Revision Weight Loss Surgery in Mexico
Patients may inquire about revision weight loss surgery for several reasons. A single weight loss surgery procedure is sufficient for many patients, providing adequate long-term weight loss. For others, a single weight loss surgery procedure may not cause the desired results, either through insufficient weight loss, poor resolution of co-morbidities and/or medical complications resulting from the weight loss surgery itself. Dr. Alberto Aceves is an experienced weight loss surgeon Mexico patients turn to in order to receive high-quality treatment that yields long-lasting results. He works with patients to help them understand all of their weight loss options.
Risks and Results of Revision Weight Loss Surgery
Revision weight loss surgery is a big decision and the decision should be based upon the risks versus the benefits. Revision weight loss surgeries are generally riskier than the first time a weight loss surgery is performed. The following reasons make revision weight loss surgery higher risk:
- Revision weight loss surgery procedures generally take longer.
- Open incisions are frequently but not always needed.
- There is greater blood loss.
- Leaks and infections occur more frequently. It is thought that leak rates increase due to changes in blood flow to the stomach caused by the original weight loss surgery.
The results of revision weight loss surgery are relatively predictable when it comes to the treatment of medical conditions. With this said, predicting the impact of revision weight loss surgery on weight loss itself, is less accurate. It is common to see less weight loss after revision weight loss surgery than if the procedure was being done for the first time. The reason for this is metabolic, where metabolic adaptations occur after the initial weight loss surgery, making it more difficult to lose weight after revision weight loss surgery. Individuals who are metabolically obstinate, fail more frequently after the initial weight loss surgery.
Due to the unique needs of each and every patient seeking revision weight loss surgery, each revision must be tailored to meet the particular needs of the patient.
Reasons for Revision Bariatric Surgery
Inadequate Weight Loss and/or Weight Regain
Of the reasons to have revision bariatric surgery, inadequate weight loss and/or weight regain is the number one reason patients seek revision bariatric surgery. Not every patient is the "average" patient and therefore may not lose weight as a result of any one type of bariatric surgery the way an average patient would. Where one type of bariatric surgery meets the needs a particular patient, the same surgery may not meet the needs of another patient; of course there are reasons for this.
- A patient may not adapt well to the lifestyle required after a particular bariatric surgery.
- Perhaps a specific bariatric surgery does not address the metabolic needs of a patient.
- There are anatomical changes made to a patient's body during bariatric surgery and these changes are not always maintained.
Bariatric surgery may fail for all of the above reasons.
It must first be established whether it is the patient who has failed the bariatric surgery, or the bariatric surgery that has failed the patient. Patients may not be properly educated on how to make their bariatric surgery work best for them. While ensuring proper education prior to bariatric surgery will help a patient achieve and maintain weight loss, adequate long term care and support may be all a patient needs to get “back on track.” After a period weight regain however, it may be extremely difficult for a patient to lose the weight they have gained back.
Quite frequently, the bariatric surgery metabolically and/or mechanically fails the patient.
Mechanical failures are caused when the anatomical changes made during the original bariatric surgery, are not maintained. Examples of these changes are as follows:
- the pouch may stretch and become larger
- the outlet of a gastric pouch may increase in diameter
- a gastro-gastric fistula may form between the gastric pouch and the bypassed stomach
- the intestine may increase its absorptive abilities beyond what was expected
- restriction may decrease as a result of a band slippage
Reconstructing the original anatomy created during the first bariatric surgery may work for the above cases, restoring the environment that allowed for weight loss initially. Re-trimming a dilated gastric bypass pouch or re-trimming a stretched-out vertical sleeve gastrectomy, are options for treating pouches that have stretched and enlarged. A suitable fix for a dilated outlet requires placing a band around a dilated gastric bypass outlet. It was previously suggested that deteriorated staple lines of gastroplasty procedures could be re-stapled, but due to the high long term failure rates of gastroplasty procedures, it is now recommended that gastroplasty procedures be converted to a different bariatric surgery type.
