Second Time Around: Why Bariatric Revisions Are Sometimes Needed
February 19, 2024Introduction
The overwhelming success and safety of bariatric surgery compared to diets and medication is well known to the medical community. However, a surgical revision of a previous bariatric surgery is sometimes necessary. Around 15% of bariatric patients will proceed with revision, and this number is on the rise due to the sheer popularity of bariatric surgery. There are several important factors which influence the need for revision, including complications from the original surgery, suboptimal lifestyle or eating choices leading to weight regain, or weight loss, which wasn’t quite as much as expected. In many cases, surgical revision is a great option for the original surgical tool to become effective again. In other cases, a different procedure altogether will be considered. While surgical revision may have higher complexity and potentially more risk than the original procedure, this is generally a reasonable and safe option for patients to consider.
In this article, we will explore the most common reasons for a bariatric revision and also examine the most popular surgical options currently available for patients.
To determine which revision is recommended, we will often order testing to evaluate the original surgery. Typically, this includes upper GI barium swallow x-ray and/or a procedure called Esophagogastroduodenoscopy (EGD), where we use a tiny camera to see how the surgery looks from the inside. We refer many of our patients to a behavioral psychologist and registered dietician to discuss eating habits, portions, food choices, and lifestyle modification to be prepared for life after revision. It may be determined that life-style change alone is adequate. If surgery is deemed appropriate, it is performed laparoscopically with small, minimally invasive incisions. Most patients will start a special low-calorie diet before surgery and continue a liquid diet for 3 weeks after. In most cases, the patient will be discharged home the same day or the next day after surgery. Patients typically return to work within 1-2 weeks, and sometimes sooner! Now let’s look at the most common revision bariatric surgeries.
Adjustable Gastric Band Removal with Conversion to Gastric Sleeve or Gastric Bypass
The adjustable gastric band or Lap Band ™ was once a very popular procedure preferred to the more invasive gastric bypass. The band is like a belt around the stomach that provides restriction and decreased appetite. Unfortunately, the long-term interaction of the silicone material of the band with the stomach will often create scarring, which can make it difficult to swallow food, can cause severe acid reflux, or can cause regurgitation of foods and liquids. This can occur even when the band has been completely deflated. Some patients request removal of the band without revision. However, the majority of patients prefer to move forward with revision to either the gastric sleeve or gastric bypass.
In general, I recommend the gastric sleeve for most patients requesting to convert to another procedure. It is safe, effective, and lower risk than some of the other revision surgeries.
Once the band is removed, we proceed by stapling and removing a large portion of the stomach (around 75%). This procedure removes a hormone called Ghrelin which lowers hunger. The remaining stomach is the size of a banana and resembles the sleeve of a shirt. The restriction created by the surgery also helps the patient feel full with smaller amounts of food. No prosthetic device is required to lose weight! If a gastric bypass is deemed necessary, this more complex restrictive procedure not only reduces the stomach size but also requires repositioning the intestines to decrease digestion of food. This procedure can have better weight loss but also can increase the risk of vitamin deficiencies, ulcers, or obstruction of the intestines. With increased complexity comes increased risk.
Resection of Dilated Gastric Sleeve or “Re-sleeve”
It is possible for an existing gastric sleeve to stretch over time. This will usually occur at the top part of the sleeve where food and liquids enter the stomach. The main cause of this is passing too much volume of food and drink through such a small space. To lower the chance of this happening, we advise patients with a gastric sleeve to thoroughly chew food, avoid eating and drinking simultaneously, and avoid carbonated beverages. In other cases, the sleeve was created too big at the original surgery. This can lead to weight regain as the patient is able to consume larger portions. Resection of a dilated gastric sleeve involves stapling and removing any portions of the stomach which appear stretched or too large. This can help restore the sleeve to its intended size, which can also restore the ability of the patient to feel full with smaller portions.
Conversion of Gastric Sleeve to Gastric Bypass
The most common complaint of the gastric sleeve is gastroesophageal reflux disease (GERD). While many patients will have improvement of GERD with weight loss, some will have persistent symptoms or even worsening symptoms despite taking acid reducing medications. Other patients might have weight regain after initial success. In cases where the goal is to try and improve GERD and lose weight, converting the gastric sleeve to the gastric bypass is usually the best option. As mentioned earlier, the gastric bypass is restrictive (due to having a smaller stomach pouch than the sleeve) and also malabsorptive (due to the intestinal rearrangement component).
Conversion of Gastric Sleeve to Single Anastomosis Duodenal Switch (SADI)
The Single Anastomosis Duodenal Switch (SADI) is a less common but increasingly popular revision option. This procedure is suited for patients who have weight regain or mild GERD symptoms after gastric sleeve. This involves attaching the distant intestines immediately downstream of the sleeve. It is malabsorptive like the bypass but doesn’t require any further surgery on the stomach itself (in contrast to the gastric bypass). This procedure has lower long-term risk and better average weight loss than the gastric bypass but has risk of malabsorption and chronic diarrhea. Patients who move forward with the gastric bypass, or SADI, commit to daily vitamin supplementation and yearly blood work to make sure vitamin levels remain within normal limits.
Revision of the Gastric Bypass
Revision of a gastric bypass is typically considered when there is a significant weight regain or if complications arise from the initial surgery. This is usually due to stretching of the gastric pouch or stretching of the connection between the gastric pouch and intestine. The revision involves resizing the stomach pouch, intestinal connection, or adjusting the length of the intestinal bypass. Some gastric bypass revisions require a combination or all these options. In many cases, revision of the gastric bypass is considered to have higher surgical risk than other revision procedures.
Conclusion
Revision bariatric surgery requires careful consideration and a thorough evaluation of the patient's health, weight loss history, lifestyle, food choices, and the challenges faced with the initial surgery. These revision procedures can offer renewed hope and a path to better health for patients struggling after their primary bariatric surgery. However, surgery also carries risk and requires a commitment to lifestyle changes and follow-up care. As with any medical procedure, consultation with a knowledgeable and experienced bariatric surgeon is essential to determine the best course of action.
Dr. Thomas Roshek specializes in the treatment at Nicholson Clinic for Weight Loss Surgery.
 | ABOUT THE AUTHOR Dr. Thomas Roshek specializes in the treatment of obesity and performs sleeve gastrectomy, gastric bypass, gastric balloon and revisional weight loss surgery. He also specializes in the repair of abdominal and groin hernias/complex abdominal wall reconstruction. Dr. Roshek works at the Nicholson Clinic for Weight Loss Surgery, one of the country’s premier destinations for weight loss. |
