VSG to RNY due to reflux/lack of sufficient weight loss?

Hi there. I had the VSG 3 years ago. My highest weight was 380 and I'm currently about 270 (lowest 255). I still need to lose another 100 pounds or so. I gained some weight after my most recent pregnancy and can't seem to get any more off.

In any event, I have major acid reflux. I am going for an EGD next Thursday. My doctor thinks I have a hiatal hernia due because I have a definite increase in reflux and I have a racing heart after eating at times (apparently that's common with a hiatal hernia). I never had that before, but he said sometimes the sleeved stomach is more narrow and can pu****s way through the diaphragm. I had never heard that before.

Anyway, he said he read a paper about post-sleeve reflux and said that although a small study, the few people who were converted to RNY completed resolved their reflux and began to lose weight again.

The reason I didn't opt for the RNY the first time was because I didn't want malabsorption! So this just upsets me a little bit. I mean, I obviously don't have to do it, but I'm taking high doses of PPIs and Zantac and it's not working. I am afraid of the damage that might be lurking in my esophagus, but I need to find out. Also, I believe due to the PPIs, I'm not absorbing iron, magnesium, or calcium that well, so I'm already anemic and have to watch my other nutrients.

Has anyone heard about this conversion to RNY due to reflux complications/inadequate weight loss?

Thanks!

Shannon

I am not sure about vsg to rny but have you considered the DS?  VSG is the first step to a DS.  I am not sure it is going to do anything for the acid reflux.  It seems to me a vet on these boards actually had the top of his stomach, bottom of espohogus (where they meet) was tightened because he was experiencing horrible gerd.  I wish I could remember who it was so you could contact him.  

Good luck to you.

 I think that was ThinLizzy.  She can often be found on the VSG Maintenance group.

I have a friend tht had terrible reflux. Kaiser talked about revising her to RNY.  She just gave birth to a baby and I think her reflux is getting better without revision.

 
This is where my surgeon has a lot of experience.......

Sleeve shape to promote proper food flow......and aggressive hiatal hernia treatment (repair/tighten)

frisco

The change to an RNY for reflux does make some sense as reflux is one of the few common complications or downsides to the VSG, and as the bulk of the protein pump ports in the stomach are clustered around the pyloric valve which gets bypassed along with the rest of the stomach in the RNY, there is some merit to the idea. However, I am skeptical about moving to the RNY to get improved weightloss performance, as both procedures are very similar in that regard (something akin to trading in a Camry for an Accord to get better gas mileage - they're too similar to each other for it to make sense.) Further, if you are having mineral absorption problems with the VSG, that's nothing compared to what is typically seen with the RNY. The majority of our minerals are absorbed in the duodenum (the part of the small intestines immediately below the stomach) which gets bypassed along with the stomach in the RNY. Further complicating the anemia problem is that the part of the intestines that are joined with the RNY pouch is not resistant to stomach acid as the bypassed duodenum is, that suture line between the pouch and intestine often never fully heals due to irritation from the stomach acid and can weep small amounts of blood long term (this is also why NSAIDS are a no-no with the RNY, but are ok with the VSG and DS.)

The DS is usually the better choice for revisions from the VSG for improved weight loss or regain resistance since its caloric malabsorption is long term as opposed to the transient effect of the RNY (though the mineral malabsorption is lifelong with the RNY,) and mineral malabsorption with the DS is not as severe as the RNY since only a portion of the duodenum is bypassed. The tough issue here is still the reflux - virgin DS's tend not to have severe problems with reflux because they usually use a larger version of the sleeve, but with a revision, you will have the same sleeve that you have now, with the main hope for improved reflux coming from further weight loss rather than a change in stomach configuration.

I can't speak for what other options exist on repairing the hernia while leaving the sleeve intact, but I would certainly consult with a DS qualified surgeon about those options as well as your own existing surgeon (Dr. Paul Kemmeter is a well regarded DS surgeon in Michigan). One other consideration in all of this (as if things weren't complicated enough!) is that the RNY is something of a dead end surgically speaking - if it doesn't work for you, there is little that the RNY surgeons can do to improve things (there are minor tweaks they can do like tightening the stoma or banding the pouch, but nothing that really alters its character,) and a revision from and RNY to a DS is a very complicated procedure for which there are maybe a half dozen surgeons in the US and Canada that are truly qualified, so it pays to be very thorough on your research and consults before making a decision. I do know of a couple of people who have revised from bands to an RNY only to have to further revise to a DS to get the job done - not something that you really want to do if you can avoid it (and that assumes there there is enough stomach left after converting the sleeve to the RNY to convert that to a DS.)

Another reason to consult with a DS surgeon is that they are very comfortable with the sleeve (since the sleeve is a part of the DS procedure) and they may have insights into your hernia problem that another doc who is relatively new to the sleeve (though he may be very experienced with the RNY and bands,) may not be aware of. So, some good second (and maybe third!) opinions would be very worthwhile from several perspectives.

Good luck in finding a good solution,

Wow, thank you for the thorough response. You gave me a lot of information to think about. I really don't think I want to convert to any new WLS procedure. I didn't gain very much weight with my pregnancy and I just had the baby. I'm going to try to get some more weight off. But if I decide to convert to one, I think I will definitely look into the DS. It just sort of scares me. I know there are many proponents of the DS, but the malabsorptive nature really scares me, especially with the size of my sleeve. I still cannot eat very much at a time. I am interested to see what the shape of my stomach is and if I have a hiatal hernia where half of the sleeve is above the diaphragm and half below, creating like an hour-glass. I've heard this can happen with the thin nature of the sleeve. If I don't have a hiatal hernia, my doctor said he'd be very surprised.

I am so glad you took the time to respond and give me the information about the RNY vs DS. It makes a lot of sense. I didn't go for the RNY the first time because of malabsorption. So I really don't want to do it now. I just need to find a way to get back to the basics. My doctor had me increasing my calories during pregnancy to make sure I was eating enough. And although I didn't gain too much weight, I just need to buckle down and get back to a reasonable eating plan now that I'm done nursing (which did not help my weight loss, btw!).

Thanks, everyone. I have a lot to think about. I am going to see what my endoscopy shows on Thursday and go from there. With the amount of reflux I'm having, I'm just hoping I don't have severe damage. In the meantime, I'm doing to increase my protein and see if I can't get some of this weight off. The increased protein not only satisfies my hunger, but I definitely notice a decrease in the reflux feeling.

I will try to contact ThinLizzy also...that might be something to look into.