Removing the pouch?

[nightowl1971 3]

Hi guys!

I had a gastric bypass R-n-Y in Latvia in 2011. All went well, and I have now a BMI at 20,4.

Two weeks ago I had severe cramps in my stomache, and my GP sent me to hospital to "take a look" with a tube down my throat (don't know what it's called in english - gastroscopy?) The doctor found that I have GERD, inflammation in my eating tube (?) due to defect muscle between the pouch and this eating tube. This hurts so bad. Acid-medication doesn't help. I have called a hospital in my homecountry (not Latvia), and asked if it is possible to remove the pouch, and thereby get rid of the inflammation and acid problems. And they could do it.

Has any of you done this? The small intestine is placed directly on to the eating tube. How does this work for you?

Edited February 26, 2021 by nightowl1971

[catwoman7 11,284]

RNY is reversible, although it's a complicated surgery and usually not done unless there's a serious medical problem that can't be resolved any other way. If the problem is something like a hernia, they should be able to repair that without reversing your RNY. I'm not sure about the defective muscle you mentioned -- hopefully they can repair that easily...

[nightowl1971 3]

I don't want to reverse it, just remove the rest of the little pouch so that that the small intestine comes directly on to the eating tube (oesofagus) instead.

[catwoman7 11,284]

2 minutes ago, nightowl1971 said:

I don't want to reverse it, just remove the rest of the little pouch so that that the small intestine comes directly on to the eating tube (oesofagus) instead.

a surgeon will probably know if they can do that or not. I don't think they could remove the pouch since that is created by dividing your stomach with staples, but they may be able to move the intestine to a different place - I'm not sure. A surgeon would know.

[nightowl1971 3]

It can be done, I have already spoken to a surgeon. It is called total gastrectomy. Usually done if there is cancer in the stomach. (But I don't need to remove the rest of the stomach, as I don't have cancer).

My question was if someone here in this group had done this procedure

[catwoman7 11,284]

Just now, nightowl1971 said:

It can be done, I have already spoken to a surgeon. It is called total gastrectomy. Usually done if there is cancer in the stomach. (But I don't need to remove the rest of the stomach, as I don't have cancer).

My question was if someone here in this group had done this procedure

oh - OK. I think your situation is pretty rare so not sure if anyone on here has had it, but maybe someone has who'll respond.

[RickM 1,753]

It can be done - it is called a total gastrectomy and is usually done for cancer, gastroparesis or other severe gastric problems - but it is something of a big deal to do. The long term functional difference to your RNY is small, but healing time is the big issue - the esophagus (eating tube) is only a two layer structure compared to your stomach pouch which is four or five layers (depending upon how you count things) so the direct attachment to the intestine is trickier than the stomach to intestine. This was an option I looked into some years ago on a cancer issue, and the partial gastrectomy (basically an RNY) had a normal RNY post op healing and eating progression. The total gastrectomy would have required several months on a feeding tube to let things heal before any food could be introduced. So, this is not something to go into lightly. (And, no, I never had either procedure done - second and third opinions indicated that they weren't necessary, at least for the time being.)

Something else to look into - have they determined if the GERD is acid, or bile? That's a big difference in treatment, as if it is bile reflux, the basic RNY structure is already somewhat predisposed to that, and taking out the pouch will no help, and likely make it worse. A possible clue here is that the anti-acid meds aren't working, and they wouldn't if it was a bile problem.

It sounds like your problem, or a good part of it, is a weak Lower Esophageal Sphincter (LES) which is the muscular valve between the stomach and the esophagus. That can be weakened by your obesity history (though that was a long time ago), by over eating - over stuffing your pouch can put pressure on it and weaken it, or by some other disease mechanism. There are procedures available specific to this problem that may solve things without having to go through the gastrectomy. Do some research on surgical treatment for GERD.

You need to research and find a surgeon who is very experienced with bariatric problems and revisions to figure out what exactly is going on, and then what the proper solution would be. The RNY (or any procedure, for that matter,) does occasionally cause significant problems so you need someone experienced with that.

Good luck in working this out!

Note - there are some Facebook groups that cater specifically to people with total or partial gastrectomies, so that would be a good place to look to get a better idea of what living with that procedure is like.

