Revisional Bariatric Surgery

As a matter of combating morbid obesity, bariatric surgery is a method of putting physical restrictions on eating habits. Many would argue the eating behavior should change, not the digestive tract. Reasonable enough in an ideal world, but in reality – especially over many years – behavior modification as an independent approach doesn’t work very well. Bariatric surgery stands the test of time much better. However, it’s not perfect. As with all surgery, there is a potential for complications and not all bariatric procedures achieve the desired weight loss. In extremely rare situations, bariatric surgery may need to be undone or revised.

Current thinking is that revisional operations do not work very well and for that reason they are reserved for unique cases. As with many things in surgery, much depends on the circumstances and the available options, some of which we’ll describe below. In any case, I strongly suggest that patients return to their original surgeon who performed their first operation, as every surgeon individualizes the digestive arrangements in a particular manner. The only revisional operation I regularly perform is for patients who have a failed laparoscopic gastric banding. Those patients may benefit from having the band removed and then converting to a gastric bypass or a gastric sleeve.

Why does bariatric surgery sometimes fail?

Bariatric surgery most often fails because patients do not make the necessary lifestyle and diet changes that are needed in order for the surgery to provide a lasting good result. Although they are the exception rather than the rule, there can be medical complications from the original bariatric surgery.

Many of the complications relate to specific bariatric procedures. For example, adjustable gastric banding (AGB) may have band slippage, gastric erosion (where the stomach tissue is damaged because of the band pressure), pouch dilation (spreading of the stomach behind the band restriction) and laparoscopic port complications (infection). By reports, up to 70% of gastric band operations will have some form of complication, many of which will require surgical intervention.

For vertical banded gastroplasty (VBG) and gastric sleeve (GS) operations, long term complications include a worsening of reflux, and stomal stenosis (a narrowing of the new connection between stomach and intestine). Roux-en-Y gastric bypass (RYGB) operations are associated with “dumping syndrome,” where the contents of the gastric pouch empty into the intestines before adequate digestion by stomach fluids. This can lead to nausea, dizziness and diarrhea.  

In addition to complications from specific procedures, there are a few complications associated with almost any kind of digestive system surgery including bowel obstruction. Bowel obstruction is intestinal blockage because of the scar tissue that forms after any operation. Although laparoscopic surgery causes less scar tissue, a blockage that may require hospitalization or even a repeat operation is always possible.

Although not strictly a medical condition, the most common and obvious reason for bariatric surgery failure is insufficient weight loss, either from not losing enough weight from the beginning, or losing sufficient weight but then regaining it. According the available studies, the most effective common procedures in terms of weight loss are (in order): Biliopancreatic diversion (BPD), Roux-en-Y gastric bypass (RYGB), vertical banded gastroplasty, and then adjustable gastric banding (AGB). No procedure can guarantee sufficient weight loss to go from morbidly obese to ‘normal’ weight, especially when maintained over a period of years. However, most bariatric procedures have a good record of medically significant weight loss – but there are exceptions.

What options are available to revise a gastric bypass for failed weight loss?

The gastric bypass operation (usually a laparoscopic Roux-en-Y gastric bypass) is among the most common weight loss procedures in many parts of the world, including the United States. The procedure creates a small gastric pouch at the top of the stomach (a food-volume restriction approach) and then attaches the upper part of the small intestine (jejunum) to the pouch, bypassing the duodenum (reduced food absorption approach). The bypass is generally effective for inducing considerable weight loss, but in some cases, the weight loss is insufficient or the weight is lost and then regained. As lifestyle choices and positive change is the most important part of a bariatric operation, revision of the bypass is not typically an option.

Selecting an appropriate approach among several options is critical as, in general, revision of gastric bypass has a relatively high rate of complications.  For example, while leakage of gastric fluids may occur during your first operation, the risk is typically around 1%. In revision operations, leakage may occur in as many as 20% of cases. Surveys have also shown that these revisions have a low patient satisfaction rate, as the procedures are frequently problematic and do not always achieve a desired level of weight loss.

While there are many possible variations, there are four basic technical approaches to revision of a gastric bypass include:

• Endoscopic revision of the pouch and the connection of the upper intestine to the pouch (gastro-enteral or gastro-jejuno anastomosis). This may be used to alter the size or shape of the gastric pouch, which usually means adjusting the intestinal bypass connection.
• Laparoscopic distalization (moving, lengthening, or shifting position) of the bypass limb (section of upper intestine, jejunum), which may affect the rate of food absorption.
• Laparoscopic banding of the pouch, adds a lap band or similar device around the gastric pouch to restrict its size. This is more easily done than restructuring the pouch itself.
• Laparoscopic revision of the gastric pouch, such as by folding (plication), or revision of the ‘candy cane’ (twisting) portion of the jejunal limb.

Illustrating the importance of choosing the right revision approach, there are instances where the decision requires a multidisciplinary team including:

• A dietitian to analyze a patients eating habits and diet for the type of revision
• A psychologist to evaluate the patient’s ability to respond well to a surgical revision
• A gastroenterologist and radiologist to determine the details of the current condition of the stomach and intestines (checking the size of pouch, looking for ulcers or other abnormalities)
• An endocrinologist to consider repercussions on insulin and other hormone production
• A bariatric surgeon to determine the surgical procedure compatible with all the other conditions spelled out by the team.

In general, these revisions of a gastric bypass may result in significant drop in BMI (Body Mass Index), however significant weight loss does not always occur and it is difficult to say whether performing a revision is typically worth the risk. Several studies indicate that weight loss for revisional gastric bypass is usually less than for the first (primary) operation. For these revision procedures, hospital stays were around 6 days. While death is a rare complication of revisional operations, there is a re-operation rate of around 7% and severe complications (morbidities) run as high as 20%. As mentioned, the high morbidity rate is one of the reasons why these revisions are not very popular with patients.

