Revisional surgery for weight loss includes procedural intervention to achieve weight loss potential in a patient who has had previous gastric surgery or previous surgical weight loss procedures. Due to the previous intervention the risks of additional procedures can be higher. These higher risks include, but are not limited to enteric leaks, tissue ischemia, higher conversion rates to open intervention, enteric fistulas, sepsis, prolonged hospitalizations and higher failure rates for obesity and co-morbidity resolution.
Because of the higher risk with an associated lower potential for success fewer bariatric surgeons are offering revisional options. Patients with previous surgical weight loss attempts who have begun to see recidivism (weight regain) should make sure that the surgeon they are consulting offers revisional procedures as part of their program. The surgeon should have extensive experience with revisional surgery and an acceptable success rate. Expectations should be reserved when considering revisional intervention.
Successful revisional surgery can re-establish early satiety and appetite restriction in a patient who has failed previous surgical weight loss techniques. It is very important that the reason for initial failure be carefully investigated prior to consideration of revision. Reasons for failure include: anatomic disruption of previous procedure, poor design or implementation of initial procedure and poor or inappropriate eating behavior by the patient after the initial surgical weight loss procedure. Deciding why the initial procedure failed to produce the desired results is paramount in deciding a course of action that can improve the patients ability to attain and sustain long term weight loss.
The first step with any surgical weight loss investigation is education. Attending a well structured and informative seminar is important to ensure the patient understands the limitations and options regarding surgical weight loss. Attending support group meetings and utilizing online informative programming like the EMMI software is also helpful for patients considering primary or revisional surgical weight loss. After a patient has attended an informational seminar, then consultation with the surgeon is appropriate. The surgeon will require any available documentation of the initial procedure. This includes operative reports, pre-operative and post-operative clinic notes, any post-operative endoscopy or radiological reports. I feel that anatomical problems need to be ruled out initially, so I favor proceeding to endoscopy and contrast studies to evaluate the upper GI anatomy. An EGD and UGI study will go a long way to deciding if the problem is anatomical or behavioral. If an anatomical problem is identified, then careful discussion regarding the risks, benefits, and limitations of revisional surgery should be accomplished.
I cannot stress enough the importance of understanding the risks and limitations, and knowing the potential failure rates of revisional bariatric surgery.
If a patient has an anatomical issue with a prior surgical weight loss procedure that is amenable to an acceptable revisional procedure and clearly understands the risks, then the patient should proceed with the program guidelines towards further surgical weight loss intervention. This might include but not be limited to cardio/pulmonary testing, dietary and nutritional parameter evaluation and education, insurance preauthorization, pre-operative psychological evaluation and possible mandatory support group indoctrination.
Types of Revisional Surgery
- Gastric bypass has been the mainstay for primary and revisional surgical weight loss. The gastric bypass has been modified several times throughout its 30 year history. Previous techniques such as non-separated gastric pouches, large gastric pouch creation (over 100 ml), short limb bypass, and loop bypass have resulted in higher rates of weight regain or recidivism. The current technique of laparoscopically creating a 100cm roux limb with a small (less than 50ml) separated gastric pouch has resulted in less recidivism. Patients who have had previous gastric bypass may be candidates for bypass revision if their gastric pouch exceeds 300ml, they have developed a gastrogastric fistula, or their roux limb is too short.
Stoma size is also an important concept. The stoma is the opening from the gastric pouch to the roux limb. This opening is an essential component to the long term restrictive capabilities of this procedure.
A difficult issue is when a patient has a large initial stoma creation or has dilated the gastric stoma through poor eating behavior or intervention after gastric bypass.
Patients can show significant weight regain despite adequate (small) gastric pouch size if their stoma is too large. The food ingested is not slowed by the size of the pouch because no resistance to food passage into the intestinal (roux) limb exists. This results in larger meal volumes and increased caloric consumption. Large stoma size can be addressed by bypass revision but has a higher recurrence rate if the underlying cause is not addressed. For this reason other options are considered for weight regain due to large stoma size before proceeding to bypass revision.
Attempts to decrease the size of the stoma with endoscopic techniques such as the "Rose procedure" has variable results. This procedure is still considered investigational and is limited in availability as a revisional tool.
- Gastric banding has gained popularity in recent years as a safer revisional alternative than bypass in selective patients. Patients with large gastric pouches, disrupted gastric staple lines, and gastrogastric fistulas can consider the placement of an adjustable gastric band. This procedure has a higher laparoscopic success rate due to the less invasive nature of the technique. Variable result can be expected and patients should be cautioned that appetite control will not approach the level of their initial procedure for a variety of reasons. Laparoscopic banding revisions have been performed for previous gastric bypass, VBG and sleeve gastrectomy patients who qualify.
Banding over previous staple lines should be cautioned as higher erosion rates have been theorized.
- Sleeve gastrectomy is a procedure that has been performed in coordination with bypass procedures in the past. Patients with weight loss failure after sleeve gastrectomy as a "stand alone" procedure should be considered for Biliopancreatic diversion, duodenal switch or gastric bypass revisions. Gastric banding of sleeve gastrectomies has been performed but is considered investigational and should be reserved for patients who are not good bypass candidates. Theoretically a sleeve gastrectomy patient undergoing band placement may have a higher band erosion rate.
- Adjustable gastric band failures are usually the result of anatomical disruption or poor compliance with dietary recommendations. It is important to understand that bands are limited in their success because they are true restrictive procedures. They have no significant metabolic component. This means that if a patients basal metabolic rate decreases due to decreased meal volume and less caloric intake then weight loss will slow and potentially stop. A new set point is reached between the new lower basal metabolic rate and the current caloric intake and weight loss is essentially stalled. The best resolution for this scenario is metabolic exercise program initiation. This should result in raising the basal metabolic rate and resuming the weight loss.
Sometimes gastric prolapse ("slips"), hiatal herniation from pouch dilation and band erosion can result in weight regain after band placement. Fluid removal for treatment of esophageal and pouch dilation can also result in weight regain but should resolve when fluid is reintroduced and restriction is regained. Patients with repetitive episodes or patients who feel that the band is not compatible with their lifestyle may elect to revise or remove the band.
Revisions to gastric bypass can usually be performed laparoscopically with similar success rates as primary gastric bypass patients. The utilization of band removal to sleeve gastrectomy should be cautioned. The current "investigational" use of sleeve gastrectomy as a stand alone procedure has been met with a great deal of success. The incorporation of the use of this procedure as a revisional tool may confuse the data and warrants an abundance of caution. I cannot recommend the use of the sleeve gastrectomy procedure as a routine revisional option for adjustable gastric band, VBG or bypass patients until long term data is available.
- Previous gastric procedures will alter the structure, blood supply and innervation of the stomach. This can have variable effects on the success of surgical weight loss procedures. Patients with previous gastric procedures (anti-reflux procedures, partial gastric resections, gastric or duodenal drainage procedures) should be treated like they are undergoing a revisional procedure for these reasons.
Data on adjustable gastric band placement over previous fundoplications have shown a higher erosion rate and should be performed with caution.
Patients with prior history of pancreatitis should also be cautioned due to the higher gastric perforation rate associated in these patients. Imaging should be done to evaluate for pseudocyst formation and elective procedures avoided if pseudocyst formation is noted. Cautionary approach is recommended even after pseudocyst resolution as these patients will continue to be high risk for posterior gastric perforations at the time of surgery.