What is revision bariatric surgery and when is it indicated?

Revision bariatric surgery may be necessary when:

• an intervention does not achieve its goal or fails over time. In other words, when the weight loss is not as expected and the weight is regained over time (weight regain); 
• complications arise, such as:
  • dysphagia;
  • vitamin deficiencies;
  • malnutrition;
  • onset of gastroesophageal reflux. 

“The basis of successful bariatric surgery is, on the one hand, the correct choice of the best surgery for the individual patient, and, on the other hand, the perfect execution of the surgery. 

A key role, however, is also played by the patient's focus on following the dietary and lifestyle directions prescribed after surgery and his/her psychological profile in his/her relationship with food,” Professor Olmi explains. 

If these conditions are not met, the results can be unsatisfactory both in terms of quality of life, as in the case of malnutrition or onset of other complications, and in terms of weight loss.” 

What happens if there is excessive weight loss 

After the first intervention, excessive weight loss may be triggered in some situations, which may result in a state of hydro-electrolyte imbalance or malnutrition. 

“The following frameworks are possible:

• after malabsorptive surgeries such as By-Pass, mini By-Pass, and biliopancreatic diversion: in this case, diarrhea with steatorrhea prevails as a warning symptom;
• after restrictive surgeries such as Sleeve (gastric sleeve or sleeve gastrectomy): in this case the warning symptom is vomiting. 

In both, it is imperative to identify the cause of malnutrition and weight loss that has gone beyond the desirable limits. This is often an anatomical alteration, caused directly or indirectly by the surgery,” Professor Olmi continued. 

What happens if the patient does not lose weight

At the other end, after the first surgery, there may be a failure of the patient to lose weight, which generates dissatisfaction thus leading to a new request for surgery. “In this case, the causes may be different:

• the patient may substantially alter the type of diet, a possible event particularly after restrictive interventions, becoming a “continuous eater” and a “sweet tooth.”
• the alimentary tract, and especially the stomach, may have undergone morphological changes, particularly with an adjustment in volume and an increase in reception capacity that frustrates the possibility of maintaining the achieved result. 

In all these cases, the surgeon is faced with the problem of Redo Surgery, which is characterized by a major technical commitment requiring a great deal of experience in the operating room and in interpreting the clinical picture, in order to perform a surgery capable of giving the patient a brilliant and lasting result.”

In the case of regaining some or all of the weight lost, there are several surgical techniques from which the specialist can choose depending on the patient's BMI, general condition, and the type of surgery he or she underwent the first time. Specifically, in cases of: 

• sleeve patients: depending on BMI, a re-sleeve, i.e. a second sleeve operation, or converting the sleeve to a By-Pass (RYGB) or the so-called single-anastomosis By-Pass without dissecting the stomach or duodenum so that the alimentary canal remains intact (SASI) can be performed;
• patients who have had a By-Pass: a revision with reduction of the gastric pouch (resizing), placing a small silicone ring (Fobi's ring, which slows the passage between the gastric pouch and the intestine), lengthening the distance between the biliary and alimentary loop, or lengthening the alimentary loop (SAGI) can be performed;
• patients with mini By-Pass: the surgery can be converted to By-Pass or the gastric pouch can be further reduced.

Revision surgery in gastroesophageal reflux disease

In the event that complications appear after the first surgery, the most common of which is gastroesophageal reflux, the technique that will be used in revision surgery must take into account not only the complication itself, but also the type of surgery the patient underwent the first time. Thus, in case of:

• sleeve patients with the occurrence of gastroesophageal reflux with or without hiatal hernia: the only solution is conversion to By-Pass and correction of the hiatal hernia. Performing a re-sleeve in a patient with acid reflux would further worsen the acid reflux;
• By-Pass patients with gastroesophageal reflux: often the cause is a hiatal hernia that needs to be corrected laparoscopically. There also may be a dilated gastric pouch that will need to be revised; or the food loop may need to be lengthened to reduce acid and bile reflux;
• mini By-Pass patients with acid or bile reflux or presence of ulcers at anastomosis site: can be converted to By-Pass.

Obviously, a preoperative evaluation is important in order to choose the surgery which would be best for the individual patient. All of these revision surgeries are performed laparoscopically.

Even in the case of revision surgery, follow-up, that is, the period after surgery in which patients undergo periodic checkups, is as important as the surgery itself in achieving the goals. 

“The follow-up visit consists of an interview with the surgeon, dietician, and possibly the psychologist. Visits are scheduled:

• at 1 month after surgery;
• at 3 months;
• at 6 months;
• at 1 year;
• from the first year onward, every year. 

Through interviews and evaluation of blood tests, it is possible to follow the progress of weight loss, make corrections in eating habits, correct any therapies, and prevent, identify and treat the occurrence of any long-term complications of surgery. A patient who does not scrupulously adhere to follow-up visits puts himself at risk of developing even severe complications that could have been avoided with the surgeon's or dietician's instructions and could lead to the need for re-intervention,” Prof. Olmi concludes.