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Gastric Revision

February 11, 2021

For obese patients, bariatric surgeries are like a dream come true. Pounds (or kgs) of weight seem to drop effortlessly and their health improves dramatically. Bariatric surgeries are proven to have long-lasting and a significant impact on weight loss and have been practiced by surgeons worldwide.

Unfortunately, for some patients the results of these surgeries are short-lived. After certain years of surgery, their weight starts creeping upward and the health concerns associated with obesity also return.

When bariatric surgery fails to offer a long-term result in weight loss, many such patients can get a second chance through bariatric revision procedures.

Depending on the surgery you have undergone, the revision procedure helps to address the inadequate weight loss or weight regain. These procedures also help to address gastric issues associated with bariatric surgeries such as acid reflux or gastroesophageal reflux disease (GERD).

About Gastric Revision Surgery

Gastric revision surgeries are bariatric surgeries performed in patients who have already undergone gastric bypass or gastric band surgery but have failed to achieve weight loss or have had complications.
Most of these gastric revision surgeries are performed laparoscopically. It involves inserting a scope (flexible fiber-optic video camera attached to a narrow tube) and other instruments needed to perform the surgery through small incisions (new or previous) in the abdomen. Once the procedure is complete all incisions are closed using absorbable sutures.

Indications for Gastric Revision Surgeries

The prime reason for gastric revision surgery is insufficient weight loss after the first surgery. Other possible reasons for a gastric revision surgery include:
  1. Anatomic changes due to weight loss surgery such as:
    • An enlarged gastric pouch opening
    • A slipped gastric band
    • Leaking staple lines
    • Band intolerance
    • Formation of an opening (or fistula) between the stomach pouch and bypassed stomach
    • Esophageal dilation
  2. Medical complications, including:
    • Ulcers that cause pain, blood loss, nausea, and vomiting
    • Scar tissue (stricture) that can build up in the digestive tract
    • Food intolerance
    • Infection through band or port
    • Malabsorption syndrome due to inadequate absorption of essential nutrients
    • Metabolic bone disease or osteoporosis
    • Anemia
    • Bowel function complications
  3. Unresolved comorbidities associated with obesity, such as:
    • High blood pressure
    • Heart disease
    • Diabetes
    • Respiratory problems
    • Vascular problems
    • Genitourinary problems

Types of Gastric Revision Surgery

Depending on the indications for revision and the primary surgery performed, there are mainly three types of gastric revision surgery:
  1. Gastric band revision : Gastric band surgery is a minimally invasive procedure which reduces the size of the stomach by placing a silicone band around the upper portion of the stomach laparoscopically (through small incisions made) and thereby reduces the amount of food it can hold.
    Gastric band revision surgery is for people who experience lap band failure or complications due to gastric band such as nausea, vomiting, band erosion where the removal of the lap band is highly recommended. During the revision procedure, the gastric band is either adjusted by tightening or loosening the band or by removing it. However, after removal of gastric band, your stomach will regain its original size and shape. In such cases, other bariatric procedures like sleeve gastrectomy or gastric bypass are recommended to help with further weight loss.
  2. Gastric bypass revision : Gastric bypass surgery is the procedure in which the size of the stomach is reduced and a part of small intestine is bypassed so that digestion process is altered and less food is consumed and absorbed.
    Gastric bypass revision is recommended for patients who have received a gastric bypass surgery and are experiencing some medical complications, or are gaining weight or not losing weight. Bariatric surgeon will also recommend bypass revision surgery, if the patient has developed an enlarged stomach pouch that causes overeating. During the procedure, the gastric outlet (connection between the stomach and small bowel) is reduced by its size. To achieve this, surgeon will suture the enlarged gastric pouch to make it smaller. This will delay food processing and keep the patient feeling full for a longer period of time.
  3. Gastric sleeve revision : Sleeve gastrectomy, also called as vertical sleeve gastrectomy is a surgical procedure which permanently reduces the size of your stomach and will restrict your food intake.
    If the stomach pouch or sleeve has been stretched or if the patient experiences any medical complications due to the prior surgery, a gastric sleeve revision surgery can be performed. During the procedure, the gastric sleeve is repaired or will shrink the gastric pouch. This surgery will eliminate the extra volume of the stomach in the same way as the initial gastric sleeve surgery.

