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Revisional Bariatric Surgery
The Weight Loss Surgery Center offers a comprehensive set of options for patients who have already undergone bariatric surgery.
Many operations that were at one time considered attractive in theory and in initial outcome have led to unanticipated and unpredictable consequences. Moreover, inappropriate patient selection, poor patient education, and lack of a multidisciplinary approach have contributed to failure of prior weight loss surgery.
As one example, the jejunoileal bypass operation was abandoned many years ago because of unintended metabolic complications. Many of these operations were converted to Roux-en-Y gastric bypass. More recently, the vertical banded gastroplasty (VBG) operation has fallen out of favor because of unsatisfactory weight loss and band-related complications.
Our Approach to Revision
Revisional weight loss surgery is far more complex than the first operation. Our first goal is to understand why the initial operation failed. There can be many reasons for failure and we enlist a multidisciplinary team of dieticians, psychologists, radiologists, and endoscopists to try to determine the exact reason(s).
Anatomy of Prior Operation
The first goal of this evaluation is to find out if the prior weight loss operation is anatomically intact. We do this by asking patients to obtain their old operative reports from the hospital where they had their surgery so that we understand precisely what operation was performed. This is important so that if we consider re-operating we understand the exact manner in which the prior operation was performed so our revision operation can proceed safely.
Then, our surgeons perform upper endoscopy with a camera to view the inside of the stomach and assess the size of the previous stomach pouch, the positioning of the band (if present) and any problems with erosions or strictures. We also do biopsies of the inside of the stomach for any abnormal appearing areas. Finally, patients undergo upper gastrointestinal barium swallow study (UGI) in the radiology suite to determine the precise size and connections of the esophagus, stomach, and other intestines (such as the Roux limb of intestine).
The second goal is to determine if the patient is complying with dietary restrictions and behavior modification.
We require all patients being considered for revision to undergo preoperative counseling with a bariatric dietician and psychologist or psychiatrist to ensure that healthy techniques for eating are being used, a formal exercise program is underway, and that behavior is modified prior to undergoing revisional operation.
Indications for Revision
These depend on the type of operation that each patient underwent previously. For patients who have previously undergone vertical banded gastroplasty (VBG), the most common indications for conversion are as follows:
- Unsatisfactory Weight Loss - whether the operation is anatomically correct or not.
- Stomal Stenosis or Dysfunction - sometimes the ring or mesh used to band the stomach has caused the opening into the lower stomach to be too narrow.
- Silastic Ring or Mesh Erosion - this can lead to bleeding, nonhealing ulcers, obstruction of the stomach and perforation.
- Reflux Symptoms (heartburn) or Barrett's Esophagus--these are caused by backward flow of stomach juices into the upper pouch.