Revisional Bariatric Surgery

In Which Conditions are Revision Surgeries Performed?

1-Conditions in which gastric band cannot be tolerated (they are usually common and cannot be prevented):

• Severe and continuous reflux
• Food intolerance
• Band dislocation
• Band prolapse
• Band erosion, i.e. migration
• technical defects related to the band, perforation, port rotation

2-Inadequate weight loss or weight regain:

• They are common especially after gastric band surgery. However, they are also observed after many sleeve gastrectomy operations done by surgeons, who have newly begun to do such operation.
• Stomach pouch that appears after a properly performed sleeve gastrectomy or bypass: It is rarer and possible to be prevented.

3-Revisions of historical surgeries, which are no longer performed:

• Jejunoileal bypass
• Vertical banded gastroplasty

In Which Situations, Which Revision Surgeries Are Preferred?

If the first surgery was a gastric band surgery, and if revision is to made for reasons such as inadequate weight loss or unhealed diabetes, a surgical procedure like gastric bypass or SADI-S should be preferred. In sleeve gastrectomy or gastric bypass can be preferred for cases of gastric band intolerance. Gastric bypass revision should be performed in patients with reflux development after the sleeve gastrectomy. In patients, who have been operated with sleeve gastrectomy and have currently no reflux problem, the procedure can be converted to SADI-S.

In case of weight gain after gastric bypass, the enlarged pouch and stoma can be intervened in. SADI-S revision can be considered. Volume reduction with an endoscopic method such as Apollo is a new promising procedure. In this procedure performed by us for the first time in our country, we still have the largest patient series. In patients having severe reflux after loose duodenal switch surgeries, conversion to gastric bypass would be appropriate.

As can be seen from these options, prevention of weight regain is not guaranteed in any procedure, and it is possible to find a solution for all problems. What should essentially be understood is that if there is no technical error (such as incomplete removal of the fundus is sleeve gastrectomy), the underlying cause of weight gain is almost completely the non-compliance with eating habits and lifestyle changes. There is no sense in attempting to make a revision before changing these behavioral patterns. In such a case, the revision may not even be as effective as the first surgery. It is because most of revision patients are more likely to exhibit improper behaviors and eating habits, by thinking that he/she have undergone a more potent surgery.

Gastric Band Revisions:

 Until today, about half of the patients, who had not previously had gastric band, had to have the band taken out. There can be a great variety of reasons for this. About 40% of patients cannot achieve adequate weight loss. This group of patients can lose only 25% of their excess weight. Other patient groups are those suffering from band related technical complications such as band infections, band erosion and band dislocation. In another group of patients, enlargement in the lower part of the esophagus, swallowing difficulty and severe reflux development can be seen in the course of time. Most of these complaints are eliminated with the removal of the band. However, even if patients achieve their ideal weights, weight regain is seen after the removal of the band in a majority of patients. At our center, we perform band removal operations and revisions with a more effective obesity surgery during the same session or a few months later, with the lowest risk of complications.

What Is Gastric Band Migration And How Is It Treated?

The word ‘migration’ means relocation. In particular, it is the condition in which the gastric band made of old, high-pressure, and hard silicone penetrates the stomach by abrading its wall. When happens, this first shows infection indications in the form of discharge from the port site. In most patients, migration is the essential underlying cause of chronic abscess at the port site. The second sign of migration is the disappearance of the gastric band’s effect of restricting food intake. It is because some portion of the band that needs to wrap around the stomach has penetrated into the stomach, and therefore, has lost its restricting effect.

Although migration is not a problem that requires acute intervention, the most important factor for the elimination of the chronic infection is removal of the band as soon as possible. If an adequate portion of the band has penetrated into the stomach, we perform the band removal operation endoscopically, by accessing it with special devices inserted through the mouth. By this means, the patient avoids the side effects of an operation. Since it is impossible to perform a revision surgery in the same session when there is a migration, it would be a great advantage to remove the band endoscopically.

After removal of the migrated band, the second surgery can be performed about 6-8 months later. Since there will be intense adhesions in the migration site, revision with bypass instead of sleeve gastrectomy would be more reasonable in patients with a band complicated by migration. Otherwise, a stomach larger than enough may remain in the upper part.

Gastric Bypass Revision:

Gastric bypass operations are usually very potent; and therefore, very few patients require revision. However, if the patient does not comply with nutritional rules and consumes increasing amounts of food, the stomach pouch and stoma (stomach-intestinal passage) may get larger in the course of time. In such a case, the pouch can be tried to be narrowed or this can be done surgically. Besides narrowing the stoma, there is another procedure for carrying the bypass area a little bit downward, i.e. for increasing the malabsorptive effect.

Are Revision Operations Risky, and What Are Their Risks?

The main problem in revision surgeries is the serious adhesions and anatomical changes that occur in the abdomen, as related to the first surgery. Therefore, revision surgeries should definitely be done by very experienced laparoscopic/bariatric surgeons. Previously operated tissues never be able turn back to their original conditions. They increase many risks, especially the risks of wall thickening from place to place, impaired tissue nutrition, and leakages. For a bariatric surgeon, who has yet to complete his/her learning curve in bariatric surgery, i.e. has not performed an average of 100 surgical operations from each surgery type, it would be beneficial not to perform a revision surgery without cooperating with an experienced surgeon.

Even operations intended for gastric band removal, which are sometimes considered to be a very simple procedure, may involve unexpected challenges. Especially revision surgeries of full gastric or bypass surgeries involving the resection of the stomach are the surgical procedures with top level challenges of laparoscopic surgery, and they require the surgeon to have full knowledge of the patient’s anatomy. However, revision surgeries can be performed by experienced hands in such a way as to require the same hospitalization duration required after the first surgery, i.e. 3 days. Revision surgeries are open-ended in terms of operation time. It may take hours depending on the anatomical challenges.