sleeve after bypass

Question
QUESTION: I had gastric bypass in 2004.  I Lost 80lbs and maintained it till 2010, when my I was dilated to fix a blockage from scar tissue caused from ulcers.  This caused a gastric fistula and i have regained 40 lbs.  My surgeon wants to perform a gastric sleeve to fix it. I was a pack a day smoker, but have for the last 3 weeks I have only smoked 1-2 a day. I am now not smoking at all. My surgery date is 16 days away. Do you have any suggestions on this?  I hear that the sleeve is usually done first but cannot find any info on when it was done after the bypass itself.  Please help!  I am nervous.

ANSWER: Rosa,
You are smart to be checking on facts and plans in your care.  You are correct that Gastric Bypass is not often changed to sleeve, but when smoking is part of the equation then Sleeve can be a good idea because the Sleeve is much more resistant to smoking than the Gastric Bypass.  I noticed you wrote that you quit smoking in the last few days and that's a good thing; it's very important for healing to have your system free of tobacco and nicotine going into surgery.

While it's respectable and good for your health that you've stopped smoking, I suspect your surgeon is concerned that you may resume smoking at some point in the future.  Your surgeon is probably making his recommendation to you based on the fact that each revision operation is much more difficult to accomplish, and he/she wants to accomplish the procedure that has the least possible chance of long term side effects or recurrent ulcers.

I definitely encourage you to talk through your concerns with your surgeon as well.

Best of luck!
Dr JP

---------- FOLLOW-UP ----------

QUESTION: I appreciate how fast you responded. Thank you.
He recommended the sleeve before he knew that I was a smoker. I asked if he could just go in and restaple the opening, but he said the sleeve would be a better option. Should I be concerned?

Answer
Hi Rosa,
A Sleeve can certainly be a reasonable option, but anytime one is doing a surgical revision to treat a fistula it is a difficult situation and there is no "right" answer.  I think it is important for you to be comfortable with the plan, and since you have reasonable questions I strongly suggest that you make arrangements to sit down again with your surgeon before the operation.  You might ask things like:
-have you done this type of revision before?
-if so, was it done for a fistula?
-will you please explain your thought process in recommending the Sleeve over a revised gastric bypass

If you don't feel comfortable after sitting down with your surgeon, or if you can't get that type of visit with him/her, you may want to think about visiting with another bariatric surgeon.  If you follow that path I recommend you check in with your primary doc for suggestions.

Best of luck,
Dr JP

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