Revision options for RNY gastric bypass

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Dr. Pleatman emailed me this discription of revision possibilities:

There are a number of options available for patients who have regained

weight after gastric bypass surgery. The first thing to do is figure out

why you have regained weight. Are you eating healthy? Are you "grazing,"

or snacking all day? Are you exercising? Only you know the answer to these

quesitons. If you are "misbehaving," an operation is not the answer. You

have to change your behavior.

Now, let's assume that you are trying to do the right things. Let's assume

that you have lost the feeling of fullness you used to have after a very

small meal. You get hungry sooner. You can eat much more than you used to.

In spite of doing everything right, you are regaining weight. If this is

the case, it is time to investigate what can be done. Perhaps your pouch

has stretched out. Perhaps the opening from the pouch into the Roux limb

(the stoma) has stretched out, allowing food to empty rapidly into the small

bowel. Perhaps there is a fistula (abnormal connection) from the pouch to

the excluded stomach. Each of these problems will have a different

solution. An upper GI series or endoscopy will help us decide which of

these, if any, exist.

Once we have this information, there are several options available, ranging

in complexity, risk, and expense. Here they are, sorted from highest risk,

greatest expense, and greatest likelihood of success, down to , least risk,

least expensive, and, possibly, least likely to succeed.

1. Complete un-doing of the gastric bypass, with conversion to vertical

gastrectomy and duodenal switch. This is the most complex operation, but it

adds significant malabsorption, which will help maintain long-term weight

loss. It is also the most dangerous operation, with the highest risk of

complcations. This can be done laparoscopically, but most likely would be

done "open."

2. Surgical revision of the pouch to make it smaller, with possible

revision of the anastomosis (connection of pouch to small bowel). Possible

lengthening of the Roux limb to increase malabsorption. This procedure is

somewhat questionable, and certainly not guaranteed. The main indication

for this procedure would be a fistula into the excluded pouch. Another

indication would be a very very large pouch which could not be shrunken by

other means. This can often be done laparoscopically.

3. Add a LapBAND. This is a fairly new concept, and currently there is not

much data available documenting long-term results. It may help by reducing

the size of the pouch, requiring you to eat slower, and helping you feel

full longer after eating. This operation can be done laparoscopically. Of

course, as with all gastric banding operations, it obligates you to having

lifel-long follow-up with your surgeon so your band can be monitored and

adjusted as necessary. Of course, this operation can generally be done


4. (Finally!) Endoscopic procedures.... procedures done through the mouth,

without any abdominal incisions. If you pouch is stretched out, it can be

reduced in size with the StomaphyX device. This device allows the surgeon

to place multiple fastners in such a way as to pucker in or pleat the

tissue. An enlarged pouch can be considerably shrunken in size. Another

option for shrinking the pouch is the ROSE procedure, which is another

device for placing sutures to shrink the pouch. If your pouch is not

stretched out, or is very small (as in the "micropouch"), your problem may

be that the opening into the small intestine is too big. This may be

treated by injecting a sclerosing medication into the tissue around the

anastomosis. This medication is similar to what is used to treat varicose

veins or spider veins... the medication is very irritating, and it causes

scarring and contraction of the tissue. These procedures, as I mentioned,

are all done endoscopically through the mouth, and have a low risk of

complications. None of the endoscopic procedures has a "track record."

There are no long-term studies. They are investigational, and not covered

by insurance companies.

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Thank you for that info. Hopefully, I'll never have to use it. But if I do, I know where to come. ;)

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