Thinking about revision

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

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

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. 

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.

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.