. Ayoola in Texas and Dr. Marchesini in Brazil. I have spoken with Dr. Ayoola office manager in depth and he suggests RNY to DS revision. He would reverse the RNY and then do a DS.

However, I have a Skype call tonight with Dr. Marchesini but by email so far he appears to be pushing an RNY to BPD (Scopinaro operation). He sent me a paper yesterday that shows that the BPD and BPD/DS have the same results. Dr. Marchesini believes that revision to BPD would be easier and safer because he would only work on the intestines as opposed to with a BPD/DS he would work on both, stomach and intestines intervention. The BPD/DS has more chance to complicate and to maintain and longer hospital stay as well as extra costs.
he stated the he has done several cases of revision from RNY to DS. Both open and laparoscopically. These are operations that involves higher risk. The same results can be achieved with revision from RNY to BPD (Scopinaro operation) or Distal RNY (Brolin operation). These two procedures are easier to be done and with minimal risk compared to revision to DS. What matters to you is to loose weight, get rid of the comorbidities and have good life quality. He thinks I could reach similar results with these three operations.

This where I am now. I am sorry for not just putting it all on the line earlier. I hope I can get some good advice. I am reading and learning a lot. I should have come here long ago before the 2nd revision.

 

[southernlady]

Sorry you haven't had good results so far and need a third revision. At this point, I would suggest only TWO surgeons for a revision given your history...and I'm not sure if they could do it. But it would not hurt to contact them. I really would NOT have anyone else touch me if I were you at this point.

The two I would suggest are both in California:
Dr. Ara Keshishian
Dr. John Rabkin

Personally I would say HELL NO to the BPD as a stand alone...Good luck in your quest.

 

[Spiky Bugger]

Much better...thanks...I was trying to figure which one of us was communicating in a secret language. LOL

If Rabkin and Keshishian didn't exist, I might consider Ayoola...but I'd go into that knowing that he has little to no experience with a situation like "mine."

What Larra explained over on OH really covers the issues on which surgeries. If you do not revise to the more technically complicated DS and go ERNY, then you will be living with some of the DS "issues" without its malabsorption benefits..."the worst of both worlds," so to speak.

And, once you decide on a procedure, you have pretty much already selected your surgeon.

 

[Elizabeth N.]

Hi Tee. Now I recognize your story from elsewhere. On that other site, several people (many of whom also post here) gave you some excellent advice, so you need not expect to hear any different "technical" advice here.

You also got some rather strongly worded feedback which I'm sure was difficult to hear, and that was that your history, as shown in your posting there, indicated that there's a lot more to your story than "just" problems with your first and second RNY procedures. If you do not very seriously address those issues, there is zero point to going forward with another revision. Indeed, another revision, in particular to an ERNY or a DS, with the severe malabsorption involved in both procedures, might very well IMO endanger your life.

There are worse things in life than being fat. You have a bunch of things in your life that sound like they need fixing far worse than you need another WLS.

 

[Elizabeth N.]

I also see that the thread in which you got that advice was removed from the other site, so I will mention that as a warning to other members here that all is not as it seems.

 

[Larra]

Hi and welcome. I'm glad you've found your way here.
As you know by now, your situation is complicated. Each operation causes tissue damage and blood supply damage, making each further operation more difficult and risky.

So I'll keep this brief. The more I think about it, the more I agree with Southernlady that you need the most experienced revision surgeon possible. That means either Dr. Rabkin or Dr. Keshishian. I have great respect for Dr. Ayoola but his experience with revisions is more limited. Definitely notanyone in Mexico! (said with great respect for Dr Ungson, whom I would recommend without hesitation for a virgin DS)

Contact one or both of these guys. Tell them the whole story, like you've done here. See what they say. I hope a real DS will be possible for you.

 

[DianaCox]

Can you please explain whether any of the measurements you have posted constitute a structural or functional failure of the surgery? 25 mm sounds pretty normal size for the stoma; the measurement of the pouch should be expressed in terms of cc, not cm - as such, 7 or 10 cc is still very small.

 

[cboone]

I also see that the thread in which you got that advice was removed from the other site, so I will mention that as a warning to other members here that all is not as it seems.

Do you mean someone in particular's response to my thread? I don't know what you cant say on these sites please let me know if I say something or reveal something I should not.

