Revisional Bariatric Surgery

Revisional Bariatric Surgery

Dr. Garber is experienced in Revisional Bariatric Surgery, having performed bariatric surgery for 9 years, in the New York area. In this section we will discuss the special concerns one must think of when having a revision of a bariatric surgery. We'll also discuss 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.
• 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 can usually determine the type of surgery simply by knowing when and where it was performed.

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, 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 operation.

Likewise, complications occurring after the 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.

Real World Example

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 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.

One Last Word

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 the surgeon is scheduled. At that time all tests are reviewed as well as the operative report, if provided. Our surgeon then assesses the risks and potential benefits of revision surgery for the patient. 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.

New non-surgical endoscopic revisional surgery using the new Stomaphyx for gastric bypass patients with weight gain.

Over time a small percentage of gastric bypass patients will start regaining some of their weight. One reason for the weight gain is that the connection between the stomach pouch and small intestines which starts out very small may start to dilate over time. The patients lose the sense of satiety because the stomach pouch can now empty faster. Also over time the gastric pouch can stretch and accommodate more food when eating. Dr. Shawn Garber and Dr. Spencer Holover are the first bariatric surgeons in the New York area to offer endoscopic stoma reduction using the new Stomaphyx device. This procedure involves no incisions and no recovery and involves placing an endoscope through the mouth into the stomach pouch and suturing the connection between the stomach pouch and small intestines resulting in slower emptying of the stomach and earlier satiety and more weight loss. The procedure also shrinks the stomach pouch and makes it small (similar to the original gastric bypass procedure).

Please contact Dr. Shawn Garber at the New York Bariatric Group on Long Island if you have any weight gain after gastric bypass surgery. The procedure can also be used to close a gastric-gastric fistula if necessary. Dr. Garber is on the forefront of this new technology and looking at ways to apply this technology to maybe one day perform a bariatric surgical procedure completely endoscopically with no incisions at all.

For more information on the Stomaphyx procedure click here.