There are instances where bariatric surgery fails to meet the metabolic needs of patients.
Success after bariatric surgery involves more than just eating properly. A patients metabolism does influence weight loss/ weight maintenance. When patients fail after bariatric surgery for metabolic reasons, this is know as "Metabolic Failure." Where corrective procedures for mechanical failure of bariatric surgery attempt to restore the previous anatomy, correcting metabolic failure involves converting the patient to bariatric surgery type that is more metabolically active. A prime example of this would be to convert a Gastric Bypass to a Duodenal Switch instead of re-trimming the pouch.
Unsatisfactory resolution of co-morbidities after bariatric surgery is an additional reason a patient may consider revision or conversion bariatric surgery. Unsatisfactory resolution of co-morbidities is generally related to the factors causing metabolic failure, as unsatisfactory resolution of co-morbidities generally coincides with insufficient weight loss and co-morbidities are strongly associated with metabolism. Cases involving unsatisfactory resolution of co-morbidities, require a similar approach as cases of metabolic failure, usually requiring conversion of the failed bariatric procedure, to a more metabolically active bariatric surgery type.
As a result of bariatric surgery, some patients do have medical complications that must be treated with revision bariatric surgery. In some cases, treating medical complications with revision bariatric surgery will be similar to the treatments previously discussed for mechanical and metabolic failure, but others may require reversal of the original bariatric surgery while weight loss is preserved. Possible medical conditions requiring revision include the following:
- severe dumping
- metabolic bone disease
- iron deficiency/anemia
- vitamin deficiency
- vitamin-D deficiency
- thiamine (vitamin B-1) deficiency.
Lap Band Revision Surgery
After Lap Band patients may need revision weight loss surgery for a number of reasons. The Lap Band could slip leading to a slow chronic condition or an acute condition requiring emergency surgery. Both circumstances ultimately lead to the Lap Band not functioning the way it should. While each circumstance is different, treating these issues may require removing the Lap Band, repositioning the Lap Band or replacing the Lap Band all together. Removing the Lap Band obviously opens the door for potential weight regain.
Lap Band erosion is another possible complication of Lap Band surgery. Lap Band erosion occurs when the Lap Band causes a hole to be worn into the stomach, making the Lap Band rather ineffective. Patients may experience a single occurrence of vomiting blood as the first signal of Lap Band erosion. The most frequent symptom of Lap Band erosion is an infection around the site of the port. Due to erosion caused by the Lap Band, saliva leaks through the hole in the stomach and flows along the Lap Band tubing, causing the tissue under the skin of the Lap Band port to become infected. Treatment requires removing the Lap Band, leaving the patient with no weight loss surgery and a high likelihood of weight regain. It is often recommended to treat Lap Band erosions by converting the patient to a procedure based upon the Vertical Sleeve Gastrectomy; this could be the Vertical Sleeve Gastrectomy itself, the Duodenal Switch or Ileal Transposition. Since the portion of stomach that has been eroded is weakened and more prone to leaking, these weight loss surgery procedures can be completed with little cutting to the eroded area.
The Lap Band may simply fail to produce the desired results and require revision bariatric surgery. Lap Band is a restrictive weight loss surgery and some patients may not have the metabolism needed to lose weight with the Lap Band. Other patients may not be able to eat the way that is needed to achieve success after Lap Band. This may in turn lead to maladaptive eating behaviors ultimately resulting in failure and/or weight regain. Lap Band failures may be converted to any other weight loss surgery but it should be considered that a patient will more likely achieve success if a more metabolically active procedure is performed instead of a purely restrictive weight loss surgery. There is a decent amount of evidence suggesting that a well managed Lap Band is almost as good as Gastric Bypass over time, since both depend on maintaining restrictive eating via a similar size pouches. Converting a patient to Gastric Bypass after Lap Band failure will produce marginal results and put the patient at risk for developing a leak.
