Revision Bariatric Surgery

Although bariatric surgery is usually quite effective, at times, it does not work as well as one would like. In such instances, a revisional bariatric surgery procedure may be considered. It is important to remember that revision operations are more technically challenging and carry a higher complication risk. Patients need to seek out very experienced bariatric surgeons that perform revisional bariatric surgery procedures routinely. Not everyone who regains weight or fails to lose as much weight as they would have liked are candidates for revisional bariatric surgery.

One must stress that  morbid obesity is a multi-factorial disease, hence a multi-disciplined approach should be utilized to treat patients that have regained or failed to lose weight. Successful bariatric surgery starts with the operation. Some operations have been done much longer and have been proven to be more durable over time. Postoperative instruction and support is also very important. Snacking behavior, poor water intake, lack of exercise, and poor supplementation intake can all lead to poor outcomes. When patients are being evaluated for a revision in our program, a consultation with the surgeon is scheduled.

There are a few reasons for a patient with a gastric bypass to have inadequate weight loss. One of the most common is the stomach pouch or stoma,( the opening of the new stomach pouch to the small intestine), of a gastric bypass having been made too large by the surgeon Another possibility is the pouch and/or stoma stretching out over time. If the pouch is too large, than patients need to eat more to fill the pouch to feel full. If the stoma stretches out, food passes quickly from the stomach into the small intestine thus patients become hungry too soon after eating a meal. In all of theses cases, the patient may initially lose weight but eventually loses their sense of satiety or restriction and weight gain ensues. Usually an upper GI x-ray series or endoscopy will help us determine the pouch size, and to determine which of the revision options are best.

Fortunately, there is now a highly successful, safe option for gastric bypass patients that have been “left behind” in their weight loss.  A revision with Lap-Band surgery over the previous gastric bypass may be the answer — known as a banded bypass, or simply band over bypass. Whether you have regained weight after a gastric bypass or you never lost the expected weight, a band over bypass can give you back the restriction that you felt in the first months after your gastric bypass. The gastric banding surgery will give you the tool necessary to restore your ability to limit your food intake and promote a feeling of fullness (satiety) after meals.  This procedure is also considered safer than traditional revisional procedures. As with primary Lap-Band surgery, lap band over bypass surgery can most often be placed laparoscopically even if your initial gastric bypass was done open By placing a Lap-Band around the bypass can control the outlet of the stomach via the tightness of the band, in other words tighten down stoma and pouch and restore the restriction that you may have lost over time or even give you the restriction that your may have never had. Like the traditional or “primary” placement of an adjustable gastric band, in a band over bypass, a silicone band is placed around the stomach pouch and an injection port is attached to the abdominal wall under the skin. The port is connected to the gastric band with tubing. The silicone band is lined with an inflatable balloon that can be filled with saline (this can be done right in our office), via the access port in order to adjust the size of the stomach pouch and stoma. Adding fluid tightens the band and increases weight loss, while removing liquid loosens the band and reduces weight loss.

A second revision option for Roux En Y Gastric bypass patients who are seeking a revision is non-surgical endoscopic revisional surgery also known as a ROSE procedure, (Revision of Obesity Surgery Endoscopically), using the new Apollo OverStitch procedure for gastric bypass.

This gastric bypass revision procedure is performed using a four-channel tube and special Incisionless Surgery tools. The surgeon advances the flexible tube and a small endoscope through the patient’s mouth, into the stomach pouch. The surgeon will then insert the surgical tools through the channels of the tube. Tissue anchors are used to create multiple tissue folds around the stoma to reduce the diameter. The surgeon will then use the same technique to place anchors in the stomach pouch to reduce its volume. This results in slower emptying of the stomach and earlier satiety and more weight loss. The revisional bariatric surgery procedure also shrinks the stomach pouch and makes it small (similar to the original gastric bypass procedure).Due to the lack of external incisions, this procedure provides important advantages, including, less risk than traditional open or laparoscopic surgery, minimal postoperative pain, fast recovery time and no scarring. As with any weight loss procedure, results of gastric bypass revision vary with each patient. The OverStitch procedure is new and long term data are not yet available. Avoiding weight gain after gastric bypass is vital to improve your health and reduce the co-morbidities associated with obesity such as Type II diabetes, heart disease, joint disease and respiratory conditions. If you have started to regain weight since your initial surgery, ask your doctor about ROSE-OverStitch procedure gastric bypass revision.

