• Weight Regain and / or Inadequate Weight Loss
These are the most common reasons to undergo Revision Weight Loss Surgery, since just not every single individual fits into the "average patient" profile, so weight loss doesn't happen with any single bariatric surgery in the same quantities happening with average patients. Since there are different kinds of bariatric surgical procedures, sometimes a surgery that did the job for a certain set of patients will accomplish or not the exact same achievements it does for another individual, and this feat is also due to different reasons...
- Some persons have a hard time or total inadequacy at adapting to the new lifestyle that should be engaged after a particular bariatric procedure
- A specific kind of procedure does not properly address a certain patient's metabolic needs
- The anatomical changes happening to the patient's biology during bariatric surgery are not maintained afterwards
The bariatric surgical procedure can fail due to some or all of the above mentioned reasons. Before deciding to undergo Revision surgery, it's very important to establish whether the bariatric weight loss procedure was inadequate for the patient or rather if the patient failed to the surgery (and therefore to the whole weight-loss process). Sometimes, a patient does not receive enough information previous to undergoing a bariatric surgical procedure in order to select the best procedure according to his/her biology, needs and/or expectations; other times a patient is not properly instructed about the necessary changes in eating and/or exercising behavior after a weight loss surgery in order for the procedure to work the best for them; these delicate procedures require a full heads-on follow-up from patients in order to keep being successful in the long term, following instructions from specialists as not to gain back undesired weight.
It is often that the bariatric surgery's failure is due to metabolically and/or mechanical problems. The latter are caused due to anatomical changes (made during first time weight loss surgery) not being maintained in the short to mid-term after an intervention, some of these examples are:
- Pouch enlargement
- Gastric pouch outlet's diameter increases
- A gastric fistula (also gastro fistula) has recently formed between the bypassed stomach and the gastric pouch
- The intestine's absorbing qualities may have increased beyond expectations
- Restriction decreases due to band slippage
In most of the above cases, the best solution is restoring an environment allowing proper weight loss by reconstruction of the anatomy's shape during the first bariatric procedure. Dilated, stretched or enlarged pouches can be subject to a re-trimming. This kind of fix requires a band placed around a dilated gastric bypass outlet. Previously, it was suggested to re-staple any deteriorated staple lines of gastroplasty procedures; but because of high rates of long term failure for gastroplasty procedures, it has been recommended that these should be converted to a different bariatric surgical procedure.
Sometimes bariatric weight loss surgical procedures simply do not meet what a particular patient's metabolism needs.
Aside from the detailed processes involving any bariatric weight loss surgery kind, it is just part of a complete goal: losing weight, avoid gaining back any more weight as not to become overweight again and thus provide a healthy lifestyle during the rest of the patient's lifetime. All of this means that the success measure of this feat goes beyond eating properly. Any person's metabolism influences weight loss and same-weight maintenance, and any failure of these sorts is considered a Metabolic Failure. Meanwhile corrective surgery attempts to turn the anatomy back to its previous shape, the correction of metabolic failure implies a patient's conversion through a kind of bariatric weight loss procedure more metabolically active; for example converting a Gastric Bypass (also known as RNY) to a Duodenal Switch (or DS), as opposite to just re-trimming the gastric pouch.
• Weight loss and comorbidities (also known as polypathy)
The failure to address and heal/stop any other illnesses or affecting conditions after a weight loss procedure is also a much-recurred reason to consider undergoing a revision or conversion bariatric surgical procedure. The unsatisfactory resolution of other illnesses is normally related to factors that cause metabolic failure, thus resulting in insufficient weight loss. A condition displaying metabolism failure and other comorbidites need a conversion of the failed bariatric surgery towards an improved metabolic activity derived as end result of a surgery.
• Medical Complications
As with many other kinds of surgeries and also different body biology within many different patients, sometimes an individual presents medical complications due to bariatric weight loss surgery which must receive Revision Bariatric Surgery. In some occasions, the medical complications receiving revision surgery will be treated pretty much in the way of previously discussed mechanical and metabolic failure; others may be apt for reversal of the first-time surgery while preserving weight-loss. Some of the medical conditions subject to revision surgery include:
- Anemia (iron, thiamine and other minerals and vitamin deficiency)
- Malnutrition
- Metabolic bone disease
- Severe malabsorption
- Severe dumping syndrome
- Stricture
- Ulcer
Laparascopic Banding / Lap Band Revision Surgery as a Remedy
The possibility of Lap Band failure due to band slippage -leading to a slow chronic condition or in need of immediate attention- requires the patient to go through emergency surgery. When the lap band is not working the way it is meant to, the issue may be solved by removing the Lap Band, repositioning the Lap Band or replacing it altogether. Removing the band will -of course- take the patient back to potential weight gain.
