Sleeve Narrowing

[Amanda Oh 23]

I had a laparoscopic sleeve gastrectomy in August of 2018 and have had amazing results, from 346 lbs to 172 lbs. Since November of last year I have been vomiting in my sleep sometimes and waking myself up. Also, I have always gagged after eating no matter the amount that I ate, even two ounces. I recently relocated to Florida and saw a surgeon here to establish care and he reviewed a recent CT that I had for a hospital visit for flank pain and discovered that my sleeve healed in a hourglass shape at the suture line and now my esophagus is narrowing from working so hard to push down food. I have an EGD and upper GI scheduled for next week and then next month he’s doing a laparoscopic gastrojejunostomy and partial gastrectomy. He said it’s basically the bypass surgery. Has anyone else had this happen? I’m so scared because I don’t have much left to lose and don’t want to end up malnourished but I also don’t have any other options, I’ll malnourish and end up with esophageal cancer and or obstruction if I don’t have the surgery. Any feedback would be greatly appreciated.

[GreenTealael 25,360]

I was converted to RNY from VSG for structural (and other) reasons too. My surgeon just said we were doing bypass so I’m not sure if there any specific differences between that and what you will have done.
It’s completely possible to maintain (and even gain) weight after your revision. The malnutrition aspect comes with how long of a bypassed Roux (or alimentary) limb will be. Your surgeon may choose to make that length shorter to prevent excess weight loss, but that’s a plan you will come up with together.

Below are links for both the steps of a gastric bypass and info on just the gastrojejunostomy.

Hope that helps ❤️

https://www.laparoscopic.md/bypass/surgery

https://www.ncbi.nlm.nih.gov/books/NBK560493/

[catwoman7 11,212]

malnutrition with bypass is pretty uncommon as long as you keep on top of your supplements.

[RickM 1,747]

Sadly, it happens - more frequently a few years ago (6-10) when most bariatric surgeons were still learning how to do sleeves than more recently, but I guess that there are always some who are still learning! The sleeve tends to want to bend in the middle, or form an hourglass shape, if it isn't done quite right, it may not yield a total blockage type of stricture, but it can leave the narrowing that can impede the flow and/or exacerbate reflux problems. While most surgeons in the US are now far enough up the learning curve to usually avoid this problem, knowing how to fix it can be beyond their experience, hence many prefer to go with a bypass instead.

It may be possible to correct your sleeve, but you may need to find a surgeon who is very well experienced with the care and feeding of the sleeve construction. My suggestion, if you want to go for a second opinion (which I think anyone should do when considering a revision,) is to book a virtual consult with Dr. Ara Keshishian, who happens to be on the wrong coast for you, out in Pasadena, CA, but he has been doing virtual initial consults for years before Covid as he has patients all over the country. This will at least give you a reading as to whether this is a viable option in your case, or give you confidence that the RNY approach is the best. If a resleeve is an option, then you can decide whether to travel across the country, or seek out another surgeon closer to you who can do it. I would suggest looking for one who routinely does the duodenal switch (DS) procedure, as they tend to have the longest and most extensive experience with sleeves. I believe that there are at least a couple in FL, and several further north along the East Coast.

If you do choose to proceed with the RNY route, do discuss things carefully with your surgeon, as there are tradeoffs in how he proceeds. Limb lengths, as suggested above, are a compromise as if they are too short to minimize malabsorption, you can be more prone to bile reflux. There are several Facebook groups that cater to total and partial gastrectomy patients (primarily for cancer or gastroparesis) and bile reflux is one of their common complaints. When I was considering such a thing a few years ago, the surgeon I was dealing with said that as long as he kept the limb over a certain dimension (80cm, IIRC) then they saw no problems with it. Hopefully, the surgeon that you are dealing with has enough experience on both the WLS and non-WLS side of it to know those tradeoffs. Bariatric programs that are associated with major cancer center hospitals readily "swing both ways" on that, but one that only specializes in bariatrics may not.

I wouldn't worry too much about the malnutrition issue, as the RNY is very well understood; it is somewhat fussier than your sleeve in supplement needs but things are pretty straightforward on it if you keep up with labs and change things up as those dictate; it can be problematic for those who get overly casual about such things and let it slide - then you can get into trouble. If you fall into that camp, then I would try to do everything to preserve your sleeve and its greater flexibility; otherwise, the RNY is a good alternative. My personal preference, as I was faced with some similar decisions, is/was to stick with the sleeve if it is viable, as the RNY (or something different) is always an option for the future, but once one has an RNY, changing things gets more difficult, so options are fewer. Also on the option front, with the bypass, there remains a "blind" remnant stomach along with the duodenum and upper intestine which are unavailable for endoscopic evaluation or treatment (things much be done surgically.) As there are an increasing number of procedures that can be done endoscopically these days, and into the future, and I have already had one lifesaving endoscopy this is an option that I am keen to preserve, if at all possible.

Short term, you may lose too much as you go through the high level of restriction that comes in those first few months after surgery. In that case, there are ways to "eat around" your pouch by basically doing all of the "wrong" things for your WLS - drinking calories, eating slider foods, higher calorie options particularly fats as tolerated. The tricky thing is to avoid making too much of a habit of it as the restriction does diminish over time and you can naturally eat more of conventional foods to maintain your nutrition