For patients who want nothing but restrictive weight loss surgery, Vertical Sleeve Gastrectomy is a great option. Vertical Sleeve Gastrectomy will still be limited by the metabolic activity of the surgery itself, in addition to the patients metabolism, but there are several reasons why the Vertical Sleeve Gastrectomy will produce better results than the Lap Band over time. As mentioned previously, Duodenal Switch and Ileal Transposition are two weight loss surgery procedures that offer patients metabolic mechanisms to cause weight loss in addition to restriction. If a patient is willing to undergo Duodenal Switch or Ileal Transposition, these procedures will offer weight loss advantages beyond what the Lap Band can offer.
Gastric Bypass Revision Surgery
Roux-en-Y Gastric Bypass
Gastric Bypass patients generally seek revision weight loss surgery for two reasons: 1) failure to lose adequate weight and/or weight regain, 2) medical complications (medical complications after Gastric Bypass may lead to failure). Failure after Gastric Bypass may be due to mechanical or metabolic reasons; the eating behaviors of a patient should be considered as well. In fact, the first step in assessing a patient who has failed to lose adequate weight after Gastric Bypass, is to look carefully at the patient's food consumption. The best way to analyze food intake is to simply start a detailed food diary. Patients are often shocked at how many calories they do consume on a daily basis. While we may think we have a good idea of our food consumption, it only takes tracking food intake in a food diary to get a true picture of how much we consume. When patients are not eating how they should, getting back on track is the next step.
There are a variety things that could happen next:
- Some patients are able to return to the type of behavior they should be following, essentially getting back on track.
- Some patients may not be successful at weight loss despite returning to proper dietary behaviors.
- Other patients are never able to return to proper eating habits. This could mean a patient is non-compliant but not necessarily.
There are mechanical reasons that may cause patients to resort to maladaptive eating behaviors. An example of this is a patient with an anastomotic stricture who slips into the "soft-calorie syndrome" due to the fact that soft foods are the only foods that the patient can tolerate without vomiting. Another point to consider is exactly what "compliance" is after Gastric Bypass. "Proper" eating after Gastric Bypass represents an entirely foreign pattern of eating for the majority of humanity who have not had weight loss surgery. Some individuals are just not "wired" to live this type of lifestyle, even with the assistance of a small gastric pouch. A person's character, for better or worse, does not necessarily contribute to this problem.
Gastric Bypass may fail for the following mechanical reasons:
- gastro-gastric fistula
- pouch dilation
- anastomotic dilation
Gastro-gastric fistula is where the stomach pouch grows back and re-connects to the bypassed stomach. This can occur as a consequence of a pouch leak, where the resulting local inflammation from the leak disrupts the staple line of the bypassed stomach where it lies next to the pouch. More often though, gastro-gastric fistula formation is a result of a less acute, slower process. Regardless the cause, gastro-gastric fistula allows food to pass from the pouch to the bypassed stomach, effectively partially reversing the Gastric Bypass. Revision surgery for this condition may consist of closure of the fistula, restoring the original surgical Gastric Bypass anatomy. Conversion to a Vertical Sleeve Gastrectomy based procedure is an option as well, especially if there are reasons other than mechanical failure to explain the patient’s weight gain.
Pouch dilation is a condition where the stomach pouch stretches out and enlarges; anastomotic dilation is where the connection between the stomach pouch and the intestine stretches out. Both conditions result in allowing the patient to eat more than what would be required to remain successful. Re-trimming the pouch to make it small again is one approach to treating pouch dilation. Surgical banding and endoscopic fixation are two approaches to treat an enlarged anastomotic connection. These approaches to pouch and anastomotic dilation are both directed at restoring the anatomy of the Gastric Bypass procedure back to what it was prior to stretching out. Another approach is to make a paradigm shift and convert to a more metabolically active procedure such as Duodenal Switch. Other Vertical Sleeve Gastrectomy based procedures are options as well, especially if the patient’s Gastric Bypass is complicated by nutrient malabsorptive issues, such as osteoporosis and anemia.
