Weight Loss Surgery – When is it time to consider a Revision?
By George R. Merriman II, MD, FACS, FASMBS
What is Bariatric Revision Surgery?
A bariatric “revisional” surgery is a procedure correcting a complication of a prior bariatric weight loss surgery and/or modifying a prior bariatric surgery to reestablish its effectiveness as a metabolic and weight loss tool.
What kind of complications would require this surgery?
In general, a revision is considered for a patient when there has been either a clinical failure and/or a technical failure of the original surgery. The complications are specific to each surgery, and the list is too long to be complete. An example of a technical failure would be repair of a staple line failure after Gastric Bypass, revision of a dilated Sleeve Gastrectomy, or removal and replacement of a malfunctioning component of a Lap-Band. An example of a complication generic to all surgeries would be problems resulting from scar tissue and adhesions from the primary surgery.
Could you explain what a clinical failure of weight loss surgery is and why a patient might have one?
A clinical failure of a weight loss surgery is an inadequate resolution of weight related health problems, which are almost always associated with an inadequate weight loss. Simply put, the particular surgery, wasn’t a powerful enough intervention to overcome the severity of the individual’s disease or the patient was not able to adopt and maintain the profound behavioral changes necessary to achieve and sustain success. The later issue is usually the result of inadequate teaching and training of the patient, which is a problem with the post-surgical support program, not the patient. What this means is most revisions for clinical failure are done to increase the power of the original surgical procedure.
What is the most common bariatric revision surgery you do?
The most common revision we see today is Lap-Band to Sleeve Gastrectomy revision. This involves removal of an unsuccessful or complicated Lap-Band and creation of a Vertical Sleeve Gastrectomy. The need for this type of revision surgery may be due to either a clinical failure, which would demonstrate itself as inadequate weight loss or inadequate resolution of weight related serious health issues, called comorbidities or a technical failure wherein the patient has been clinically successful but has had a complication with the Lap-Band that requires removal. This patient will still require a successful weight loss surgery to continue an uninterrupted successful outcome, thus making the revision necessary.
What are some other examples of revision surgery?
I want to preface this by saying that the answer is technically too detailed and for the reader to not worry about fully understanding these details at this point. Another good example of revision for a clinical failure is what we call “Band over Bypass.” This revision is the placement of a Lap-Band around the small stomach previously created by a Gastric Bypass that has clinically failed. The added power of the Lap-Band helps this individual re-achieve his/her prior success. Another example of a technical revision is what we call a “Re-Sleeve.” This patient has had a failure due to the dilation of their remnant stomach, which results in significant complications including weight regain. By recreating the small size of the remnant stomach, we reestablish the successful power of the original Sleeve Gastrectomy.
How common is the need for revision of prior weight loss surgery?
Thankfully, the incidence of technical failures requiring revision surgery is very low. This is a testament to how good a job we have done in bariatric surgery to standardize these procedures. The frequency of revisions for clinical failure is actually growing but not for the reasons one might think. As we understand more and more about the disease of morbid obesity, we appreciate how it is truly a chronic illness and therefore incurable at this juncture. Some individuals’ diseases progress as they age or other external stressful life events amplify their problem. We now have more tools in our toolkit to surgically enhance a previously successful weight loss surgery that has been diminished by these external events and that’s a good thing.
What advice would you patients who think they might need a revision to their weight loss surgery?
The first thing is they definitely need their situation evaluated. The second thing is that the evaluation needs to be performed by not only a very experienced, ASMBS certified bariatric surgeon but also one who has significant experience in evaluating and performing revision surgeries. Even though the risks of complications are low in the hands of a surgeon experienced in revision surgery, these risks are higher than with the primary or original surgery.
For more information on revisions of weight loss surgery, please visit FreedomFromObesity.com or call (318) 222-4282. For information on ASMBS visit ASMBS.org.