Revision's WLS Story

[Deleted]

Hi everyone…I wanted to introduce myself to this wonderful community. I am 41 years old, married with 2 small kids (5 and 3 yo). I am also a physician (GP and radiologist).

I had RNYGB (Dr. Christou at McGill in Montreal, QC, Canada) in 2004, the summer after I completed medical school. My surgical weight was 375 lbs. I had a stenosis which required dilatation (via bougie). The lowest I got after bypass was 260 lbs. The weight came back on gradually over the next 3 years, during which time I completed my residency in family medicine. In 2007 I had a LapBand placed (Dr. Couburn in Mississauga, ON, Canada). This likely gave me some minimal help and probably slowed my weight regain (a bit).

I got married in 2008 to a wonderful and supportive (but non-obese) woman. My weight at that time was around 270lbs.

I decided to pursue additional training in diagnostic radiology in 2009. By the time I finished the program (which was a bit of a difficult and unfriendly experience) in 2013, my weight had increased to 320 lbs. Since then I have tried increasing the lifestyle modifications (personal training, Ideal Protein, Jenny Craig, etc, etc). My weight is now 335 lbs.

I have decided at this point to pursue revision surgery. I have met with Dr. Gagner in Montreal and have scheduled the first step of my revision for early May 2015. The first step will involve revising the RNY and performing the VSG. This is to be followed in 6-12 months (probably 6-ish) with a DS (and choley/appy – I figure might as well).

I came across your website today and it seems like a wonderful resource and community.

I would sincerely appreciate any insights/guidance/suggestions from anyone who has gone through a similar journey. I must admit I’m a little scared about the upcoming procedures and life afterwards. I am generally healthy (other than the obesity), with no associated conditions and no medications.

It’s unfortunate that I have to put my children at risk in order to undergo another procedure, but I do not see another feasible route for an acceptable solution to this complex problem.

As you all know, this is a very difficult condition to live with and is certainly multi-factorial in origin. You are all very brave and admirable for dealing with this struggle. God bless you all.

Cheers.

[newyorkbitch]

Apr 1, 2015 12:59:17 GMT -5 @revision said:

Hi everyone…I wanted to introduce myself to this wonderful community. I am 41 years old, married with 2 small kids (5 and 3 yo). I am also a physician (GP and radiologist).

I had RNYGB (Dr. Christou at McGill in Montreal, QC, Canada) in 2004, the summer after I completed medical school. My surgical weight was 375 lbs. I had a stenosis which required dilatation (via bougie). The lowest I got after bypass was 260 lbs. The weight came back on gradually over the next 3 years, during which time I completed my residency in family medicine. In 2007 I had a LapBand placed (Dr. Couburn in Mississauga, ON, Canada). This likely gave me some minimal help and probably slowed my weight regain (a bit).

I got married in 2008 to a wonderful and supportive (but non-obese) woman. My weight at that time was around 270lbs.

I decided to pursue additional training in diagnostic radiology in 2009. By the time I finished the program (which was a bit of a difficult and unfriendly experience) in 2013, my weight had increased to 320 lbs. Since then I have tried increasing the lifestyle modifications (personal training, Ideal Protein, Jenny Craig, etc, etc). My weight is now 335 lbs.

I have decided at this point to pursue revision surgery. I have met with Dr. Gagner in Montreal and have scheduled the first step of my revision for early May 2015. The first step will involve revising the RNY and performing the VSG. This is to be followed in 6-12 months (probably 6-ish) with a DS (and choley/appy – I figure might as well).

I came across your website today and it seems like a wonderful resource and community.

I would sincerely appreciate any insights/guidance/suggestions from anyone who has gone through a similar journey. I must admit I’m a little scared about the upcoming procedures and life afterwards. I am generally healthy (other than the obesity), with no associated conditions and no medications.

It’s unfortunate that I have to put my children at risk in order to undergo another procedure, but I do not see another feasible route for an acceptable solution to this complex problem.

As you all know, this is a very difficult condition to live with and is certainly multi-factorial in origin. You are all very brave and admirable for dealing with this struggle. God bless you all.

Cheers.

I would ask very specifically why he will not do the DS in one step. I would not consider, in your position, doing a 2-step DS unless there was a serious risk to you in doing a 1-step.

