Revision for Chronic Malnutrition

[canadadser]

Hello,

I'm five years out and I've been struggling for about a year and a half now with severe protein malnutrition and multiple nutritional deficiencies. This came on rather suddenly, after over three years of no nutritional deficiencies and good weight loss, followed by a couple of years of weight stability. I've been hospitalized twice for TPN during this time and recovered significantly, only to slowly over months fall back into severe protein malnutrition and deficiency, despite consuming 150g protein daily and following the Vitalady DS schedule. My medical team is investigating exocrine pancreatic insufficiency and does not see long-term enzyme supplementation as an adequate fix, and I agree.

I'm looking for opinions and research on the difference between common channel lengthening vs. kissing-x revisions. My Canadian surgeon performs both and I'm trying to understand which is more likely to address my specific problems. I currently have a 100cm common channel, 150cm alimentary limb, and the length of my biliopancreatic limb is unknown as I had a 'standard' rather than Hess style DS, but given my height, it could be estimated to be 500cm. My most severe deficiencies are albumin, serum protein, hypoglycaemic A1C levels, calcium, and copper, which has led to a number of hemo problems and weird forms of non-iron deficient anemia.

Any help or advice greatly appreciated!

 

[Larra]

If you are right about your BP limb being that long, it sounds like maybe lengthening both the common channel and AL would be possible and might make a difference. But this is one of those things that come up so infrequently that there may be no way for either you or your surgeon to determine what might work and what might not without taking your best guess at it and seeing what happens.

 

[canadadser]

If you are right about your BP limb being that long, it sounds like maybe lengthening both the common channel and AL would be possible and might make a difference. But this is one of those things that come up so infrequently that there may be no way for either you or your surgeon to determine what might work and what might not without taking your best guess at it and seeing what happens.

Thanks for your response, Larra. I'm confused how that would be possible? What would have to happen, surgically, to lengthen the alimentary limb and the common channel at the expense of the BP limb? I understand typically the common channel would be lengthened at the expense of the alimentary limb by a simple moving of the anamastosis up the BP limb. I think the best result would be a longer alimentary limb and shorter BP limb, which I understand would help with protein especially. I just don't know how that happens at this point.

 

[DSRIGGS]

Hello and welcome. I am sorry to hear of your struggles and you have my empathy and ear.

As you know I went through a revision to lengthen my AL(Total AL= CC + AL)...some Docs call the total AL the roux limb. Anyways I replied to your PM and it is a side to side anastomosis. The Doc won't completely cut the limbs apart, move and then reattach. Dr K says this is the easiest surgery he does. It sounds like this is likely needed for you so I am glad you are investigating/researching. As I mentioned in my PM I was able to completely stop CREON and maintain labs where they were or a little better when taking 400,000 IU of CREON daily, but I still have some health issues. If I had it to do over again I think maybe we should have added a bit more length, but I am gaining weight recently so maybe my atrophied BPL that is now Roux/absorbing limb is finally really kicking into its max absorption phase. We shall see. I have other issues (large colon is tortured) that I believe are causing a lot of my issue right now so I am investigating getting that fixed.

BTW, Dr K was invited to on DS and RNY to DS revision ata Canadian Bariatric society (Don't remember the exact name) event. This is May 18-20 in Niagra Falls if you by any stretch of luck live anywhere near there.


Hit me up as often as you need, in this forum or PM me if you have things you don't want to discuss on the open forums.

Best wishes and I hope you get fixed up very soon.


Scott

 

[canadadser]

Hello and welcome. I am sorry to hear of your struggles and you have my empathy and ear.

As you know I went through a revision to lengthen my AL(Total AL= CC + AL)...some Docs call the total AL the roux limb. Anyways I replied to your PM and it is a side to side anastomosis. The Doc won't completely cut the limbs apart, move and then reattach. Dr K says this is the easiest surgery he does. It sounds like this is likely needed for you so I am glad you are investigating/researching. As I mentioned in my PM I was able to completely stop CREON and maintain labs where they were or a little better when taking 400,000 IU of CREON daily, but I still have some health issues. If I had it to do over again I think maybe we should have added a bit more length, but I am gaining weight recently so maybe my atrophied BPL that is now Roux/absorbing limb is finally really kicking into its max absorption phase. We shall see. I have other issues (large colon is tortured) that I believe are causing a lot of my issue right now so I am investigating getting that fixed.

BTW, Dr K was invited to on DS and RNY to DS revision ata Canadian Bariatric society (Don't remember the exact name) event. This is May 18-20 in Niagra Falls if you by any stretch of luck live anywhere near there.


Hit me up as often as you need, in this forum or PM me if you have things you don't want to discuss on the open forums.

