Since 2011, I have been working as a bariatric surgeon. Over this time, I have found that my patients are not seeking solutions exclusive to their weight. I am equally invested in addressing their overall heath. Moreover, it is not uncommon to see patients who have already undergone a bariatric procedure and need help addressing a number of issues to include inadequate weight loss, weight regain, and/or complications resulting from their original surgery. Of course, this is a particularly stressful situation for patients. As we know, undergoing bariatric surgery for the first time is inherently taxing on the patient. Therefore, one can imagine the extra stress involved in having to undergo bariatric surgery for a second time. Therefore, I have made it a priority to distinguish myself as a bariatric surgeon with a unique skill set available to address revision surgeries. It is fair to say that I specialize in these more difficult cases. In fact, approximately 40% of my practice is comprised of revision surgery.
Over the years, I have worked with patients who have undergone previous lap band, sleeve, stomach stapling (VBG), and even gastric bypass surgeries. There are a variety of reasons why a patient’s original surgery resulted in unforeseen negative consequences. For example, the initial surgery may have been the wrong option for the patient given his or her BMI. For instance, a sleeve gastrectomy will typically provide patients with a net loss of 65% of their excess body weight (that is, they will lose 65 lbs for every 100 lbs they are overweight). However, if patients have a BMI over 50, they may still be morbidly obese (BMI > 35) even if they lose all the weight that the sleeve can provide. In this instance, the patient would have benefited from a gastric bypass or duodenal switch as they both offer more upfront and long-term weight loss. In addition to inadequate weight loss or weight regain, patients can experience several other complications to include the following: nausea, vomiting, food intolerance and reflux from band prolapse, anatomic complications from inadequate sleeves, and ulcers / persistent pain with gastric bypass secondary to surgical failure. As you can see, it is of primary importance that your surgeon provide the proper education relative to the appropriate surgery to pursue in an effort to avoid these problems down the road.
The American Society for Metabolic and Bariatric surgery has specifically looked at the outcomes for revision surgery and their success rates. Research in this area emphasizes that “with any surgery, there will be a subset of patients who are non-responders or have recurrent/persistent disease or complications of therapy.” ASMBS further reported that “the paradigm of revision surgery is well-established for other fields.” For instance, there is a well-established revision rate for patients undergoing joint replacement. “When initial therapy fails, revision, replacement or conversion is offered. This is also seen in heart valve surgery, coronary artery bypass grafting, abdominal wall hernia repair, and oncologic surgery. In all of these instances, the need for conversion/revision is clear and covered by insurance plans. Unfortunately, there does seem to be a bias in the field of bariatric surgery. Patients may face not only scrutiny from family / friends but may also face the real issue of not having insurance coverage for the procedure.”
So, what are the long-term success rates for the various bariatric surgeries and can/should they be revised? In my experience, I have found that my patients do well with revision surgery, have low complication rates, and enjoy the benefits of more weight loss and resolution of their health problems. My basic rule of thumb is to choose a procedure that is the next level or two above the original. However, there is not one perfect surgery, and procedure selection is dependent upon the patient’s anatomy, health issues, and previous surgery. The following includes a summary for each procedure.
As band placement has declined, the number of patients seeking revision surgery has grown dramatically. Studies show that more than 50% of patients who have undergone gastric banding surgery need to have an additional surgery within 5 years of band placement. Patients can experience increased heartburn, food intolerance and vomiting, and abdominal pain. This is most often due to prolapse or band slippage down the stomach. The most feared complication is erosion of the band through the stomach wall. These patients are at risk for infection and prolonged recovery and hospital stays. The options for conversion surgery include revision to sleeve, gastric bypass, or duodenal switch. While up to 28% of patients opt for conversion of band to gastric bypass, conversion to sleeve is the most widely performed operation in the US. However, I have found that patients who undergo band to sleeve revision surgeries do not experience the weight loss that they desire. Moreover, they often experience a worsening of their acid reflux (even once the band is removed). Typically, I have found that patients have much better long-term results with revision to gastric bypass or duodenal switch. A band and a sleeve are both purely restrictive surgeries. A gastric bypass and duodenal switch combine both restriction and mal-absorption. I recommend that patients who are undergoing revision surgery opt for a surgery that will take them to the next level. That is to say, patients are encouraged to convert from a restrictive surgery to a procedure that offers BOTH restriction and mal-absorption. The result will be long-term weight loss similar to undergoing gastric bypass or duodenal switch from the start. Band to bypass revision surgeries can offer up to 70-75% excess body weight loss. Band to duodenal switch revision surgeries can offer up to 80% excess body weight loss.