[Deleted]

Hi NYB...thanks for the question.

He actually wasn't too opposed to trying it in one shot initally. But when we started to add up the time for Lapband removal, RNY reversal, VSG, DS, Choley and Appy...it started to get a little long. He was still willing to try it in one go...but I actually said I don't mind a 2-step approach to reduce the potential for complications (ie 2 small steps vs 1 big step). Thanks again and congratulations on your journey (and thanks for all the great info in your posts). 

[OnMyWay2Thin]

Welcome, Revision! NYB is one of the local experts here, she's straightforward and to the point and really knows her stuff. I admire you for taking this big step to make your life better. ...and I do mean better, much better! I'm only nine months out and thought my life was perfect (except my weight), I didn't think I could be any happier or that my life could change for the better so much just by losing 100 pounds. But it did and I'm astounded at all the things I can now participate in, not to mention, with your children being so young, this is the perfect time to do it. You'll be able to enjoy them so much more by running and playing with them even more than you can now. Just now, my son's new dog got loose and I literally ran two miles through the woods to try and get him! That never could have happened a year ago. (By the way, he circled around and ran right up to my older son at the house!)

One thing, though, I'm fully in agreement with NYB on do it in one step. I was also a lapband to DS with appendix removal. My doctor was fantastic. It was a longer surgery but no other surgery looms before me. I'm a Ph.D. so research is my thing. I researched for 3 years before getting this surgery. One thing I saw was that people who did it in the two step often did not return to get the second step, though they were still very obese. They just didn't want to go through another serious surgery. The recovery time is about the same for those that get the one step vs. the two step. I also saw the DS surgery in the long term clearly surpassed the one step. You're a smart individual or you wouldn't be a medical doctor so really give this some thought. Better to cut once, in my opinion. One surgery, one cutting, one recovery.

Good luck and welcome, I wish you all the best in the world. Good things are coming your way!

Kelly

[Deleted]

Hi OMW.

Thanks for you feedback and encouragement! Congratulations on all your success!!

I was definitely interested in the one-step prior to my consultation. But as we started adding up the surgical time (I was pushing for the appendix and gallbladder as well), he started to feel it was too much surgical time for one-step. I do feel that it is alot of surgery for one sitting (especially with RNY reversal, lapbnad removal and then the extra stuff I'm asking for)...but you make some excellent points which I will definitely consider......having "failed" the RNY, I will definitely be following up for the DS regardless of any weight loss from the VSG, as I am looking to be non-obese after this (rather than just losing some weight)...

Your story is inspiring and reassuring....many thanks!!

 

[nursemelanie]

Welcome to our forum. I had a VSG in 2010 after being talked out of a DS. I only lost 72 lbs and had total regain within 2 1/2 yrs. I had my DS last July (with a different surgeon) and although I am still losing, it is at a much slower pace than a virgin DS or revisional DS. I am not by any means giving up hope of reaching goal weight, but having a 2 step DS definitely lowers the odds of reaching goal, in mine and my surgeon's opinion. Ultimately, you must do what you feel is right for your own body, and I wish you the best in your journey to a better you.

[goodkel]

Apr 1, 2015 15:12:34 GMT -5 @revision said:

Hi OMW.

Thanks for you feedback and encouragement! Congratulations on all your success!!

I was definitely interested in the one-step prior to my consultation. But as we started adding up the surgical time (I was pushing for the appendix and gallbladder as well), he started to feel it was too much surgical time for one-step. I do feel that it is alot of surgery for one sitting (especially with RNY reversal, lapbnad removal and then the extra stuff I'm asking for)...but you make some excellent points which I will definitely consider......having "failed" the RNY, I will definitely be following up for the DS regardless of any weight loss from the VSG, as I am looking to be non-obese after this (rather than just losing some weight)...

Your story is inspiring and reassuring....many thanks!!

 

Welcome!

You sure are a mess. So you need a band removed, an RnY reversed, and a DS. I agree, independent of what they find when they open you up, you are looking at a long surgery.

If you have adhesions or other damage from the band (they are known for embedding themselves into nearby organs), you might want to make the first surgery all about repair. Then return in a few months for the full DS.