 

[cboone]

Can you please explain whether any of the measurements you have posted constitute a structural or functional failure of the surgery? 25 mm sounds pretty normal size for the stoma; the measurement of the pouch should be expressed in terms of cc, not cm - as such, 7 or 10 cc is still very small.

My stoma at first surgery was 10mm and to my understanding the norm is 10 to 12mm. It was dilated to 15mm then to 20mm and now it is at 25mm. The problem is that though the pouch is small everything is dumping right through because the stoma restriction to slow down the emptying of the pouch is not happening. So in an hour or so the gastric pouch is empty again. This is my understanding. The problem that I have is carbs (cereals and breads). I slowly let them in and now they are a big problem. I also have no mal-absorption from my understanding I never did because my limbs are too short. I have only had restriction which is temporary so I am and was trying with the 2nd revision to get the mal-absorption and the restriction working together at the same time. My nutritionists told me when I was at 220lbs and could not get past it that my body was very efficient and adjusted to changes very quickly and reached a happy place and likes to just hang out at that place/weight. I was on 100gm protein per day with 50%protein, 30%carbs and 20%fat diet. But I had some major family issues that took me off track for about 6 months and it has been uphill weight gain since. I was doing so well with the lack of mal-absorption. With the first RNY I was told that my pouch was made too long at 10cmm and that I had been overly dilated which was why I had very slow weight loss and eventually weight gain. So I was told it was a functional problem but it can be coupled with poor eating too. Returning too the carbs (cereal and breads). I have learned what I need to do. I really want to try again with the right procedures I think I can join you all with a successful WLS story for life and help others as you all do. I wish I could just do it alone but I need help and I don't know if I am going to get it but I'm trying and hope to make a very informed decision (the right decision). Thank all of you so much for chatting and getting me to open up. It has been so hard to talk about.

 

[DianaCox]

Well, clearly you are suffering from a combination problem of a subpar surgery and your own admitted problems with food choices. With a DS, you can't be plowing down carbs either, so perhaps the first thing to do is get your carb issues under control - because you need to do that anyway, and so perhaps you can see if just doing that will help you be more successful with the surgery you have.

The other issue is, what are your obesity-related comorbidities?

 

[Elizabeth N.]

@cboone I'm getting the impression that you just might be hyperfocusing on things that might not be as meaningful in the grand scheme of your WLS problems as you *think* they are. These measurements might or might not be good/bad/indifferent.

There are things you can do to maximize the use of your pouch. First things first: Eliminate the carbs. Eat DENSE protein that will take a while to pass through your stoma. Take your daily carb intake down to Atkins-like levels. Many people here have to keep their total carbs to 50 grams a day in order to maintain their weight loss, even with a DS.

A third WLS is a huge, huge risk. You are never going to be able to eat everything you want to eat. If you do not fix your poor eating first, there is absolutely no point in having another revision.

You have said nothing about taking supplements or getting labs done. What is your nutritional status like? What labs do you get done and how often? Do you know how to interpret them? These are skills you need to acquire BEFORE you move forward with another revision. You are very, very far from being ready to consider further surgery. It's time to fix what you can fix WITHOUT further surgery.

 

[cboone]

@cboone I'm getting the impression that you just might be hyperfocusing on things that might not be as meaningful in the grand scheme of your WLS problems as you *think* they are. These measurements might or might not be good/bad/indifferent.

There are things you can do to maximize the use of your pouch. First things first: Eliminate the carbs. Eat DENSE protein that will take a while to pass through your stoma. Take your daily carb intake down to Atkins-like levels. Many people here have to keep their total carbs to 50 grams a day in order to maintain their weight loss, even with a DS.

A third WLS is a huge, huge risk. You are never going to be able to eat everything you want to eat. If you do not fix your poor eating first, there is absolutely no point in having another revision.

You have said nothing about taking supplements or getting labs done. What is your nutritional status like? What labs do you get done and how often? Do you know how to interpret them? These are skills you need to acquire BEFORE you move forward with another revision. You are very, very far from being ready to consider further surgery. It's time to fix what you can fix WITHOUT further surgery.

@cboone I'm getting the impression that you just might be hyperfocusing on things that might not be as meaningful in the grand scheme of your WLS problems as you *think* they are. These measurements might or might not be good/bad/indifferent.

There are things you can do to maximize the use of your pouch. First things first: Eliminate the carbs. Eat DENSE protein that will take a while to pass through your stoma. Take your daily carb intake down to Atkins-like levels. Many people here have to keep their total carbs to 50 grams a day in order to maintain their weight loss, even with a DS.

