Losing Weight With a Bariatric Surgery Revision, Part 2October 21, 2019
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 of each procedure.
The Gastric Band (Lap-Band) 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 five 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 an 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 a revision to sleeve, gastric bypass, or duodenal switch. While up to 28% of patients opt for conversion of the 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 a 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 malabsorption. I recommend that patients who are undergoing a 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 malabsorption. 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. A band to duodenal switch revision surgeries can offer up to 80% excess body weight loss.
The Vertical Sleeve Gastrectomy (VSG) Procedure
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
a staged procedure).
The Vertical Banded Gastroplasty (VBG) Procedure
Stomach stapling (VBG, vertical banded gastroplasty) is a procedure that was commonly performed in the 1980s and 1990s. 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.
The Roux-en-Y Gastric Bypass (RNY) Gastric Bypass Procedure
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 the 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 the creation of a new pouch AND moving the food limb. This combination offers both more restriction and malabsorption. 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 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).
Talk to Your Surgeon About a Bariatric Surgery Revision
Most importantly, I recommend that all patients seeking a revision do their homework! Ask your surgeon the following questions:
- What surgeries do you typically perform? Do you offer more than one surgery?
- Do you perform revision surgery? How many revision surgeries have you performed? What types of revisions do you offer?
- What do your preoperative workup and postoperative care program entail?
- 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!
ABOUT THE AUTHORCharlotte Hodges, MD is a bariatric and general surgeon practicing in Irving, TX bringing her experience and expertise at the New You Bariatric Center. She is known by her patients for her surgical expertise, and as a caring, knowledgeable surgeon with a great bedside manner. She is board-certified by the ASMBS and specializes in advanced laparoscopic procedures. Dr. Hodges has performed more than 3,000 weight loss and general surgeries.
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