Weight Loss Surgery Revisions - New Opportunities for Success
email to a friend
printer-friendly version| by Tomasz Rogula, MD, PhD and Philip Schauer, MD, FACS - March 2007 Bariatric surgery is considered successful if 50 percent of excess weight is lost and maintained for at least five years, resulting in improvement of obesity-related conditions and quality of life. Failure to obtain these results does not necessary mean a patient is simply overeating. Testing may be needed to find out why a previously-performed operation was not successful and whether surgical revision is appropriate. Revisions often involve converting a failed procedure of some other type to Roux-en-Y (RNY) gastric bypass, but patients who have received the Roux-en-Y gastric bypass sometimes require revision of the procedure to clear up complications or to achieve further weight loss. Revision of Vertical Banded Gastroplasty Vertical Banded Gastroplasty became very popular in the early 1980s. Directly following this operation, most patients achieved excellent weight loss with very few complications. This surgery, however, has fallen out of favor, because as many as 50 percent of patients experienced problems over a longer period of time. Weight gain and greater than expected appetite were common, usually due to a disruption of the staple line. Other patients complained of excessive weight loss, frequently accompanied by nausea, vomiting, heartburn and stomach discomfort or pain. Obstruction of the stapled stomach by scar tissue or erosion of a plastic band used for this surgery may cause these problem. In some cases the operation resulted in bleeding from the stomach. X-ray studies or endoscopy may reveal the source of the problems. Sometimes endoscopic (non-invasive) dilatation of the constricted stomach provides temporary relief until a more definitive procedure is done. This usually involves surgery to convert the failed procedure to the RNY, as simply removing the band or re-stapling the stomach results in poor outcomes. Revision of Jejunoileal Bypass Jejunoileal bypass is another weight loss procedure that was previously very popular. It is no longer recommended due to its serious consequences, including liver and kidney damage, electrolyte abnormalities, severe diarrhea and various gastrointestinal problems. The majority of patients who have had this procedure require a reversal. Following a revision to the RNY, most problems improve. Revision of Loop Gastric Bypass The currently performed Roux-en-Y gastric bypass evolved from an operation called ?loop gastric bypass,? which often predisposed patients to bile reflux and inflammation of the stomach with poor weight loss and various pulmonary problems. Some of these patients also need their surgery revised to the RNY. Revision of Gastric Banding (example: Lap-Band) Gastric banding is becoming more popular among patients and surgeons. Some patients, however, fail to achieve satisfactory weight loss due to poor toleration of food. Others have various immediate and long-term complications, including erosion or slippage of the band. Operative intervention involves the removal of the band and the conversion of the operation to RNY. Revision of Roux-en-Y Gastric Bypass Although the RNY is very successful for the majority of patients, approximately 10 percent of patients are not satisfied with their weight loss following the operation and others may experience complications. Patients using non-steroidal anti-inflammatory medications for pain relief?such as Motrin, Advil or aspirin?may develop ulceration of the gastrointestinal anastomosis (the connection between the gastric pouch and the small intestine created during surgery). This may be accompanied by bleeding or restriction of the anastomosis. Solutions involve stopping ulcerative drugs and taking antacid medications. Some patients, however, will need endoscopic treatment of bleeding ulcers, dilatations of the constrictions or major surgeries if endoscopic therapy is not effective. An enlarged pouch is a common reason for unsatisfactory weight loss or weight regain after the RNY. Also, a stomach pouch that is too large can cause ulceration. In rare cases, the excluded stomach can reconnect with the stomach pouch, leading to increased appetite and weight gain. Surgical revision consists of downsizing a large pouch or re-stapling it to correct the complication. Patients not satisfied with their weight loss following the RNY may also benefit from surgical elongation of the Roux limb, which will further decrease food absorption. Persistent diarrhea and protein and fat malabsorption after the RNY can be experienced by patients whose Roux limb is too long. Here, surgical treatment is necessary to lengthen the common channel and shorten the Roux limb. Choosing the Right Center for Revisional Procedures Revisional bariatric operations, regardless of the previous surgery, are always challenging for a surgeon. They require adequate expertise to achieve desired results. Bariatric Centers of Excellence certified by the American Society for Bariatric Surgery provide a multi-disciplinary team and facilities for managing patients requiring revision of their surgery. It is highly recommended that patients requiring revisional surgery find a surgeon at a bariatric center that has much experience with revisional bariatric surgery.  Revision of failed Vertical Banded Gastroplasty to Roux-en-Y gastric bypass. Left: How the stomach is downsized. Top right: The stomach is re-stapled to make a small gastric pouch. Bottom right: The newly created stomach pouch is connected to a Roux limb.  Dr. Philip Schauer is President of the American Society for Bariatric Surgery and is the Director of Advanced Laparoscopic and Bariatric Surgery at Cleveland Clinic. In addition to bariatric surgery, his special interests include laparoscopic, gastrointestinal and colon surgeries. A frequent national and international lecturer, Dr. Schauer also has published numerous articles related to laparoscopic surgery and his first textbook on this subject will be published this year. Dr. Tomasz Rogula is a Staff Surgeon at the Bariatric and Metabolic Institute at Cleveland Clinic. He has trained in weight-loss surgery in the United States, Italy and France. In addition to bariatric surgery, his special interests include hernia repair, laparoscopic, robotic and gastrointestinal surgery. Dr. Rogula has pioneered research on weight-loss surgery innovations. He also has published multiple articles and book chapters on bariatric and laparoscopic surgery. |
Most Active
Recent Topics