When to Revise a Weight Loss Surgery
A small number of patients who have weight loss surgery relapse years later. How much depends on the procedure they originally had to address their obesity. These individuals may benefit from an additional procedure, called revision surgery, to help them lose again and treat specific symptoms.
There are many different factors that might contribute to weight regain. Revision surgery may be done because the patient's anatomy has changed over time and needs repair. "Patients also come to us for help because they've gained weight related to behavioral changes or some new stress in their lives," says Dr. Abraham Krikhely, of the Columbia Center for Metabolic and Weight Loss. "Others have had gastric band procedures and now see their friends or family members getting better results after the sleeve gastrectomy or the gastric bypass. Now they want these benefits."
In this interview, Dr. Krikhely describes when and how revision surgery can help.
Why do some individuals end up putting the pounds back on—regaining enough weight to consider another operation?
Simply put, life happens. Weight gain a few years after bariatric surgery is often the result of personal changes. You regain because you've had kids, you've just left a relationship, you've changed the way you eat, your finances took a hit, you have a new job, or maybe because you've just stopped exercising. Circumstances play a big role and so does attitude. I often tell my patients, "The shape of your stomach is less important than the shape of your mind."
Obesity is a chronic disease, and while weight loss surgery can be life-saving, it is not a cure. Its success also depends upon one's ability to stick to certain lifestyle and nutrition guidelines.
If my patients start losing ground I ask them to take stock of their situation. Then we discuss how they can get them back in balance. It's critical to deal with lifestyle components before talking about a further surgical intervention. The most important thing is to find out if people are making the right food choices, exercising enough, and doing everything possible to stick to a healthy program. So that's where we start.
Some regain their weight for anatomical reasons. You might come for revision surgery if your stomach has stretched out allowing you to eat more than you did right after your initial surgery. This is not a failure—it is normal and we expect the stomach to stretch with time.
We also learn from our experience as surgeons. Today we can do things that were not available ten years ago. And so, some patients come to us asking for a new procedure that will make it easier for them to lose weight faster.
When revision surgery is called for, what are the options?
It depends on your particular life situation and what surgery you had initially. We will often start with an esophagram, an x-ray of the esophagus and stomach, to evaluate the general shape of your anatomy. Once we have this information, we can see what options might be right for you.
The most common revision we do is for patients who previously had a Lap Band, an adjustable silicone band, placed around the top part of the stomach to restrict food intake.
That surgery was very popular until a few years ago but about a third of those patients now require additional surgery to lose weight, because there has been a loosening or slipping of the band over time. If you're in this category, you may be a good candidate for revision to a sleeve gastrectomy or a gastric bypass.
In sleeve gastrectomy, a portion of the stomach is removed and the stomach is reduced in size, leaving a sleeve or tube-like structure. Patients eat less due to both the small size of the stomach and change in hormones affecting appetite.
In gastric bypass, the stomach is divided into a small upper pouch that processes food and a much larger lower portion that is bypassed. Then the small intestine is then connected to the pouch. After this operation, the stomach is smaller and there are also changes in hormones affecting appetite.
Hormone changes after sleeve and gastric bypass make these weight loss operations particularly effective at reducing diabetes.
In gastric bypass, the flow of acid and bile is also redirected away from the esophagus, making this is a very effective way of treating heartburn.
How do you choose the surgery that's right for each patient?
This depends on the success of your initial operation. Let's start with the Lap Band, which has the highest rate of revision.
Removal of the band and conversion to a sleeve or bypass can be often done in one stage. If there is extensive scar tissue, however, it is often better to let that heal and then proceed with a sleeve or bypass a few months later. With a bypass we can generally work around the scar tissue, so if you have significant scarring that will be the better option.
Another factor we consider a patient's likelihood of developing acid reflux. About 20% of patients who get a sleeve have this problem. We have to get the shape of that sleeve just right in order to minimize reflux, and much depends upon the surgeon's skill. That's why it's important to come to a center like ours with extensive experience in revision surgery.
Do you perform revisions after the sleeve and bypass operations as well?
Yes, but not as often.
Research shows that two years after the sleeve operation, the volume of stomach can double—as I've said, that's natural and it's no one's fault. As the stomach expands, some patients begin to eat more. This group may benefit from a revision. Options include conversion to a bypass, conversion to a duodenal switch or re-sleeving.
A conversion to a gastric bypass is particularly effective for those who also have an element of reflux as the bypass would treat both the reflux and help with weight loss.
The duodenal switch, a combination of the gastric sleeve and a bypass of the intestines, however, has demonstrated the best weight loss. Yet because of the amount of intestines bypassed, there is a greater risk of vitamin deficiency. Patients need to take vitamin supplementation regularly and follow up with our care team.
Years ago the duodenal switch was routinely done for patients with a high BMI. As this surgery was time-consuming, surgeons started performing it in two stages, months apart. The sleeve gastrectomy was done first, and then after initial weight loss, the surgeon completed the intestinal bypass. Many patients had such good results with the sleeve alone they did not need the second step. Now, when sleeve patients require more weight loss, we can complete the duodenal switch.
In a few cases, we may also consider re-sleeving—trimming a portion for the stomach that has re-expanded to create a smaller tube, or sleeve.
What about revisions for gastric bypass patients?
After a gastric bypass, the stomach also stretches out, and we can place a band around the stomach to restrict intake. Dr. Marc Bessler pioneered this procedure here at Columbia.
Another option is a stapled reduction of the pouch, also thought of as "sleeving the bypass." That means removing a portion of the pouch and reducing the size of the passageway to the intestines, thus restricting the amount of food a patient can ingest.
A third option is to bypass even more of the intestines, so patients absorb fewer calories.
A fourth option is endoscopic repair. Without making any incisions, we can tighten the connection between the stomach and intestines, making it tighter and restricting how much you can eat. While this approach is promising, we don't yet know how long the results will last.
What types of revision surgery are reimbursed by insurance?
Insurers all have different requirements, but they generally cover revisions to the band, sleeve or bypass to address weight regain, if you meet these criteria: If your BMI is greater than 40, or if you have a BMI of 35 along with a medical problem related to obesity. Endoscopic revision is not covered at this point.
What is the recovery time for revision surgery?
It takes a day or so longer than the original surgery because revisions involve dealing with scar tissue, and altered blood supply. You may have to stay in hospital for two to three days to be monitored. But recovery at home is about the same, with most patients resuming their normal schedules in a couple of weeks.
What kind of results do you see after these procedures?
We have very good outcomes. I recently revised a gastric sleeve operation to a gastric bypass for a middle-aged man. He lost more weight, his reflux went away, and he's happy because he has a new lease on life. Many patients use this surgery to get a second start.
What makes Columbia a primary center for revision surgery?
When people start to gain weight, we look at the whole picture. A relapse can be related to genetics, environment, food choices, behavioral patterns, or new life stresses. We address those factors first. Then a revision surgery has a better likelihood of succeeding. Because we're known for our surgical expertise, we get many referrals for these re-operations.
Our licensed social worker offers group sessions on diet and behavior both before and after the procedure. Physicians in our COMMiT program focus on managing diabetes, supervising a patient's response to dietary changes and providing medications that suppress appetite and metabolism. A gastroenterologist also plays a key role in keeping our patients healthy.
At the Columbia Center for Metabolic and Weight Loss Surgery, a multidisciplinary team provides the highest level of patient care. Our goal is to help guide our patients through a challenging time so they can take ownership of their lives again.