Revisional Weight Loss Surgery
Different weight loss surgical procedures have different short and long-term results. Additionally, different weight loss surgical procedures are prone to their unique long-term complications. Patients who have had weight loss surgery in the past may require other procedures to correct the complications or undo the ill effects of their original operation. These types of operations are called revisional weight loss surgical procedures.
It is important to consider that the need for revisional surgery, does not necessarily mean there is a complication from the primary weight loss surgery.
Conditions that may require revisional weight loss surgery include:
- Inadequate weight loss.
- Weight regain after initial weight loss.
- Dumping syndrome.
- Solid intolerance.
- Marginal ulcers.
- Nutritional deficiencies including vitamins, minerals, etc.
- Anemia.
- Significant bowel dysfunction (constipation, diarrhea, malodors of flatance).
- Significant gastroesophageal reflux disease.
- Infection involving implanted devices (ports or bands).
- Erosion or slippage of the adjustable band.
- Partial resolution of the comorbid conditions, or recurrence of the comorbid conditions after initial or partial resolution.
- Stricture (narrowing at the site of bowel anastomosis).
The goal of the revisional weight loss surgery is to:
- Correct the problem that brings a patient under our care. This would include correction of any of the above outlined conditions.
- Make the revisional weight loss surgery a definitive procedure. This will be discussed further when we discuss specifically each type of procedure that we revise.
- Accomplish the primary goal of weight loss surgical procedure, which is maintenance of the weight in a favorable range and resolution of the patient’s comorbid conditions.
- Revisional weight loss surgery should have acceptable risk as a surgical intervention.
The majority of the patients that seek a revisional weight loss surgery are those that had acceptable short-term outcome after initial weight loss surgical procedure. They may have lost the weight only to gain it back, some may have had inadequate weight loss. There are also those patients that had ill effects of their primary operations including ulceration and stricture in the case of Roux-en-Y gastric bypass, and slippage or erosion in the case of adjustable gastric banding. There are some patients that have been able to lose the weight and keep it off; however, this comes at the expense of near constant nausea and frequent vomiting episodes. It has been our experience that the failure of primary weight loss surgical procedures is quite frequently “blamed” on the patient. In the majority of the case, however, this is not the case. A less than ideal outcome of a weight loss surgical procedure, in the majority of the cases, can be traced back to a procedure that did not work for that patient. This would be the same circumstance when a patient has to try a number of blood pressure medications to find the one that works for them best.
Alternatively the procedure may have delivered the best outcome possible, which may be inadequate for that particular patient or the condition.
The causes of failure of primary weight loss surgical procedures may be:
| Cause | Procedure |
|
Roux-en-Y Gastric Bypass |
|
Duodenal Switch |
|
Adjustable Gastric Banding |
Each one of the surgical procedures will be discussed in great length with the rationale for the recommended revisional weight loss procedure.
Roux-en-Y, Gastric Bypass
Roux-en-Y Gastric Bypass is a procedure where a small stomach pouch is created and it is connected to a limb of small bowel with a deliberately small opening created. The purpose of the small pouch and the small opening is to restrict the amount of food that a patient can eat at any given setting and furthermore to purposefully delaythe emptying of the pouch to give the patient a longer period of feeling full.
Complications of Roux-en-Y gastric bypass are known to be dumping syndrome, marginal ulcer, and persistent nausea and vomiting with solid intolerance, inadequate weight loss, weight regain. It is my opinion that in almost all of the cases the best option for a Roux-en-Y gastric bypass that is in need of revision is the Duodenal Switch operation. Adjustable gastric banding (Lap Band) placement as a revisional weight loss surgery for a primary Roux-en-Y may only be indicated in patients that have had initial success of weight loss followed by weight regain. This, however, should be in the absence of dumping syndrome, marginal ulcer or reflux disease, which can potentially get exacerbated by placement of the band on top of a gastric pouch.
Adjusting the length of the common channel, alimentary limb, allows a revisional weight loss surgery to be tailored to the patient’s needs. Examples of this would be if a patient is seeking revision of a failed gastric bypass to Duodenal Switch for persistent nausea and vomiting; In the case of a patient having a revision of Roux-en-Y for persistent nausea and vomitimg with an adequate weight loss a relatively long common channel and alimentary limb (percentage based) will be set for the patient thus preventing any further weight loss yet correcting the persistent nausea and vomiting problem.
In contrast a patient that is seeking revision of a failed gastric bypass to Duodenal Switch because of inadequate weight loss and/or weight gain will have a relatively shorter common alimentary channel (percentage based) in order to maximize the amount of weight loss. It is my opinion that revising a failed gastric bypass, from a proximal to a distal Roux-en-Y is an extremely poor choice in the majority of the patients due to the fact that the distal gastric bypass has the worst nutritional safety profile of all the known surgical procedures.
Adjustable Gastric Banding
Lap Band, Realize
Adjustable gastric banding is a restrictive procedure in which a very small pouch of the stomach is created and partitioned solely by placement of a ring that can be adjusted by addition or removal of sterile saline through a port.
In the majority of the cases, the reason for inadequate weight loss may be related to inadequate adjustments or unrealistic patient expectations with regards to the anticipated weight loss. All the published reports to date identify the amount of weight loss to be approximately 50% of the excess body weight, and patients that have a large amount of weight to lose may never attain adequate weight loss to have their comorbid conditions resolve. This may be an example of patients that have attained the weight as expected by the surgery yet they had a less than ideal weight loss surgical procedure for their general health condition to include their excess weight and their comorbid conditions. The majority of the patients that had adjustable gastric banding being inadequate weight loss or significant reflux disease in the presence or absence of hiatal hernia. It is our recommendation to have this procedure conversed to Duodenal Switch.
Duodenal Switch
Duodenal Switch operation is the primary weight loss surgical procedure that we perform. It is a hybrid operation where a banana-shaped stomach is created. Additionally, two parallel limbs of small bowel are created to carry down the ingested food separately from juices from the liver and pancreas. No small bowel is removed. This limits the amount of absorption of calories and nutrition thus magnifying the amount of weight loss.
The most common reason for revision or reversal of the Duodenal Switch operation in our experience has been 1) inadequate weight loss, and a distant second) significant diarrhea. In the case of inadequate weight loss, greater than 80% of the patients in our experience have had dilated stomach which has rendered itself easily to a regastrectomy with excellent results. Very few patients have benefited from shortening of the common channel.
The revision/reversal of the Duodenal Switch operation for significant amounts of loose bowel movements and malodorous flatus is easily accomplished by creation of a side-by-side anastomosis.
In fact having extensive experience with revision of weight loss surgical procedures it is our opinion that from a technical perspective, revision or reversal of Duodenal Switch operation is technically the safest and easiest of all the other surgical procedures.