Revisional Bariatric Surgery

Some patients who have undergone a previous surgical procedure for obesity may desire to have their surgery revised or ‘fixed’.  Reasons may include the following:

• weight regain
• inadequate weight loss
• poor tolerance of solid food
• persistent vomiting
• gastroesophageal reflux, ulcers, or other problems

Revisional bariatric surgery is complicated and should only be undertaken after evaluating the risks and benefits. Not every patient with poor weight loss after bariatric surgery is a candidate for revisional surgery.

All patients being evaluated for a revision of bariatric surgery will need to have the following information/evaluations:

• original operative reports (if possible)
• upper GI X-ray series (at West Penn Hospital) – we will set this up
• upper endoscopy (at West Penn Hospital) – we will set this up
• evaluation by our bariatric team
• food diary compliance

Three types of revision surgery may be performed, as described below.

Revision of vertical-banded gastroplasty (VBG) to Roux-en Y gastric bypass (RYGB)

Vertical banded gastroplasty (VBG) is referred to by many patients as ‘stomach stapling”.  Although VBG was often performed in the 1980s and 1990s for the treatment of severe obesity, this procedure has largely been abandoned in the United States in favor of other operations. It has been reported that after VBG, up to 80% of patients have poor long-term (10 year) results, including the following:

• poor weight loss
• high rate of blockage of the banded pouch
• tendency to adopt a high-calorie, sweet-liquid diet that leads to poor nutrition and regaining of weight

Indications for Revision of VBG to Roux-en Y gastric bypass (RYGB):

Revision of VBG to RYGB should be considered if a patient has any of the following conditions or complications:

• Poor weight loss or weight regain
• Symptoms due to the banded portion of stomach
• Solid food intolerance (protein, vegetables)
• Frequent vomiting
• Protein malnutrition
• Gastroesophageal reflux symptoms and complications
• Band erosion

Laparoscopic (minimally invasive) revision of VBG to Roux-en-Y gastric bypass is possible. As of March 2007, we have performed 55 revisions of VBG to Roux-en Y gastric bypass laparoscopically.

Revising VBG to gastric bypass is a longer operative procedure due to the previous scar tissue. The hospital stay is usually 2 days. A temporary drain (plastic tube) is placed at the time of surgery and patients are discharged to home with this in place. The drain is usually removed 7-10 days later. There is also a small chance that a temporary feeding tube may be placed into the bypassed portion of stomach at the time of surgery.

The improvement that can be expected in obesity-related health problems after this type of revision surgery is similar to the improvement that can be expected after initial gastric bypass:

• Most patients have an improvement or resolution of their diabetes, high blood pressure, and sleep apnea.
• Patients are able to tolerate protein and solid food better than with the vertical banded gastroplasty. 
• Weight loss is usually 50% to 80% of excess weight.

There is a slightly higher risk of complications (leak, stenosis, abscess) when RYGB is performed as a revision (second) versus the first weight-loss surgery, because of scar tissue from the previous operation. These complications are usually managed by keeping the drain in place (for leaks), and stretching the stricture with upper endoscopy balloon dilatation.

Patients need to be compliant with diet and follow-up appointments with us to have long-term success.

Follow-up care with or without revision surgery after previous gastric bypass

Patients who have undergone gastric bypass surgery elsewhere are welcome to receive follow-up care in our program. Some patients can be helped by just having guidance and involvement in our organized bariatric program. Some patients may need surgical help to fix a problem or to help with their weight.

Weight loss after a primary gastric bypass operation usually ranges from 60% to 85% of excess body weight at 12 to 18 months postoperatively.  Follow-up care is important because of the following:

• Approximately 10% to 15% of patients who undergo a gastric bypass procedure will fail to achieve ‘adequate’ weight loss of 50% of their excess weight, although obesity-related health problems (diabetes, blood pressure, sleep apnea) usually improve.
• Patients may gain weight after the first year and at 5-10 years after surgery, average excess weight loss ranges from 50% to 60%.
• Most often this weight gain is due to poor patient compliance with diet, behavioral changes, or lack of exercise.
• It is recommended that patients begin by keeping a food diary, limit their portion sizes, and make better food choices (avoiding carbohydrates, avoiding “grazing”).
• An exercise program and behavioral awareness of eating habits are also important.

For some patients with weight gain after gastric bypass, revisional surgery may be able to fix a ‘technical’ problem. There may be a connection from the small gastric pouch to the ‘old’ bypassed portion of stomach. This is called a gastro-gastric fistula. This can be evaluated and detected by upper GI X-rays and endoscopy. This problem can also lead to ulcer disease and should be repaired by surgery. The weight loss result of these technical problems tends to be good.

Patients with an enlarged pouch or a wide gastric pouch-small bowel connection (gastro-jejunal anastomosis or connection) may be able to eat more than they should at meal time. Unfortunately, there are few options presently available to help fix this. Patients sometimes want surgery “to make my gastric pouch smaller”. Surgery may be of help, but health insurance companies may not approve revision surgery and thus will not cover its costs. Patients need to be extremely compliant with their preoperative evaluation to even hope for approval through their insurance company. The surgical results of weight loss after these revisions are not always good, and only occur if the patient is extremely compliant with the diet and behavioral changes required after surgery.

Some patients expect the gastric bypass surgery “to do all the work” of weight loss, without changing their behavior or eating habits. Patients have requested “bypassing more bowel” to increase the malabsorption part of the procedure. The weight loss results of this revision surgery are usually not good, and there is an increased risk of severe nutritional problems. Patients will have to adjust their diet habits and lifestyle in order to achieve more weight loss. Further surgery of this type does not usually help with additional weight loss.

Often, with proper guidance from our bariatric team and patient compliance with our recommendations, patients can achieve further weight loss without additional surgery – but hard work and discipline are required.

Revision of laparoscopic adjustable band surgery

The laparoscopic adjustable band is a restrictive surgical weight loss procedure. The weight loss achieved with the band is, on average, not as much as seen with a gastric bypass procedure. This can be upsetting to patients who were expecting to lose more weight.

Complications of laparoscopic gastric banding that may require revision include the following:

• band slippage
• early pouch dilation
• perforation
• infection of the port or band
• erosion of the band
• problems with the band

Some of these complications can be addressed while leaving the band in place.

Some adjustable bands may need to be removed and a gastric bypass procedure performed.