Revisional Bariatric Surgery

Revisional bariatric surgery is performed to alter or repair a preexisting operation for treatment of morbid obesity. In light of the increasing number of surgical procedures performed, the need to revise/repair operations will likely also increase.

Overview

The concept of revisional bariatric surgery is not new. In fact, the first two operations that were widely performed for treatment of morbid obesity were associated with a high rate of revision. The first, jejunoileal (intestinal) bypass, was associated with a large number of severe and unpredictable nutritional problems and diarrhea. Consequently, many of these procedures were revised or reversed. The second popular operation, stapled gastroplasty (stomach stapling), was associated with many weight loss failures due to both poor design (of the earliest procedures) and the fact that the staples frequently "popped," thus ruining the operation.

The two currently popular procedures, Roux-en-Y gastric bypass and the LapBand, while successful, also require occasional revision. In fact the revision rate for the LapBand is at least 10% during the first two years for either device-related problems or unsatisfactory weight loss. Likewise, the revision rate for gastric bypass is roughly 5-10% over 5 years for either troublesome complications, e.g., ulcer, or unsatisfactory weight loss.

Revisional Bariatric Surgery FAQ

• What are the indications to perform revisional bariatric surgery?
• There are two:
  
  1. Poor weight loss or weight regain;
  2. Complications of the original procedure - these are generally procedure-specific, e.g., ulcers for RY gastric bypass and slippage for the LapBand.

• Who qualifies for revisional bariatric surgery?
• Patients able to demonstrate their complications are usually promptly approved by their insurance carrier due to the medical necessity of their condition. Those with unsatisfactory weight loss may have more difficulty depending upon their insurance carrier. In general, the indications for revisional bariatric surgery mirror those of the primary procedure, i.e., if someone meets the usual weight criteria (100 pounds over ideal weight or significant obesity-related health problems). Many insurance companies require another diet history.

• Does weight regain after a bariatric operation "automatically" qualify a patient for revisional surgery?
• The general answer is no unless the above weight criteria are met. Regaining a small amount of weight is common following all bariatric operations. The key is not to regain too much weight. Certainly if weight control again becomes a problem, patients should seek out their original bariatric surgeon for evaluation.

• What are the results of revisional operations?
• The results can vary widely. In the hands of an experienced bariatric surgeon, the results of operations for complications are generally good. This means that the complication is corrected and the associated problems are resolved. Weight loss following revisional procedures is generally less dramatic than following the primary operation. This is primarily because patients who have revisional surgery for weight loss failure have considerably more difficulty losing weight.
  
  The results also depend on the original bariatric procedure. Many patients who have failed either gastroplasty or LapBand procedures have fairly good weight loss after conversion to Roux-en-Y gastric bypass. Conversely, patients who fail gastric bypass tend to lose less weight following conversion to a more malabsorptive bariatric procedure. Patients who have "popped" their staples usually do well when this situation is repaired.

• What are the risks of revisional procedures?
• Historically, revisional bariatric surgery has been high-risk. Two decades ago, the overall complication rate approached 50% with a mortality rate as high as 5-10% in some published reports. During the past ten years, these results have improved. It is generally acknowledged that revisional bariatric procedures should NOT be performed by general surgeons with no bariatric experience. Several recent publications emphasize the "learning curve" associated with improved outcomes. The best results following revisional bariatric operations are obtained by the most experienced surgeons.

Summary

Revisional bariatric surgery is difficult to perform due to its high complexity and complication rate. However, the outcome of most revisional operations is generally favorable when in the hands of an experienced bariatric surgeon. Furthermore, appropriate selection of patients for revisional operations by an experienced practitioner is more likely to improve the outcome.