Thinking about revision

I'm in the early stages of considering revision surgery. 

"Why?  You lost the weight, didn't you?"

March 2004 - Mama - 300 lbs!147 lbs.Much like Special K: The prize is inside.DSC_6547

Yes, mostly.  I went from 320 pounds to 149 lbs.  SUCCESS!  I've been up to 210 lbs. [during pregnancy] and have been down to 150-175 lbs. since that point.  I have bounced from 150 – 175 lbs since 2006.  When I DIET, I get close to 150.  When I just, EAT, I hit the 170's.

My goal is 130 lbs, and I realize it's pretty unlikely.  I would settle for 150 lbs. if I could maintain it without having to eat less than 1,000 calories a day to do so.  The realistic thing is, I CAN lose weight, for short periods of time, but eating a very low calorie diet makes you go nuts.  Not to mention, next to impossible when you have to eat every two hours.

After chatting with a family member who is also considering revision, I realize it may be worth my time to at least look into my options.  She's looking to revise because she never saw a huge weight loss, and regained after that point.  That seems to be the most common reason for revision surgery.

And, for her, duodenal switch looks promising:

Revision bariatric surgery: laparoscopic conversion of failed gastric bypass to biliopancreatic diversion with duodenal switch.
Gagner et al. Jun 2009
PubMed Abstract

With more than 40% failures of gastric bypass in Body Mass
Index>50 kg/m2, a successful alternative has to be proposed.
Laparoscopic conversion of failed Roux-en-Y gastric bypass to
biliopancreatic diversion with duodenal switch is technically feasible,
safe and can be performed in 1 or 2 stages. This revision surgery is
the most effective treatment to date, and should also be proposed for
failed vertical-banded gastroplasty, adjustable gastric banding and
Magenstrasse and Mill procedure, as it may provide the most durable
weight loss of all revision surgeries with acceptable morbidity. This
may result in lesser degrees of hypoproteinemia, commonly seen after
distal gastric bypass.

But, that's not what I am looking for.  I am overweight, and fighting further regain, but I am looking more at the possibility that a revision would help stop my reactive hypoglycemia.  If I can stop THAT, maybe, juuuuuuuuuust maybe it would effect my seizure condition?  The two issues are not connected (supposedly) but… come on. 

sugar sugar honey honey

I never had one issue without the other.  They came at the same time.  It seems like a "DUH!?" to me.  During a glucose challenge test, I had a god damned seizure.  While TESTING!  While SHOOTING my insulin to the SKY to LET IT DROP.  But, since I was not "low" at the time, it was ignored, and called merely neurological, go see a neurologist.


Duodenal Switch

It's been suggested that revising to a duodenal switch would cease the reactive hypoglycemia in time, and give me BACK some absorption if vitamin issues have been triggering any of these neurological issues as well.  To view an animation of this procedure
click here

If you told me it would fix those issues, I'd lay on the table TODAY.  I might have to finance it for 15 years, but…  Cut me open, let's go, except there aren't any doctors in Boston, MA that DO IT. 

Source:  Husted, MD

Specific Revision Considerations for RNY Gastric Bypass Patients

Patients with Gastric Bypass are candidates for revision surgery
for two general reasons: failure (weight gain/inadequate weight
loss) and medical complications.

Sometimes medical complications
of Gastric Bypass may result in failure as well. The causes of failure
may be either mechanical or metabolic, with consideration of the
patient's eating behaviors as well. Adhering to the principle of
"making the best of what you've got", the first step in
evaluating a post-Gastric Bypass patient with weight-loss failure
is to take a careful inventory of their food intake. Keeping a detailed
food diary is the best way to begin to make such an assessment,
and patients are often surprised to see what their actual daily
intake is. We may have a general idea of what our food intake consists
of – what we believe we are eating – only to look back on an accurate
food diary and be confronted with the truth. If patients are off
track with what they should be doing from a dietary standpoint,
getting them back on track is the next step. What happens next is
variable: some patients are able to get back on track and back to
where they were; some patients get back on track with their eating
without success at weight-loss; some patients are never able to
resume appropriate eating behaviors, which does not necessarily
mean that the patient is "non-compliant". There may be
a mechanical reason for patients having to resort to maladaptive
eating behaviors, such as what occurs when a patient with an anastomotic
stricture falls into the "soft-calorie syndrome" out of
necessity, because soft foods are the only foods that can be tolerated
without vomiting. We must also realize what it means to be "compliant"
with a Gastric-Bypass. What constitutes "appropriate"
eating for a Gastric Bypass patient would be a most unusual pattern
of eating for the rest of humanity; some people just aren't cut
out for that sort of thing, even with the help of a small gastric
pouch, and not necessarily due to any character flaw, either.

