Revisional bariatric surgery comprises around 10 to 15 percent of the operations performed in most experienced bariatric centers of excellence.

If you had bariatric surgery and for some reason, you are contemplating revisional bariatric surgery continue reading because I will give you all the information required to decide if a revision is indicated or necessary.

Demand for Revisional Bariatric Surgery

With the increase in the number of bariatric operations done in the last several years in the United States of America, it is inevitable that more revisional bariatric surgery will be needed.

The number of trained bariatric surgeons that are highly skilled to perform these procedures is low throughout this country.  The number is even smaller if you are looking for laparoscopic or minimally invasive surgeons.

This is of vital importance since revisional bariatric surgery is technically difficult and may result in relatively higher morbidity and mortality when compared to primary bariatric surgery.

It is my recommendation that if you decide to undergo revisional bariatric surgery, you do extensive research about your surgical options and the surgeons in your area.

 Indications for Revisional Bariatric Surgery

Many bariatric procedures have been described throughout the years and some of these procedures are no longer performed.  The indications for revisions can be many and they vary depending on the primary procedure.

Below is a list of some of the most common reasons why patients might need a revision. The list below is for educational purposes only and just because you experience one or more of the below-mentioned problems doesn’t mean that you need a revision.

You need to discuss your particular situation with your doctor or surgeon.

• Inadequate weight loss
• Weight regain
• Stomal or anastomotic stricture (narrowing)
• Dysphagia (difficulty swallowing)
• Frequent vomiting
• Abdominal pain
• Stomach ulcers
• Gastrointestinal reflux or bile reflux
• Gastric or esophageal dilation (enlargement)
• Band erosion
• Band slippage or prolapse
• Gastro-gastric fistula
• Internal hernias or bowel obstruction

Things to Consider Before a Revision

As I already mentioned above, revisions have a higher risk of complications.

In some cases, it is twice as much risk.  If you go to a bariatric center of excellence for consultation, consider asking your surgeon or the bariatric coordinator what is their complication rate after revisional bariatric surgery at that institution.

It is a requirement by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) that these numbers are tracked and that the information is easily available.

It is your obligation to ask…

Most likely you will require several diagnostic tests or procedures prior to any intervention.  If you had any recent tests related to your bariatric surgery and the current issues, get copies of the results.  Get a disk with the x-rays, bring the pictures of the endoscopy, and bring the operative note of your primary bariatric surgery.  The surgeon will extremely appreciate your initiative and commitment to your own health.

I will ask you for them so mind as well get them before you come to see me.

Some surgeons might require another psychological and nutritional evaluation.  Others might want you to lose some weight prior to any surgery to test your level of commitment.

If you are over 50 years of age and never had a colonoscopy or you are due for one, get that schedule or ask your primary care doctor to help you arrange it.  If you are going to undergo a major intra-abdominal operation you want to make sure no lesions are present in the colon that should be taking care of.

What About Weight Loss After a Revision

Now let’s talk about the weight loss after revisional bariatric surgery. It is well documented in the surgical literature that bariatric surgery revisions produce less overall weight loss than a similar primary procedure.

For example, lets assumed that you underwent a gastric bypass 15 years ago and your overall weight loss was 70% of your excess body weight (EBW).  In the last several years you managed to regain all your weight back because of overeating and now you have a pouch dilation. A bypass revision was performed and now you are disappointed because your weight loss is not as fast and the overall weight loss is only 50 percent of the EBW.

The above scenario is very common. The body has adjusted to your prior surgery and the effect of the revision is not as pronounced.  You will lose weight after the revision but you cannot expect to be as pronounced as the primary procedure.

Notice that above I mentioned weight loss in similar procedures like “bypass after bypass” or Duodenal switch after bypass”.

Now let us look at another scenario.  

Lets assumed you had a lap band and you failed to lose a significant amount of weight. Your surgeon now removes the band and converts it to a gastric bypass.  In this scenario most likely your weight loss will be higher on the secondary procedure. A gastric bypass is a more aggressive surgery than a band placement.

Every patient situation is different, so make sure you have this discussion with your surgeon so you can have realistic expectations before you put yourself through revisional bariatric surgery.

Revision of Vertical Banded Gastroplasty or VBG

A Vertical Banded Gastroplasty was a very common bariatric procedure done in the 80’s and ’90s.  Many of the patients that underwent a VBG are now having a variety of side effects.

Most patients developed dysphagia, weight regain, frequent vomiting, band erosion, stomal stenosis, and reflux.  The vast majority of these surgeries were done through a large abdominal incision that just by itself can cause complications like adhesions and hernias.  

Open surgery also makes revisions more challenging.

The revision of choice tends to be a Roux en Y gastric bypass but I have performed sleeve gastrectomies or complete reversals in very selective cases.

It is my preference to do these procedures laparoscopically, even if the initial surgery was done using an open approach.  I have done a large number of VBG revisions with great outcomes, lower morbidity, and no mortality.

If you had a vertical banded gastroplasty and now you have complications from that surgery please look for help.  Most likely your frequent vomiting or reflux has a solution.

I enjoy doing this type of revision because the patient’s symptoms will improve significantly right after surgery.

 Read Kim Womack’s story, one of my patients that underwent a VBG conversion to a sleeve gastrectomy. CLICK HERE 

Laparoscopic Adjustable Gastric Band or Lap Band Revision

The laparoscopic adjustable gastric band or better known as the Lap-Band was very popular back in 2010.  Thousands of bands have been placed and hundreds continue to be placed but the popularity has dramatically decreased because of long term issues, weight regain or weight loss failure.