There are many reasons why someone who has a Lap Band might consider revision surgery. Often, patients who had lap band surgery initially experience excellent weight loss, then the band fails for technical reasons like a port infection, lap band slip or erosion. Because these patients did have successful weight loss prior to the technical issue, repairing or replacing the band is an good option. Other lap band patients who never had good success with the lap band or have lost weight and then regained the weight for a non technical issue, converting to a different procedure is a path that should be strongly considered. In these patients converting to either a Sleeve Gastrectomy or a Roux En Y Gastric Bypass are good options. If a conversion is right for you, our experience shows that doing this in a “two stage” fashion is the safest. What is meant by a two stage procedure is first removing the band and taking down and eliminating any folds of the stomach that were meant to hold the band in place. We then wait approximately 2-3 months prior to conducting the next procedure whether it be a conversion to a Gastric Sleeve or Roux en Y Gastric bypass. We wait 2-3 months after removing a Lap Band because the stomach tissue becomes thickened as a reaction to the lap band. By waiting the 2-3 months, it gives your stomach time to recuperate and normalize closer to its original thickness from prior to the band. This more normal thickness stomach tissue holds the staples that are required to seal the stomach for a sleeve gastrectomy and gastric bypass better than the thicker stomach tissue does and appears to be a safer way of converting a patient from a band to a sleeve or bypass. On the other hand, if a patient had a technical issue with the Lap Band and decides to have the Lap Band repaired or replaced, this usually can be done in one stage and usually does not require a second operation but that determination is always made on a case by case basis as some exceptions do exist. You can learn about sleeve gastrectomy here. You can learn about gastric bypass here

Sleeve revision surgery should be considered when the initial sleeve has failed to achieve the desired results. Sometimes a patient who undergoes a gastric sleeve does not experience sufficient weight loss. This could be due to the sleeve being made too large by the initial surgeon (which oftentimes happens early in a surgeons experience conducting this operation), the sleeve stretching out over time, or the result of poor reduction of calorie consumption. Revision surgery is an excellent option for the first two types of problems whereas the third type patient would benefit mostly from proper instruction and can therefore avoid revisional bariatric surgery. The revisional options for sleeve gastrectomy include Re-Sleeving, placing a gastric band over the sleeve or converting to a Roux En Y Gastric Bypass.

• Re-Sleeving is an excellent option for those patients who have a sleeve that appears too large. After conducting an endoscopy, your surgeon will know first hand if the sleeve appears to have stretched or perhaps was made too large initially. Re-sleeving will involve re-sizing the stomach pouch again in a matter similar to the initial sleeve operation. Most of the time this procedure can be conducted laparoscopically and usually involves just an overnight stay in the hospital and return to light duty work in approximately 7-10 days. The risks of this surgery (including leaks, bleeding, gastric outlet obstruction) are slightly higher than the initial surgery but are still quite safe.
• Band over sleeve is an excellent option for those patients that appear to have an larger upper portion of the stomach (fundus), but have a narrow middle and lower portion of the stomach. Because of the narrow lower parts of the stomach, an attempt at re-sleeving could cause a blockage to the exiting part of the stomach and that would result in having to convert the patient to a roux en y gastric bypass to “bypass” the blockage.
• Converting to a Roux en Y gastric bypass is an option for patients who have inadequate weight loss, or who have severe reflux after sleeve gastrectomy.

1. If your BMI is 40 or higher, you qualify for revisional surgery
2. If your BMI is between 35 and 40 and you have a medical condition due to obesity, you qualify for revisional surgery
3. If you are having medical problems related to your procedure you may qualify for revision procedure without meeting the BMI criteria.