If the repair work is minimal, I would skip the appendix and gallbladder in favor of getting the full DS in one surgery.

The appendix isn't effected by the DS at all. It is only taken out to speed up diagnosis in the event of a blockage.

Some people don't have problems with their gallbladders post-op. It is a helpful option, but not required.

One of the problems of getting the DS in two steps is that people can lose a lot of weight with the VSG. Sometimes not enough to reach a normal BMI, but enough to make them ineligible for part two. If you are going into the two part procedure with the attitude that the switch portion is a given, be sure to protect yourself by getting that agreement in writing from your surgeon.

Your children are babies. You know full well the toll that morbid obesity is taking on your body even if high blood pressure, heart disease, and diabetes haven't raised their ugly heads, yet. Besides being able to run, play, and be active with them throughout their childhood, I am sure you would like to be there for your children's graduations, weddings, the birth of your grandchildren. Morbid obesity will steal that from you, from them. Remaining morbidly obese presents a more substantial risk than surgery.

I am happy that you found us.

[Deleted]

Thanks Melanie...you've all really given me something to think about....I did not consider the possibility of a less overall weight loss with the 2-step approach. In fact, I spoke with a few bariatric docs (unofficially) and we were wondering if having 2 steps would increase the overall weight loss (given 2 "honeymoon" post-op periods with relatively rapid weight loss...this was only supposition/speculation...it seems that doesn't fit with a number of people's experiences!). 

Thank you for sharing your story and for your encouragement.

[Deleted]

Thanks Goodkel...yes I am quite the mess indeed!! I agree....I think that was part of his concern was how eroded the band might be (its been in for almost 8 years)....may take a while to come out....I agree the appendix is definitely only a bonus to avoid future issues. In terms of the ineligibility question...I am self-paying, and with my previous history of regain, I believe we have a good understanding that I would get the second part, but perhaps I should clarify that with him. 

Yes...I couldn't agree more...we all try to do the best of our kids and I'm hoping that this is the right choice as you suggest...thank you so much for the insight and reassurance....it means a great deal.

[goodkel]

Eight years. Who knows what mischief that band has been up to? It was about time to get it out, anyway. I don't know if you read the documentation that comes packaged with the band, but it explicitly states that the band is not a lifetime product. You'll never see it on the billboards or in the ads, of course. They are like breast implants.

Being self pay certainly helps, but definitely clarify that you will be guaranteed the switch no matter your weight at the time. The sleeve works well getting weight off, the malabsorption of the DS is what helps you keep it off.

So, is this your expected itinerary?

1. Remove band and Rny, get the VSG

2. Get switch, remove gallbladder and appendix

[Deleted]

Yup...exactly...that is the current plan. My hope was that two-steps might actually be superior to one in terms of overall weight loss, but it seems that is not some peoples experience.

Will give it some more thought now for sure with this new information. May still have to proceed along this path given his reservation about the band etc...but will revisit the discussion for sure.

[newyorkbitch]

Apr 1, 2015 20:04:32 GMT -5 @revision said:

Yup...exactly...that is the current plan. My hope was that two-steps might actually be superior to one in terms of overall weight loss, but it seems that is not some peoples experience.

Will give it some more thought now for sure with this new information. May still have to proceed along this path given his reservation about the band etc...but will revisit the discussion for sure.

Keep your plan. Gagner knows what he is doing - he is probably the most experienced DS surgeon in the world. Do not go against his advice.

The name of the game is risk mitigation.

You have children. Caution above all else.

[goodkel]

Apr 1, 2015 20:04:32 GMT -5 @revision said:

Yup...exactly...that is the current plan. My hope was that two-steps might actually be superior to one in terms of overall weight loss, but it seems that is not some peoples experience.

Will give it some more thought now for sure with this new information. May still have to proceed along this path given his reservation about the band etc...but will revisit the discussion for sure.

The RnY to DS revision requires a top notch, highly experienced DS surgeon. Few surgeons are qualified and many people travel long distances for their revisions.

On top of that the band can wreak havoc without symptoms.

I understand Gagner's reservations and he IS a top notch surgeon.

That is a lot of stress on your body. Then you want to add the removal of 75% of your stomach on top of that. That is more than enough for one surgery.

