Revisional Bariatric Surgery

Patients may require revision of prior bariatric procedures because of: (1) anatomic failure with persistent or recurrent obesity, (2) development of secondary complications, or (3) need for reversal.

Anatomic failure

In planning revisional bariatric operations, surgeons must have an understanding of the prior procedures and typical anatomic complications, as well as the current state of the relevant anatomy. In past decades, several procedures have been employed and have since fallen out of favor. A number of pure restrictive procedures that involved gastric partitioning with staples have been limited by stomal dilation or recanalization of nondivided staple lines. Even procedures acceptable by today's standards, such as VBG, RGB, and AGB are at risk for anatomic derangement that may be amenable to surgical revision. In recent years, the explosion of bariatric surgery has also resulted in application of interventions that may create unfamiliar anatomy and complications for surgeons performing revisional procedures. For all these reasons, it is vital the surgeon makes every effort to define the prior procedures performed by medical record review and preoperative radiographic and endoscopic assessment. Upper GI contrast studies may define the location and integrity of gastric staple lines, as well as the nature and patency of outflow from the proximal stomach. Endoscopy will assess for ulcers and internalized foreign bodies, and may allow for therapeutic dilatation in some cases. Indirect evidence of gastric or intestinal motor dysfunction may also be appreciated. Finally, in some cases, imaging by CT scan will allow for visualization of pathology in excluded portions of the anatomy or suggest internal hernias. Patients who never lose weight may have had a technical complication such as incomplete stapling, or an inappropriate operation. Those who regain weight after years may have suffered staple line recanalization or behavioral failure. Reoperation on a previous gastroplasty usually involves creating a Roux-en-Y, if not already present, to a newly stapled proximal stomach pouch above all prior gastric interventions. However, BPD, AGB, and other operations have also been employed in this setting. Likewise, most authors advocate RGB for revision of AGB because of complications or insufficient weight loss, although other operations have been applied. Finally, in cases of failed BPD+DS some have advocated use of a pouch reduction procedure, and in failed RGB use of either AGB to improve the restrictive component or lengthening to improve the malabsorptive component. Comparative data are lacking.

Secondary complications

In some cases, bariatric procedures require revision when unexpected complications emerge over time. For example, the jejunoileal bypass resulted in dramatic weight loss, but became marred by the occurrence of malabsorptive complications including renal and hepatic failure. The importance of long-term follow-up is a lesson that must not be forgotten as new procedures are introduced. Contemporary bariatric patients may seek revision due to evolution of other conditions or complications, such as gastroesophageal reflux (GER), bile reflux, complicated ulcers, or obstruction. Severe GER may occur after gastroplasty or VBG in the absence of outflow obstruction, whereas bile reflux may occur in procedures that utilize Bilroth II gastrojejunostomy. In either case, conversion to RGB is therapeutic. Easily treated marginal ulcers are common in the healing phase, but later should raise concern for salicylate or NSAID abuse, or gastrogastric fistula. Late gastrogastric fistula closure may be a difficult procedure requiring laparotomy, sometimes with resection, whereas marginal ulcer perforation is more easily managed with a laparoscopic approach. Obstruction due to internal herniation may require major resection and intestinal reconstruction. Excessive weight loss, steatorrhea, or evolution of severe nutritional complications, particularly protein-calorie malnutrition, may indicate an excessively long malabsorptive component. Proximal relocation of the pancreaticobiliary secretions by intestinal reconstruction should be considered. One option is to relocate the junction of the biliary and alimentary limbs more proximally, with a 50 cm distance being suggested by Hamoui. An alternative, and a technically easier operation is to leave the original anastomosis intact and to create another enteroenterostomy 100 cm proximally, allowing for more proximal partial mixing of biliary and pancreatic secretions with the alimentary limb contents. This is effective in resolving malnutrition and diarrhea, while causing minimal weight gain. However, complication rates are high even in this simple procedure, presumably due to the poor physiological state of the malnourished patient. Desire for reversal Ease of reoperation after laparoscopic AGB is one of the putative benefits, and up to 33% of patients may come to reversal or major revision. Laparoscopic RGB and BPD cause more dramatic anatomic changes that trade ease and possibility of reversal for better weight loss outcomes and independence from an implantable device.

Role of laparoscopy in revisional procedures

Revisional bariatric operations may be performed laparoscopically or via open technique. Complications are more common after reoperations than after primary bariatric procedures. Surgeons may prefer an open approach to address severe adhesions, or to permit tactile localization of prior partitions in the stomach to avoid creating undrained or ischemic segments during restapling. Foreign-body removal and partial gastric resection may also be required. Drain placement is often performed in response to a recognized increased possibility of leak.