Bariatric Revision Surgery
As the number of bariatric procedures have increased and we come to understand the chronicity of the condition, there will be a number of patients who have gone through additional procedures (revision) due to inadequate weight loss, inadequate resolution of comorbidities, weight regain, or complications from the initial procedure.
Patients may want to revise from their original procedure from a Lap Band if they have not had adequate weight loss, difficulties with managing reflux, esophageal dilation, band slippage, migration or erosion, weight regain, or port complications. Depending on the individual circumstances, first-stage band removal is followed by an interval healing period anywhere from six weeks to six months. Patients then decide on either the Gastric Bypass or Gastric Sleeve procedure. Results have been excellent so far with this approach.
Most revisions for Gastric Bypass are due to weight regain (25% of patients have significant weight regain between three to five years after surgery) and this is usually due to stomal/pouch dilation (the small opening to the small stomach dilates so that food can pass through it easily or the pouch itself dilates. The former is four times more likely than the latter). It is the body’s inherent ability to adapt and not the patients fault for “stretching out their pouch.” This is an incorrect and shaming conclusion even our own profession jumps to.
Weight regain or failure to lose enough weight is most effectively treated by placing a Lap-Band on the pouch, thus recreating the small pouch with a narrow opening like that of the original pouch. In our hands, this has led to an average of 70% excess weight loss, though this is more than has been seen nationally with this procedure.
Other methods such as surgical pouch revision may be reserved for such things like chronic ulcers. Surgical pouch revision potentially has a high complication rate and only limited success with weight loss. Creating more malabsorption by lengthening the roux limb to a roux distal is also an option, thus shortening the small intestine by a significant amount creating more malabsorbsion. This does not have a very high complication rate, but it also has a limited success for further weight loss. Those patients who have had significant, but rare complications from the Gastric Bypass such as uncontrolled hyperglycemia or dumping, complete reversal of the Gastric Bypass and conversion to a Gastric Sleeve is an option.
For some patients, the Sleeve Gastrectomy does not provide enough weight loss and therefore a second stage procedure may be necessary. For these patients converting, the Sleeve to a Gastric Bypass or even a Duodenal Switch may be an option. For the 5% of patients whose sleeve eventually dilates enough so that they regain weight; re-sleeving, or converting to one of the previous procedures recommended is an option. There is no clear consensus today on what the best procedure is for sleeve revision and should be done on an individualized basis until more data is available.
Robert V. McKeen, M.D.