If anastamosis is too large. What can be done? - ThinnerTimes - Gastric Bypass Forum, Lap Band Forum, and Vertical Sleeve Gastrectomy Forum

MiladyB · 08-29-2006, 10:49 AM

Mary's post on the possibility of her anastomosis being too large prompted me to go digging for some info. The topic had been discussed in one of my recent support group meetings so I emailed someone who I was sure would have some information. She did and I thought I would pass it on to all of you. The email talks about a procedure called Sclerotherapy which is used to treat a person whose anastomosis has stretched making continued weight loss extremely difficult. I found it to be some excellent information and something I suspect many of us are not aware of. I know I wasn't. So here is an except from an email Julie Janeway and Karen Sparks sent to a patient who was asking about this procedure. They were kind enough to send it on to me in response to my question to them. Hope it is of some help to someone.

Excerpt from a previous email to another patient:

Don't apologize for asking questions! The only stupid question is the one you never ask! We're professional educators for goodness sake. That's what we do here at Little Victories - we educate. That's why we wrote the book "The REAL Skinny on Weight Loss Surgery: An Indispensable Guide to What You Can REALLY Expect!" so people would know what was coming their way in every aspect, and have about a zillion tips on how to deal with it. People don't get enough education before, during, or after their surgeries to make them successful. We're changing that. It's a mission!

I was about 25-30 pounds from my goal weight when I had the procedure done. I had been stalled out for about a year and was starting to put on a little bit of weight (like 5-6 pounds). I also wasn't feeling full anymore when I ate. That was the big trigger for me (and is a big trigger for Dr. Baker). I didn't have satiety anymore. I followed all the rules (I am a support group leader, author, national speaker, educator, and support group leader trainer!) and yet things just weren't going right. I was very frustrated and finally decided to talk to Dr. Baker about it.

I'm very lucky in that Dr. Baker is not only my surgeon, he is also a close friend (and co-author on the book!) He agreed that he needed to have a look at the anastomosis, or the opening at the bottom of the pouch to see if it had stretched. As a rule, most pouches don't stretch because of the way they are made these days. If you've had your surgery done in the last five years (Roux-en-Y Gastric Bypass) then it isn't the pouch that will stretch, it is the anastomosis that will stretch. If your surgery was other than a Roux-en-Y, or you had surgery longer than five years ago, it may actually be the pouch that has stretched.

There are several ways that the anastomosis can stretch. The major one is from eating too much and stretching it out. This makes the bottom of the pouch and the roux limb closer in size to each other (think of it as a funnel: if you make the opening bigger at the bottom of the funnel, the tube will have to accommodate and get bigger or you'll have a big back up) The roux limb actually becomes a storage device for food instead of just a passage way for food to go through on the way to the intestines.

There is also a variation of this. If you are drinking while eating, you are mushing up the food in your pouch which is allowing it to force itself through faster and thus you are getting more food, and you are stretching it out slower, but stretching it nonetheless.

The second way is grazing. Grazing is eating a little bit here and there all day long. Every single thing that goes in your mouth has calories. We are supposed to eat three meals a day and a snack. Grazing is not a hunger issue. Grazing is a behavioral issue. You need to examine what makes you graze. Often when you graze your body is using food to keep you awake because you are tired, so go sleep. Maybe it's using it for hydration, so take a drink of water. Perhaps you are stressed, take a walk or run around the back yard, or whip a basketball at the wall a few thousand times. Remember: HATTS - hungry, angry, thirsty, tired, stressed. Which one is making you graze?

The last way is very rare, and what happened to me. Some people just don't scar. I don't scar. I don't form scar tissue well. When Dr. Baker hooked up my roux limb to my pouch it healed so well that you can't even tell I had surgery. It looks like God made me that way. My body just started to adapt and even out the size of the two structures. Very weird, but extremely, extremely rare. If you have a scar on your outside somewhere, this is probably not you. See causes one and two. I don't scar. You can't find my laparoscopic scars from either my bariatric surgery or my gallbladder surgery. You can't find the one from my wrist surgery where I had my bones all reset and I spent a year in a cast either. Yes, I'm a medical marvel.