Conversion from Gastric Bypass to Duodenal Switch is the most definitive revision procedure for inadequate weight loss or weight regain after Gastric Bypass. This approach addresses the issues of metabolic failure and maladaptive eating as causes of failure. This conversion may be done laparoscopically in many cases. A potential concern with this procedure is proper stomach function after surgery. The bypassed stomach is now brought back into use, and some patients may have had the nerves to the bypassed stomach cut during their original Gastric Bypass procedure. This is rarely a problem, as the nerves seem to grow back as the bypassed stomach “wakes up” and resumes working again. Sometimes it may not be safe to re-connect the gastric pouch to the bypassed stomach due to excessive scar tissue. If the patient has acceptable protein tolerance and satisfactory calcium metabolism, conversion to a Scopinaro-type Bilio-Pancreatic Diversion makes a very satisfactory option.
Medical issues complicating Gastric Bypass include marginal ulcer, stricture, and severe dumping syndrome. These conditions may often be treated conservatively, but when conservative treatment fails, revision surgery is indicated. Treatment for ulcer or stricture may involve resection of the ulcerated/strictured connection between the pouch and the intestine. Another approach is to convert to a Vertical Sleeve Gastrectomy-based procedure, as stricture and marginal ulcer are conditions that arise as a result of the intrinsic physiology of Gastric Bypass. This approach is favored for cases of severe dumping as well, as it is the inherent nature of the Gastric Bypass itself that results in the condition. Rarely, reversal of Gastric Bypass may be necessary to treat cases of malnutrition, including issues of vitamin and mineral malabsorption. Reversals for nutrient malabsorption may be accompanied by revision to a non-malabsorptive weight-loss procedure, allowing patients to stave off any weight re-gain that may otherwise result from the reversal of their malabsorption.
Mini Gastric Bypass
Revision of Mini Gastric Bypass operations are the same as for Roux-en-y Gastric Bypass. Bile reflux is a potential condition unique to this type of Gastric Bypass. Although bile reflux is uncommon and the concern is more theoretical than actual, converting the Mini Gastric Bypass to Roux-en-Y Gastric Bypass is sufficient to treat this condition. This is a fairly straightforward revision to complete and is performed without having to interrupt the first connection made between the stomach pouch and intestine.
Vertical Banded Gastroplasty (VBG) Revision Surgery
Patients who have had Vertical Banded Gastroplasty (VBG) or other “stomach stapling” procedures, generally seek revision weight loss surgery for two reasons, 1) weight regain and, 2) maladaptive eating. While some failed Vertical Banded Gastroplasty cases can treated by re-stapling and re-banding, the majority of these cases require conversion to a more substantial procedure. Since many patient’s bodies are reluctant to lose weight after a failed weight loss surgery, restriction alone will not cause adequate weight loss, therefore conversion to a more metabolically active weight loss surgery is necessary. Revising the Vertical Banded Gastroplasty or other stomach stapling procedure to Duodenal Switch is one option that can be performed laparoscopically. For individuals who have had Vertical Banded Gastroplasty, removing the band is not always needed during a revision to Duodenal Switch.
Since there is a significant number of different stomach stapling procedures, there are a variety of ways an individual’s anatomy may change after surgery making it necessary that each case be treated uniquely.
Vertical Sleeve Gastrectomy (VSG) Revision Surgery
Although Vertical Sleeve Gastrectomy (VSG) is effective for many patients, some do not lose adequate weight, therefore revision weight loss surgery may be needed to cause additional weight loss. Failure after Vertical Sleeve Gastrectomy may be caused by a couple of different factors.
- If a stomach has been stretched, re-sleeving of the stomach may be a sufficient revision procedure.
- Other individuals may require the addition of metabolic and malabsorptive aspects to compliment Vertical Sleeve Gastrectomy. Procedures such as the Duodenal Switch and Ileal Transposition may be appropriate.
Most revision operations are higher risk than the first time a weight loss surgery procedure is performed. Revision of Vertical Sleeve Gastrectomy to Duodenal Switch actually carries with it less risk than performing the Duodenal Switch in a single operation for the first time. This is possible due to the fact that Vertical Sleeve Gastrectomy is one portion of the Duodenal Switch procedure. When converting to Duodenal Switch from Vertical Sleeve Gastrectomy, a significant piece of the operation has already been performed. This results in a smaller surgical procedure than performing the Duodenal Switch all at once.