Even though the Lap-Band surgery has a very low initial risk, the risk of requiring a revision is significantly higher.  Many patients are seeking band removal or revisions due to reflux, difficulty swallowing, esophageal dilation, weight regain,  band erosion, or slippage.

Because the Lap-Band surgery is completely reversible, patients have many options for revision.  Band removal followed by gastric bypass, sleeve gastrectomy, or duodenal switch are all viable options.

Some surgeons will do the band revisions as a one-stage surgery, others will only do them as a two-stage procedure.  I make the decision base on each specific case. If the removal was simple and the tissues are healthy I will do a single-stage surgery.  

It is important that patients understand that revision surgery has a higher complication rate and a higher risk of leaks and other morbidities.

Sleeve Gastrectomy or Gastric Sleeve Revision

The Sleeve Gastrectomy in the early days was used as a two-stage procedure for the super-obese patients.  Most patients underwent a revision to bypass or duodenal switch as the second stage of their weight loss journey.

 Currently, the gastric sleeve is done as a single-stage surgery using the standard criteria for weight loss surgery.

Most of the sleeve gastrectomy revisions are done for significant reflux, not enough weight loss, or for weight regain. Another common reason is difficulty swallowing.

Let’s discuss the reflux issue first.  

One of the relative contraindications for a sleeve gastrectomy is severe acid reflux.  If before surgery you had bad reflux, you have a good chance that the reflux will get worse after a sleeve.  Other patients will develop esophageal reflux after the sleeve that does not resolve with medications requiring surgery.

The normal anti-reflux procedures are not possible after a sleeve because most of the fundus of the stomach is gone, so the alternatives are limited to the Stretta endoscopic procedure, Linx procedure (see acid reflux post on my blog for more details) and conversion to Roux en Y gastric bypass.  If more weight loss is desire then a Roux en Y gastric bypass is the best option.

The sleeve gastrectomy offers 60-70% excess body weight loss but some patients will fail to achieve the weight loss target. In particular older patients with poor exercise tolerance or mobility limitations.  A sleeve could be converted to a bypass or a duodenal switch to promote more weight loss.

In the case of weight regained after a sleeve gastrectomy revisional bariatric surgery can be performed but in my opinion, this issue is a lack of discipline more than a surgical issue.  I will discuss this further below.

Gastric Bypass or Roux en Y Gastric Bypass Revision

The gastric bypass surgery has been done for over 25 years now. What that means is that many patients will need a revision of some kind for many reasons.

Surgeons will see patients with internal hernias, marginal ulcers, anastomotic strictures, pouch dilations, bowel obstruction, gastro-gastric fistulas or weight regained just to mentioned a few.  We won’t go over all of the issues in this post but I will give you a quick overview of the types of revisions I will do in patients with previous Roux en Y gastric bypass surgery.

If you have a mechanical issue after your bypass I am more willing to perform a bypass revision than if your only issue is the weight regain.

Revising a gastric bypass is not an easy operation and it is high-risk surgery. Just because your initial surgery went without any hiccups doesn’t mean that the revision will be the same. I see many patients that come to me for a revision thinking that it will be just like the first time or thinking that they will lose as much weight as before.

If you did very well after your initial bypass and then you went back to your old bad eating habits and regained all your weight, then a revision, in my opinion, is not the answer.  You need to dig deeper and figure out what failed.  

What are you doing now that you were not doing before? Are you eating a lot of “CARBage”?

Count your calories, see what your eating, and how much. What about physical activity, are you exercising, or are you in the comfort zone.

If you developed a marginal ulcer that is not healing or is causing pain, a revision can be indicated.  Internal hernias usually present as an emergency and most of the time they require surgery.  During surgery for an internal hernia, a bypass revision might not be needed and only a reduction of the hernia is necessary in some cases.

Anastomotic strictures are commonly seen and usually serial endoscopic balloon dilations will fix the problem.  If serial dilations are not fixing the problem then revision of the anastomosis will be needed.

Mini Gastric Bypass Revision

The Mini Gastric Bypass was developed in the late 1990s as another alternative to a Roux en Y gastric bypass.  The mini-gastric bypass is not as popular but many patients have undergone this procedure.

The most common long term complication after this surgery is bilious gastritis or bilious esophageal reflux. The best way to divert the bile away from the gastric pouch is by converting the mini gastric bypass to a Roux en Y gastric bypass.

Laparoscopic Versus Open Revisions

In my hands, most revisions are done laparoscopically. Even if your primary bariatric surgery was done open a laparoscopic revision can be completed in 80-90 percent of the cases. Every patient is different, some patients create a lot of scar tissue and others have minimal scar tissue after similar operations.

If your initial surgery was done laparoscopically a revision will be significantly easier but that doesn’t guarantee that the revision will be completed laparoscopically.

Final Thoughts

Revisional bariatric surgery in many patients is a medical necessity. In cases like this, I am very willing to help you improve your quality of life. I see many patients that have been dealing with complications from Mini Gastric Bypass, Lap Bands, or Vertical Banded Gastroplasty for years.  Some have seen a surgeon and were told that nothing can be done so they continue to deal with the frequent vomiting, reflux, or pain.

If the above sounds like you, get a second opinion. Find a bariatric surgeon in your area that is fellowship trained and has experience doing these procedures.

I will be very happy to see you in my office and go over your issues and possible solutions.  Call us today and make an appointment. We accept most commercial insurance and have very competitive cash pay rates.

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