The sleeve is now the most commonly performed bariatric surgery in the US. In turn, I am now beginning to see more and more patients seeking revision surgery for their sleeve gastrectomy. The most common reasons for revision are inadequate weight loss and GERD that is refractory to medical treatment. Anatomic complications such as stricture (narrowing) or leak also require revision surgery. In my practice, I do not perform a “re-sleeve” as this will offer little long-term weight loss. Conversion to gastric bypass or duodenal switch can offer not only more weight loss, but it will provide correction to anatomic issues from surgical complications. Patients will usually have about 10-15% less weight loss from their revision to gastric bypass (i.e., 60-65% excess body weight loss). However, patients can have up to 80% excess body weight loss when they are converted to a duodenal switch. (A duodenal switch can be a staged procedure, with a sleeve performed as step one. However, patients experience similar weight loss whether a duodenal switch is performed as a single operation or staged procedure).
Stomach stapling (VBG, vertical banded gastroplasty) is a procedure that was commonly performed in the 1980’s and 1990’s. It has fallen out of favor secondary to its high rates of surgical failure. In fact, up to 61% of patients who have undergone VBG experience food intolerance, maladaptive eating behaviors (from the food intolerance), and inadequate weight loss. They can also suffer complications such as band erosion, staple line erosion, GERD, and incisional hernias. The leak rate when converted to a sleeve or duodenal switch has been noted to be 14% and 22%, respectively. Due to this, patients are most often recommended to undergo a conversion to a gastric bypass. Patients who are converted to bypass have good long-term weight loss with lower complication rates. In my experience, patients who have a VBG to bypass will lose about 60-65% of their excess body weight.
Finally, patients who have undergone gastric bypass in the past can also have relief from complications and achieve further weight loss with revision surgery. While there are several ways in which to revise a bypass, outcomes have been mixed. Surgeons have offered a number of different options, such as:
– Placing a band around the pouch (to increase feelings of restriction)
– Endoscopically narrowing the opening between the stomach and small bowel (to increase feelings of restriction)
– Resecting redundant small bowel near the gastrojejunostomy (this can offer patients increased feelings of restriction)
– Revising the pouch to a smaller size by over-sewing the pouch (with a measuring device as a guide) or stapling off redundant pouch and creating a new anastomosis (connection) between the stomach and small bowel
– Moving the roux limb (food limb) further down the common channel to achieve more mal-absorption
– Any combination of above
In my practice, I have found that patients who undergo gastric bypass revisions can lose anywhere from 55-75% of their excess body weight. In my experience, these patients can have a much better outcome with creation of a new pouch AND moving the food limb. This combination offers both more restriction and mal-absorption. If I find that the pouch is not amenable to revision, then moving the limbs can still provide about 50-55% excess body weight loss. These outcomes are a bit higher when compared to reported national averages. However, there just are not a lot of studies with head-to-head comparisons of the various gastric bypass revisions.
As a certified bariatric surgeon with ASMBS, I report all surgeries and outcomes to the national database. Based on this data, I have found that complication rates are the same, regardless of the surgery (be it a first-time bariatric surgery or revision).
Most importantly, I recommend that all patients seeking a revision do their homework! Ask your surgeon the following questions:
1. What surgeries do you typically perform? Do you offer more than one surgery?
2. Do you perform revision surgery? How many revision surgeries have you performed? What types of revisions do you offer?
3. What does your preoperative workup and postoperative care program entail?
4. How well do your patients do? What are the short and long-term complications you see in your patients?
It is also important to keep in mind that a team approach is going to give patients the very best possibility for long-term success. For example, research has shown that routine follow up with your surgeon and nutritionist can offer the best results. In my practice, having my patients follow up with me not only throughout the first year, but every 6 to 12 months thereafter, allows me to help my patients maintain their long term goals. So….if you have had weight loss surgery and haven’t had the results you expected, or if you are suffering complications, help is out there! Your ‘New You’ is waiting!