Sleeve to RNY at 6 months post-sleeve?

[JRL1989 3]

Has anyone had an "early" revision? I see most sleeve to RNY's happen at 2+years out from sleeve.

I had no GERD at all before I got sleeve on October 15/20. I literally felt the acid as soon as I woke up in recovery. My program has us switch to soft foods at 2 weeks post-op. As soon as I switched from liquid to softs, I felt food rise in my esophagus after eating (regurgitation, but not full on puking - it rises, and then goes down again). At 1 month post-op, surgeon did a barium swallow and noted that I was regurgitating the barium and also that my esophagus was showing dysmotility and tertiary contractions. I've been on 60mg Pantoprazole 2X daily - then switched to 60mg Dexilant 2X daily, in combo with 1g of Sulcrate 4X daily now. I don't feel these meds help the regurgitation at all.

I experience regurgitation (the acid reflux movement feeling up and down in my esophagus) after eating solid food. Almost every single food I try. Because of this, I eat very little. Also, I have to wait around 90 minutes after eating to try to drink Water, or else the regurgitation is worse. Because of this, I also struggle to get in more then 30oz of water a day. There is a fine balance between food and water for me, and if I go too much on one - the other one suffers. My dietician says she wants me at 1200 calories (seems really high, I'm in Canada and I notice they do things differently here), and at least 64oz of water. I'm at max 500 calories and 30oz water.

My low food intake and water intake is now causing me to have internal hemorrhoids and now I bleed every time I have a bowel movement (which to be honest, is once every 4-5 days. It's not often). I've lost over 130lbs and I'm just over 4 months post-op.

My surgeon says I need the revision to RNY and wants to do it at around the 6-month mark (so April 2021), but I have not heard of anyone getting a revision this early due to GERD.

Has anyone here got a revision from sleeve to RNY due to GERD, less than 1 year out from sleeve? How did it work out for you?

Edited February 23, 2021 by JRL1989
details added

[catwoman7 10,845]

8 minutes ago, JRL1989 said:

Has anyone had an "early" revision? I see most sleeve to RNY's happen at 2+years out from sleeve.

I think it's because a lot of times people are a year or two out before the GERD kicks in (or severe GERD, anyway - I'm not sure if some of them have milder cases at first or not). Sounds like you got hit right away, though. Sorry to hear that. Hopefully there's another early revisionist on here who'll respond.

[RickM 1,747]

It sounds like you may have a stricture in your sleeve (makes it hour glass shaped) - did he mention anything like that, as that would show in the barium swallow test? The drugs that you are taking wouldn't help that as they are just to treat the acid overproduction (the pantoprazole and Dexilant) and the resulting insult to the tissue (the sucrafate). From what I have seen over the years (not an MD, just an interested bystander) the problems with the esophagus are likely a result of the stomach problem (assuming that it is a stricture - I have seen such things sited as a result of lap band damage resulting in such symptoms)

Strictures of such severity (if indeed that is what it is) were more common several years ago when the sleeve was new and most US bariatric surgeons were just learning how to do them. The stomach, when sleeved, tends to like to bend or twist in the middle if you don't do it just right - it takes practice. These days, I see it discussed more commonly in countries, like Canada and Australia, that were slower to adopt the sleeve, so as a result, their surgeons, as a group, are at about the same place in the learning curve as the US surgeons were 6-10 years ago. Usually, it is treated by a bypass revision as the surgeon won't know how to repair it (if it can be done.) Often, it can be repaired, or resleeved, to correct the problem, But that needs a surgeon who is much more experienced with the sleeve, so if it is possible in your system to get a second opinion on it (particularly from someone more sleeve savvy) that would be the way to go, if for no other reason than to get concurrence with your surgeon's solution (or hopefully, an alternative approach.) Ideally, you would like to find someone who is experienced with the duodenal switch WLS, as that uses the sleeve as its' basis and those surgeons tend to be much more experienced with them than the average bariatric surgeon, but they tend to be few and far between. The only one that I know of in CA is Michel Gagner, who IIRC works out of Montreal. Likely, the RNY revision is the standard of care within the Canadian system (and much of the US as well,) for this type of problem/

Good luck,

[JRL1989 3]

41 minutes ago, RickM said:

