Stretched Stoma

[Guest guest]

said " Does anyone know what the fix is for a stretshed stoma? What

are the signs that you may have this? Has anyone else been diagnosed with

this, and if so, what is your exoerience withit. "

, I am a 75cm RNY Proximal of some 26 months duration. I am not sure

how often you read, but there have been several posts and several responses

on the list regarding this condition.

First, let me say that from what I can find out the stoma is normally made

approximately 12mm in diameter and is expected to expand over time in a

functioning RNY to about 17mm or so. I learned about ten months ago in an

Upper GI series directly from the radiologist who was doing the exam that

mine was estimated at 3cm or 30mm. Dr., Latham Flanagan who authored a paper

on Small Pouch Function, (which has been condensed by someone to something

called Pouch Rules for Dummies) stating in the original article that anything

beyond 17mm renders the pouch/surgery ineffective and should be fixed by the

surgeon.

I have said before that stretched stomas appears to me to be the step child

in bariatric surgery that no one seems to want to deal with or will even in

some cases (a lot) that such a condition exists. I am am also told by some

sources that banding procedures have proven ineffective in serving as a

remedy and that most revisions or re-operations for this purpose are not

effective. I dunno, that is my impression thus far.

I needed to lose some 130 lbs to get into a good BMI range of approximately

25 as a pre-op and from month three the weight loss was sporadic at best and

I really did not have a sense of " restriction " in what I could eat. I read

daily about folks much further out than I who still eat " two tablespoons of

fresh air and half steamed butterfly wing and are absolutely stuffed. " That

was and is never my experience. All sense of restriction on food intake was

gone for me at three months. I can, but do not eat large amounts. I think I

eat now pretty much like a normie regarding capacity. I am not talking a

stretched stomach here, I am talking a naturally thin person. But then again

I have watched many of those folks eat like field hands and never gain an

ounce.

The other side of that coin is that the upper section of the small bowel

attached to the pouch can and usually does enlarge with the restriction on

intake removed and the effect is to form a surrogate stomach wherein the

markedly increased food intake is stored pending the journey down to the Y

connection and then mixes with digestive juices exiting the stomach. This is

the scene in my case and was confirmed by the radiologist as well.

I am not sure your surgeon will receive you with open arms if you open this

discussion with him. In my case I got an upper GI done by another facility

other than the one who did my surgery, did the research on the " norms " (if

one can call the meagre available info " norms " ), got a copy of the report and

then took the x-rays to see my surgeon. I did not bother to tell him that I

had a copy of the report and had done the background. I was just curious as

to what his reaction would be. I chatted with the program nutritionist first

when I got there (a 3.5 hr drive) and she was astounded that I thought

stretching was the case with me. She said " we have never heard of such a

thing. " The surgeon was a bit more direct than that. He said " these

pictures indicate to me you have a pouch far smaller than is to be expected

for one sixteen months post and I estimate it to be 50-60cc. " I asked if he

thought the stoma may be stretched and he got most defensive and said

absolutely not and that my weight loss cessation at the nine month mark also

was simply a result of my being non-compliant, drinking gallons of beer and

eating high calorie dense liquid foods. " I asked him if the stoma were

indeed stretched would it not render the surgery ineffective since it was -

his words - " was a restrictive procedure that was expected to function for

about 18-24 months. " I told him that I had effectively been dieting since

month ten as a post op and he not so politely informed me that that was

exactly what I should be doing at this point and that the procedure was not

the " answer. "

I was not there to accuse him of not doing a good job and had been forewarned

by others that I could prepare myself for an attack by suggesting that his

work was somehow flawed. That was not my purpose. I was just there to try

and get a professional evaluation of a problem that was mechanical in nature

and find a solution. No blame involved for anyone. He was not about to have

that and essentially gave me the " my work is perfect response, you have just

been a normal stupid fat guy who cannot control food intake and ruined what I

did so beautifully in the beginning " treatment. How sad. But worse was that

he was not aware that I had done some research as I could, had a copy of the

radiologist's report and in my opinion was less than forthcoming about the

true state of my plumbing and it's effectiveness for it's designed purpose.

I am able to maintain around a BMI of about 30, give or take a point or two

each way and have done so for a year and more. I made a decision to try and

deal with this by assuming all responsibility for what I am eating (was it

ever anyone eles?) and my health. The risks of revision are just not worth

it for me at this time. That is subject to change and constant re-evaluation

over the next six months as I am sure that getting off another 50 lbs would

do much to alleviate stress on a heart that has had two angioplasties and two

stents installed over the last then months as well. If I feel like the risk

to my health (or longevity) is greater from weight regain then I will revise,

but go to a more malabsorptive procedure but if not, I will not take on the

risks of another surgery. Kinda sorta is a Catch 22 situation at the moment.

I hope you do not have to run the gauntlet of such an experience as I, or

that you have to endure accusatory but well meaning suggestions to " control "

your food intake and stop eating all the wrong things etc. It is sad enough

to have to fight the genes and the other issues that cause MO and brings us

to the last ditch decision for surgery to begin with. News that we might be

falling into the category of those whose surgeries have failed is always made

worse by such chastisement.

My recommendation is to have the state of your surgery evaluated for

function. Normally an Upper GI will rule out Staple Line Disruption and a

scope can allow the surgeon to get a looksee on exactly what your condtion is

at the moment. If you want to read the original article that I mentioned

that mentioned some standards for stomas, write me privately and I will be

glad to send it along.

Dan Slone

Surgery 5/2/2000