I still think that my original idea of one surgery to fix everything and one for the full DS might be your safest bet. Or add the sleeve as an option if he doesn't have a lot of damage to repair.

The only surgeon I know who could conceivably carry it all off at once is Dr. Keshishian in California. If you want to ease your mind with a second opinion, his would be the one to listen to. This is his contact info:

Ara Keshishian, MD, FASMBS, FACS *
Email: [e-mail]

Central Valley Bariatrics
Phone: [phone]
Fax: [phone]

Not to say that the two step DS doesn't have spectacular results. It does. But, often they do lose more slowly and/or not as much. Not always, but often.

I don't think that the science has caught up enough to explain why, but the synchronicity of the reduced volume of the sleeve and the effect on the metabolism and insulin resistance of the switch working concurrently produces optimal results.

However you go about this, ultimately I think you will be very pleased with the results.

[Deleted]

I agree...caution is key. I think I may be a bit stuck with a 2-step approach given the complexity of my particular situation.

Dr. K seems great and appears to have a very well-rounded practice. His online videos are great!

Dr. Gagner is extremely experienced and I feel tremendously grateful to have access to him at this time. One does get the sense that his clinic in QC is a little less concrete in terms of some of the supporting aspects of this process (ie pre-op prep, nursing, (bariatric) dietitian, counselling, etc.), but I think I am able to figure out or arrange a lot of that on my own, with the help of my GP. Clearly, the expertise of the surgeon is the most important consideration, but I think these other aspects are also significant.

...feeling a little nervous, but hopeful!!

Thank you everyone for your kindness and encouragement....I have to admit I've always had difficulty discussing this issue (due to shame, denial and pride among other things), but I realize now that I need to connect with others to understand and manage this problem. 

[newyorkbitch]

Apr 2, 2015 10:10:52 GMT -5 @revision said:

I agree...caution is key. I think I may be a bit stuck with a 2-step approach given the complexity of my particular situation.

Dr. K seems great and appears to have a very well-rounded practice. His online videos are great!

Dr. Gagner is extremely experienced and I feel tremendously grateful to have access to him at this time. One does get the sense that his clinic in QC is a little less concrete in terms of some of the supporting aspects of this process (ie pre-op prep, nursing, (bariatric) dietitian, counselling, etc.), but I think I am able to figure out or arrange a lot of that on my own, with the help of my GP. Clearly, the expertise of the surgeon is the most important consideration, but I think these other aspects are also significant.

...feeling a little nervous, but hopeful!!

Thank you everyone for your kindness and encouragement....I have to admit I've always had difficulty discussing this issue (due to shame, denial and pride among other things), but I realize now that I need to connect with others to understand and manage this problem. 

Gagner was my surgeon, 15 years ago.

If I were in your shoes, I would do it in 2 steps too.

Please be sure to read all the vitamin boards here - Gagner's support is woefully inadequate.

[Joanne]

Hi, and welcome

There is a thread here from a few years ago that I think you will find very interesting about revisions. Dr Roslin did a presentation to ASMBS about revisions called "Does the Patient Fail the Procedure or Does the Procedure Fail the Patient". He talks a lot about LapBand failure, along with RNY failure. He promotes the sleeve and DS here, and since I know has shifted his preference towards the SADI (which he calls SIPS). Good or bad about the SADI, this is an excellent presentation and discussion on revisions:


weightlosssurgery.proboards.com/thread/3804

[Deleted]

Hi Joanne,

Thanks for the note. I did watch Dr. Roslin's video last evening and found it very enlightening. It certainly highlights how far we have to do in our understanding of obesity. 

I will not be surprised if, as he says, the DS overtakes RNY as the go to procedure. I sure wish I went that way 11 years ago. Feel very lucky to have the opportunity to correct it now.

Thanks again!

[newyorkbitch]

Apr 2, 2015 10:10:52 GMT -5 @revision said:

I agree...caution is key. I think I may be a bit stuck with a 2-step approach given the complexity of my particular situation.

Dr. K seems great and appears to have a very well-rounded practice. His online videos are great!