It sounds like you may have a stricture in your sleeve (makes it hour glass shaped) - did he mention anything like that, as that would show in the barium swallow test? The drugs that you are taking wouldn't help that as they are just to treat the acid overproduction (the pantoprazole and Dexilant) and the resulting insult to the tissue (the sucrafate). From what I have seen over the years (not an MD, just an interested bystander) the problems with the esophagus are likely a result of the stomach problem (assuming that it is a stricture - I have seen such things sited as a result of lap band damage resulting in such symptoms)

Strictures of such severity (if indeed that is what it is) were more common several years ago when the sleeve was new and most US bariatric surgeons were just learning how to do them. The stomach, when sleeved, tends to like to bend or twist in the middle if you don't do it just right - it takes practice. These days, I see it discussed more commonly in countries, like Canada and Australia, that were slower to adopt the sleeve, so as a result, their surgeons, as a group, are at about the same place in the learning curve as the US surgeons were 6-10 years ago. Usually, it is treated by a bypass revision as the surgeon won't know how to repair it (if it can be done.) Often, it can be repaired, or resleeved, to correct the problem, But that needs a surgeon who is much more experienced with the sleeve, so if it is possible in your system to get a second opinion on it (particularly from someone more sleeve savvy) that would be the way to go, if for no other reason than to get concurrence with your surgeon's solution (or hopefully, an alternative approach.) Ideally, you would like to find someone who is experienced with the duodenal switch WLS, as that uses the sleeve as its' basis and those surgeons tend to be much more experienced with them than the average bariatric surgeon, but they tend to be few and far between. The only one that I know of in CA is Michel Gagner, who IIRC works out of Montreal. Likely, the RNY revision is the standard of care within the Canadian system (and much of the US as well,) for this type of problem/

Good luck,

Thanks Rick! I too, also thought it was a stricture. I was convinced. But nope, on my barium swallow it showed my sleeve looking like a nice fat little sausage. The surgeon is who said it must be GERD-related, as the barium swallowed showed me regurgitating the barium. When I don't take the PPI, I get heartburn AND regurgitation - but if I take the PPI I only get regurgitation. He said something about "refractory GERD".

I wish my province offered the DS. I'm in Alberta, they don't cover it and the surgeon isn't trained in it (I asked). He's actually the most experienced sleeve surgeon in the province (Which is why I'm a bit worried about doing RNY with him, hah. He IS experienced in both, but there are more experienced RNY surgeons in terms of total numbers of procedures completed, but to switch surgeons at this point would put me back months).

Did you have a revision from sleeve to RNY? I guess part of my worries is that I'm playing with fire and possibly creating more problems. OR, that I will lose all the restriction my sleeve affords me (colloquially, I have seen RNY patients post food photos and they can eat more at 1 month post-op than I can eat now at 4 months post-op). I want to get pregnant, so the surgeon said that I need to do RNY so that I'm able to eat enough food to sustain a pregnancy. It's a bit of a mind trip.

Surgeon ordered an esophageal manometry test and an endoscope. Manometry is next week, still waiting on scope booking.

[RickM 1,747]

That is curious, and beyond my limited experience! I suppose that is can be strictly an esophageal problem, though as I noted, I have only seen such things as they related to other root causes. No, I haven't had such a revision, though it was suggested at one time for another issue, but I have avoided having to go that route (with the help of some second opinions that basically said to leave well enough alone for now.) I do have minor GERD, which is readily treated with low level OTC meds, so there is nothing worth fixing at this point on that account. The sleeve is predisposed to GERD by virtue that the stomach volume is reduced a lot more than its acid producing potential, but the body usually adapts to that over a few months, and most surgeons prescribe a PPI for the initial few months and then wean off of them. (Similarlly, the RNY is predisposed to dumping, reactive hypoglycemia and marginal ulcers, so there is no free lunch in that regard, no matter what procedure one goes with - there is always some risk there.) I would prefer to keep the sleeve as long as it cooperates, as the RNY is a little bit fussier to live with, but it's not the end of the world, either, and certainly preferable to what you are going through; my wife has a DS which is a bit fussier still, so I'm familiar with all that entails if I need to go there.