Another complication derived from Lap Band Surgery is Lap Band erosion happening for a number of reasons: from not enough bloodflow into the part of the stomach where the Lap Band is placed to friction in this same area; the band becomes ineffective and weight is gained again. Some of lap band erosion's symptoms is blood vomit, and another symptom is an infection around the port's side. Because of this erosion, saliva keeps leaking through overtures in the stomach and flows into the Lap Band tubing, which causes tissue under the skin of the Lap Band port to become infected. As told, the band removal leaves the patient in a condition as if he hadn't been through weight loss surgery, with -of course- weight regain. So it is recommended that Lap Band erosions receive the treatment in order to convert the process into Vertical Sleeve Gastrectomy (VSG), Duodenal Switch (DS) or Ileal Transposition. Considering a portion of the stomach may be weakened and prone to further leakage; all of these procedures may be completed with some trimming of the affected area.
Lap Band surgery still can fail for a number of different reasons, thus requiring Revision Bariatric Surgery. With Lap Band being a restrictive weight loss surgery, some patients' bodies' metabolism is not proper to help weight loss through a Lap Band procedure. Other cases regard patients not being able to change their eating habits the way it should be in order to embark in a successful process and, as a consequence, the usual weight gain is brought back. Failed attempts at Lap Band surgery can be converted to other kind of weight loss procedure, considering that those surgeries more likely to succeed are the ones which go beyond restrictive weight loss surgery into turning the body into a more metabolically active organism. There's more than enough evidence proving that in the long run, properly managed Lap Band surgery processes are about as efficient as Gastric Bypass (RNY), as in the aftermath both procedures imply keeping a restrictive diet due to reduced size gastric pouches. For patient conversion from a Lap Band failure into Gastric Bypass Surgery, there are risks of leak development as well as marginal results.
Finally, for individuals looking no further than restrictive bariatric weight loss surgery, Vertical Sleeve Gastrectomy (VSG) is their option. Vertical Sleeve Gastrectomy remains limited to the patients' metabolism and the metabolic activity of surgery in itself. But VSG produces better long-term results than Lap Band. Ileal Transposition and Duodenal Switch (DS) both provide the patient of a metabolic process able to cause weight loss besides restriction. Patients subject to Ileal Transposition or Duodenal Switch are subject of weight loss advantages beyond those the Lap Band procedure offers.
Laparascopic Banding / Lap Band Revision Surgery as a Remedy
The possibility of Lap Band failure due to band slippage -leading to a slow chronic condition or in need of immediate attention- requires the patient to go through emergency surgery. When the lap band is not working the way it is meant to, the issue may be solved by removing the Lap Band, repositioning the Lap Band or replacing it altogether. Removing the band will -of course- take the patient back to potential weight gain.
Another complication derived from Lap Band Surgery is Lap Band erosion happening for a number of reasons: from not enough bloodflow into the part of the stomach where the Lap Band is placed to friction in this same area; the band becomes ineffective and weight is gained again. Some of lap band erosion's symptoms is blood vomit, and another symptom is an infection around the port's side. Because of this erosion, saliva keeps leaking through overtures in the stomach and flows into the Lap Band tubing, which causes tissue under the skin of the Lap Band port to become infected. As told, the band removal leaves the patient in a condition as if he hadn't been through weight loss surgery, with -of course- weight regain. So it is recommended that Lap Band erosions receive the treatment in order to convert the process into Vertical Sleeve Gastrectomy (VSG), Duodenal Switch (DS) or Ileal Transposition. Considering a portion of the stomach may be weakened and prone to further leakage; all of these procedures may be completed with some trimming of the affected area.
Lap Band surgery still can fail for a number of different reasons, thus requiring Revision Bariatric Surgery. With Lap Band being a restrictive weight loss surgery, some patients' bodies' metabolism is not proper to help weight loss through a Lap Band procedure. Other cases regard patients not being able to change their eating habits the way it should be in order to embark in a successful process and, as a consequence, the usual weight gain is brought back. Failed attempts at Lap Band surgery can be converted to other kind of weight loss procedure, considering that those surgeries more likely to succeed are the ones which go beyond restrictive weight loss surgery into turning the body into a more metabolically active organism. There's more than enough evidence proving that in the long run, properly managed Lap Band surgery processes are about as efficient as Gastric Bypass (RNY), as in the aftermath both procedures imply keeping a restrictive diet due to reduced size gastric pouches. For patient conversion from a Lap Band failure into Gastric Bypass Surgery, there are risks of leak development as well as marginal results.
Finally, for individuals looking no further than restrictive bariatric weight loss surgery, Vertical Sleeve Gastrectomy (VSG) is their option. Vertical Sleeve Gastrectomy remains limited to the patients' metabolism and the metabolic activity of surgery in itself. But VSG produces better long-term results than Lap Band. Ileal Transposition and Duodenal Switch (DS) both provide the patient of a metabolic process able to cause weight loss besides restriction. Patients subject to Ileal Transposition or Duodenal Switch are subject of weight loss advantages beyond those the Lap Band procedure offers.
