Weight loss surgery can and does fail at times for a variety of reasons. Patients who experience failure many times are reluctant to seek assistance because they feel that every attempt they have made to reach a stable, healthy weight has failed so they are a failure. NOT TRUE!
How Revision Surgery Works
The first step in revision surgery is to have an endoscopy and upper GI series not only to determine the cause of failure but also for the surgeon to be able to visualize and plan precisely how he will execute the revisional surgery. If your insurance covers these two diagnostic procedures, you may elect to have them done in the U.S. If your insurance does not cover the procedure, you may want to fly into your surgical destination of choice at least a day prior to your revisional surgery to complete the diagnostics and discuss with your surgeon the options available to you.
Lapband patients will want to remove their lap band and revise to a sleeve gastrectomy or bypass. Some surgeons can or will revise a sleeve pouch; others will not revise the pouch but alter the sleeve surgery to an RNY (gastric bypass) or a DS (duodenal switch). Gastric bypass patients can sometimes have the staple lines repaired and the pouch trimmed. If the stoma has failed, the approach with the least amount of risk is to apply a lap band over the gastric bypass. The bypass may also be revised to a distal bypass, and some surgeons will attempt to revise the stoma. A failed gastric bypass typically can’t be altered to a DS by most surgeons.
Review of Types of Revision Surgeries:
Gastric Bypass Revision Surgery
If roux-en-y gastric bypass fails to produce desirable weight loss, or if patients lose too much weight, revising to another surgery type could be ideal. Although, gastric bypass is considered to be semi-permanent, patients can convert to a variety of options including a duodenal switch, and Lap-Band. In Lap-Band, the band is placed around the stomach to help induce weight loss. Other options include:
- Shrink the stoma by injecting a sclerosant (“sclerotherapy”)
- Reduce the Size of the Pouch
- Add Lap-Band around the stomach (lap band surgery)
- Lengthen the Roux limb
Gastric Bypass Failure can be caused by:
- Pouch enlargement
- Staple-line disruption
- Stoma enlargement or failure
- Patient’s body adjusting to lowered caloric intake
Gastric Banding Revision Surgery
Increasing in consensus is dissatisfaction of gastric banding as a tool to treat obesity. More and more patients are experiencing insufficient weight loss and undesirable complications. The most common revisional surgery is Lap-Band to Gastric Sleeve. The gastric sleeve provides the restriction familiar to Lap-Band patients but also includes a suppression of appetite. List of revisional surgeries include:
- Re-Adjust Lap-Band Placement
- Lap-Band to Gastric Sleeve
- Lap-Band to Gastric Bypass
Statistically, ten years post op 60% of all lap band patients no longer have their lap band. Lapband failure can be caused by:
- Pouch enlargement
- Poor access to adjustments
- A certain percentage of patients simply do not lose weight with Lap-Band.
Gastric Sleeve Revision Surgery
If gastric sleeve surgery fails to produce sufficient weight loss, many patients opt to go with the duodenal switch or have a re-sleeve. Both options should work to increase the amount of expected weight loss. List of revisional surgeries:
- Gastric Sleeve to Duodenal Switch
- Re-Gastric Sleeve
Vertical Sleeve Gastrectomy failure can be caused by:
- Pouch enlargement
- Patient’s body adjusting to lower caloric intake
Vertical Banded Gastroplasty (VBG)
Vertical Banded Gastroplasty, or stomach stapling, is an outdated weight-loss procedure that uses stitches and an implant to achieve weight loss. Developed by Dr. Edward E. Mason, the developer of the original Gastric Bypass in 1966, it was originally developed in 1980. Since that time, long-term studies over ten years show disappointing results.
Compared with other surgery options, Vertical Banded Gastroplasty doesn’t produce the significant weight loss and can allow patients to regain their weight. Other possible reasons for weight loss failure is the lack of duplicate stitching (a practice that is now standard), which can tear or open. When this happens, patients must convert to another surgery.
Surgeries VBG can be revised to:
- Gastric Sleeve Surgery (Likely)
- Gastric Bypass Surgery (Less Likely)
Patients with weight loss surgery must also factor in their personal genetics. Certain individuals are merely designed to store fat and several years after weight loss surgery, their bodies adapted to the malabsorption component and lowered caloric intake, and patients begin to gain weight slowly again.
Risks of Revision Surgery
Patients considering revision must also be aware that revisional surgery has almost a 50% higher rate of complications than a first surgery. Human tissue does form adhesions after the first surgery. Adhesions vary from person to person and have no bearing on the external scars on the skin. An example would be to picture 50 sheets of tissue paper in a stack, then pour a glass of water over the top and allow to dry. Each piece of paper adheres to the one above, and below, human tissue is similar in that a second surgery takes much more operating room time and skill because of the careful dissection of layers of adhesions.
Risks common with revisional surgeries are leakage, the necessity to revise a laparoscopic surgery to open surgery, incisional hernia (from open surgeries), bleeding, etc. With all surgeries there is always risk with anesthesia, this can be minimized by using a surgical team with an anesthesiologist well versed in bariatrics.
Great strides have been made in the field of trans-oral surgery (surgery via an endoscopy procedure). While this area is still very experimental and in its infancy, this type of surgery may offer a low-risk alternative in the future to repairs of enlarged stomas and other types of revisional repairs.
Mexico Bariatric Center Revisional Case Studies: