Revisional Surgery/Redo Surgery
Revision bariatric surgery refers to different bariatric procedures that are undertaken after any primary weight loss surgery. Depending on the primary surgery there can be several reasons for that but most often its inadequate weight loss or weight regain later on. For instance when results of primary lap-band surgery are unsatisfactory or band is poorly tolerated the band removal with simultaneous gastric bypass or gastric sleeve surgery can be performed.
There is a good reason weight loss surgery patients usually do not have to be disappointed in long term surgical outcomes: good and sustainable weight loss, excellent control of chronic illnesses and improved quality of life. Today, surgery is and remains for a foreseeable future a single effective and accessible method of treatment for morbid obesity. If there would not be surgery those patients would practically have no chance for care.
Nevertheless it can't be stated that surgery is invariably effective and there is sometimes a gap between surgical outcomes and patients expectations. Weight loss less than expected, weight regain over years, uncomfortable side effects with nutritional issues are problems laying frequently behind dissatisfaction.
We perform 40-50 revision bariatric surgeries per year (250-300 primary procedures). Most of them can be performed safely laparoscopically even after open primary surgery. Revision procedures are always complex implying excellent surgical skills and understanding anatomic and surgical principles that are prerequisite for sustainable weight reduction. Detailed history of weight loss, appetite control, eating patterns and adverse outcomes after primary procedure is mandatory before considering redo surgery to understand what has gone wrong. Additional instrumental investigations like upper gastrointestinal endoscopy and radiography are always used before elaborating definite treatment plan.
Weight loss after revision bariatric surgery is usually slower and smaller than that would be after primary surgery. Usually, a loss of 50% of excess weight patient is having at the moment of secondary surgery can be expected and considered satisfactory.
Reasons for poor surgical outcome
Treating obesity is like treating any other chronic and multi factorial health condition. Hardly ever is there one universally effective method available for achieving equal results in all patients. Combining and re-doing different surgical procedures gives us a chance to overcome those limitations. Disappointing or non-durable results of primary weight loss surgery do not automatically mean permanent failure of treatment.
Patient related
All patients vary in their biological response to surgery and in certain cases a well performed and technically correct primary procedure does not give expected results regardless of patients adherence to dietary and lifestyle guidelines after surgery. Also, the side effects of otherwise effective procedure may prove to be intolerable like severe hypoglycemic episodes after gastric bypass or heartburn after sleeve gastrectomy. A revision surgery can strongly be considered here with excellent results.
On the other hand, inability and unwillingness to change ones lifestyle after surgery, or substance abuse occasionally may lay behind failure and it is unlikely that secondary surgery would improve the outcome without adopting new habits.
Some medicines may increase appetite by affect eating behavior and metabolism leading to weight regain after good initial weight reduction. Revising medicine lists and searching for alternatives should be considered here.
Surgeon related
Technical errors made in primary surgery may reveal themselves 1-2 years later when initial excellent weight loss is halted and replaced with weight gain. For instance, oversized gastric pouch in gastric bypass or gastric sleeve too large in diameter may enable good initial weight loss followed by loss of restriction and appetite control later, leading to weight regain. If the patient is well motivated and follows the lifestyle guidelines their revision surgery may have excellent results here. A prerequisite for efficient revision is understanding of normal weight loss facilitating post-surgical anatomy and recognition of the technical shortcomings in every particular case.
Procedure related
It is obvious, that not all weight loss procedures can stand the test of time and some of them inherently require further actions. In up to 10 years perspective gastric band can function predictably and satisfactorily but being a foreign body it eventually breaks down or migrates losing its effect. Longstanding weight loss after sleeve gastrectomy may fade as gastric tube stretches out resulting in loss of restriction and portion control.