Options for revision of laparoscopic adjustable band bariatric surgery

From a patient’s point of view, it often seems that the laparoscopic installation of a gastric band around the stomach (a “lap band”) is the easiest and safest method available. It’s true that a lap band procedure can be done with a very short hospital stay (1 or 2 days), has a very low mortality (death) rate of about one-half of one percent (0.05%) and is reversible (the band can be removed). However, lap bands present their own set of complications, which range from movement (slippage) of the band, to erosion (tissue destruction) under the band, to the failure in significant weight loss. Overall, the failure rate of adjustable bands is a rather breathtaking 16% to 50% (in the U.S.).

There are two principle surgical options for lap band revision: Converting the band to gastric bypass, or substituting a gastric sleeve for the band. Both revisions require surgical alteration of the stomach and upper intestine, which makes them essential non-reversible. As with all bariatric revision, the decision to revise a lap band can be complex, for example, patients with a tendency to ‘graze’ (eat small amounts frequently) are better served by weight loss operations that limit food absorption (typically in bypassing sections of the intestines). People who tend to eat large meals (volume eaters), may be better served with gastric restriction (decreasing the size of the stomach). As we understand more about how bariatric surgery works, we realize that a problem with the lap-band is that it does not control hunger, it just helps with portion control.

Converting a Lap-Band to a Sleeve Gastrectomy

Converting  a laparoscopic sleeve gastrectomy (LSG), means removal of the gastric band, and then the surgical resection of the stomach – reducing the size of the stomach to a channel or ‘sleeve’ about 15% of the volume of the original stomach. In removing most of the stomach, the portion that produces the hunger hormone (Ghrelin) is also removed, which temporarily reduces appetite. Like banding, the gastric sleeve is another form of restrictive food control that does not change the flow of food through the intestinal tract, but in this case is not reversible.

The previous presence of a gastric band adds some potential complications to the gastric sleeve operation, and in general, a revisional gastric sleeve is likely to have more complications than a primary gastric sleeve operation.

Conversion of a Lap Band to a gastric bypass

Converting a lap band to a laparoscopic Roux-en-Y gastric bypass (RYGB), adds the control of food absorption element by connecting the upper intestine (jejunum) to a gastric pouch at the top of the stomach. In this procedure, the gastric band is removed and a gastric pouch is constructed from stomach tissue. However, since the gastric band also created a kind of pouch and restriction in the same location, there is a possibility of surgical complications caused by scar tissue, adhesions and other effects of the band. In general, however, the results of a revisional gastric bypass are good short to medium term weight loss, with no increase in complications and no increase in hospital stay.  

Outcomes for revised bariatric surgery

There is a tendency for people to believe that bariatric surgery is – by itself – a permanent fix for morbid obesity. It can go a long way in the right direction by placing physical limitations on the intake and absorption of food, but it is not necessarily permanent, not necessarily a real ‘fix,’ nor is it all there is to a successful loss and maintenance of weight.

For one thing, bariatric surgery of any kind (primary or revisional) is not a license to eat anything, at any time and in any quantity. In fact, because of the new physical restrictions on food intake, a great deal of attention must be paid not only to diet, but also to quantities, chewing habits and the timing for eating. Nor does it mean that because less food is eaten, being a couch potato is suddenly OK. Exercise remains as important as diet for good health. It also contributes to regulating the amount of food people should eat for a revised digestive system.

In this regard, revisional bariatric surgery can change the diet rules for patients, which can be a source of confusion. In fact, recent studies seem to show that revisional bariatric surgery may have a negative effect on food selection, food tolerance, normal eating patterns and physical activity. There is speculation that the stress of revisional procedures with their long periods of focus on eating, digestion and healthy behavior has a tendency to provoke ‘rebellious’ behavior such as binge eating, uncontrolled eating and grazing.

Another aspect of weight loss associated with revisional bariatric surgery is a change in expectations. In general, people who need bariatric surgery in the first place have already come to grips with the idea that other methods of losing weight failed. Not that the inability to control diet and physical activity is in any way unusual, but when people resort to surgery, it’s a signal of having reached a certain level of desperation – perhaps even medical emergency. Then too, expectations are high. Most people expect that if they undergo primary bariatric surgery, their weight loss will not only be considerable but enough to return them to ‘normal.’

If this doesn’t happen, if weight loss is insufficient or there are serious medical complications, considering a revised bariatric procedure is, in a way, a sign of yet another failure. This has many psychological and behavioral possibilities, most of which tend to make the revisional surgery less effective.

The outlook for revisional bariatric surgery

While in general, revisional bariatric surgery makes continued or additional significant weight loss possible, and the level of complications is generally acceptable though higher, it’s important to understand that the benefit (or risk) depends a great deal on the individual (attitude and behavior), the previous form of bariatric surgery, and the choice of revisional surgery.

For example, for those who have trouble with a lap band, conversion to gastric bypass or a gastric sleeve has almost the same potential weight loss as the original band procedure; however, they are technically more demanding operations with a higher risk for complications. This is even truer for revision of a gastric bypass, where the rate of complications is high enough to provoke risk aversion in doctors and patients.

The field of bariatric surgery is relatively young, less than thirty years old, and is in a constant state of development. At the same time, its use is growing. As obesity spreads worldwide and becomes epidemic – as it is already in many developed countries – there will be more bariatric surgeries every year, and correspondingly more revisions of bariatric surgeries. The techniques for revisions are improving, as are the technology and support for patients who go through the revision process. Still revisional bariatric surgery is distinctive and it remains up to physicians and patients to make appropriate decisions about selection of revision procedures and the overall approach to health and lifestyle that will make them successful.