Types of Revisional Surgery
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 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
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 pretty meager. Moreover, because the glue alters the tissue where it is 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 4 times with 2 significant complications and virtually NO weight loss. She is now scheduled for a surgical revision.
Banding the Bypass
This is the placement of a laparoscopic adjustable band above the stretched anastomosis. Subsequently, this procedure functions like a primary lap banding 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 and our group 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 is important to know or ascertain why the first operation failed. Did the operation itself breakdown, e.g., 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.
It seems logical that the remedies for this diverse set of problems would be different. Indeed they are. It is therefore important for patients who fail their initial bariatric operation to find a surgeon who is experienced in the treatment of all of the circumstances/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 indicated.
The knowledge and experience of the surgeon selected to perform the revisional procedure is of paramount importance. How many revisions of this type has the surgeon performed? What were the outcomes? In a previous article, the basics of revisional bariatric surgery were reviewed. Because the risks of revisional surgery are higher and the likelihood of a good result are lower in comparison with primary operations, the choosing the right surgeon is at least as important as selecting the appropriate procedure. Don’t hesitate to obtain more than one opinion.
Dr. Robert Brolin has performed nearly 250 revisional bariatric operations during his career spanning three decades, including revisions of gastroplasty (VBG), jejunoileal (intestinal) bypass, Lap Band and several types of gastric bypass. This is one of the largest personal series in the world. His experience includes both open and laparoscopic operations. Dr. Brolin is frequently invited to lecture on this topic at national and international surgical conferences. 
- 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.
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