Dr. Gagner is extremely experienced and I feel tremendously grateful to have access to him at this time. One does get the sense that his clinic in QC is a little less concrete in terms of some of the supporting aspects of this process (ie pre-op prep, nursing, (bariatric) dietitian, counselling, etc.), but I think I am able to figure out or arrange a lot of that on my own, with the help of my GP. Clearly, the expertise of the surgeon is the most important consideration, but I think these other aspects are also significant.

...feeling a little nervous, but hopeful!!

Thank you everyone for your kindness and encouragement....I have to admit I've always had difficulty discussing this issue (due to shame, denial and pride among other things), but I realize now that I need to connect with others to understand and manage this problem. 

Just want to tweak a bit. The experience of the surgeon is the most important consideration in terms of surgery itself, and getting you through surgery and healed. But equally important is educating yourself as to how you have to take care of yourself for the rest of your life. This is not easy, and you will get a lot of bad advice from physicians, no matter how knowledgeable you are.

I urge you to read this board very very thoroughly. And please read vitalady.com very thoroughly too.

[goodkel]

About 95% of DS surgeons provide inadequate post-op information, if they provide any at all. More often, the DS patient is given a handout with RnY information or sent to a nutritionist who also has their head stuck in bypass rules.

DSers have had to learn to take care of themselves post op. From handing their pcp a list of labs to draw to tracking the results and adjusting dosages as needed themselves. Learning about nutritional requirements must also be self-taught.

Luckily, we have all that info here.

I was in Mexico for ten days for my DS with Dr. Ungson. I have not been in touch with him since I saw him on the morning of my departure. My pcp took out my staples and orders all the labs I request of her. I get a hard copy of them and track them myself on a spreadsheet.Three years after my DS I developed an internal hernia that caused a blockage. I did not require a DS surgeon for that, either.

I believe that it has to do with surgeon training and the mindset that entails. They cut. They make sure that their cutting heals as it should. Then they say goodbye. If anything, they may have one class in basic nutrition way back in med school. They do not have the education in long term DS vitamin and nutrition follow up. It doesn't seem to occur to most of them that they should educate themselves on these issues, at least so that their handouts are accurate.

[whit]

Hi,
I revised from RNY to DS the end of 2012. It was preformed in one step. Two step process was not even mentioned. My surgeon, Dr. Kesheshian, is not only very skilled he is also a very kind and compassionate human being. I traveled from Northern California to Southern California for surgery and could not be happier with the results.

Recovery for me was a little slow and the first year was a real struggle but I am now happy and healthy. I have lost 110% of my excess weight and as strange as it sounds hoping for a bit of a bounce back.

I am happy to answer any questions you have.

Whit

[newyorkbitch]

I know that plenty of people have revised from RNY to DS in one step - but every case is different, and revision's case is complex.

Gagner knows what he is doing. He is as pro-DS as any surgeon could be. If he feels 2 surgeries would be safer, listen to him.

[Deleted]

Hi Whit,

Thanks for your insights.

I think in my case the confounding part is the addition lapband removal with the RNY reversal. Also, I do want the GB out as well for sure.

I think Goodkel raises an interesting possibility of reversing the RNY, removing the band and possibly doing the choley and/or appy (which is just a bonus) in the first step and then doing all the VSG+DS stuff in the second step (giving me the one-step switch set-up). Only 3 things about that...

1. That wasn't Dr. Gagner's assessment of how the 2 surgeries should be split (which makes me wonder about a possible technical/surgical reason?)

2. I would be worried about the possibility of weight gain in between the 2 steps (since I will essentially be back to normal anatomy). It seems that the higher the surgical or maximum weight, the higher the eventual plateau level may be. (I'm around 335 lbs now).

3. I'm still kind of wondering if there might be some additive benefit to the 2-step approach, with a tightly-timed 2nd step at the 6-month mark....Does anyone out there support this notion? (or is this just not what people are experiencing)

This all has to be weighed against the (apparently common) contrary experience that the 2-step procedure produces overall less weight loss than the 1-step DS-VSG.

I'm not as concerned about slower weight loss (which in itself may not be a bad thing). But slower may very well mean less overall (the final plateau), which would be disappointing, especially if I was left in the overweight, or worse, obese category after going through all this.

Its a bit of tough position with no totally clear answer that I can see either way. In that situation, I'm kind of left deferring to the surgeon's preference.

