What to Expect of a Revision from RNY to DSOctober 21, 2016
Obesity is a tough disease and can often recur even after bariatric surgery. Making poor food choices is often a guilt-ridden process. Nothing good comes from beating yourself up mentally. Guilt and condemnation will only lead to more poor food choices used to medicate the pain you are experiencing. This spirals into a vicious cycle leading to more weight regain.
If you have had RNY gastric bypass surgery and have experienced weight regain do not be discouraged. You are not alone.
The weight regain is likely multi-factorial. The responsibility is shared between patient and bariatric surgeon. The effectiveness of the bypass in terms of malabsorption of calories is diminished over time. Additionally, there are several different ways to perform a surgical gastric bypass that will influence both the short and long-term weight loss and management.
I would encourage you to see your bariatric surgeon, or another bariatric surgeon, that is comfortable with revisional bariatric surgery and revision of gastric bypasses. There are a couple of surgical options that exist for folks with a gastric bypass that have regained a significant amount of weight back.
First, in some instances, you can have your gastric bypass revised. This is not an option for all gastric bypass patients and you should see your surgeon regarding this. While the focus of this article is conversion to a duodenal switch (DS), suffice it to say that there are several different surgical ways to revise a bypass but many do not work well. Any revision or conversion of a bariatric surgery should only be done by an experienced bariatric surgeon. It is important to remember to ask lots of questions as you contemplate going through this surgery.
If your surgeon becomes annoyed or you are discouraged to ask questions then I would advise you to find a new surgeon. Open and honest communication is critical between you and your surgeon.
Surgical Revision of a Gastric Bypass to a Duodenal Switch
Converting a gastric bypass to a duodenal switch is a significant surgery. Some surgeons perform it in two separate surgeries while others perform it in one. The first part of the surgery is a reversal of the gastric bypass. This means reestablishing gastric continuity and introducing the intestinal limb back into absorption of digestive enzymes.
The second surgery is the duodenal switch which itself has two parts. First, the creation of the sleeve gastrectomy and then secondly the intestinal bypass through a division of the duodenum.
Keep in mind that the DS is truly the most powerful weight loss procedure in terms of both short and long term weight loss as well as a potential resolution of type II diabetes.
When the DS is compared with the gastric bypass and the sleeve gastrectomy, they are consistently more impressive across numerous published studies. Typically, this conversion surgery can be accomplished laparoscopically. Your hospital stay will be between four and five days and full recovery in four weeks. You will need also preoperative psychological evaluation and a nutritional evaluation both before and after surgery.
Nutritional Requirements for the Duodenal Switch
It is very important that you are committed to taking your vitamins and nutritional supplements after surgery. You should be comfortable with the nutritional requirements of the gastric bypass. Depending on which nutritional supplement you are taking with respect to your daily multivitamin, you will also need to be taking vitamin D, calcium, vitamin B12 and, in some cases, iron as well.
As I have said to my patients before, it is preferable to be taking a few vitamins rather than high blood pressure and diabetic medications.
An adult chewable is preferable, especially after surgery. We will go through a brief overview of the vitamin and micronutrient requirements, but you will still need a thorough evaluation and education at your own program. You want to begin a high potency multivitamin the day after you are discharged home. Preferably a chewable or liquid. Choose one with at least 18mg of iron, and 400 micrograms of folic acid. It is also important that they contain selenium and zinc as well. Vitamin B12 injections may be started 1-3 months after surgery. Nasal preparations are also available. Elemental calcium is also very important as well. You should take between 1800-2400 mg/day and you may also start this 1 day after discharge.
Choose a brand that contains calcium citrate and vitamin D3. This can also be taken as a chewable or a liquid. Elemental iron intake should be a minimum of 18-27mg per day as well. Make sure you take your calcium and iron at least 2 hours apart as iron may impair the absorption of calcium. The fat soluble vitamins are also important to take as supplements with the DS more so that the gastric bypass. Specifically, vitamins D, A and K should be started 2-4 weeks after surgery. Daily requirements are as follows, vitamin A, 10,000 IU; vitamin D, 2000IU, and vitamin K 300 micrograms per day.
We also recommend a B complex vitamin that includes B1 (thiamine) and B6 (pyridoxine). Deficiencies are rare but have been reported in the medical literature. A B-complex vitamin should handle this and can also be started one day after hospital discharge. Obviously, protein intake as well will be critical, between 60-80 grams a day. Immediately following surgery, you will be on a liquid protein diet such as protein shakes and protein water. This will be graduated to a pureed diet and eventually a return to regular food. It will be important that you have your nutrition labs done three months after surgery and then at six, nine and 12 months. The DS does have long-term vitamin and nutritional requirements that you must be comfortable with.
Life With a DS
Life after the duodenal switch can be healthy and satisfying. Eating with a DS will also be different than an RNY in terms of the amount of food you can eat in one setting. It is usually a larger amount such six to seven ounces. You should only entertain switching to this procedure if you are committed to the lifestyle changes that it will require long-term. Taking your vitamins and micronutrients on a daily basis, as well as long-term follow-up in a bariatric program where the appropriate laboratory values can be monitored, is essential. The surgery is not a quick fix but rather a life long commitment. If you have a reemergence of your diabetes and/or a significant increase in your BMI several years after your bypass you should consider the DS.
ABOUT THE AUTHORDr. Patrick Domkowski is board certified by the American Board of Surgery, and a fellow of the American College of Surgeons as well as a fellow of the American Society of Metabolic and Bariatric Surgeons. He has also previously served as chief of surgery and chief of staff in one of the area hospitals. He is currently the medical director of Riverside Surgical & Weight Loss Center. His passion and calling are helping people to eliminate obesity disease and regain their lives, health and well-being.