What to Expect from a Lap-Band Revision to VSG, RNY, or DSJanuary 16, 2017
Tens of thousands of people have had success losing weight and improving their health with a laparoscopic adjustable gastric band (lap-band). For those who haven’t met their weight loss goals, or who have had a band-related complication, a revision is an option: conversion to a vertical sleeve gastrectomy (VSG), Roux-en-Y gastric bypass (RYGB), or duodenal switch (DS).
The lap-band is a great choice for many people struggling with obesity and willing to stick to its associated dietary and lifestyle modifications. In particular, for patients who maintain long-term follow-up with their specialized bariatric team, the lap-band has been shown to result in long-term, durable weight loss rates similar to those of the Roux-en-Y gastric bypass . Current surgical techniques for placement of the modern lap-band have evolved to minimize the risk of a complication that might require re-operation. Despite our best efforts, however, some may find that their weight loss is inadequate, they regain weight, complications arise, or simply that “the band is not for me.” Whatever the reason, there are people for whom this operation is not ideal and the device must be removed.
It is important to note that removal of the band does not mean the end of the weight loss journey — it means another path must be taken. Revisional bariatric surgery procedures are thus indicated in instances of complication or failure of adequate weight loss despite conservative measures.
Most people who have the lap-band removed will not lose weight meaningfully without an alternative procedure. In recent years there has been increasing consensus that the gastric bypass is the procedure of choice in people undergoing revisional bariatric surgery following a lap-band (a primary restrictive surgery). However, the decision to undergo revision to either VSG, RYGB, or DS should be made in concert with your surgeon, and with a good understanding of what to expect post-operatively.
Preoperative workup for all procedures is essentially the same, and very similar to what patients have already undergone in preparation for lap-band surgery. Many surgeons will deflate the band entirely one month before surgery, particularly if there is documented slippage of the band, or symptoms such as difficulty swallowing, frequent vomiting, or severe reflux. Our practice is to have an upper endoscopy performed to evaluate the esophagus and stomach lining for irritation, ulcers, or other conditions that might affect surgical outcomes. Finally, a liquid diet is recommended two weeks preoperatively in order to shrink the liver and make surgical exploration easier.
One-Stage or Two-Stage Procedure
In all cases, the lap-band, port, and tubing are entirely removed and any scar tissue carefully removed. Revisions can be safely accomplished in one-stage, where the band is removed and the sleeve, bypass, or duodenal switch performed at the same time, under general anesthesia. There are some instances requiring two-stages, in which the band is removed first and then, several weeks to months later, the next bariatric procedure is done. This is primarily the case when a lot of scar tissue is encountered, or there is significant stomach swelling or deformity after a longstanding band slip or erosion. The two-stage procedure allows for healing of scarred or abnormal tissue, and can make the revision somewhat less technically challenging. Some surgeons will simply prefer the two-stage procedure for all cases.
Lap-Band Revision to Sleeve Gastrectomy (VSG)
While primarily a restrictive surgery (just like the lap-band), the sleeve gastrectomy involves removing about 70-80% of the existing stomach and sealing it closed with a specialized stapling device. Furthermore, studies have shown that the VSG also results in a decrease in the amount of hunger hormone produced (called ghrelin), thereby reducing appetite and increasing the feeling of satiety between meals. The main risks of the surgery include bleeding, infection, and leak of the stapled stomach. There is also a small risk of stenosis, or abnormal narrowing, of the stomach due to scar tissue from prior surgery. Because the stomach is inherently such a stretchy organ, there is also the real risk of developing an enlarged stomach over time, especially if eating large meals, leading to weight regain.
Many patients prefer the VSG because it does not involve rearrangement of intestine, and there is no malabsorptive component of the procedure. The risk of long-term nutritional deficiencies is quite low, and supplementation of iron or B-vitamins, if necessary, is straightforward. However, patients for whom the lap-band has failed to help with weight loss — in particular, those who “cheat” the band by eating high-calorie, high-carb foods and drinks — are susceptible to the same problems with the sleeve. Milkshakes will go down easily, but they aren’t part of a low-calorie, healthy diet! Furthermore, the stomach will stretch over time to accommodate large meals. The risk of weight regain is real when replacing a restrictive device (the lap-band) with a procedure that acts effectively the same way (the VSG).
Lap-Band Revision to Gastric Bypass (RNY)
For patients who have been unsuccessful at losing significant weight with the lap-band, conversion to a gastric bypass is an excellent option. This type of revisional surgery has been widely studied and, in experienced hands, is safe and effective. The surgery involves cutting the stomach in order to make a much smaller stomach “pouch” about 25 milliliters in volume, as well as re-routing the small intestine in order to bypass around 100-150 centimeters. There is therefore a restrictive component, in that the stomach pouch can only handle small volumes of food, as well a malabsorptive component, in that food bypasses much of the small intestine, resulting in absorption of fewer calories and nutrients. Risks of this surgery are similar to those for VSG — including bleeding, infection, and leak.
There is also a higher risk for nutritional deficiencies that require lifelong supplementation and monitoring via blood tests. Deficiencies can occur with fat-soluble vitamins, B-vitamins, calcium, and some other minerals. Anemia may also occur. All can be corrected with oral supplements if detected early.
Lap-Band Revision to Duodenal Switch (DS)
Conversion to a duodenal switch procedure is an alternative to the gastric bypass for the super-obese patient (BMI>50). A greater segment of the small intestine is bypassed, resulting in greater malabsorption. This results in significant, sustained weight loss for most patients, however, the risk of nutritional deficiencies is higher and can be more severe. Protein-calorie malnutrition and mineral deficiencies can have severe physiologic effects. Strict adherence to appropriate diet and supplements is crucial, as is regular monitoring of blood tests.
Key Points to Maximize Success
The bottom line is that revisional surgery after gastric banding is safe and effective. For patients, there are several key points to help maximize success:
- Don’t give up if the band doesn’t work out. For most patients, revisional surgery will lead to sustained weight loss, improvement in associated medical problems, and better quality of life.
- Be well-prepared. Understand what the surgery will change about you anatomically and physiologically, and be prepared for what to expect post-operatively. Always ask questions of your provider!
- Choose an experienced surgeon with whom you are comfortable, and develop a good relationship with the entire surgical team and staff. There will be bumps along the way after surgery, and having a dependable team that knows you well will make the journey easier.
- Be prepared to make a life-long commitment. Close follow-up, even years after surgery, is crucial to staying healthy and maintaining weight loss. Remember, for some of these surgeries, you will need vitamin and mineral supplements for the rest of your life, as well as regular check-ups and blood tests.
- Stick to good habits. Bariatric surgery is a tool in achieving good health. Maintaining good health requires a lifetime of mindful eating and daily physical activity.
- Don’t underestimate the power of support. Friends, family, dietitians, doctors, nurses, and mental health professionals are wonderful and necessary resources in your weight loss journey. Ask for help, and you will receive it!
 O’Brien PE et al. Ann Surg. 2013 Jan;257(1):87-94.
ABOUT THE AUTHORDr. Andrea S. Bedrosian is an assistant professor of surgery at NYU Langone Medical Center and a member of the NYU Weight Management Program. Dr. Bedrosian is actively involved in bariatric surgery research. She is also devoted to resident surgical education and making sure that the next generation of surgeons is even better trained than the last. She believes in approaching each patient as a whole person, and that a medical problem is much more than a solitary physiologic issue.