Revision procedures in the treatment of obesity

Patients undergoing surgical treatment of obesity approach the procedure with the hope that a reduction of the stomach capacity and introduction of dietary recommendations will help them to achieve a significant body weight reduction and to return to a normal BMI. Although in many cases this effect is achieved after the first operation, e.g., after sleeve gastrectomy (so-called gastric sleeve), there is a group of patients who, due to non-following the dietary restrictions or due to genetic predisposition, will experience relapse and become obese again.

In such cases, and after using fewer permanent solutions (e.g., gastric banding, gastric plication or gastric balloon) it may be necessary to perform a second operation. What do such operations look like and what are the indications for performing them?

What are revision procedures?

Revision procedures are used in the treatment of obesity to recover patients who, despite previous bariatrics surgery, are still obese, have returned to excessive weight after initial weight loss or whose bariatric surgery has not brought the desired effects. Revision surgeries enable to replace the type of surgery performed (e.g., gastric banding or sleeve resection) with another bariatric procedure (e.g., sleeve gastrectomy, mini gastric bypass or so called RYGB gastric bypass) in order to achieve better, visible and long-term results.

Revision surgeries, due to their scale and the area operated on, present a challenge for the surgeons and their teams and should only be carried out in proven clinics specialising in bariatrics and revision surgeries. Currently, similar to the first surgery, revision surgeries are performed using laparoscopic method to reduce the risk of surgery, significantly increase safety and shorten the postoperative recovery time.

Primary revision procedures in bariatrics

Revision procedures after surgical treatment of obesity are currently performed in three cases, two of which are surgeries performed on patients who opted for a gastric band in the first place. Over the years, this band moves and may no longer be performing its job in limiting the capacity of the stomach – its removal is crucial to keep the patient safe.

If the patient is aware that the gastric band surgery has not brought the desired result or if the patient is determined to reduce the capacity of the stomach permanently, they may opt for sleeve gastrectomy or gastric bypass (or mini gastric bypass). A third option for revision surgery is the conversion of sleeve gastrectomy to gastric bypass or mini gastric bypass, recommended when the first method has not brought the desired therapeutical effects.

Conversion of gastric banding to sleeve gastrectomy

Revision procedures are meant primarily for people who have gastric band in place and require its removal, but wish to have surgical support in the fight against excessive weight. Converting a gastric band to a sleeve gastrectomy involves removing the band (which causes the stomach to return to its original shape) and then performing a standard sleeve gastrectomy, during which about 75-80% of the stomach’s volume is removed and the remaining part is placed in a special sleeve.

As a result, the new stomach has a much smaller volume, which makes it impossible to eat large meals, but it retains the digestive functions and does not need to create new connections between the other elements of the digestive system. During such surgery, i.e., with only one anaesthesia of the patient, the surgeon performs two procedures.

Conversion of gastric band to gastric bypass

After the patient’s gastric band is removed, it is also possible to perform gastric bypass – an operation which unlike sleeve resection requires the exclusion of part of the stomach and the creation of a small reservoir (so-called pouch) in its upper part, capable of holding about 40-50 ml of liquids/meals at a time. The new stomach is connected to a further section of the small intestine and the excluded part of the stomach continues to produce digestive juices, allowing the digestive system to function properly. Ingested food falls into the new reservoir and immediately into the small intestine, reducing the time it takes to be absorbed and digested, making it easier to keep a healthy weight and tackle obesity in patient with indication for gastric bypass.

Conversion of sleeve gastrectomy to gastric bypass

The reduction of the stomach is one of the most effective and the most frequently performed operation worldwide aiming to reduce gastric volume. If the expected results are not achieved, it may be recommended to perform a revision surgery and replace the gastric sleeve with a gastric bypass or mini gastric bypass. This method poses a challenge as it is necessary to reconnect part of the stomach with the small intestine and the created pouch, in order to achieve that the digestive system adapted to the new method will function properly.

Indications for revision surgery after bariatric surgery

The primary indication for revision surgery in the treatment of obesity is the failure of the previous method, particularly if it was a reversible method (e.g., gastric band or gastric balloon) with the intention of two-stage treatment.

It is a frequent situation that patients are referred for revision surgery when previous surgical methods have ended with complications, that could be removed (e.g., gastric band displacement) or when the previous method has not provided the expected results. Patients with contraindications to surgery and those whose problems with keeping the weight are solely related to not following the postoperative recommendations after the primary bariatric surgery are not eligible for a revision bariatric surgery.

There is also a group of obese patients with a BMI over 60 whose treatment, due to their high initial weight and stage of obesity disease, should be divided into two stages, the first one being sleeve gastrectomy, followed by the second stage, such as a mini gastric bypass that can be performed after a significant weight loss.