Potential Complications 3+ years post op. Any assistance appreciated!!

Where to begin? So I had Lapband in 2009 but had to revise to VSG in 2012 due to mild complications. I wasnt overly successful with my sleeve as I had severe acid reflux from the very beginning and never lost my hunger. I also only lost 50lbs total for the first year with a lot of hard work and began regaining right after the 1 year mark. I am almost 4 years post op, have regained almost all of my weight and am having some health concerns that may be connected to my sleeve. I had to have my gallbladder removed in February. Now I am having severe pain in my abdomen. After going to urgent care it was discovered I have three Hernias but the doctor also suspects Gastric Outflow Obstruction. I havent yet met with the doctors I am being referred to, to discuss the location of these hernias (one is hiatial, one is inaugural, unsure about the third) and how they impact my stomach sleeve. I would prefer to not see the general surgeon they are sending me to and would like to go back to mine or another bariatric surgeon to troubleshoot the issues but Im not even sure how to request that referral instead. So my questions for anyone with experience in any of the above issues are:

1. Do you know anything about Gastric Outflow Obstruction (connection to the pyloric valve) in regards to post bariatric surgery? Could this be a leak? I cant find anything that discusses this as a complication of VSG so I am completely in the dark as to whether this has any connection to my surgery esp so many years post op?
2. Any thoughts or experience relating to hernia repair post VSG or bariatric surgery?
3. Any advice on how I can request a bariatric surgeon over a general surgeon?
4. Has anyone been able to revise to RNY or DS under a 40 BMI with complications of this nature or is this not grounds to discuss VSG failure? I do believe there has been something not completely correct since the very beginning but I never had anything substantial to investigate until now.

Thanks in advance for any help!

1. No particular experience with the GOO, but cursory research indicates that the causes can be anything from something fairly simple and readily treatable to the extremely nasty. I would think that a gastroenterologist would be the first stop to have that evaluated. How did they diagnose the hiatal hernia - endoscopy or barium swallow? - and did that provide any insight to the cause of the GOO? Over the years that I have been involved in WLS between my own and my wifes' years ago, it is not something that has been discussed as a common complication of WLS
2. Hiatal hernias are not uncommon, particularly amongst the obese (and are often repaired in conjunction with a WLS procedure,) and they are not all that uncommon post op after some years. Other hernias may be surgically related (incisional or umbilical hernias) or completely independent.
3. Requesting different surgical specialties would be dependent upon the terms of your particular insurance/health care plan. Getting the GOO evaluated may well drive the rest of the surgical decisions.
4. Revisions that are needed as a result of complications of the original surgery are often covered by insurance irrespective the BMI. This may get into a negotiating process between the surgeon and insurance company in establishing the need and rationale for the revision (and may become an integral solution to the GOO problem, depending upon its cause.)  

Good luck in all of this, as it sounds like you may have a fair bit of doctoring ahead of you,

Thank you for responding!! The hernias were found through a barium swallow/ CT SCAN. I havent seen a doctor yet since they were discovered but have been referred to a gastric group (they are not bariatric surgeons but they specialize in gastric issues) as well as a general surgeon to address the hernias so I will know more once I meet with them. Unfortunately despite daily pain they cant see me until late September.

I feel sort of convinced that the hiatial hernia has been there for some time due to the extreme acid reflux and regurgitation that has been occuring for awhile, however the inaugural hernia is the one causing a lot of pain (this one I can feel through my stomach, it feels like a tennis ball and was described as my bowels protruding through my abdominal wall). My BMI is back up to 36.8 so I am not sure if they will consider fixing my sleeve or revising when they go in but I imagine if my sleeve is twisted or the hernias are directly impacting the sleeve there wont be much of a choice. I was kind of hoping they would just directly refer me to a bariatric surgeon and skip the other doctors all together so no matter what I would be in the hands of a doctor experienced with sleeve.

Thanks again for chiming in!!

I can address a bit about a hiatel hernia. I had my first hiatel hernia repaired during the vsg. 4 years later I had a 2nd very large hiatel hernia and signficant reflux. My first couple of years post op were fine. I had it repaired this past Decembe along with geting my gallbladder out. The surgeon indicated that it was riskier due to being the 2nd repair and not much to work with. My sleeve appeared streched in the upper gi, but once he got in there and put the stomach back where it belonged it resumed the sleeve shape and no tightening was needed. It was a slower heal this time around, and up until just a few weeks ago I was still taking a lot of PPI to help manage the acid. The doc indicated that shoud the hernia continue to be an issue there is not much he could do to repair it again, but revision to rny to deal with the acid issues would likely be the next step. I also had a hernia near the belly buttonr repaired during my TT, and no worse for wear from that as far as I know. 

I did have a litte regain going into that hernia repair. In hindsight I feel it had a lot to do with the acid and eating more due to either it mimicing hunger or it (short term) felt better to eat. The regain is now off, but mostly due to struggling to keep food down prior to that surgery in December. Feeling pretty good now, so it seems that everything is working pretty well now.

hang in there-

Forgot to add-

I was also referred to a gastro doc. Once diagnosed with the gallbladder we discussed surgeon choices, and he was good with my bariatric guy doing it. The bariatric guy was an internist and did more than just bariatric. The hernia was also diagnosed via a CT scan. The bariatric guy ordered an upper gi saying he wanted to confirm that, as apparently the Ct could be wrong. Literally the morning of the gallbladder surgey he read the upper gi resuts, confirmed the hernia, tossed around a few options with me, and then I went into surgery. Your gastro doc likely would not be the person to do the surgery I suspect, so ask for a referral. Even if they want to do the surgery 2nd opinons are usually covered- go see a bariartic doc. I agree with you- they are more familiar with our issues so at the very least I would want their input.

Thank You!! It seems like you had a similar situation to mine. I had my gallbladder removed in February. Had I known that it was going to be the tip of the iceberg I think I wouldve began working on getting back to see a bariatric surgeon at that time but I can only move forward now. Thanks for sharing your story. Do you think you are likely to have to revise to RNY in the future?

1. It sounds like gastroparesis. This can happen if the VSG or gallbladder surgeon somehow damaged the Vagus nerve (the nerve that controls stomach emptying), although the nerve can also become damaged by diseases. I actually got the VSG surgery to stop gastroparesis and it has so far done the trick. My VSG was modified to keep the Atrium (portion of stomach containing the muscle closes to the pyloric valve) intact.
2. No thoughts on repair but the triple hernias is worrisome. That should not have happened as the sleeve surgeon should have checked for issues and made sure that the stomach would not slip up into the esophagus area. It also is worrisome that it follows after the gallbladder removal.
3. This is easy. You have real serious gastroenterology issues. Insist on only a specialist. It is your life we are talking about.
4. My insurance gave a general approval for all bariatric procedures at a BMI of 35. Mine was approved because of the diabetic gastroparesis. That is because my doctor presented the information and request for surgery to leave open the decision of actual surgery. Your Gastric Outflow Obstruction may be the complication needed to convince the insurance but all nsurance companies view things differently.

For your issues, you may want to ask the doctor for Reglin. The reviews are mixed on it. My general doctor prescribed it to me and I thought it helped my gastroparesis. My bariatric surgeon believed it does nothing to help.

Sorry, I'm no help, but I wish you the best!!

Thank You!