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Revisional Weight Loss Surgery

Each weight loss surgical procedure has a different short and long-term result, as well as unique and long-term complications. Patients who have had complications or ill effects as a result of weight loss surgery may require other procedures to correct the original operation. These types of operations are called revisional weight loss surgical procedures. Dr. Ara Keshishian has performed more than 500 revisions from other Weight Loss Surgeries such as RNY Gastric Bypass, Adjustable Gastric Band, and Sleeve Gastrectomy to Duodenal Switch. He first published his data on Revisional Weight Loss Surgery in 2004.

Conditions that may require Revisional Weight Loss Surgery include:

  • Inadequate weight loss.
  • Weight regain after initial weight loss.
  • Dumping syndrome.
  • Solid intolerance.
  • Marginal ulcers.
  • Nutritional deficiencies, including vitamins, minerals, etc.
  • Anemia.
  • Significant bowel dysfunction (constipation, diarrhea, malodors flatulence).
  • Significant gastroesophageal reflux disease.
  • Infection involving implanted devices (ports or bands).
  • Erosion or slippage of the adjustable band.
  • Partial resolution of the comorbid conditions or recurrence of the comorbid conditions after initial or partial resolution.
  • Stricture (narrowing at the site of bowel anastomosis).

The goal of the revisional weight loss surgery is to:

  • Correct the problem that brings a patient under our care, including the correction of any of the above outlined conditions.
  • Make the revisional weight loss surgery a definitive procedure. This will be discussed further with each type of procedure that we revise.
  • Accomplish the primary goal of the weight loss surgical procedure, which is maintenance of the weight in a favorable range and resolution of the patient’s comorbid conditions.
  • Revisional Weight Loss sSurgery should have acceptable risk as a surgical intervention.

The majority of patients seeking a revisional weight loss surgery are those who experienced an acceptable short-term outcome after the initial weight loss surgical procedure. They may have lost the weight only to gain it back, or experienced inadequate weight loss. There are also certain patients who have had ill effects from their primary operations, including ulceration and stricture in the case of a Roux-en-Y gastric bypass, and slippage or erosion in the case of an adjustable gastric banding. While there are some patients who have been able to lose the weight and keep it off, this comes at the expense of near constant nausea and frequent episodes of vomiting. It has been our experience that the failure of primary weight loss surgical procedures is quite frequently blamed on the patient, which is usually not the case. In the majority of cases, a less than ideal outcome of a weight loss surgical procedure can be traced back to a procedure itself. A similar circumstance would involve a patient trying a number of blood pressure medications to find the one that works best. Even the best possible outcome may be inadequate for the patient and his or her particular conditions.

The causes of failure of primary weight loss surgical procedures may be:

Cause Procedure
  • Dilated pouch stoma
  • Fistula (gastro-gastric, gastro-enteric)
  • Marginal ulcer
  • Significant nutritional deficiency including iron deficiency anemia
  • Stricture
  • Excessive diarrhea or debilitating malodorous flatus
  • Significant protein calorie malnutrition
  • Gastric bypass revisions are indicated for any of the above conditions
Roux-en-Y Gastric Bypass
  • Significant nutritional deficiency including iron deficiency anemia
  • Excessive diarrhea or debilitating malodorous flatus
  • Significant protein calorie malnutrition
Duodenal Switch
  • Slipped Band
  • Erosion of the Band
  • Port problem including flipped port or infection
  • Inadequate weight loss
  • Incomplete resolution of co-morbidities
  • Revision of a lap band may be indicated for any of the above conditions
Adjustable Gastric Banding

Each one of the surgical procedures will be discussed in great length with the rationale for the recommended revisional weight loss procedure.

Roux-en-Y, Gastric Bypass

Roux-en-Y Gastric Bypass is a procedure in which a small stomach pouch is created and connected to a limb of small bowel in which a deliberately small opening is made. The purpose of the small pouch and the small opening is to restrict the amount of food that a patient can eat in any given setting and to purposefully delay the emptying of the pouch to give the patient a longer period of feeling full.