[nightowl1971 3]

50 minutes ago, RickM said:

It can be done - it is called a total gastrectomy and is usually done for cancer, gastroparesis or other severe gastric problems - but it is something of a big deal to do. The long term functional difference to your RNY is small, but healing time is the big issue - the esophagus (eating tube) is only a two layer structure compared to your stomach pouch which is four or five layers (depending upon how you count things) so the direct attachment to the intestine is trickier than the stomach to intestine. This was an option I looked into some years ago on a cancer issue, and the partial gastrectomy (basically an RNY) had a normal RNY post op healing and eating progression. The total gastrectomy would have required several months on a feeding tube to let things heal before any food could be introduced. So, this is not something to go into lightly. (And, no, I never had either procedure done - second and third opinions indicated that they weren't necessary, at least for the time being.)

Something else to look into - have they determined if the GERD is acid, or bile? That's a big difference in treatment, as if it is bile reflux, the basic RNY structure is already somewhat predisposed to that, and taking out the pouch will no help, and likely make it worse. A possible clue here is that the anti-acid meds aren't working, and they wouldn't if it was a bile problem.

It sounds like your problem, or a good part of it, is a weak Lower Esophageal Sphincter (LES) which is the muscular valve between the stomach and the esophagus. That can be weakened by your obesity history (though that was a long time ago), by over eating - over stuffing your pouch can put pressure on it and weaken it, or by some other disease mechanism. There are procedures available specific to this problem that may solve things without having to go through the gastrectomy. Do some research on surgical treatment for GERD.

You need to research and find a surgeon who is very experienced with bariatric problems and revisions to figure out what exactly is going on, and then what the proper solution would be. The RNY (or any procedure, for that matter,) does occasionally cause significant problems so you need someone experienced with that.

Good luck in working this out!

Note - there are some Facebook groups that cater specifically to people with total or partial gastrectomies, so that would be a good place to look to get a better idea of what living with that procedure is like.

I don't know if it's acid or bile, but after reading about it, I'm quite sure it's bile. The acid meds doesn't help at all, and even the smallest meal causes pain.

I know that there are good surgery options for GERD, fundoplication surgery. But I'm not sure that my pouch is big enough to be fitted around the esophagus.

And you are absolutely right: there is a weakening in the LES. You explained what I couldn't say in English with the right words.

[RickM 1,753]

The fundoplication is used in the case of a hiatal hernia (where part of the stomach is pulled up through the opening in the abdominal wall, through which the esophagus passes) which can be the cause of acid reflux, and you are right in that in may or may not be appropriate depending upon whether there is enough fundus left to plicate. If your problem is more with the LES than with a hernia, there are other things that are sometimes done for that - there are implantable devices that replicate the function of the LES (LINX is one of them, there are probably others as well) and likely some purely surgical approaches to it (I am far from any expert on this!).

Bile reflux is rarely a problem these days with the RNY, mostly because the surgeons have learned how to set up the limb lengths to avoid it in the most part; it is not uncommon in non-WLS versions of the procedure, such as the total or partial gastrectomies for cancer and the like, where they shorten the limbs to minimize malabsorption and weight loss in patients who can't afford to lose more weight. What can be done if bile is your problem is to move the pouch farther downstream on the intestine to move it farther away from the bile ducts. Revision to the Duodenal Switch WLS is the best response to it as it is virtually impossible for the bile to work its way back to the stomach and esophagus, but thats a very complex procedure that few surgeons in the world can do. The distal (or long limb) RNY is next best, but has similar nutritional consequences as the DS and by your figures, it doesn't look like you need to lose more weight. But there can be in between compromises on limb lengths that can do the job, if that indeed is your problem.

[nightowl1971 3]

I don't know what the best thing for me is... All I know is that something has to be done, soon. Because I can't take this pain any longer, and cannot imagine a lifetime further on with meds to deal with this... 😞

[RickM 1,753]

5 hours ago, nightowl1971 said:

I don't know what the best thing for me is... All I know is that something has to be done, soon. Because I can't take this pain any longer, and cannot imagine a lifetime further on with meds to deal with this... 😞

The best that we can do at our knowledge level is to consult with as many doctors as you can to get different, or hopefully, concurring opinions and then decide. In my situation, which was a very early stage cancer thing, I consulted at least four different doctors with relevant experience, and got four different approaches to the problem and then weighed all of the options. Ultimately in my case the most sensible was the simplest that also left the most options for future treatment if it ever became necessary (which was basically to do nothing except continue monitoring things.) In your case, it looks like there are more questions that need to be answered, so likely more tests will be needed to see what's going on inside you.

[nightowl1971 3]

Thank you, that sounds reasonible 😊