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Gastric bypass surgery done. Gaining weight and experiencing nausea. MRI done. How to lose weight?

Mar 2013
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I am a 37 y/o morbidly obese female. I had gastric bypass is 1994. At the time, I weight almost 300 lbs. I lost down to 220 then the weight started coming back on. Now, my weight is up to 411. I regularly experience nausea and a few years ago, I visited with a GI doc about this. He performed an upper GI on me and told me I would never lose weight the "normal way". He told me my stomach was now into 2 stomachs so to speak. One small portion which explains why I am full so quickly and feel nausea. This empties into the larger portion of my stomach thus making me feel hungry again. He suggested I see a bariatric physician for a surgical revision. I am extremely nervous about this. However, I must lose weight. The upper GI results above...does this make sense? Is this common? I had this about 3 years ago. Should I repeat this? My driver at the moment is the current state of my knees. I had an MRI today and the final report states "Significant diffuse degenerative arthritic changes at all compartments with large osteophytic hypertrophy". I am a professional woman and an executive at my company. This is affecting my day to day since walking is very difficult. I cover it up all I can but need some medical advice on this please. I have a lot of anxiety about this.
Posted Tue, 5 Mar 2013 in Weight Loss
Answered by Dr. Aarti Abraham 2 hours later
Thanks for writing in to us.
Firstly, with a weight of 411 lbs, you have no option other than to consider a revision bariatric surgery.
You have a long list of co morbidities, all of which are due to your excessive weight.
Arthritis, pulmonary embolism etc are all attributed to morbid obesity, and your family history is very risky also ( hypertension, coronary arterial disease and CVA ).
Please consult a bariatric surgeon AT THE EARLIEST for a revision surgery. There is no other option for you.

Meanwhile some other details which might help you ;

Although bariatric surgery is usually quite effective, at times, it does not work as well as one would like. In such instances, a surgical revision may be considered. Various factors affect the failure of primary surgery ;

When the initial operation was performed.
Where the initial operation was performed.
At what stage the surgeon was in his / her career at the time of the operation.
The postoperative instructions given after the initial surgery.
Initial weight loss history following surgery.
Any complications that may have occurred following the initial operation.

The type of bariatric surgery initially performed is very important when considering revision because some types of surgery have been known to fail or have less long-term success. Obtaining an operative report for your surgery is very helpful.
A “learning curve” exists for most operations and bariatric surgery has one of the longest. This is especially true for Laparoscopic Gastric Bypass. It is often helpful to know at what stage your surgeon was in their career when you were treated. For example, from a technical standpoint the success of gastric bypass surgery is largely dependent upon the size of the gastric pouch. This part of the surgery is technically challenging and often requires the surgeon to have performed many operations before mastering it. As a result, a surgeon may have made very large gastric pouches early in their career. Furthermore, some surgeons continue to make large pouches despite our current understanding that pouch size and weight loss are more directly related.

Oftentimes, the postoperative instructions given to patients are incorrect or lacking. Therefore, the patient did not know the best way to use their new “tool”. Even though the patient may be out of the “golden period” for rapid weight loss, they usually benefit considerably from proper instruction and can therefore avoid additional surgery.

Weight loss history following the initial surgery tells if the operation was ever effective or if it “failed the patient” from the very beginning. If postoperative weight loss never occurred or was minimal then it is likely that there was a technical problem with the initial operation.

Likewise, complications occurring after the initial surgery may have led to technical problems that have influenced the durability of the weight loss. Such complications may include intraabdominal infections, ulcerations, band infections, and prolonged vomiting postoperatively.

Finally, please remember that revision operations are more technically challenging and carry a higher complication risk. You need to seek out very experienced bariatric surgeons that perform revision surgeries.

Some more details of the procedure for you to go through :

Research shows that up to 20% of patients who were morbidly obese prior to their initial surgery and up to 35% of patients who were super obese have gained back more than 50% of their excess weight after 10 years.
Before undertaking a repeat surgery, your surgeon will want to rule out diet or exercise problems before moving forward with another procedure and will likely take the following two steps:
Rule out diet as the cause of insufficient weight loss or weight regain
Work with your dietitian to very carefully track what you eat using a handwritten or online free diet journal.
Work with your psychologist to determine whether any emotional issues could be causing your diet or exercise goals to veer off-track.
Rule out exercise as the cause
Your dietitian can use a special device called an indirect calorimeter (see video below) to test your basal metabolic rate (BMR), which is the amount of energy your body burns when you are resting.

Patients with an extremely low BMR could have issues with weight loss even if pouch size and dietary habits are where they should be. Your base metabolic rate can be increased if you add more lean body mass (muscle), so if low BMR is a problem your surgeon will most likely have you work with a personal trainer to properly adjust your exercise after gastric bypass surgery.

After diet and exercise problems are ruled out, your surgeon will want to check your stomach pouch size and the opening between your stomach and your small intestines (also called your “stoma”). If either is too large (or has stretched), it may be the cause of your post-surgery weight loss problems.

In addition to determining whether your pouch and stoma size are an issue, an upper GI and endoscopy can detect issues such as staple line problems, gastrogastric fistula, esophageal abnormalities and Roux limb abnormalities.
If stomach stretching or stoma enlargement is identified, a revision surgery may be your only option to halt or reverse the weight regain.

The five most common gastric bypass revision procedures include:
Shrink the stoma by injecting a sclerosant
Make the stomach pouch or stoma smaller using a device to create XXXXXXX "folds"
Add adjustable gastric band (convert to lap band surgery)
Lengthen Roux limb
Convert to duodenal switch

Please do not worry, and deal with this as the primary priority in life, as you are only 37, and I wish you many more decades ahead in good health and fitness.

Take care and feel free to ask for further clarifications.
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