BMI

It requires a lot of motivation for obese subjects to convince themselves for surgery. Now, imagine after the entire ordeal, the patient either does not have an adequate weight loss (failed promises can go down very badly with anyone, you know) or, someone develops undesirable side effects (nutritional deficiencies, chronic vomiting, hernias mainly) after bariatric surgery. It can be a huge emotional setback for obese patients. Embarrassing question like “ why the procedure did not work for me?” or “I did everything you told me” will pop up. Bariatric surgeons must be ready to understand the situation and answer them. In this article we will concentrate, for the sake of brevity only on revision bariatric surgery for inadequate weight loss.

Overview

When these situations arise, the surgeon has a lot of work to do. As starters, he or she needs to find out what caused it. Is it the technical failure of the procedure or is it the noncompliance of the patient to diet and lifestyle modifications? The patient can cheat too, you know.

On the basis of what is wrong, surgeons may recommend medical management in terms of dietary and lifestyle modification or another intervention (which is technically called revision bariatric surgery).

Common scenarios

The common bariatric procedures are – Lap Band, Lap Sleeve Gastrectomy and Lap Gastric Bypass. Most of the problems of inadequate weight loss are seen in Lap Band and Lap Sleeve Gastrectomy. This happens because these procedures work on the principles of only restricting the quantity of food and drinks. This makes it possible for the patient to eat and drink, however little in quantity, high calorie dense foodstuff (colas, chocolates, for example) and thus cheat. Obviously these subjects are not going to lose weight adequately. Also the Lap Band in particular has a high failure rate due to slippage, malposition and erosion of the band. The Lap Gastric Bypass is immune to this cheating as because the procedure makes the patient intolerant to sugary foods and also because it works by causing non absorption of ingested food, too. However, it is still possible to have inadequate weight loss after Lap Gastric Bypass if the pouch (small remnant of the stomach which is joined to intestine) is large sized or if the stoma (orifice joining the stomach and intestine controlling the speed of transit of food) is big.

What to do? Or not to do

The best thing to do in “cheaters” are to identify them before surgery and tell them politely that it is not going to work for them unless they are going to participate in the weight management process too. Even better, refer them to your friends. Why suffer with a poor reputation at the expense of a noncompliant patient. If identified after surgery, these patients need to be managed by counseling regarding food habits alone. Mostly they do not need surgery.

The other situation of inadequate weight loss may be due to technical reasons like dilatation of the pouch/ remnant stomach after the primary bariatric procedure. This may be due to faulty technique (big pouch, inadequate removal of stomach especially the fundus) or due to gorging (excess food here acting as a dilator). The latter is because of binge eating disorder, something that should have been identified and eliminated before surgery. These patients will benefit from revision surgery.

What are the surgical options?

The following are the commonest options for bariatric revision procedures1:

1. Lap Band – an inflatable silicone prosthetic device that is placed around the top portion of the dilated left over stomach. This will slow down the passage of food from the stomach to intestine and decrease the eating. This procedure can be performed as a revision procedure for patients who have had a Sleeve Gastrectomy or Gastric Bypass surgery but have regained weight due to dilatation of the pouch/ remnant stomach.

2. Lap Gastric Bypass is a commonly chosen revision technique2 particularly in patients who have not been successful in meeting their weight loss goals after Lap Band or Sleeve Gastrectomy. Often the really really obese (super obese) may be offered this as a preplanned strategy as a two stage procedure. Here, the first operation is usually a Sleeve Gastrectomy and the second surgery in the form of Gastric Bypass is performed only after a modest weight loss has taken place. This reduces the risk of complications with a single shot gastric bypass that is a technically more demanding procedure especially in the super obese. The weight loss success rate after Gastric Bypass revision surgery is generally excellent.

3. StomaphyX is a new kid in the block. This procedure is a completely endoscopic procedure3. This obviates the need to perform any second surgery. Imagine, having an option where no scalpel (for the second time, for God’s sake!) is required. Here a stretched gastric pouch is made smaller by using internal sutures or fasteners through an endoscope. It may be used in patients who have had prior Gastric Bypass surgery and have a stretched stomach pouch.

Outcome of revision bariatric procedures

The revision procedures should not be taken lightly. They have their own share of problems despite their efficacy. In a recent article published in 2010, Dr Spyropoulos4 has published data regarding the outcome of revision bariatric surgery. As can be obviously guessed, it is way higher than with initial procedures. The anastomotic leak rate is (the most important complication as far as safety is concerned) is 13.1%. Compared to the standard leak rate of 0.5-3% after primary bariatric surgery, this is hell of a lot. Hernias, stenosis (narrowing of outlet orifice) and intestinal obstruction are also more frequently seen.

However, the benefits are also encouraging. The weight loss achieved in revision surgery is substantial (body mass index drops from a mean of 55.4 kg/m2 to a mean of 35 kg/m2 ) and most patients are satisfied with the results.

Take Home Message

The message is that these procedures should be done by experts with experience to make it as safe as possible.

I have always found convincing patients for second surgeries (after any surgery for that matter) a difficult task. The patient may take the entire previous exercise as a failure. The patient may lose confidence in the surgeon. However the patient would also need to understand that the only failure is in giving up. And there are now options available (even endoscopic) to rectify the primary surgery if desired results are not attained. Having said that, we at BMI believe that the most important management of inadequate weight loss after bariatric surgery is to prevent them by identifying the noncompliant patients and by meticulously performing first surgery. If however, the weight loss is not adequate, the Revision Bariatric Surgery should be taken with utmost regard given to case selection and safety.

REFERENCES:

1.Medical and surgical options in the treatment of severe obesity, Barry L. Fisher, M.D., Philip Schauer, M.D., American Journal of Surgery, Volume 184 • Number 6B • December 2002

2.The weight reduction operation of choice : vertical banded gastroplasty or gastric bypass, Capella JF et al. The American Journal of Surgery, ISSN 0002-9610, CODEN AJSUAB

3. The role of endoscopy in bariatrics, Shou- jiang Tang MDa and Don C. Rockey MDa, 2008 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc.

4. Spyropoulos C Arch Surg. 2010;145:173- 177.