More than two decades ago, bariatric surgeons performed a variety of surgical procedures that focused on making gastrojejunostomy anastomosis (stoma) smaller in patients who regained weight after gastric bypass. Virtually all of these operations failed to produce much weight loss.
During the past two years, a number of new minimally invasive methods for revising bariatric operations laparoscopically have come onto the scene. Several of these are focused on making the gastrojejunostomy opening (anastomosis) smaller in patients who either have regained weight or did not achieve satisfactory weight loss after their first gastric bypass. Although the risks associated with the new techniques are quite low, preliminary weight loss results are similar to those of the operations performed 20 years ago. A critique of these new approaches is found below.
Sclerotherapy is injection of a glue-like substance via an endoscope in and around the stretched anastomosis to make it smaller.
Although sclerotherapy may accomplish the intended purpose, there is very little evidence that this approach is effective. Weight loss in most patients who have had this procedure is meager. Moreover, because the glue alters the tissue where it’s injected, subsequent surgical revision is likely to be more hazardous.
Endoscopic/Endoluminal Suture Plication
This refers to the narrowing of the circumference/size of the stretched anastomosis using either sutures or metal fasteners which are placed through an endoscope.
Although plication accomplishes its intended purpose, the preliminary reports of subsequent weight loss are unimpressive. Moreover, the “bariatric” qualifications of some physicians who perform this procedure are not well established. I was recently referred a patient who had this done four times with two significant complications and virtually NO weight loss.
Banding the Bypass
This is the placement of a laparoscopic adjustable band above the stretched anastomosis/stoma. Subsequently, this procedure functions like a primary LAP-BAND operation.
The first report of this approach in eight patients was very positive in that all of the patients lost a substantial amount of weight1. Other bariatric surgeons including our group at NJ Bariatrics have subsequently performed this operation in a few patients with mixed results, i.e., some of our patients experienced satisfactory weight loss while others did not. These mixed results have led us to more closely examine the eating behavior of our patients prior to recommending this procedure.
Selecting the Right Operation
Choosing the appropriate revisional procedure is probably more important than selecting the first bariatric operation. This is because it’s crucial to know or ascertain why the first operation failed.
Did the operation itself breakdown? e.g., A ruptured band or displaced port with a LAP-BAND or disruption of staples or stretching of the pouch and/or outlet stoma with RY gastric bypass.
Conversely, some patients fail to lose enough weight with an anatomically intact operation. This suggests that the patient somehow “out ate” their operation.
Selecting the Right Surgeon
It seems logical that the remedies for this diverse set of problems would be different. Indeed, they are. Therefore, if you’ve failed your initial bariatric operation, it’s important to find a surgeon who’s experienced in the treatment of all of the circumstances and conditions that result in failure.
Each patient who presents as a candidate for revisional bariatric surgery should be evaluated individually since no two cases are identical. Such evaluations should have a multidisciplinary flavor, including nutritional, radiologic and endoscopic evaluations. Occasionally evaluation by a psychologist or others medical specialists is recommended.
Experience Makes All the Difference
The knowledge and experience of the surgeon selected to perform the revisional procedure is of paramount importance. Consider these questions:
- How many revisions of this type has the surgeon performed?
- What were the outcomes of those revisional surgeries?
Because the risks of revisional surgery are higher and the likelihood of a good result are lower in comparison with primary operations, choosing the right surgeon is at least as important as selecting the appropriate procedure. Don’t hesitate to obtain more than one opinion.
A Revisional Bariatric Surgery Specialist
We encourage you to do your homework and compare different local surgeons. However, if you’re looking for a specialist to do your revision, Dr. Robert Brolin is quite possibly the most experienced bariatric surgeon you’ll find.
Dr. Brolin has performed more than 300 revisional bariatric operations during his 30+ year career, including revisions of gastroplasty (VBG), jejunoileal (intestinal) bypass, LAP-BAND and several types of gastric bypass. He has one of the largest personal series in the world. His experience includes both open and laparoscopic operations. Additionally, Dr. Brolin is frequently invited to lecture on this topic at national and international surgical conferences.
As one of the few revisional bariatric surgery specialists in the United States, it’s quite common for Dr. Brolin to perform revisional surgery on patients who did not have their original surgery with him.
If you’re considering revisional bariatric surgery, we can help you get started.
- Bessler M, Doud A, DiGiorgi MF, et al. Adjustable gastric banding as a revisional bariatric procedure after failed gastric bypass. Obes Surg 2005; 15:1443-1448.