Vertical Sleeve Gastrectomy (VSG) Revision Surgery
Even though Vertical Sleeve Gastrectomy (VSG) is one the most effective kind of surgeries regarding weight loss, there are a number of patients not losing enough weight after undergoing this operation, so Revision Weight Loss Surgery is sometimes required in order to obtain the desired weight loss. The following are the two most common beliefs causing VSG surgery failure:
- For a stretched stomach, undergoing re-sleeving via a Revision Surgery may be enough
- In some other cases, a Duodenal Switch or Ileal Transpositon should be performed so patients improve a certain metabolic and/or food malabsorptive aspect of their entire process, thus completing the purpose of a Vertical Sleeve Gastrectomy.
When undergoing the process of a Revision Surgery with the purpose to switch from Vertical Sleeve Gastrectomy to a Duodenal Switch, there is less risk than that of performing the latter as a first-time weight loss surgery, because a completed VSG surgery involves part of the process that the Duodenal Switch surgery requires, thus resulting in a shorter procedure.
Stretching the stomach is not always the best procedure, since it may cause other problems different than regaining weight or inadequate weight loss. The stomach’s tube may stretch in a non-uniform manner, thus having parts of the stomach tube larger than the others and the stomach takes the shape of an hourglass, with the upstream and downstream portions being large and separated by a very narrow part. Food intake in itself does not increase because of this reason, but it sure causes disordered and/or uncomfortable eating. Depending on the symptoms a patient presents and the volume of food consumption, there are two revision options resulting in a more direct food flow through the stomach.
Duodenal Switch (DS) Revision Surgery
With weight loss surgery in general being in whole a recently developed series of surgical procedures, we are all becoming more adept at completely understanding and striking the balance between malnutrition and proper weight loss. As of today, about 2% to 5% of patients that had been through Duodenal Switch are possible candidates for Revision Weight Loss Surgery. The number of individuals having to go through Revision Surgery after DS will certainly decrease, though not eradicated entirely. These are usual reasons for Duodenal Switch revision:
- Excess weight loss
- Inadequate weight loss
- Malabsorption / nutritional deficiencies
Excess weight loss and nutritional deficiencies are conditions that clearly require Revision surgery after Duodenal Switch, and more than often these happen simultaneously. In this cases timing is a factor upon which much of the success of a remedy depends on. With the passing of time, the possible malabsorptive effect after undergoing Duodenal Switch will decrease as the intestine evolves by increasingly improving protein and other nutrients absorption. This means Duodenal Switch revision shouldn't be considered too early for patients suffering from malabsorptive complications; conservative therapy is much rather recommended before undergoing Revision surgery, so the intestine's increase in abilities develop within enough time. If this time lapse seems interrupted by Revision surgery, then the patient risks excessive weight re-gain after the intestine increases its full absorptive capacity.
Malabsorptive complications due to Duodenal Switch usually require elongation (adding intestinal length). To attain the desired results in the common limb, elongation can be achieved by using the biliopancreatic limb. For common elongation surgery, then the alimentary and common limbs must be elonged, thus providing protein, starch and fat absorption of additional surface area. An increase in fat absorption abilities helps the body's ability to absorb soluble vitamins such as vitamin D. In fact, the revision procedure treatment after Duodenal Switch surgery will treat both excessive weight loss as well as the patient's ability to absorb fat soluble vitamins.
Enteroenterostomy, also known as "the kissing X" is the most simple revision surgery procedure able to increase both common and alimentary limbs length by just a single connection to the small intestine. Patients are enabled to keep a certain level of weight loss due to the "neuro-endocrine brake" effect, which is also the cause for weight loss after Ileal Transposition surgery
Ileal Transposition is also a recurring procedure when a calcium and iron malabsorption condition is present after Duodenal Switch; this surgery is the mean of intestinal elongation providing remedy for such cases, in which the conventional Ileal Transposition is replaced by the same procedure done at the duodenum level, without the need to re-connect such organ. This isn't considered an easy procedure, since only a segment of the alimentary limb may be used to perform the transposition in what is known as High Duodenal Ileal Transposition. What is left of the alimentary limb takes part in the "Parallel Ileal Transposition", which is done at the level of the biliopancreatic limb and which joins the food flow resulting from the above mentioned (and performed) High Duodenal Ileal Transposition. Calcium and iron absorption restoration is accomplished through this procedure without a complete reversal of the Duodenal Switch procedure.
Sometimes after the initial weight loss happening by the Duodenal Switch procedure, some patients may experience inadequate weight loss or weight re-gain. Assuming that there have been failed non-surgical weight loss attempts, two theoretical approaches to solve this problem are considered:
- Reducing the stomach size
- Shortening of the common limb's length
In North America, stomach size reduction seems to achieve better results than common limb length's shortening, even though results of these revisions may vary.