A third WLS is a huge, huge risk. You are never going to be able to eat everything you want to eat. If you do not fix your poor eating first, there is absolutely no point in having another revision.

You have said nothing about taking supplements or getting labs done. What is your nutritional status like? What labs do you get done and how often? Do you know how to interpret them? These are skills you need to acquire BEFORE you move forward with another revision. You are very, very far from being ready to consider further surgery. It's time to fix what you can fix WITHOUT further surgery.

Well, clearly you are suffering from a combination problem of a subpar surgery and your own admitted problems with food choices. With a DS, you can't be plowing down carbs either, so perhaps the first thing to do is get your carb issues under control - because you need to do that anyway, and so perhaps you can see if just doing that will help you be more successful with the surgery you have.

The other issue is, what are your obesity-related comorbidities?

I am pre-diabetic with an AIC of 6.2 and my glucose is normal at 95 fasting. I do not have hypertension, high blood pressure or anything else. I have gone through a bout of anemia and iron deficiency but not at all anymore. All my labs are normal expect protein was a little high. So my doctor is having me repeat my labs in a week. My B12 is double the norm so they backed me off my B12 and B complex supplements and continue to monitor. My B12 has always been abnormally high since first RNY. I do all my labs regularly. I have a local bariatric doctor and a PCP that has followed me since I have been in Virginia very well. I have had 2 Upper GI with KUB and 2 endoscopy in the last 3 years to include last week. Gallbladder function test and its intact and normal as well. Bone density done and its also normal. I do my multi-vitamin, daily calcium, and other vitamins as ordered. I am not getting in the protein like I should but my blood work says its high. The lipid test, the comprehensive metabolic test, iron test, albumin, lipids. etc. The pouch is still restrictive but only for a short period of time. I can only eat small amounts at a time still.

 

[DianaCox]

So basically, you have no real functional failure, you are "non-compliant" by your own admission with the dietary requirements of the RNY, and your single minor comorbidity is slightly elevated A1C, which would likely be lowered by a modest 5-10% weight loss (~20 lbs), which itself could likely be accomplished by cutting the carbs.

Nevertheless, you are presumably (depending on your height) MO at 260 lbs and qualify for repeat bariatric surgery per se. Given the dangers of an RNY to DS revision, your lack of significant current health problems and your admitted non-compliance, I would suggest you try a low carb diet first, while documenting your CURRENT weight at a medical appointment in case you eventually do need to have a revision.

 

[Elizabeth N.]

Frankly, until you become able to comply with basic diet requirements and address your emotional reliance on the very foods that will sabotage any wls, it's pointless and probably dangerous to undergo further surgery.

There is a significant body of knowledge you need to acquire to live with the DS. While you are fixing your eating, you can be learning what you need to know.

try the super low carb path, relying heavily on dense protein for your food, for a couple weeks. Then tell me your pouch has no restriction.

 

[Larra]

OK gang, I agree about the carbs and all, but let's not be too harsh. 25mm stoma is too large IMHO. These days (and for at least the past few years) bariatric surgeons have been making that stoma a mere 10 mm. You can't make them narrower than that because that would lead to a stricture, but a 25 mm stoma is large enough for food to drop right out of the pouch into the small intestine. That seems to be what is happening to Tee, and is one of the factors (maybe the main factor) that Dr. Roslin discusses as a cause of RNY failure because it causes near constant hunger as the pouch is almost always empty. Combine that with the fact that RNY patients are instructed to chew chew chew their food til it's practically liquid and you can imagine that even appropriate foods, such as dense protein, will just flow right through that stoma.

So while better food choices would be helpful, and getting control of carbs would be a good thing, there really is something functionally wrong with Tee's RNY. What's more, the "something wrong" was already addressed at her first revision, and yet it's still wrong. I guess it could be addressed again (I really don't know) but each operation on the same tissues brings on more and more scar tissue, and to me there is no telling how it will heal, how large the stoma will end up, will it stricture (either made too small or heal with stricture due to poor blood supply) and need to be dilated yet again which could result in a too large stoma AGAIN, .....

Tee, get in touch with Dr. Rabkin and/or Dr. Keshishian. See what they say. These guys are revision experts. If THEY tell you it's too risky, so be it. I would respect their judgement 100%. But they might offer you some hope.