“I had undergone gastric bypass surgery a few years prior, and I knew I had put quite a bit of weight back on, but something just clicked, and I knew I had to do something about it. Dr. Averbach said he could perform the surgery and give me a second chance, but only if I was really ready to make the changes necessary to be successful this time around.” – Nicole
Dr. Averbach and Dr. Hamdallah combined have more than 20 years’ experience performing bariatric surgery in Maryland, which makes them uniquely qualified to treat patients who require revisional bariatric surgery.
Bariatric surgery is usually successful, both in terms of helping a patient achieve significant weight loss and minimizing complications. Unfortunately, some patients after primary bariatric procedure may experience side-effects or failed to succeed in losing the expected amount of excess weight or experience weight regain. In these situations, a follow-up bariatric procedure, known as a bariatric surgery revision, may be necessary to alter or repair the initial bariatric surgery.
Bariatric revisions may also be necessary due to surgical complications from an earlier procedure.
Although it can be an emotional setback for obese patients when bariatric surgery does not lead to the expected amount of weight loss, the only failure is in giving up. Obesity is a chronic disease and is prone to relapse if patients do not adhere to healthy eating and life style modifications. As with any serious health condition, if the first treatment is not effective, then the doctor will recommend additional treatment options. With weight loss surgery, a bariatric revision surgery may be necessary as an additional treatment for obesity.
REVISIONS AFTER GASTRIC BYPASS
A gastric bypass revision is necessary in approximately 5 to 10% of patients over 5 years due to complications, unsatisfactory weight loss, or weight regain. Complications that may occur after gastric bypass surgery, such as ulcers, chronic vomiting, hernia, staple line failure, can often be improved through revisional bariatric surgery.
If gastric bypass fails a patient has several options, including:
- If the problem is lack of weight loss or weight regain, non-surgical approach includes examining eating habits and exercise routines and participating in nutritional counseling, exercise program, behavior modification therapy, psychological counseling, and support groups. In our practice all candidates for revision surgery after initial gastric bypass are supposed to attend STRIVE programthat includes nutritional education and behavioral modification. You may find further information on this program on Bariatric Dietician and Psychologist pages.
- If the problem is lack of weight loss or weight regain, surgical options include full revision of initial bypass with reduction of proximal pouch and stoma size as well as lengthening of the Roux limb or conversion to distal gastric bypass.
- It is important to understand that revision surgery is associated with lower success rate compared to initial bypass because it is offered to group of patients prone to recurrence of morbid obesity. Consequently, without successful preparation with the help of bariatric dietician and behavioral psychologist successful weight loss is difficult to achieve.
- Every revision surgery is also associated with slightly higher risk of postoperative complications due to charged anatomy and postoperative scarring.
REVISIONS AFTER LAP BAND
The revision rate for the LAP BAND is required for over 50% of patients within 5 years due to either device-related problems , severe reflux or unsatisfactory weight loss. One of the most common gastric banding complications is slippage of the gastric band, which requires a follow-up procedure to fix the problem. While some patients will have the band replaced, others choose to revise to another procedure, such as gastric sleeve or gastric bypass. Choice of procedure for conversion of failed Lap Band is based on presence of reflux symptoms, other co-morbidities like diabetes and degree of excess weight prior to revision surgery. Your surgeons, after appropriate work up, will help you choose what is best for you.
REVISIONS AFTER GASTRIC SLEEVE
The gastric sleeve is one of the most frequently done primary weight loss procedure that involves reducing the size of the stomach to restrict food intake. In the past, it was used primarily as the first stage in a two-stage procedure, or the gastric component of the duodenal switch procedure (gastric sleeve and intestinal rerouting). Although many people will lose sufficient weight with the gastric sleeve procedure, if further weight loss is needed, than conversion to duodenal switch or gastric bypass may be an option.
With Gastric Sleeve being the dominant bariatric primary procedure in use today, it has become recognized that the most significant potential side-effect is severe reflux symptoms. About 24-40% of patients might experience reflux and in 5-10% of Gastric Sleeve patients, symptoms of GERD maybecome so bothersome that surgery is required. There are several reasons for severe reflux/GERD (development or recurrence of hiatal hernia, stricture or deformity of the sleeve, bile reflux and etc.), but whatever the cause is, there is nearly 100% success rate with symptom resolution with conversion to Gastric Bypass with simultaneous Hiatal Hernia repair. Coupled with additional dietary education, this treatment usually results in additional weight loss if needed.
PATIENT CRITERIA FOR REVISIONAL BARIATRIC SURGERY
Before a revisional bariatric procedure is performed, the patient will be examined by Drs. Averbach and Hamdallah to determine the cause of failure and to evaluate for the appropriate treatment options. He will need to determine if post operative weight loss failure is due to a problem with the original surgery or a result of the patient’s inability to follow the necessary dietary and lifestyle guidelines. The latter situation makes the STRIVE program mandatory prior to revision for weight loss failure.
Another consideration is whether the patient has unresolved co-morbidities that may improve with additional surgery. Drs. Averbach and Hamdallah will discuss the options with you and explain what to expect with the bariatric revision.
Besides that, there might be additional requirements for coverage of revision surgery based on your insurance plan.
HIATAL HERNIA REPAIR
Some 10-15% of morbidly obese patients suffer from reflux symptoms frequently associated with hiatal hernia that was not addressed during initial bariatric procedure, recurred or developed in in later years.
It is especially significant finding after sleeve gastrectomy, but happens after gastric bypass and Lap Band.
Hiatal hernia may be associated with significant bothersome reflux symptoms affecting patients quality of life and does not always respond to medical therapy with antacids. Depending of clinical situation, hiatal hernia can be repaired as a separate procedure or in conjunction with other revision surgery.
Procedure consists of reduction of the herniated junction of the esophagus and stomach into the abdomen with closure of diaphragm muscle defect to keep stomach in the abdomen.
MARGINAL ULCER EXCISION
Marginal ulcer is a condition that can complicate gastric bypass in about 5% of patients at various time intervals after the procedure. It develops immediately below the stoma on the side of small bowel. If detected early it can be healed with medications. Delayed diagnosis or unresponsiveness to medications might result in development of deep, penetrating ulcer with callous margin that will not heal.
In such circumstances ulcer excision with revision of the stoma might be required.