Revisional Bariatric Surgery
Laparoscopy or Minimally Invasive Bariatric Weight-Loss Surgery
Laparoscopic procedures for weight loss surgery employ the same principles as their “open” counterparts and produce similar excess weight loss. Not all patients are candidates for this approach, just as all bariatric surgeons are not trained in the advanced techniques required to perform this less invasive method. The American Society for Metabolic and Bariatric Surgery recommends that laparoscopic weight loss surgery should only be performed by surgeons who are experienced in both laparoscopic and open bariatric procedures.
Dr. Wittgrove is an Experienced Revisional Bariatric Surgeon
Dr. Wittgrove has been performing revisional bariatric surgery for 20 years, in the San Diego area and now in La Jolla. He has performed over 200 such operations, just in converting Vertical Banded Gastroplasty operations into Gastric Bypasses. He has presented lectures on this subject both nationally and internationally. In this section we will discuss the special concerns one must think of when there is a consideration of having a revision of a bariatric surgery and our program’s philosophy regarding these issues.
Although bariatric surgery is usually quite effective, at times, it does not work as well as one would like. In such instances, a surgical revision may be considered. When contemplating another bariatric operation, we must decide if a revision will work and what the risks of such a procedure will be. There are several factors that help us make this decision:
- When the initial operation was performed.
- Where the initial operation was performed.
- At what stage the surgeon was in his / her career at the time of the operation.
- The postoperative instructions given after the initial surgery.
- Initial weight loss history following surgery.
- Any complications that may have occurred following the initial operation.
Now, we will discuss each of these factors individually. The type of bariatric surgery initially performed is very important when considering revision because some types of surgery have been known to fail or have less long-term success. Obtaining an operative report for your surgery is very helpful. However, if you cannot provide an operative report, we usually know the type of surgery simply by knowing when and where it was performed. Also, because Dr. Wittgrove has been a bariatric surgeon since 1986, he is familiar with many surgeons currently practicing as well as those who have since retired.
A “learning curve” exists for most operations and bariatric surgery has one of the longest. This is especially true when we consider the Laparoscopic Gastric Bypass. It is often helpful to know at what stage your surgeon was in their career when you were treated. For example, from a technical standpoint the success of gastric bypass surgery is largely dependent upon the size of the gastric pouch. This part of the surgery is technically challenging and often requires the surgeon to have performed many operations before mastering it. As a result, a surgeon may have made very large gastric pouches early in their career. Furthermore, some surgeons continue to make large pouches despite our current understanding that pouch size and weight loss are more directly related.
Oftentimes, the postoperative instructions given to patients are incorrect or lacking. Therefore, the patient did not know the best way to use their new “tool”. Even though the patient may be out of the “golden period” for rapid weight loss, they usually benefit considerably from proper instruction and can therefore avoid additional surgery.
Weight loss history following the initial surgery tells us if the operation was ever effective or if it “failed the patient” from the very beginning. If postoperative weight loss never occurred or was minimal then it is likely that there was a technical problem with the initial operation.
Likewise, complications occurring after the initial surgery may have led to technical problems that have influenced the durability of the weight loss. Such complications may include intraabdominal infections, ulcerations, band infections, and prolonged vomiting postoperatively.
Considering bariatric surgery as a “tool” to be used for long-term weight loss, we must determine if the patient has used their “tool” ineffectively or if the patient’s “tool” does not work. If the “tool” has not been used effectively then it is unlikely that a revision would be beneficial. However, if the “tool” is broken or never worked, then a revision may be beneficial.
For example, if the pouch of a gastric bypass was made too large then the patient may lose weight for the first year but eventually lose their sense of satiety or restriction and gain weight. Usually an upper GI x-ray series will help us determine the pouch size.
If a patient had gastric banding, they may never feel “satisfied” with small meals. Commonly, gastric banding does not give patients the same feedback of satiety that the gastric bypass provides. In such cases, a revision to a gastric bypass may benefit the patient. However, taking down the scar around the band can be quite technically difficult.
If a patient had a vertical banded gastroplasty (VBG)/ stomach stapling, they may have initially lost weight only to lose their feeling of restriction and regain the weight. Several technical failures arise with this type of surgery over time. It is appropriate to consider revision to a gastric bypass if one of these failures has occurred.
Finally, remember that revision operations are more technically challenging and carry a higher complication risk. Patients need to seek out very experienced bariatric surgeons that perform revision surgeries. Not everyone who regains weight or fails to lose as much weight as they would have liked are candidates for revisional surgery. Because morbid obesity is a multi-factorial disease, a multi-disciplined approach should be utilized to treat patients that have regained or failed to lose weight.
Successful bariatric surgery starts with the operation. Some operations have been done much longer and have been proven to be more durable over time. Gastric bypass surgery is one such operation. Postoperative instruction and support is also very important. Snacking behavior, poor water intake, lack of exercise, and poor supplementation intake can all lead to poor outcomes.
When patients are being evaluated for a revision in our program, a consultation with Dr. Wittgrove is scheduled. At that time all tests are reviewed as well as the operative report, if provided. Dr. Wittgrove then assesses the risks and potential benefits of revision surgery for the patient. Nearly all our program’s operations are now performed laparoscopically and with that in mind, Dr. Wittgrove will discuss the possibility of performing the revision operation laparoscopically. If surgery is indicated and the potential risks are understood, our program can provide years of experience in revisional bariatric surgery to help you achieve your goal.
- We need to determine where the issues lay. After fully assessing we are able to best determine the course of action that will help the patient. We have the ability to offer a multi-disciplinary approach to the programmatic variables that can assist the patient in “getting back on track” if that’s what is needed.
- Bands can be revised to gastric bypass operations if complications occurred or inadequate weight has been lost.
- Gastric sleeve operations may not have durability and can be converted to gastric bypass operations.
- For gastric bypass patients who had an operation with too large a gastric pouch and therefore no restriction. Usually a laparoscopic revision is needed although we can consider some of the newer endoscopic techniques.