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Bariatric Revision Surgery: What Are Your Options?

The decision to get bariatric revision surgery can be as complex as the procedure itself—here’s what you need to know.

Bariatric surgery promises major results for people who need to lose a lot of weight. This procedure is usually performed only on the severely obese, restricting the amount of food the stomach can hold and limiting the amount of nutrient absorption. It can produce dramatic amounts of weight loss that just can’t be achieved by diet and exercise alone. It can also help people manage health complications of obesity, such as type 2 diabetes, sleep apnea and high blood pressure.

After bariatric surgery, your surgeon will be working with you during your follow up appointments to see if you are tolerating the surgery well. If over time your doctor sees signs of inadequate weight loss, he or she may determine that there has been a change to the size of your gastric pouch. If X-rays of your gastrointestinal tract confirm this suspicion, you may need to consider a bariatric revision.

For patients considering bariatric revision surgery, bariatric surgeon Dr. Gintaras Antanavicius often explains that the procedure is part art, part science. Choosing the proper revision – or sometimes deciding not to operate – is critical to success. “Every detail matters,” says Dr. Antanavicius, medical director for Jefferson’s Institute for Metabolic and Bariatric Surgery. “Patients, working with their physicians, must approach their decisions methodically,” he notes. For the patient, this means having a precise anatomical evaluation, a lifestyle evaluation, and a nutrition behavioral assessment. The surgeon’s expertise and how many procedures they have performed should also be considered. “All of this matters because there are so many variables at play in order to make an informed decision.”

Why Revision Surgery?

The human body has a marvelous ability to adapt to changes, and trimming down the size of your stomach is not a guaranteed fix for weight loss. Though the size of your new stomach is dramatically smaller after surgery, over time, your stomach pouch can stretch. Eventually, this, among other reasons, could lead patients to consider bariatric revision surgery.

“The reasons could range from weight regain, insufficient weight loss, or too much weight loss, to some unintended symptoms from the original bariatric operation, such as dumping syndrome (a condition in which food, especially food high in sugar, moves from your stomach into your small bowel too quickly after you eat), glucose issues, nausea, vomiting, reflux, etc.,” says Dr. Antanavicius.

Stretching of the gastric pouch happens for two reasons. It can occur naturally as your body attempts to adapt to the new arrangement of your digestive tract, or it can happen as a result of over-eating. Gastric bypass patients need to maintain a very strict diet of tiny meals. Failing to keep to this diet can lead to eating more food than your stomach can handle. Doing this repeatedly will eventually cause the gastric pouch to stretch.

Once your new stomach has stretched, the restrictive effect of your surgery will no longer be as effective. If you are relying on the feeling of fullness to tell you when to stop eating, you will slowly begin taking in more and more food as your stomach stretches. Over time, this will lead to post-surgery weight regain, something that can feel devastating if you have paid a considerable amount of money and changed your diet and lifestyle in the hopes you would finally find the freedom you were looking for from excess weight.

Revision Surgery Options

There are revision procedures for any type of bariatric surgery. Here are some of the more common bariatric revision procedures:

  • Sleeve conversion to DS (duodenal switch)
  • Sleeve conversion to SADI (modified switch)
  • Sleeve conversion to gastric bypass
  • Band removal
  • Band conversion to sleeve, gastric bypass, SADI, DS
  • Gastric bypass revisions due to pouch, anastomosis problems, conversion to SADI, DS, lengthening the roux limb

Like the initial surgery itself, considering any of these bariatric revisions will involve assessing the complication rate of the procedure, your particular weight loss goals and factors such as base metabolic rate and physical condition.

“Revisions can be done for any procedure, depending on what problem the patient is experiencing,” says Dr. Antanavicius, who has performed over 2,500 bariatric surgeries. One of the most common reasons for revision to a sleeve gastrectomy is inadequate weight loss due to super-obesity, or a body mass index (BMI) of 50 or higher. This would call for duodenal switch (DS) procedures involving modification of the intestines, such as the “classic DS” or the modified switch, also known as “SADI-S” or “Loop DS.”

Another cause of revisions in a sleeve gastrectomy is reflux and heartburn. After careful evaluation, many patients may get conversions to gastric bypass, notes Dr. Antanavicius.

According to Dr. Antanavicius, there is always a question of whether surgery failed the patient or the patient failed the surgery. It could be a combination of both. “I always conduct a careful anatomical evaluation with my patients — it is paramount in decision-making,” he notes. “We also sit down and do a thorough assessment of lifestyle and nutritional issues.” Patients should be aware that conversion – when a second, different surgery is performed to completely change the initial procedure — should be considered if the initial surgical anatomy is intact. If there is an anatomical problem, you should address that issue with your physician. “If none of the surgical options are feasible, medical weight loss management is always possible,” he adds. “Fortunately, at Jefferson Health, we have all options available.”

Revision Results

Results for revision procedures, Dr. Antanavicius says, are mixed and largely depend on the extent of the revision. For example, revision results from sleeve to duodenal switch might be very close to the initial/original operation, but re-doing a gastric bypass procedure to a new bypass result is not as promising. “It is essential to make the right decision in defining the problem and choosing the type of operation to make a difference,” he says. “If the choice is right – the results might be as good as those attained from the initial operation, but if the choice is inadequate – the risks might not be worth the benefit.”

Dr. Antanavicius and his team have done extensive research on conversion to duodenal switch, by far the most complex revision procedure, because it involves rearranging the GI track. Conversion to duodenal switch is widely thought to carry the highest rate of success in terms of weight loss, comorbid resolution and maintenance of weight loss.

What’s Right for Me?

Choosing the revision procedure that’s right for you comes down to your surgeon’s experience, which, Dr. Antanavicius says, “plays a paramount role in revision success,” along with a combination of decision-making and technical ability to perform complex revisions. In addition to expertise, technology enhances success even further. “We use the newest technological advances to perform even the most complex operations with great precision,” he says, noting that the DaVinci robotic systems provide surgeons with an added advantage in performing revision surgery.

When it comes to insurance coverage, most revisions are generally covered, but it can vary from provider to provider. Coverage for revisional bariatric surgery is determined by your specific insurance provider and plan. Generally, if you are experiencing complications related to your original procedure, you’ll be approved because of a medical need. However, if you are seeking a revisional bariatric surgery because of less-than-optimal weight loss or weight regain, you might experience more difficulty getting approved. This depends upon your specific insurance provider and plan.

Why Comprehensive Care Matters

Jefferson Health’s Comprehensive Weight Management Department, one of the region’s largest programs, offers all services for weight management – nutrition support, lifestyle education, medical weight loss options and surgical weight loss options, as well as experienced bariatric surgeons who can help you make precise decisions about the available options. The department takes a team approach to weight management, making sure you learn about your own physiology and how healthy changes can impact your body and weight. “We take an educational and supportive approach to weight management,” Dr. Antanavicius says.

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