Anyway, that's what is happening. About 99.99% of people needing sclerotherapy have fallen away from using the pouch tools correctly (can you remember what they are? Are you using them still?) They have fallen into old habits again, or they didn't get enough education to begin with to help them become successful.

Sclerotherapy is not a miracle cure. It is a wonderful option to help you get back on track and find that healthier, happier life you were seeking and that you deserve, but it is not an easy way out. More on that in a minute. People need to know about sclerotherapy though. Living in an unhappy, unhealthy, uneducated body is not the last resort, and neither is having another surgery to fix it. Sclero and re-education can be the answer.

I'm going to let my business partner and co-author Julie Janeway, talk about the medical parts here for a second, then I'll talk about my experiences.

Julie here. Hello anyone who may be reading this. First, sclerotherapy is a procedure that is done endoscopically, meaning it is done under I.V "conscious sedation" (they put you out and you don't remember anything, but you aren't fully intubated like during surgery), and they put a long tube with a camera and tools on the end down your throat and into your gut. It's not surgery, it's a procedure. It only takes a few minutes and is generally covered by insurance because it is not surgery, it is a diagnostic "procedure."

Let's back up, you think sclerotherapy may be an option you want to investigate so you make an appointment with a doc who specializes in this (there's only about five who know how to do this with bariatric patients around the country). These docs will generally ask you to come in and see the dietitian to evaluate how and what you are eating. This is not to pick on you, it is to help you. Embrace that opportunity. They will also ask you to see the behaviorist. Again this is not a "them versus me" scenario. The behaviorist is not there to prevent you from getting what you want. That person is not a hurdle to be gotten past. The behaviorist is there to help you assess your assets and your liabilities in this endeavor They are there to help you find the most successful route to weight loss and happiness. Look at these people as part of the team, not the enemy. THEY ARE NOT THE ENEMY! The doc may also ask you to see an exercise physiologist. AGAIN, NOT THE ENEMY! This person is simply trying to help. They are all there to help educate you, or re-educate you. They are your professional support team. They will not let you go into another situation unprepared. If your first surgeon's office let you go in unprepared and set up to fail, then you should not allow yourself to go into the second situation unprepared. Expect a team that will prepare you and help you succeed even if it takes a little more time than you planned.

Once you see all of these people and they feel that a sclerotherapy procedure is the right option for you, then you will see the surgeon. The surgeon will evaluate you and if he/she feels you are ready then they will book you for the procedure. Pre-procedure labs will be drawn to make sure you don't have any other problems.

On the day of the procedure, you must have someone go with you as you will have had sedation and cannot drive. You will receive other instructions as to what you can or cannot eat or drink before hand, as well as what medication you can or cannot take. When you get there they will have a nurse place an IV (probably the worst part of the whole thing). TIP: stay very well hydrated for several days before the procedure. It will make getting an IV in much, much easier. Also, if they can't get an IV on you then ask for a pediatric IV nurse. If they can get one in on a premie baby then they can get one in on you. They will also take a ton of information down including a medical history.

When you are ready, they will walk you to the procedure room which looks more like a hospital room with equipment in it than anything else. It's not an operating room. They will ask you to lay down on the gurney. They will make sure you are comfortable (usually with warm blankets!). The doc will ask you to open your mouth and will spray some stuff in the back of your throat. It's not really that bad. Sort of like Cepacol for a sore throat. Then they ask you to roll over on your side. The nurse arranges you a little bit, they run the sedation into your IV and you're out like a light.

The doc then puts the scope down your throat. Dr. Baker goes down the throat past the pouch, down the roux limb, and into the intestine where he sprays anti-nausea and pain medication right off the bat to get it absorbing into the system and working. Then he comes back up to the anastomosis and has a good look with the camera. The average anastomosis in a RNY-GB should be 12-15mm wide. Most people are stretched out between 16 and 22mm. Karen was stretch out to 20mm. This accounted for the lack of satiety or feeling full when she ate.