Complications of the Roux-en-Y gastric bypass include dumping syndrome, marginal ulcer, cases of persistent nausea and vomiting with solid intolerance, inadequate weight loss, and weight regain. In our opinion, the best option for cases of Roux-en-Y gastric bypass in need of revision is the Duodenal Switch operation. Adjustable gastric banding (Lap Band) placement as a revisional weight loss surgery for a primary Roux-en-Y may only be considered for patients who have experienced an initial success of weight loss followed by weight regain. This should, however, only be used for those not experiencing dumping syndrome, marginal ulcer, or reflux disease, as it can potentially get exacerbated by placement of the band on top of a gastric pouch.

Adjusting the length of the common channel, or alimentary limb, allows a revisional weight loss surgery to be tailored to the patient’s needs. An example would be if a patient is experiencing persistent nausea and vomiting and seeks the revision of a failed gastric bypass to a Duodenal Switch. If a patient seeks the revision of Roux-en-Y for persistent nausea and vomiting while experiencing adequate weight loss, a relatively long common channel and alimentary limb (percentage based) will be set for the patient, thus preventing any further weight loss while correcting the persistent nausea and vomiting problem.

In contrast, a patient seeking the revision of a failed gastric bypass to a Duodenal Switch due to inadequate weight loss and/or weight gain will have a relatively shorter common alimentary channel (percentage based) in order to maximize the amount of weight loss. In our opinion, revising a failed gastric bypass, from a proximal to a distal Roux-en-Y, is an extremely poor choice in the majority of the patients, as the distal gastric bypass has the worst nutritional safety profile of all the known surgical procedures.

Adjustable Gastric Banding
Lap Band, Realize

Adjustable gastric banding is a restrictive procedure in which a very small pouch of the stomach is created and partitioned solely by the placement of a ring that can be adjusted by the addition or removal of sterile saline through a port.

In the majority of cases, the reason for inadequate weight loss may be related to inadequate adjustments or unrealistic patient expectations in regard to the anticipated weight loss. All of the published reports to date identify the amount of weight loss to be approximately 50% of the excess body weight, and patients that have a large amount of weight to lose may never attain adequate weight loss to resolve their comorbid conditions. This may be an example of patients having attained the weight as expected by the surgery, yet experiencing a less than ideal weight loss surgical procedure for their general health condition to include their excess weight and their comorbid conditions. The majority of the patients that had adjustable gastric banding being inadequate weight loss or significant reflux disease in the presence or absence of hiatal hernia. It is our recommendation to have this procedure conversed to Duodenal Switch

Duodenal Switch

Duodenal Switch operation is the primary weight loss surgical procedure that we perform. It is a hybrid operation in which a banana-shaped stomach is created. Additionally, two parallel limbs of small bowel are created to carry down the ingested food separately from juices from the liver and pancreas. No small bowel is removed. This limits the amount of absorption of calories and nutrition thus magnifying the amount of weight loss.

The most common reason for revision or reversal of the Duodenal Switch operation in our experience has been 1) inadequate weight loss, and a distant second) significant diarrhea. In the case of inadequate weight loss, greater than 80% of the patients in our experience have had dilated stomach which has rendered itself easily to a re-gastrectomy with excellent results. Very few patients have benefited from shortening of the common channel.

The revision/reversal of the Duodenal Switch operation for significant amounts of loose bowel movements and malodorous flatus is easily accomplished by creation of a side-by-side anastomosis.

In fact having extensive experience with revision of weight loss surgical procedures it is our opinion that from a technical perspective, revision or reversal of Duodenal Switch operation is technically the safest and easiest of all the other surgical procedures.

Are you a candidate for Revisional Weight Loss Surgery?  Contact our office here.

Animation of Revision of Gastric Bypass to Duodenal Switch

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