OCC Lap Band Surgery Specialists Bariatric Center

"What is Bariatric Revision Surgery"?

March 05, 2015 by Juan Antonio Lopez Corvala

Revision in bariatric surgery is defined as an intervention that repairs or revises a prior weight loss surgical procedure. This can be patients that were never successful with the prior procedure, patients with success but who regained the weight, or patients with weight loss success but with complications.

Patients candidates for revision bariatric surgery are:

• Prior vertical banded gastroplasty (VBG, stomach stapling), gastric plication or sleeve gastrectomy with weight regain.

• Prior gastric Bypass surgery and weight regain.

• Lap band surgery and weight regain.

• Lap band surgery complications (acid reflux, slippage, erosion, port problems).

It is well known that some patients after surgery can struggle with weight loss or weight regain, in the case of restrictive procedures such as the gastric band, gastric plication, sleeve gastrectomy. This can be caused due to loss of the restriction feeling and in the case of the malabsortive procedures, such as the gastric bypass and the duodenal switch, the excluded portion of the small bowel start absorbing nutrients and also loss of restriction.

What percentage of bariatric surgeries “fail” or need to be revised?

It depends. The percentages vary according to the original procedure performed, the surgical technique that was used (ex. Size of the gastric pouch, length of the alimentary, bile and common limb),patient BMI prior to surgery, patient compliance to the new eating habits, presence of co-morbidities and post-op complications).

When the original bariatric surgery is considered unsuccessful is because of:

• Non-satisfactory weight loss and/or weight regain. Unsuccessful weight loss is considered when the patient fails to achieve >50% excess weight loss and/or patient is unable to reach a BMI

• Return of previous medical conditions such as hypertension, diabetes, back and osteo-articular pain, among others.

In a group of patients, revision surgery is needed due to complications, for example:

Gastric band possible complications that may require revision surgery:

• Severe acid reflux symptoms, in this case the original surgery might need to be converted to a gastric bypass. It can be caused by an undetected hiatal hernia during the original surgery, or by gastric motility problems.

• Obstruction. May need endoscopic dilation or conversion to gastric bypass

• Sleeve enlargement and loss of restriction induces weight regain. In this case, the sleeve can be “re-sleeved” or be converted to a gastric bypass. Bilo-pancreatic diversion.

• Leaks. The surgical approach will depend in the cause and location of the leak. May require guided radiologic drainage and/or endoscopic stent placement.

GastricBy-Pass possible complications that may require revision surgery:

• Narrowing or obstruction of the gastro-yeyuneal anastomosis

• Ulcer in the gastro-yeyuneal anastomosis

• Gastric pouch enlargement

• Widening of the gastro-yeyuneal anastomosis

Before revision surgery, it is important to evaluate each patient and determine, if possible, the reason of failure. Is the surgery anatomically intact? Is the patient following the nutritional post-op instructions?

Radiologist image test (fluoroscopy) is mandatory to evaluate the anatomic structures and in some cases an endoscopy study may be necessary to determine the better approach in the specific case.

The surgeon will inform the patient of the need, risks and benefits involved in revision surgery, as well as the importance of the followup by the multidisciplinary team.

Since 1998, the IFSO (International Federation for the Surgery of Obesity)statement of qualifications of the Bariatric Surgeons suggested:“Re operative bariatric surgery is an intricately complex and demanding area, which requires considerable primary bariatric surgical experience” (Deitel & Cowan. Update: Surgery for the Morbidly Obese).

Is mandatory that patients that require revision bariatric surgery be treated by a highly experienced surgical and muiltidisciplinary group and in a high standards facility.

Revision bariatric surgery increases morbidity and mortality, due to age,weight, BMI, body shape, medical conditions, previous bariatric surgery, hospital facilities and experience of the surgeon and the multidisciplinary team.