Expert: John Pilcher, MD - 11/27/2008

Question
Dear Dr. Pilcher,

First I wanted to say I think it's wonderful that you take the time to respond so thoughtfully to all of these questions.  Thank you.

My background story:  I had a lap band placed three years ago.  I did manage to lose 65 pounds of the 150 pounds I needed to lose but essentially got stuck there.  I feel that 85% of this weight loss was through grit-your-teeth dieting with not much help from the lap band.  My surgeon seemed to be overly cautious and very resistant to filling the band to an adequate level and balked at going over 2 cc.  At any rate,  I decided to have the band revised to a VSG by a different surgeon.  The surgeon was able to remove the lap band in September but unable to do the sleeve procedure at the same time due to extensive scar tissue from the band at the fundus of the stomach.  He rescheduled me in late February to try doing the sleeve again after things had had time to heal.  He told me he still may be unable to do the sleeve due to scar tissue (about a 10% chance) but that he thought he could do a sleeve around the scar tissue at the fundus if need be – kind of an S-shaped sleeve.  

This surgeon only does lap bands and VSGs, so I wanted to get the opinion of a surgeon who does other types of surgery.

My questions are these:
1.   Is this scar tissue a common problem with lap band revisions?  
2.   I'm not sure I understand why the time between surgeries will make a difference in the scar tissue.  Can you explain this a little?
3.   If he has to sleeve around the scar tissue that's in the fundus, will this mean that I will still have full ghrelin production (one of the reasons the sleeve is so appealing to me is to be able to conquer what feels like constant hunger when I'm dieting).  My understanding is that ghrelin is produced in the fundus.
4.  Should I consider a RNY or DS instead to have the addition of malabsorption?  This will be my third self-pay bariatric surgery if you count the lap band removal.  I chose the sleeve largely because it is less expensive than RNY or DS, but the idea of paying for a third surgery that might not be effective is scary.   The three surgeries will essentially wipe out my retirement (and I'm 54, so I don't have years and years to make up the loss).  

Thanks and best wishes,
Mary

Answer
Well Mary, I can see that you are thinking very carefully about your future and how to get the best results.  I respect that so I will try to help you in understanding.

1)  Anytime surgery is done inside the body, scar tissue is left behind.  The nature of the scar tissue varies between people with no rhyme or reason - in some it is soft and pliable (good) and in others it is hard and dense (more difficult to work with).  My guess is that your surgeon encountered hard/dense scar tissue at the time of Band removal, and that he was concerned that if he went across that scar with the stapler (designed to cut and simultaneously seal the stomach tissue) then the staples might not hold because of the hard/dense scar.  If the staples do not hold, or if the tissue does not heal well, then you have a leak which is a new serious problem.

2)  Once the source of scar (such as the Band) is removed then the scar will tend to soften over time.  Several months does usually allow time for significant softening of the scar, and this approach makes sense to me.

3)  Great question about ghrelin, and I don't think anyone knows the answer for sure.  My educated guess would be that most of the fundus and body of the stomach will be removed even if the surgeon must work around scar, so you should still benefit from a very significant reduction in ghrelin production.

4)  Another good question, and there is no one "right" answer.  I have a couple of comments that I hope you will find helpful:

-the gastric bypass and the DS will both be more reliable in lifetime weight control than the sleeve

-however, the gastric bypass and the DS both have a bit more risk than the sleeve.  In my opinion the risk of GBP is slightly higher, because involves re-routing the small intestine.  I believe the DS has substantially higher risk, because of re-routing the intestine plus a substantially higher rate of nutritional problems compared to other weight loss operations.

Best of luck!

Dr JP