He takes pictures of the site for the file, and then he begins to poke the area, systematically, with a needle and what is called a sclerosing agent. This causes the tissues to immediately inflame and get red and angry. REALLY red and angry. It puffs up and swells right before your eyes. He goes all the way around the anastomosis until it has swollen to a smaller size. The sclerosing agent will eventually scar the tissue into place like this. It is kind of like a chemical burn scar. When he feels it is even and complete, he takes more pictures, takes a final look around at everything to make sure there are no other problems anywhere (ulcers, or whatever) and then comes back out. Karen's entire procedure took 14 minutes from the point she sat on the gurney to the point they wheeled her out on it.

Afterward, in "recovery" they woke her up (although she has no memory of any of this time and neither will you) to see what her pain level was. This is a painful procedure, but they don't want you to suffer with it. They will give you pain meds to deal with it. Dr. Baker puts the pain meds on board first thing before he even does the procedure, but sometimes that's not enough. Everyone is different. Karen needed more pain meds. Also, the doc will come and talk to the patient (not that the patient remembers that) but will also talk to the person with the patient. The patient will go home with a script for pain meds as well (liquid pain meds - often Lortab).

While in recovery, and for a couple of days after, the patient may feel pain in strange places like in the shoulder, in the back, or in the lower rib cage towards the side. This is called referred pain. The actual pain is right under the breast bone or sternum. The doc has got things pretty angry, red, and inflamed in there and that kind of travels through the torso a bit. The pain often just appears other places. Don't be alarmed. Just follow the discharge instructions and watch for what they tell you to watch for. If you have pain in the legs, call a doc immediately.

When you go home you will probably need to take a day or two off. No roller coaster rides, no sitting at a desk, no mowing the lawn. Take it easy. But you will have to get up and walk and move around. You will go back to eating soft foods (yogurt, scrambled eggs, soup, protein shakes) for about 2 days, and then you should be okay.) Take the pain medication and keep the pain cycle broken. Don't let it get too out of hand. Generally after 2 days, you're in pretty good shape. Now the real work begins. Getting back on track with the pouch tools and the behavior modification. It's a lifestyle. There is no easy way out. This is only a tool. It's like a screwdriver. You can turn screws with it, or you can poke yourself in the eye. One is its intended purpose, the other is what you do to yourself when you're just playing around with it and don't use it properly.

Now, I'll turn it back over to Karen so she can tell you more about how she felt.

Karen back again. Afterward, I was very painful, but I took my pain meds. I ate soft foods but still focused on getting in my 70-90 grams of protein a day. I also tried hard to make sure I got my water in as well to get some of that sedation out of my system. Once I got a few days out and could start to eat regular food again, I noticed a difference right away. I had satiety back again. I was back to the portions that I ate four to five months out from surgery I also went through a brief period again where I had the foamies from certain foods but that might have been a signal to me that I wasn't chewing well enough or eating foods that were still a bit too hard on my pouch/anastomosis, like meats. I didn't really have any stomach pain, and I didn't have any heartburn or anything. That kind of can't happen because of how you've been replumbed. I just had the weird pain in my lower ribs off to the side, and some in my shoulder. I took the pain meds until it went away.

That only lasted for a few days or so. I started to lose weight. You really should only expect about a 1-2 pound weight loss per week, perhaps a tiny bit more if you carry more of your weight around your belly and middle rather than hips, thighs, and other places. That is to say, men tend to lose a little bit more than women. I haven't noticed any weird side effects at all, and would say that it was a tremendously beneficial procedure. I'm losing again, but I have no expectations that it will come off by itself. I still have to put in the effort to help get it off. This is old fat. It's been buried the longest. It needs exercise and good nutrition and I have to work to get it off like everyone else in the world. Sclerotherapy isn't magic. You need to be eating three meals a day and one snack. Stop grazing. Grazing is a mental issue, not a hunger issue. Get rid of the things you graze on. Get them out of the house. If you have an issue with drinking water while you eat....don't bring it to the table!