Reasons for mechanical failure of Gastric-Bypass include gastro-gastric
fistula, pouch dilation, and anastomotic dilation. Gastro-gastric
fistula is where the stomach pouch grows back and re-connects to
the bypassed stomach. This can occur as a consequence of a pouch
leak, where the resulting local inflammation from the leak disrupts
the staple line of the bypassed stomach where it lies next to the
pouch. More often, though, gastro-gastric fistula formation is a
result of a less acute, slower process. Regardless the cause, gastro-gastric
fistula allows food to pass from the pouch to the bypassed stomach,
effectively partially reversing the Gastric-Bypass. Revision surgery
for this condition may consist of closure of the fistula, restoring
the original surgical Gastric-Bypass anatomy. Conversion to a Vertical/Sleeve
Gastrectomy based procedure is an option as well, especially if
there are reasons other than mechanical failure to explain the patient's
weight gain.

Pouch dilation is a condition where the stomach pouch stretches
out and enlarges; anastomotic dilation is where the connection between
the stomach pouch and the intestine stretches out. Both conditions
result in allowing the patient to eat more than what would be required
to remain successful. Re-trimming the pouch to make it small again
is one approach to treating pouch dilation. Surgical banding and
endoscopic fixation are two approaches to treat an enlarged anastomotic
connection. These approaches to pouch and anastomotic dilation are
both directed at restoring the anatomy of the Gastric-Bypass procedure
back to what it was prior to stretching out. Another approach is
to make a paradigm shift and convert to a more metabolically active
procedure such as Duodenal Switch. Other Vertical/Sleeve Gastrectomy
based procedures are options as well, especially if the patient's
Gastric-Bypass is complicated by nutrient malabsorptive issues,
such as osteoporosis and anemia.

Conversion from Gastric-Bypass to Duodenal Switch is the most definitive
revision procedure for inadequate weight-loss or weight gain after
Gastric-Bypass. This approach addresses the issues of metabolic
failure and maladaptive eating as causes of failure. This conversion
may be done laparoscopically in many cases. A potential concern
with this procedure is that of proper stomach function after surgery.
The bypassed stomach is now brought back into use, and some patients
may have had the nerves to the bypassed stomach cut during their
original Gastric-Bypass procedure. This is rarely a problem, as
the nerves seem to grow back as the bypassed stomach "wakes
up" and resumes working again. Sometimes it may not be safe
to re-connect the gastric pouch to the bypassed stomach due to excessive
scar tissue. If the patient has acceptable protein tolerance and
satisfactory calcium metabolism, conversion to a Scopinaro-type
Bilio-Pancreatic Diversion makes a very satisfactory option.

Medical issues complicating Gastric-Bypass include marginal ulcer,
stricture, and severe dumping syndrome. These conditions may often
be treated conservatively, but when conservative treatment fails,
revision surgery is indicated. Treatment for ulcer or stricture
may involve resection of the ulcerated/strictured connection between
the pouch and the intestine. Another approach is to convert to a
Vertical/Sleeve Gastrectomy-based procedure, as stricture and marginal
ulcer are conditions that arise as a result of the intrinsic physiology
of Gastric-Bypass. This approach is favored for cases of severe
dumping as well, as it is the inherent nature of the Gastric-Bypass
itself that results in the condition.

Rarely, reversal of Gastric-Bypass
may be necessary to treat cases of malnutrition, including issues
of vitamin and mineral malabsorption. Reversals for nutrient malabsorption
may be accompanied by revision to a non-malabsorptive weight-loss
procedure, allowing patients to stave off any weight re-gain that
may otherwise result from the reversal of their malabsorption.

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