Stretching of the stomach often results in additional problems other than inadequate weight loss or weight regain. The tube of the stomach may stretch in a manner that is not uniform, resulting in portions of the stomach tube being larger than others. This can cause the stomach to become shaped like an hourglass, where both the upstream and downstream portions of the stomach are large, but they are separated by a portion of the stomach that is fairly narrow. While eating may not increase as a result of a stretched stomach tube, it may cause uncomfortable and/or disordered eating. Depending on the volume of food a patient consumes at each meal and the symptoms they have, there are a couple of revision options that all result in food flowing more directly through the stomach.
Duodenal Switch (DS) Revision Surgery
Approximately 2–5% of Duodenal Switch patients may be candidates for revision weight loss surgery. As we become more adept at understanding the balance between weight loss and malnutrition, the number of patients requiring revision surgery after duodenal switch will likely decrease, but never be eliminated completely. The most common reasons for the revising Duodenal Switch include the following:
- excessive weight loss
- inadequate weight loss
- nutritional deficiencies caused by malabsorption
Some of the clearest issues requiring surgical correction after Duodenal Switch are nutritional deficiencies caused by malabsorption and excessive weight loss, both of which often occur simultaneously. As with most things, timing plays a significant role in success. As time goes on, the malabsorptive effect of Duodenal Switch decreases as the intestine becomes increasingly efficient at absorbing protein and other nutrients. Therefore, revising the Duodenal Switch should not be done too early in patients who experience malabsorptive complications, rather, conservative therapy should be attempted prior to revision surgery, allowing sufficient time for the absorptive abilities of the intestine to increase. If enough time is not allowed and revision surgery is performed too early, patients risk regaining excessive weight after the intestine has increased its absorptive abilities.
Treating malabsorptive complications resulting from Duodenal Switch most often require adding intestinal length or elongation. Elongations of the common limb are possible utilizing the biliopancreatic limb, to attain specific results. A relatively common elongation procedure requires elongation of the alimentary and common limbs, providing additional surface area for protein, starch and fat absorption. Increased fat absorption abilities in turn increases ones ability to absorb fat soluble vitamins such as vitamin-D. Treating excessive weight loss and protein malnutrition with revision procedures after Duodenal Switch, simultaneously increase a patients ability to absorb fat soluble vitamins.
The easiest revision procedure that increases both alimentary and common limb length involves a single connection to the small intestine; this is also known as entero-enterostomy and by some, the “kissing-X.” The “neuro-endocrine brake” effect, generally enables patients to maintain some level of weight loss. The neuro-endocrine brake effect is also responsible for weight loss after Ileal Trasposition surgery.
Instances where calcium and iron malabsorption occur following Duodenal Switch, Ileal Transposition may be used as a means of intestinal elongation to treat these conditions. When Ileal Transposition is used in these cases, unlike a conventional Ileal Transposition, the Ileal Transposition can be done at the level of the duodenum, without having to re-connect the duodenum; after Duodenal Switch this is not an easy task. High Duodenal Ileal Transposition may only utilize a segment of the alimentary limb to perform the transposition. The rest of the alimentary limb is used for a “Parallel Ileal Transposition” at the level of the biliopancreatic limb. The Parallel Ileal Transposition joins the flow of food that resulted from the High Duodenal Ileal Transposition performed above. This restores calcium and iron absorption without entirely reversing the Duodenal Switch procedure.
There are some occasions where patients experience inadequate weight loss or weight regain after initial weight loss with Duodenal Switch. With the assumption that non-surgical weight loss attempts have been made and failed, there are two theoretical approaches to solve this problem,
- reduce the stomach size
- shorten the length of the common limb
While the results of these two revisions vary, reductions in stomach size seem to generate superior results over shortening the length of the common limb in North America.