Anyway, I feel great. I had the procedure done about two months ago, and I'm profoundly glad I did. My weight loss was within the average range expected following the procedure of 5-6 pounds. I like being able to feel full again. I like knowing that Dr. Baker made the "hole" smaller and my pouch works as intended again. I'm hoping the chemical sclerosing will scar in permanently like it does on other people (we think it will). I'm glad that I don't have to feel those pangs of "did I do something to cause this" popping up in the back of my mind.

Sclerotherapy is worth it 100% but only if you are willing to give 100% to educating yourself about how to live healthy. You don't have to live like a diet queen, you just have to learn to be healthy. All it takes is education and valuing yourself enough to do it. You are worth it. You are worthy of a happy, healthy life You are worthy of an outside as beautiful as the inside.

Take all the information, help, assistance, education, resources, materials, informed advice, and support you can get. You've spent a lifetime giving it to other people, now take some back. It's like paying into social security. You pay in for years, but when you need it, you don't feel bad about taking it do you? Don't feel bad about taking your health and happiness check. You've paid in for years and you will continue to pay in, so get rid of the guilt.

Well, we hope that answers some of your questions. If you are considering sclerotherapy then please wrap your head around the fact that this is a whole rededication process. It won't work all by itself. Just like a screwdriver it can't drive the screws if you aren't picking it up and using it correctly. If you want an easy button, go to Staples. There's nothing easy about fighting the disease of obesity. It's just that - a fight, a battle, a war. You always go prepared to war.

Let us know how your appointment goes. I know Dr. Baker has patients coming from all over the United States because he is the national leader in this area. It sure beats having some surgeon tell you that you have to have another surgery or there's nothing they can do.

Get the book and rededicate yourself to the concepts. If you didn't get good education in the beginning then get it now. It reads just like this email, except funnier. Tons of good info in there. You can get it at Amazon.com, B&N.com, Walmart.com, Buy.com, Shop.com, or any bookstore in North America can order it in for you. Or you can send us a check for $23.00 and we'll send you an autographed copy. (Little Victories Press, 4371 Kinneville Road, Suite 200, Onondaga, MI 49264). We're not pushing the book to push the book, we're pushing the book to educate those who need it. That's what we do, and it's why we wrote the book. There just wasn't enough education out there in digestible (pun intended) format. So read it. You'll really enjoy it. Kind of an Erma Bombeck sort of book but with a ton of information.

Best of Luck to you, and to anyone else reading this. Write or call if you have more questions.

Karen Sparks and Julie Janeway

Little Victories Support Specialists™

Little Victories Support University™

Little Victories Press™

(517) 589-5535

Authors of “The REAL Skinny on Weight Loss Surgery: An Indispensable Guide To What You Can REALLY Expect!”

Zenomia · 08-29-2006, 07:35 PM

Beth, Thanks for posting this. This is information that most don't realize is out there. Specially those folks who are really struggling, starving all the time, losing nothing and following Dr. orders religiously. It's frustration, depressing and can become a hopeless situation...even worse than pre-surgical dieting because now they think their last resort has failed them. Thank Goodness for the kindness fo Karen and Julie to respond and offer such wonderful infomation. Keeping us updated on some things that can go awry soon or even years down the road. Every piece of information is extremely valuable.

Well...Thanks! I hope this can help someone that may be lurking...

MiladyB · 08-29-2006, 11:15 PM

You're welcome, Laura. I just thought it was some really good information that should be out there. As it was mentioned this procedure is something really new and not many doctors do it but for someone who may be in the same situation I would think it could be a God-send.

Hope someone finds the info helpful.

Blueyz · 08-29-2006, 11:55 PM

It took me awhile to read it, but it was very imformative. It makes me think hard and is pretty scary.

Thanks for sharing it Beth

Mavisavis · 08-30-2006, 06:57 AM

I will share this with my friend who went through the process with me.......who convinces herself that as long as she is losing it is ok to break the eat and drink together rule! It sounds like this can backfire on her later. Thanks for the info. I love to know all I can about this life choice.

MiladyB · 08-30-2006, 07:41 AM

Dale and Marty, I'm glad you found the info helpful. I really found the information about the eating and drinking interesting. That was an aspect of the drinking with eating I hadn't heard before. We do have to educate ourselves to make our journey sucessful. That's why I shared this lengthy email with all of you.

