LAPAROSCOPIC WEIGHT LOSS SURGERY REVISIONS

 

INTRODUCTION

Revisional weight loss surgery is a developing field in bariatrics. As more weight loss surgery is performed, its role in bariatric patient care is growing. Revisional surgery is a general term applied to the repair or alteration of an existing weight loss operation or the complete change of one weight loss operation to another. There are different reasons a patient may require a revisional operation. Examples include intolerance, slippage or erosion of the band, the formation of a fistula between the pouch and the old stomach, or a non-healing ulcer at the anastomosis in a bypass patient. 

Revision surgery can offer a morbidly obese person a second chance at health and weight loss. No revision operation is the same. The new revision operation can potentially be any of the standard weight loss operations. Which operation can or will be performed depends on many factors including patient choice, the previous operation performed, changes the operation underwent, and findings during the pre-operative work-up and at the time of surgery.

Revision surgery can be performed laparoscopically (even if the previous operation was performed open). Often, an extensive work-up is required to determine what the real problem is and what can be done to fix, improve or change it. Patients of other weight loss programs are welcome to talk to us about revision surgery. At present, our program is one of the few in Kansas and around the immediate area regularly performing revisional weight loss surgery.

   

AM I A CANDIDATE FOR A REVISION OPERATION?

Criteria to qualify for revision surgery can vary broadly and depend on the reason for the revision.  Some insurance companies may still require the individual to be severely (BMI > 35) or morbidly (BMI > 40) obese to repair or change an existing weight loss operation. Insurance companies are less likely to demand these criteria when there is an identifiable problem or complication with the existing operation.  It is then treated as a needed operation, regardless of weight or weight loss surgery criteria.

To determine if you are severely or morbidly obese enter your weight and height into the BMI calculator.

Standard weight loss surgery criteria are:

  • A Body Mass Index (BMI) > 40, regardless if medical problems or co-morbidities are present or not. 

  • A Body Mass Index (BMI) > 35 and experiencing severe negative health effects or co-morbidities, such as high blood pressure, diabetes, and/or sleep apnea.  

  

REVISIONAL WEIGHT LOSS SURGERY PROCEDURES 

The most important factor influencing what type of revision operation a person will undergo will depend on what weight loss operation the person received originally. The surgeon will often request a copy of the operative report when available. The operative report helps the surgeon know what anatomical changes were made to your stomach, and potentially intestine, to determine what surgical options are still available. The usual next step is to undergo a UGI, CT Scan, and/or Upper Endoscopy. This allows the surgeon to see what changes time has brought to the anatomy described in the operative report or determine what operation was performed. Once this information is available, the surgeon sits down with the patient to discuss their options and decide on the best course of action.

A revision operation can potentially be any of the standard weight loss surgery operations offered. Which operation is chosen will depend on patient choice, type of original operation performed, and findings during the pre-operative work-up and at the time of surgery.  

One important difference between revisional surgery and first-time weight loss surgery is the operative risk and operation effectiveness.  

1. Revision surgery carries more risk because another operation is being performed in the same place that previous surgery was done. Any time this occurs in surgery, the operation carries more risk, mostly because of scar formation from the previous operation. The surgeon has to slow down and meticulously dissect out the normal, and then the altered anatomy and verify pre-operative findings before proceeding with planned surgery. The difficulty factor of these operations is increased significantly as well as the potential for injury of neighboring organs and tissues.  

2. The operation effectiveness may also differ. For example, if a biliopancreatic diversion is being used as a revisional operation for a failed bypass operation, the revision BPD may not be as effective as a BPD operation being performed as the first weight loss operation. In this example, the existing bypass pouch is being re-used as the pouch for the BPD operation. The revision BPD is not able to take advantage of the immediate restrictive component of a new pouch anymore and is mostly relying on malabsorption for the new weight loss.

 

REVISIONAL WEIGHT LOSS SURGERY RISKS

In addition to the risks of the specific weight loss operation the patient is being revised to, the patient is at additional risk for:

  • Longer operative times – due to scar from previous surgery

  • Higher risk for tissue, bowel or organ injury – due to scar from previous surgery

  • Higher risk for complications in general

  • Higher leak and infection rates

  • Weight loss results will vary when only modifying a part of a pre-existing operation

It is very difficult to predict exact weight loss outcomes with revision surgery. Every case is different, and each operation is different thus the predicted weight loss will be different.