The surgeon who has adopted our local support group does quite a few oddball and esoteric revisions (like the complex RNY to DS), people come from across the country to see him, and he sometimes pulls up scans on his laptop of one of the wonky sleeves that has come his way, so we get some feel of what can be done, that other surgeons pass on. That's why I brought up the stricture idea (beyond your regurgitation sounding like that might be it,) because that is something that many surgeons prefer to revise away rather than correct.

I does seem like you are heavily restricted, much more so than normal for a normal sleeve, or RNY. 500 calories isn't so bad - it's not that unusual for people with any of these WLS to still be down there, though more commonly somewhat higher in the 6-800 calorie range; it's the Water intake that I would be concerned with as dehydration will get one thrown into the hospital a lot faster than low Protein or other nutrients in the short to intermediate term.

The vast majority of people go through this, an RNY, or VSG, or a DS, with little or no complications, but sometimes they crop up; hopefully, you have had your share of them now and that's it. In some respects, the RNY is a more familiar procedure for the surgeons,, even if they don't do as many of them as sleeves, as it has been around in bariatrics for 40-50 years, so most started out with them; the basic procedure upon which it is based has been around for some 140 years in treating gastric cancer and other GI maladies, so it is familiar territory for most; the VSG on the other hand, had more limited application until it was created/adopted for WLS as part of the original BPD/DS, so it was not as widely used until the DS guys started using it some by itself (usually as part of a two stage DS) and saw that it offered good weight loss all on its own, so I wouldn't worry too much about your surgeon's experience with it, as that was the default WLS in Canada until fairly recently.

[JRL1989 3]

29 minutes ago, RickM said:

That is curious, and beyond my limited experience! I suppose that is can be strictly an esophageal problem, though as I noted, I have only seen such things as they related to other root causes. No, I haven't had such a revision, though it was suggested at one time for another issue, but I have avoided having to go that route (with the help of some second opinions that basically said to leave well enough alone for now.) I do have minor GERD, which is readily treated with low level OTC meds, so there is nothing worth fixing at this point on that account. The sleeve is predisposed to GERD by virtue that the stomach volume is reduced a lot more than its acid producing potential, but the body usually adapts to that over a few months, and most surgeons prescribe a PPI for the initial few months and then wean off of them. (Similarlly, the RNY is predisposed to dumping, reactive hypoglycemia and marginal ulcers, so there is no free lunch in that regard, no matter what procedure one goes with - there is always some risk there.) I would prefer to keep the sleeve as long as it cooperates, as the RNY is a little bit fussier to live with, but it's not the end of the world, either, and certainly preferable to what you are going through; my wife has a DS which is a bit fussier still, so I'm familiar with all that entails if I need to go there.

The surgeon who has adopted our local support group does quite a few oddball and esoteric revisions (like the complex RNY to DS), people come from across the country to see him, and he sometimes pulls up scans on his laptop of one of the wonky sleeves that has come his way, so we get some feel of what can be done, that other surgeons pass on. That's why I brought up the stricture idea (beyond your regurgitation sounding like that might be it,) because that is something that many surgeons prefer to revise away rather than correct.

I does seem like you are heavily restricted, much more so than normal for a normal sleeve, or RNY. 500 calories isn't so bad - it's not that unusual for people with any of these WLS to still be down there, though more commonly somewhat higher in the 6-800 calorie range; it's the Water intake that I would be concerned with as dehydration will get one thrown into the hospital a lot faster than low Protein or other nutrients in the short to intermediate term.

The vast majority of people go through this, an RNY, or VSG, or a DS, with little or no complications, but sometimes they crop up; hopefully, you have had your share of them now and that's it. In some respects, the RNY is a more familiar procedure for the surgeons,, even if they don't do as many of them as sleeves, as it has been around in bariatrics for 40-50 years, so most started out with them; the basic procedure upon which it is based has been around for some 140 years in treating gastric cancer and other GI maladies, so it is familiar territory for most; the VSG on the other hand, had more limited application until it was created/adopted for WLS as part of the original BPD/DS, so it was not as widely used until the DS guys started using it some by itself (usually as part of a two stage DS) and saw that it offered good weight loss all on its own, so I wouldn't worry too much about your surgeon's experience with it, as that was the default WLS in Canada until fairly recently.

Thanks for your reply! You are very knowledgeable and great to chat with. I will post an update after I finally get my manometry and scope, and see what surgeon says we're gonna do. Thanks!!