Gwen · 02-22-2008, 10:05 AM

.... any more thoughts on this one?

XXX

Omaha Jim · 02-22-2008, 10:31 AM

Great post - Thanks Beth!

Toony · 02-22-2008, 10:33 AM

Glad you bumped it up! I hadn't seen that before! Julie and Karen's book reads a lot like this post... very informative, putting in all the tiny details... I LOVE their book and highly recommend it to everyone!
katie

MiladyB · 02-22-2008, 10:45 AM

Quote:

Originally Posted by Omaha Jim

Great post - Thanks Beth!

Wow, Gwen you most certainly dug this one out of the archives!!

Thanks Jim. Glad you appreciated the info.

Since I posted this thread more techniques have been developed within the bariatric medical field to help with this problem. I know my surgeon's office is now also doing something called the ROSE procedure. Here is the information regarding the ROSE procedure found on their website.

ROSE PROCEDURE

Most gastric bypass patients obtain excellent weight loss after surgery. Some patients however, experience weight regain years after their original bypass surgery. This weight regain may be caused by a gradual enlargement of the stomach pouch or stoma (the connection between the stomach pouch and small intestine). We recognize this is a source of frustration and health concern and it has motivated us to pursue new options and potential solutions for our patients.

The ROSE Procedure (Revision Obesity Surgery, Endoscopic) is one of those options.The procedure uses FDA-cleared endoscopic instruments to decrease pouch and stoma size to recreate a restriction to encourage weight loss. This technique does not require surgical incisions. Rather, an endoscopic suturing device is introduced through the mouth like an upper endoscopy.

Sutures are placed in the stomach pouch to reduce its size and around the stoma to reduce its diameter. By eliminating outside incisions, the ROSE procedure is expected to provide important advantages to patients, including, reduced risk of infection and associated complications, less post-operative pain, faster recovery time, and no scarring.

The ROSE procedure is one of the first of many potential applications for Incisionless Surgery. Incisionless Surgery is considered the next wave in minimally invasive procedures and, in addition to obesity, it has generated interest among physicians in areas such as GERD, GI cancer and NOTES (Natural Orifice Translumenal Endoscopic Surgery).

(ROSE is a registered trademark of USGI Medical, Inc., San Clemente, CA.)

...and here is their information on the Sclerotherapy.

SCLEROTHERAPY

The gastric bypass pouch works optimally when a small opening keeps food in the pouch for a longer period of time. However, in some patients, with the passage of time, the opening can enlarge slightly. Until recently, there was no procedure available to address this situation. However, a study published in the Obesity Surgery Journal demonstrated that when a procedure known as sclerotherapy (pronounced: sklare-o-therapy) is performed in conjunction with a consultation with a registered dietitian, the best weight loss results are obtained.

How Sclerotherapy Works
Sclerotherapy is an outpatient procedure available for gastric bypass patients who have a dilated (enlarged) opening in their pouch. The procedure may be helpful in preventing additional surgery and may assist the patient with continued weight loss. It involves injecting an irritant around the opening from the pouch to the intestines. The body then reacts to the irritant by constricting (decreasing) the opening.

Who is Helped by Sclerotherapy?
This procedure can be very helpful for patients who are 2 – 5 years post surgery and have lost a fair amount of weight, but continue to struggle with the sensation that they can eat more than they could immediately following surgery. The procedure involves having an esophagogastroduodenoscopy (EGD) to evaluate the size of the pouch opening. If the opening is deemed large, then the irritant can be applied to decrease its size. In some cases, it may take more than one application to get the opening to constrict to the desired size.

If you have questions please call mmpc Michigan Weight Loss Specialists at 877-877-6672

I do know that the sclerotherapy works. I have had personal contact with several people who have had this problem and have gone to have sclerotherapy done. It has put them back on track with their weight loss.

So, forum if you think you are having this problem please don't be ashamed of it. Like this post says, you owe it to yourself to stay healthy. Don't beat yourself up just do something about it! There is help and answers out there.