Surgical treatment of clinically severe obesity has been proven to be an effective solution for long-term weight reduction. But as weight loss surgery rates are soaring, revisional bariatric operations are increasing as well. This is because simple gastric restrictive methods, such as adjustable gastric banding, vertical banded gastroplasty, and nonadjustable gastric banding often give rise to intolerable side effects or simply fail to control weight in the long run.
The purpose of weight loss surgery revisions is to resolve complications caused by the initial operation or to achieve weight loss success in case the primary surgical intervention was not sufficient. The frequency of reoperation in bariatric surgery has been reported to be 5% to 56%.
A 2010 study by Spyropoulos and colleagues reported on the outcome of 56 revisional procedures that were performed at the University Hospital of Patras. These surgical re-operations represented 5% of 1161 primary bariatric procedures that were performed in the same institution throughout a period of 14 years. The 56 patients that underwent revision surgery were classified into three groups based on the cause of re-operation.
Group 1. Unsatisfactory Weight Loss
Insufficient weight loss after the initial operation was the prevailing reason for revision in 39 out of 56 patients. Most of these 39 patients that experienced unsuccessful weight loss had undergone vertical banded gastroplasty (VBG) or gastric banding (GB) as the primary operation. The cause of failure was disruption of the staple line in the case of VBG, or band slippage in the case of GB. Revisional surgery was successful in this group of patients. They lost 68.9% of their excess weight within 8 years after the re-operation.
Group 2. Severe Nutritional And Metabolic Complications
The reason for revisional surgery in 15 out of the 56 revisionary patients was severe protein malnutrition. Their primary operation had been BPD-RYGBP. The revisional procedure increased the length of the common limb by one meter thereby achieving higher protein absorption in all 15 cases.
Group 3. Intolerance Adverse Effects or Mechanical Complications
Although mechanical complications are known as predominant indications for revision in bariatric surgery, in this study only 2 of the 56 patients underwent re-operation due to mechanical complications (stoma obstruction).
Complications After Re-operation
The patients in all three groups were followed up for a mean of 8.5 years. None of the 56 patients died. However, 19 (33,9%) of them presented early postoperative complications. Specifically, 2 patients developed acute renal failure, 5 patients suffered from anastomotic leaks and 8 contracted pneumonia. Complications such as bile leak, wound infection and small-bowel obstruction occurred at a rate as low as 1.8%.
The occurence of late complications was 23.2%. Two patients had stenosis of the gastrojejunal anastomosis, 2 others presented protein deficiency (hypoalbunemia), while 9 patients developed incisional herniation.
Roux-en-Y and BPD – Best Revisional Options
According to the results of this study, the types of revisional procedures that are most effective for insufficient weight loss are Roux-en-Y gastric bypass and BPD. This agrees with previous studies. Sugerman and colleagues found RYGB was effective at resolving complications and increasing excess weight loss in morbidly obese patients with a failed or complicated VBG. Westling and his group found that failure after silicone adjustable gastric banding can be treated successfully with Roux-en-Y gastric bypass. Similarly, Weber suggested that RYGB should be proposed as a rescue therapy of choice after failed gastric banding. It appears that restrictive procedures alone are not successful options when it comes to revisional bariatric surgery.
Charalambos Spyropoulos, MD, author of the study, notes that although the popularity of bariatric surgery has increased bariatric revisions worldwide, only specialized surgeons should perform reoperations. “Revisional bariatric operations require experienced surgeons and well-organized “centers of excellence” in order to use the technological innovations and the human experience for the patient’s best interest … and for extending patients’ longevity.”