Revision for Weight Loss Surgery

Why Is Revisional Surgery Performed?

Over the years many different kinds of bariatric procedures have been performed for patients with obesity. In some cases, a revision to these surgeries may be needed to address complications or weight loss goals. Newer procedures have a very low revision rate of 2% to 5%, while some of the earlier procedures have a revision rate of up to 90%.

Revisional surgery may be necessary for:

• Patients who have not lost as much weight as intended. Patients may undergo revision (reoperation to produce more weight loss), or conversion to a different weight loss procedure
• Patients who have lost too much weight. Patients may undergo reversal of the original weight loss procedure

Revisional surgery also may be required to reverse a weight loss procedure for one or more of the following complications:

• Ulcers or fistulas after gastric bypass
• Persistent recurrent vomiting after band or vertical sleeve gastrectomy
• Protein malnutrition after duodenal switch
• Reflux after vertical sleeve gastrectomy

What Happens During Surgery?

The revisional surgery performed will depend on the prior surgical procedure and the complication that is being treated. Most revisional surgeries take three to five hours in the operating room and require a two- to three-day hospital stay.

Jejeunoileal Bypass (JIB) Revision

The JIB is one of the original forms of weight loss surgery. It is no longer routinely performed, as it can result in severe diarrhea, liver disease and kidney failure. Some patients who had this surgery are still in need of revision. Most surgeons recommend revising this surgery by reattaching the small intestine and then performing either a gastroplasty or a Roux-en-Y gastric bypass procedure (RYGB). If the procedure is simply reversed, most often the patient will regain all or more of his/her original weight. Revision of this procedure is high-risk if liver and kidney damage has already occurred.

Vertical Banded Gastroplasty (VBG) Revision

VBG, also known as stomach stapling, involves creating a small pouch by separating off 95% of the stomach. A band placed around the outlet of the pouch creates a small passage into the rest of the stomach, preventing solid foods from moving through to the stomach too quickly and also preventing the outlet from stretching. While most patients have good short-term results with this procedure, some do not. The most common problems include frequent vomiting, gastroesophageal reflux and weight regain.

A VBG can be revised to an RYGB in most cases and is generally very successful. The procedure simply involves removing the band and bringing a loop of small bowel up to the pouch, which is sewn into place. This procedure is not without additional risk, as there can often be scarring of the tissue between the pouch and the liver. However, in the hands of an experienced Massachusetts General Hospital surgeon, the risk of complications is only slightly higher than the minimal risk with a primary RYGB. For people who experience daily vomiting, severe reflux or have regained the lost weight, having a revision can significantly improve their quality of life.

Roux-en-Y Gastric Bypass (RYGB) Revision

Revision of a gastric bypass is performed for four major reasons:

• Staple line break down
• Narrowing at the anastomosis (the opening between the pouch and the small intestine)
• Failure to lose sufficient weight
• Excess weight loss or dumping, in which food and digestive juices from the stomach move to the small intestine in an uncontrolled, abnormally fast manner

The type of revisional surgery recommended after gastric bypass will depend on the patient’s complications. This is a complex situation that may have more than one solution. Usually the surgeon should be able to explain exactly what he/she plans to do to fix the problem. However, sometimes the surgeon may not finalize the surgical plan until the surgery begins and he/she can better assess the situation.

Biliopancreatic diversion (BPD) Revision

BPD involves removing approximately 65% of the stomach and then bypassing most of the small intestine. The revision rate for BPD is about 2% to 10% depending on the specific procedure. The revision of BPD is less complicated than revision for gastric bypass because it does not usually involve operating on the stomach, but rather lengthening the small intestine. However, it is impossible to completely reverse BPD because two-thirds of the stomach is removed during the initial procedure.

What Preparation Is Required Before Revision for Weight Loss Surgery?

Often preoperative testing, including blood work, X-rays and endoscopy, is required before revision for weight loss surgery. You may also require treatment for vitamin or nutritional deficiencies before surgery. It is important to be patient because the more information your doctor can acquire before surgery, the more you will know what to expect for surgery and recovery. All patients must stop smoking and must be treated for any addictions before undergoing revision surgery.

What Is the Recovery Time?

Patients should expect to remain in the hospital for two to three days after surgery and out of work for two weeks. While you will be able to return to many of your daily activities after two weeks, we ask that you avoid heavy lifting and strenuous activity for six weeks.

How Safe Is the Procedure?

Revisions are associated with greater risks than primary weight loss surgeries. The complication rate is dependent on the problem being treated. Revisions performed for inadequate weight loss are the least complicated, while those performed for excess weight loss have the highest risk of complications.

The key to safe surgery is careful preoperative preparation and planning directed by an experienced surgeon. At the Mass General Weight Center, you will undergo consultation by a surgeon experienced in minimally invasive revisional surgery. Your surgeon is supported by a multidisciplinary care team.

Why Mass General?

Mass General is consistently recognized as a top hospital in the nation by U.S. News & World Report. As part of the Mass General Digestive Healthcare Center, the Mass General Weight Center is unique for its expert, multidisciplinary approach to revisional surgery.

Surgeon experience is one of the most important factors in patient outcomes. Mass General Weight Center surgeons collectively have the most experience with revisional surgery of any group in the Boston area. Our surgeons are leaders in laparoscopic, minimally invasive revisions, seeing successful outcomes even in patients whose prior surgical procedures were performed through large, open incisions.

Our surgical team members also have significant experience with conversion surgeries, which change a prior weight loss procedure. For example, our surgeons can convert adjustable gastric banding to a vertical sleeve gastrectomy. In all cases our multidisciplinary Weight Center team, comprising your surgeon, dietitian and psychologist, is prepared to help with recovery and prevent recurrent complications.