Overview of Bariatric Revision Surgery

Bariatric surgery (weight loss surgery) is usually very successful, both in terms of helping a patient achieve significant weight loss and minimizing complications. Unfortunately, some patients may experience problems with the surgery or not succeed in losing the expected amount of excess weight. In these situations, a follow-up bariatric procedure, known as a bariatric surgery revision, may be necessary to alter or repair the initial bariatric surgery.

Bariatric Patient
Bariatric revisions may be necessary due to insufficient weight loss, weight regain, or surgical complications.

Although it can be an emotional setback for obese patients when bariatric surgery does not lead to the expected amount of weight loss, the only failure is in giving up. Obesity is a chronic disease and not easily treated. As with any serious health condition, if the first treatment is not effective, then the doctor will recommend additional treatment options. With weight loss surgery, a bariatric revision surgery may be necessary as an additional treatment for obesity.

Necessity of Revisional Bariatric Surgery

Revisional bariatric surgery is not a new concept. Revisions have been performed since the time bariatric surgery was introduced in the 1950's. Many of the early bariatric operations were either revised or reversed because they did not produce the expected weight loss and were more likely to cause complications due to poor design or technique.

The jejunoileal (intestinal) bypass, one of the earliest bariatric procedures, caused many severe and unpredictable nutritional problems and diarrhea. Because of these problems, many patients had to have their jejunoileal bypass revised or reversed. This procedure is no longer being performed today and has largely been replaced by other malabsorptive type procedures - the biliopancreatic diversion (BPD) procedure and the improved variation called biliopancreatic diversion with the duodenal switch (DS). The Roux-en-Y gastric bypass surgery also has a malabsorptive component, although not to the degree of the BPD and DS procedures.

Another popular bariatric procedure in the early years of weight loss surgery was the stapled gastroplasty (stomach stapling). This procedure was associated with many problems due to both poor design and failure of the staples to stay intact. Eventually the original horizontal gastroplasty developed into more successful vertical banded gastroplasty, but eventually this procedure fell out of favor as well. Gastroplasty has primarily been replaced by laparoscopic adjustable gastric banding surgery (lap band surgery), which is a safer and more effective restrictive type of weight loss surgery.

The three most popular bariatric procedures performed today, gastric bypass surgery, sleeve gastrectomy, and LAP-BAND surgery, are considered very successful weight loss procedures overall. However, in some cases, revisions are necessary due to either insufficient weight loss or surgical complications. It is expected that the amount of bariatric revisions will continue to increase simply because of the fact that the total amount of bariatric surgeries performed is increasing as well.

Revisions After Gastric Bypass Surgery

A gastric bypass revision is necessary in approximately 5 to 10% of patients over 5 years due to complications, unsatisfactory weight loss, or weight regain. Complications that may occur after gastric bypass surgery, such as ulcers, chronic vomiting, hernia, staple line failure, can often be improved through revisional bariatric surgery.

If gastric bypass fails a patient has several options, including:

  • If the problem is lack of weight loss or weight regain, non-surgical approach includes examining eating habits and exercise routines and participating in nutritional counseling, exercise program, behavior modification therapy, psychological counseling, and support groups.
  • If the problem is lack of weight loss or weight regain, surgical options include placement of an adjustable gastric band on the stomach pouch, conversion to distal gastric bypass, and conversion to duodenal switch.
  • If stomach pouch or stomach opening has enlarged, a LAP BAND may be added to reduce amount of food that can be eaten and slow the movement of food from the stomach to the small intestine.
  • If stomach pouch or stomach opening has enlarged, the bariatric surgeon can try and fix the problem by re-operating to either remove more stomach and re-stapling the stomach line or stitching up the stomach opening to make it smaller, although it may only be a temporary fix and happen again.
  • If surgical complication, such as popped staple line, ulcers, or hernia, the bariatric surgeon will need to surgically repair the problem.
  • The StomaphyX or ROSE procedure, non-surgical (endoscopic) revisions for gastric bypass surgery, that treat the stretched stomach pouch or enlarged stomach outlet.

Revisions After LAP BAND Surgery

The revision rate for the LAP BAND is approximately 10% during the first two years due to either device-related problems or unsatisfactory weight loss. One of the most common gastric banding complications is slippage of the gastric band, which requires a follow-up procedure to fix the problem. While some patients will have the band replaced, others choose to revise to another procedure, such as gastric sleeve or gastric bypass.

Revisions After Gastric Sleeve

The gastric sleeve is a newer primary weight loss procedure that involves reducing the size of the stomach to restrict food intake. In the past, it was used primarily as the first stage in a two-stage procedure, or the gastric component of the duodenal switch procedure (gastric sleeve and intestinal rerouting). Although many people will lose sufficient weight with the gastric sleeve procedure, if further weight loss is needed, than converstion to duodenal switch or gastric bypass may be an option.

Patient Criteria for Revisional Bariatric Surgery

Before a revisional bariatric procedure is performed, the patient will be examined by the bariatric surgeon to determine the cause of failure and to evaluate for the appropriate treatment options. The bariatric surgeon will need to determine if post operative weight loss failure is due to a problem with the original surgery or a result of the patient's inability to follow the necessary dietary and lifestyle guidelines.

Bariatric surgery is a very specialized and complicated treatment process. Great care is given to maximizing weight loss success while minimizing risks and complications. Another consideration is whether the patient has unresolved cormorbidities that may improve with additional surgery. The doctor will discuss the options with the patient and explain what to expect with the bariatric revision.

Results with a Bariatric Revision

Bariatric surgery revisions are usually successful in resolving the associated problems and promoting further weight loss, although the results can vary widely depending on the original procedure and the reason for the revision. Weight loss following a revision is usually not as dramatic as the initial bariatric procedure, but it can be substantial over time.

As revision surgery can be more complex and involve more risks than general bariatric surgery, it is important to choose a bariatric surgeon that is experienced and skilled in performing revision bariatric surgery.

With all bariatric procedures, the best weight loss results are achieved by patients who are able to comply with the diet and exercise recommendations of their bariatric surgeon. The post-bariatric process can be a struggle and patients will benefit in their weight loss efforts by attending support groups, talking to a nutritionist for dietary advice, working out with a bariatric exercise program, and if needed talking to a psychologist to help deal with eating behaviors and the emotional aspect of obesity and weight loss surgery.