So very much appreciate all this guidance and insight!! Many thanks.

Thanks also NYB......I love your straight forward no-BS style (been reading lots of posts).....very grateful for your insights....everyone else also...so kind of you all to share your experiences....

[nursemelanie]

Apr 4, 2015 11:34:18 GMT -5 @revision said:

I think Goodkel raises an interesting possibility of reversing the RNY, removing the band and possibly doing the choley and/or appy (which is just a bonus) in the first step and then doing all the VSG+DS stuff in the second step (giving me the one-step switch set-up). Only 3 things about that...

1. That wasn't Dr. Gagner's assessment of how the 2 surgeries should be split (which makes me wonder about a possible technical/surgical reason?)

2. I would be worried about the possibility of weight gain in between the 2 steps (since I will essentially be back to normal anatomy). It seems that the higher the surgical or maximum weight, the higher the eventual plateau level may be. (I'm around 335 lbs now).

3. I'm still kind of wondering if there might be some additive benefit to the 2-step approach, with a tightly-timed 2nd step at the 6-month mark....Does anyone out there support this notion? (or is this just not what people are experiencing)

This all has to be weighed against the (apparently common) contrary experience that the 2-step procedure produces overall less weight loss than the 1-step DS-VSG.

I'm not as concerned about slower weight loss (which in itself may not be a bad thing). But slower may very well mean less overall (the final plateau), which would be disappointing, especially if I was left in the overweight, or worse, obese category after going through all this.

Its a bit of tough position with no totally clear answer that I can see either way. In that situation, I'm kind of left deferring to the surgeon's preference.

Kelli does raise a good option. I don't see any harm in posing that questions to your surgeon. I'm sure he will have good feedback for you either way.

In regards to "slower" weight loss, I think it has helped a great deal with my skins elasticity. I'm sure in your reading of this board, you have come across "slow and steady wins the race", plenty of times. Although, it has been frustrating at times, I believe my body is working my DS the way IT should. I am one pound from "onederland" and 41lbs to goal (depending on how I look at that time, I may lower my goal 10 more pounds).

I am excited for you and what lies ahead. Being able get on the swing with my 2 yr old in my lap was a joyous moment just recently. Here's to you and all of your joyous moments to come.

[Deleted]

Thanks Melanie...I will have a chat with him about that for sure. I am very concerned about getting a sub-optimal result...I'm trying to get to 175-ish ultimately (I'm 5'11'', medium frame).

I'm not sure how much I should be factoring in the skin issue, that is, how much extra weight should I expect to lose from the plastic surgery correction after? (of course, this depends on the extent, which I would probably try to max out).

If its 10-15lbs, then I wouldn't mind if I tapped out as "high" as 190-200 lbs from the DS and did the rest with plastics...i dunno...does that make sense?

Would be nice not to have to struggle after all this (obviously!).

Thanks again.

[Joanne]

Apr 4, 2015 13:20:24 GMT -5 @revision said:

Thanks Melanie...I will have a chat with him about that for sure. I am very concerned about getting a sub-optimal result...I'm trying to get to 175-ish ultimately (I'm 5'11'', medium frame).

I'm not sure how much I should be factoring in the skin issue, that is, how much extra weight should I expect to lose from the plastic surgery correction after? (of course, this depends on the extent, which I would probably try to max out).

If its 10-15lbs, then I wouldn't mind if I tapped out as "high" as 190-200 lbs from the DS and did the rest with plastics...i dunno...does that make sense?

Would be nice not to have to struggle after all this (obviously!).

Thanks again.

I think the amount if excess skin can vary a lot by maximum weight, amount lost, age, gender, where you carry your weight, etc.
For comparison I lost about 140 pounds, starting with a top BMI of 47. My surgeon removed about 10 pounds of excess skin. Sometimes the skin removed doesn't show completely on the scale because of fluid redistribution, too - so it's common to lose inches much more than pounds.

[whit]

Hi R,

You are welcome. I am not a medical professional nor do I consider myself qualified to give advise. Just telling you of my experience. You definitely need to follow your instincts and make the choices you are comfortable with. 

I wish you success in whichever path your journey takes.

Best,

Whit