Roux-en-Y Gastric Bypass
Gastric Bypass patients generally seek a gastric bypass revision for two reasons: 1) failure to lose adequate weight and/or weight regain, 2) medical complications (medical complications after Gastric Bypass may lead to failure). Failure after Gastric Bypass may be due to mechanical or metabolic reasons; the eating behaviors of a patient should be considered as well.
In fact, the first step in assessing a patient who has failed to lose adequate weight after Gastric Bypass, is to look carefully at the patient's food consumption. The best way to analyze food intake is to simply start a detailed food diary. Patients are often shocked at how many calories they do consume on a daily basis. While we may think we have a good idea of our food consumption, it only takes tracking food intake in a food diary to get a true picture of how much we consume. When patients are not eating how they should, getting back on track is the next step.
There are a variety things that could happen next:
- Some patients are able to return to the type of behavior they should be following, essentially getting back on track.
- Some patients may not be successful at weight loss despite returning to proper dietary behaviors.
- Other patients are never able to return to proper eating habits. This could mean a patient is non-compliant but not necessarily.
There are mechanical reasons that may cause patients to resort to maladaptive eating behaviors. An example of this is a patient with an anastomotic stricture who slips into the "soft-calorie syndrome" due to the fact that soft foods are the only foods that the patient can tolerate without vomiting. Another point to consider is exactly what "compliance" is after Gastric Bypass. "Proper" eating after Gastric Bypass represents an entirely foreign pattern of eating for the majority of humanity who have not had weight loss surgery. Some individuals are just not "wired" to live this type of lifestyle, even with the assistance of a small gastric pouch. A person's character, for better or worse, does not necessarily contribute to this problem.
Gastric Bypass may fail for the following mechanical reasons:
- gastro-gastric fistula
- pouch dilation
- anastomotic dilation
Gastro-gastric fistula is where the stomach pouch grows back and re-connects to the bypassed stomach. This can occur as a consequence of a pouch leak, where the resulting local inflammation from the leak disrupts the staple line of the bypassed stomach where it lies next to the pouch. More often though, gastro-gastric fistula formation is a result of a less acute, slower process. Regardless the cause, gastro-gastric fistula allows food to pass from the pouch to the bypassed stomach, effectively partially reversing the Gastric Bypass. Revision surgery for this condition may consist of closure of the fistula, restoring the original surgical Gastric Bypass anatomy. Conversion to a Vertical Sleeve Gastrectomy based procedure is an option as well, especially if there are reasons other than mechanical failure to explain the patient's weight gain.
Pouch dilation is a condition where the stomach pouch stretches out and enlarges; anastomotic dilation is where the connection between the stomach pouch and the intestine stretches out. Both conditions result in allowing the patient to eat more than what would be required to remain successful. Re-trimming the pouch to make it small again is one approach to treating pouch dilation. Surgical banding and endoscopic fixation are two approaches to treat an enlarged anastomotic connection. These approaches to pouch and anastomotic dilation are both directed at restoring the anatomy of the Gastric Bypass procedure back to what it was prior to stretching out. Another approach is to make a paradigm shift and convert to a more metabolically active procedure such as Duodenal Switch. Other Vertical Sleeve Gastrectomy based procedures are options as well, especially if the patient's Gastric Bypass is complicated by nutrient malabsorptive issues, such as osteoporosis and anemia.
Conversion from Gastric Bypass to Duodenal Switch is the most definitive revision procedure for inadequate weight loss or weight regain after Gastric Bypass. This approach addresses the issues of metabolic failure and maladaptive eating as causes of failure. This conversion may be done laparoscopically in many cases. A potential concern with this procedure is proper stomach function after surgery. The bypassed stomach is now brought back into use, and some patients may have had the nerves to the bypassed stomach cut during their original Gastric Bypass procedure. This is rarely a problem, as the nerves seem to grow back as the bypassed stomach "wakes up" and resumes working again. Sometimes it may not be safe to re-connect the gastric pouch to the bypassed stomach due to excessive scar tissue. If the patient has acceptable protein tolerance and satisfactory calcium metabolism, conversion to a Scopinaro-type Bilio-Pancreatic Diversion makes a very satisfactory option.
Medical issues complicating Gastric Bypass include marginal ulcer, stricture, and severe dumping syndrome. These conditions may often be treated conservatively, but when conservative treatment fails, revision surgery is indicated. Treatment for ulcer or stricture may involve resection of the ulcerated/strictured connection between the pouch and the intestine. Another approach is to convert to a Vertical Sleeve Gastrectomy-based procedure, as stricture and marginal ulcer are conditions that arise as a result of the intrinsic physiology of Gastric Bypass. This approach is favored for cases of severe dumping as well, as it is the inherent nature of the Gastric Bypass itself that results in the condition. Rarely, reversal of Gastric Bypass may be necessary to treat cases of malnutrition, including issues of vitamin and mineral malabsorption. Reversals for nutrient malabsorption may be accompanied by revision to a non-malabsorptive weight-loss procedure, allowing patients to stave off any weight re-gain that may otherwise result from the reversal of their malabsorption.
Revision of Mini Gastric Bypass operations are the same as for Roux-en-y Gastric Bypass. Bile reflux is a potential condition unique to this type of Gastric Bypass. Although bile reflux is uncommon and the concern is more theoretical than actual, converting the Mini Gastric Bypass to Roux-en-Y Gastric Bypass is sufficient to treat this condition. This is a fairly straightforward revision to complete and is performed without having to interrupt the first connection made between the stomach pouch and intestine.
Information courtesy of Dr. John Husted.
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