After you’ve seen the amazing before and after pictures on ObesityHelp.com, you’ve made the tough decision to pursue weight loss surgery, you’ve gone through the pre-op preparation, endured a life altering surgery, taken time off of work or family responsibilities to recover and shelled out hundreds or thousands of dollars in co-pays or health insurance deductibles, you’ll probably be very eager to see the new body—not to mention the new life—all your effort has brought you. But what if you don’t lose as much weight as you thought you would, or you lose it and gain it all back? It happens. Why? How can you keep it from happening to you?
Denis Halmi, MD, a Center of Excellence Surgeon in practice in Virginia who has performed over 1,500 bariatric surgeries, found to his surprise that he has recently been performing more revisions of surgeries than original surgeries! He wants first-time WLS patients to know some important things about surgery failure and revisions.
The Definition of WLS Success
A successful WLS is a case in which the patient loses 50 percent or more of his or her excess weight and keeps it off. For how long? Well ... forever. “So, at any point, if they regain 50 percent or more of their lost or excess weight, we consider that failed,” Dr. Halmi explains. Forever is a long time, so patients who regain most of their excess weight—even 20 years later—have not ultimately succeeded at their goal and may need a revision.
Reasons for Revision
It’s important that patients understand the reasons for WLS revision. Dr. Halmi says there are two. The first reason is a mechanical issue. “Over time it does happen that the pouch gets too big, or the anastomosis, the connection to the intestine, gets too big.” After doing x-rays or other testing, if the surgeon can identify a specific mechanical problem that can be corrected surgically, a revision can get the weight loss going again.
More commonly, however, the reason for WLS failure is patient eating behavior. As Dr. Halmi points out, “surgery is just a form of forceful behavior modification.” If there is nothing mechanically wrong with the first surgery, and the patient has not lost weight as expected, then eating behavior is probably the reason the surgery is not working. Dr. Halmi says that no matter how drastic the surgery, without patient cooperation, it just won’t work. “We aim to make patients understand that if they failed the first operation because they couldn’t really change enough ... the second surgery is not going to do it.”
That being said, there are times when a patient who has failed with a restrictive surgery (such as gastric banding) can benefit from a malabsorptive revision (such as biliopancreatic diversion), or vice versa. But Dr. Halmi cautions, “These patients need to be very carefully selected, as their success will require extremely strong behavior modification. Otherwise, they could be operated on every other year.” Wouldn’t that be inconvenient for the patient, especially in terms of finances?
The Cost of Revisions
It’s no secret that getting insurance approval for WLS can be challenging, and patients usually are left with some out-of-pocket costs. Dr. Halmi warns that the out-of-pocket price tag on a revision surgery is not simply the cost of surgery number one times two: most insurance companies won’t pay for a second WLS unless there is an obvious medical indication, such as when a band slips. This, again, is a mechanical problem, and the less common reason for a revision. If a patient doesn’t change his or her behavior, the second surgery will likely not be covered by insurance. Plus, Dr. Halmi says that revisional surgery can be more expensive. Generally, it’s a longer operation. Patients may stay longer in the hospital. Sometimes we need to use more equipment, because we need to do several things.” The good news is that surgery grows less and less invasive as time goes on: “transoral plication procedures” or TOPs, as Dr. Halmi has coined them, can be used to repair enlarged pouches and anastomoses through the mouth, without any incisions whatsoever! While a TOP is generally cheaper than laparoscopic surgery, it’s not standard yet, so if you have a second laparoscopic surgery, you would probably pay more for it than even your insurance paid for the first.
So How Can YOU Avoid WLS Failure?
The single most important thing you can do to ensure that your WLS is successful is to be proactive. Primarily, this will mean changing your eating behavior and following your doctor’s instructions for eating, nutrition and exercise. You’ll also do well to research the best doctor you can find, preferably at a Center of Excellence, and be honest with him or her about your habits so that together you can find the surgery that’s right for you. Finally, you’ll want to be aware of the failure rates of the surgery you finally select and the reasons for them, and talk to your doctor now about whether you might need a revision in the future and how you would pay for it.
--Denis J. Halmi, MD is one of the pioneers in the field of weight loss surgery. Currently, Dr. Halmi is the medical director of the Weight Loss Surgery Center at Potomac Hospital.