Best wishes and I hope you get fixed up very soon.


Scott

Thanks so much for your kindness and time in responding to me. I'm struck by just how similar our issues are. A recent colonoscopy also revealed a "tortuous bowel" but nothing else significant. What problems do you suspect are impacted by this?

My surgeon and dietician will both be at that conference as well! Its about an hour away from me, but I don't believe its open to the public.

I wondered if you'd mind sharing what the specifics of your labs were for albumin, total protein, zinc, copper, etc? Did you ever have a j-tube or TPN? How did you get strong enough for surgery? Thank you!

 

[canadadser]

My total protein and albumin are sitting right about 70% of the minimum. My copper is less than 50% the minimum, and zinc is 60% the minimum. My calcium is 85% the minimum, and for the past year my PTH has been climbing from the middle of the range to now officially about 5% over the top of the range.

I had TPN last July for two weeks which corrected the worst of these back into range, but I haven't been able to maintain the results and am worse now than I was then on my metals, and very close to how bad I was on my albumin and protein (60% then).

I expect my surgeon will probably want to put me on TPN for at least 10 days to get me strong before revision, and also then to support me through the decreased intake while I'm healing post-op. How long after surgery before you could have any fluids, then full fluids, then soft foods, and finally a regular diet? How long did you stay in hospital? I'm expecting I could be in 10-14 days before surgery and then another couple of weeks post-op. Does that sound realistic?

 

[southernlady]

Welcome @canadadser

 

[canadadser]

Welcome @canadadser

Thank you!

 

[DSRIGGS]

My numbers were similar to yours and the protein markers were a little lower. I never had TPN. When I dropped 17 lbs in 10 days after being on huge dose of CREON for a year Dr k said either get out here ASAP for the revision or go TPN at home until you build back up. He had reviewed my labs. So within a week I was out there, we had our consultation at which he gave me A and D injections and the next day I had surgery. As I mentioned in our PM Dr K told me that the revision to extend the Roux limb (AL and CC) is the easiest surgery he performs. I was in the hospital 3 days total I believe. As far as eating and drinking I was drinking immediately and eating regular food by dinner time surgery day. Your sleeve likely won't be touched unless there is some issue so this recovery is much easier than the original DS. In fact my wife brought me In-N-Out for lunch the day after surgery.

Dr k wants people to stay 10 days if possible after surgery in case something goes wrong but I only stayed a week after my procedure.

The worst part of that surgery was that it was hand assisted lap so I had midline incision from umbilicus down to groin. It was sore an unfortunately it became infected about 3 days after I got home and my PCP sent me to the ER when i called him. When I got there they did a CT and found a great deal of air and a small amount of fluid in my peritoneal cavity. Dr K said when the ER Doc called him and discussed the CT he thought I had a perforated bowel. I was admitted for possible emergency surgery and I had gone septic from the infected wound (I didn't know until after I was released and read discharge papers that said I was septic) and went on a big gun IV antibiotic for 3 days. The bowel ended up not being perforated but the next day Interventional radiology was called in and they did a procedure to drain the fluid and air from my peritoneal cavity. A small section was infected under the incision. Anyway the IV in hospital and oral at home knocked it out and I was okay.

BTW the day I was released from the hospital we walked 3 blocks from out hotel in downtown Burbank to the restaurants in that area. I was feeling good other than the wound pain which was annoying but not unbearable. Dr k fixed a mesenteric defect that had opened back up so my guts were feeling a lot better...Oh I forgot he also repairs a fissure I had been dealing with for 6 months.....So lime I said with my butt and gut fixed up I was feeling good.

I don't know your other specifics but I don't know if you will need more than the three days in hospital like me or not. Nutritionally my labs were better than yours before surgery because CREON was for the most part keeping me close to range, so if you are low you might need a few days of TPN and eating.

Best wishes

 

[DSRIGGS]

Regarding the tortorous colon it was causing me and still is, IBS symptoms where I would fill up with crap even though I was going g several times a day and on those days it was very painful with constipation type symptoms and partial emptying where it felt like feces was stuck in my rectum putting pressure on my prostate and bladder. Then I would have a day of diarrhea where I would lose up to ten lbs a day. I had surgery last October and Dr k was planning on removing my sigmoid and left side colon but like I mentioned before he found a damn spaghetti factory of adhesions when he went in and one had wrapped my colon pulling it way up and causing it to flip and that was causing the temporary blockage I would get. He felt it best to be conservative and not remove the colon. It was better for a few months this but my symptoms are now back so I think it is going to have to come out. Since I have extra colon it shouldn't be a problem but I am talking with Dr k to see what he thinks the best course of action is.