Patient Criteria for Gastric Revision

Revision surgeries are very specialized treatment processes and have its own complications. Hence gastric revision surgeries are only recommended for those patients who:
  • have an unsuccessful history of any bariatric surgery
  • have a body mass index (BMI) of 35 or above; or you have a BMI score 30 with one or more obesity-related comorbidities.
Before any gastric revision procedure, the patient will be examined by the bariatric surgeon to determine the cause of failure and to evaluate for the appropriate treatment options. Surgeon will recommend bariatric revision surgery only when the post-operative weight loss failure is due to a problem with the original surgery and not because of the patient’s inability to follow the necessary dietary and lifestyle guidelines. In addition to the general medical examination, some diagnostic tests are also performed to check whether the patient has unresolved comorbidities that may improve with revision surgery.

Recovery Time for Gastric Revision Surgery

Gastric revision surgeries usually take a day or so longer than the original surgery. This is because revision procedures involve dealing with scar tissue, and altered blood supply. You may also have to stay in hospital for two to three days for monitoring. Most patients can resume their normal schedules in a couple of weeks.

Risks and Complications Associated With Gastric Revision Surgery

Laparoscopic revision surgery generally has fewer short-term risks than traditional open surgery. But compared to the previous bariatric procedure, revision surgeries have the risk of:
  • Longer surgery time
  • Large incisions
  • Blood loss
  • Infection
  • Leaks
  • Anesthetic reactions

Benefits of Gastric Revision Surgery

Gastric revision surgeries will offer the following benefits:
  • gives patient a chance to get rid of the weight they expected to lose.
  • gives a chance to resolve obesity-related comorbidities.
  • helps with medical complications associated with the first procedure, such as ulcers, scar tissues and inadequate absorption of essential nutrients.
  • control the desire to eat more and hunger sensation.

Outlook

Gastric revision surgeries are successful in resolving the associated problems and promoting further weight loss, although the results can vary from person to person. The results obtained are also based on the original procedure and the reason for the revision. Before considering revision, it is important to maintain a healthy lifestyle including life-long behavioral changes such as eating less food and fewer calories, making healthy food choices, eating very small meals, taking vitamin and mineral supplements as prescribed, exercising regularly, and getting regular medical checkups.

References :

  1. Frantzides CT, Alexander B, Frantzides AT. Laparoscopic Revision of Failed Bariatric Procedures. JSLS. 2019;23(1):e2018.00074.
  2. Systematic review on reoperative bariatric surgery. https://asmbs.org/app/uploads/2015/10/Revision-Brethauer-Paper.pdf . Accessed on: 02-10-2020.
  3. Gastric Bypass Revision. http://surgery.ucla.edu/bariatrics-gastric-bypass-revision . Accessed on: 02-10-2020.
  4. When to Revise a Weight Loss Surgery. https://columbiasurgery.org/news/2017/08/14/when-revise-weight-loss-surgery . Accessed on: 02-10-2020.
  5. Revision surgery: What is it and why would I need it after bariatric surgery?. https://www.multicare.org/happy-back/blog/revision-surgery-what-is-it-why-need-after-bariatric/ . Accessed on: 02-10-2020.
  6. Park JY, Song D, Kim YJ. Causes and outcomes of revisional bariatric surgery: initial experience at a single center. Ann Surg Treat Res. 2014;86(6):295-301.
  7. Bariatric Revision Surgery. https://www.bcm.edu/healthcare/specialties/weight-loss-and-metabolic-center/bariatric-revision . Accessed on: 02-10-2020.

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