• The Insurance experts at the New York bariatric Group will verify your insurance benefits for you free of charge.
• The first step is to call or contact us to make an appointment with one of the experienced surgeons at the New York Bariatric Group.
• As a candidate for revisional bariatric surgery, you can expect to undergo a series of consultations and evaluations. A detailed comprehensive program has been developed to ensure your long-term health and safety pre- and post-surgery. A pre-operative endoscopy performed by your surgeon is required to see your anatomy and to see if you are a candidate for revisional surgery.
• Dr. Garber explains how you can initiate the process to become a new healthier you.
  Watch video
• You will receive extensive patient education from our psychologist who will perform a psychological evaluation that is required by the hospital and most insurance providers.
• Meet with our registered dietitian to discuss healthy lifestyle changes pre- and post- weight loss surgery.
• Participate in studies to determine your pulmonary, gastrointestinal and cardiovascular health. You can usually complete this entire work-up in one day in our office.
• After the work-up is completed you will meet with your surgeon for a second visit to be scheduled for surgery. Our insurance experts will then obtain approval from your insurance company.
• You will be scheduled for preadmission testing at the hospital. During this testing you will meet our bariatric coordinator who will give you a complete educational class on how to prepare for surgery? What is going to happen when you arrive at the hospital on your surgery day, as well as what to expect when you go home form the hospital.

Several factors that determine if you will be a good candidate for revisional surgery include: 1) What was the initial operation performed? 2) When was the initial operation performed? 3) Where was the initial operation was performed? 4) At what stage was your surgeon in his/her career? 5) Were the postoperative instructions and guidance given after the initial surgery adequate? 5) What was the initial weight loss history following surgery? 6) Were there any complications that occurred following the initial operation?

Lack of proper postoperative instructions and guidance after the initial surgery can result in misleading patients into believing they need a revisional procedure. In this case, the patient never learned the best way to use their new “tool”. It is this type of patient that will benefit considerably from proper instruction and can therefore avoid revisional bariatric surgery. Obtaining the weight loss history following the initial surgery tells us if the operation was ever effective or if it “failed the patient” from the very beginning. If postoperative weight loss never occurred or was minimal, then it is likely that there was a technical problem with the operation, and revisional surgery may be able to correct the problem at the root. Likewise, complications occurring after the surgery may have led to technical problems that have influenced the durability of the weight loss. Such complications may include intraabdominal infections, ulcerations, band infections, and prolonged vomiting postoperatively. Considering bariatric surgery as a “tool” to be used for long-term weight loss, we must determine if the patient has used their “tool” ineffectively or if the patient’s “tool” does not work. If the “tool” has not been used effectively then it is unlikely that a revision would be beneficial. However, if the “tool” is broken or never worked, then a revision may be beneficial.

It is important to remember that The New York Bariatric Group and its affiliate Bariatric Center has been recognized as a “MBSAQIP and its Accredited Center-Comprehensive”. This designation provides the public with the assurance that our practice provides complete care for patients before, during and after bariatric surgery, and we have a proven track record verified by an independent review organization.

Based on this designation, we have proven that your hospital stay, will provide all that is necessary for a fast and pleasant recovery. From our full time bariatric nurse coordinator to specialized equipment that is needed to fulfill the needs of patients post-bariatric surgery, including bariatric chairs, beds, gowns and other specialized equipment. At the end of your hospital stay, you will find that our program is designed solely for the purpose of the bariatric patient.

Revisional surgery time is very variable and is determined by many factors. If your previous surgery was performed through an open incision you will most likely have more scar tissue and the surgery will take longer. The surgery is performed under general anesthesia. You will usually spend one night in the hospital for most surgeries except for gastric bypass usually requires two nights in the hospital. Once you are tolerating pureed food you will be discharged home.

Recovery Period

The recovery period after Revisional Bariatric surgery is usually just 3 -5 days until you can return to work. If you undergo a gastric bypass the recovery could be approximately 2 weeks.

After Bariatric Surgery Lifestyle Changes

Adjusting to your post bariatric surgery diet and lifestyle is one of the most important keys to your long-term success. Develop healthy daily habits based on eating in moderation that match your new body instead of failed eating patterns that can ultimately lead to poor health, fatigue, depression and attempts at binge eating. Making a commitment to lifestyle change will bring fast & substantial weight loss. Let us show you how.

Is permanent weight loss after bariatric surgery possible? Absolutely! But you aren’t going to find weight loss success by merely having restrictive weight loss surgery. Get thin quick schemes are a dime a dozen.  They are usually costly plans that promise fast weight loss. They work too – temporarily. The problem with fast weight loss plans alone is they are not long-term solutions to losing weight and keeping it off.

• Tips to Avoid Feeling Deprived While Dieting (even before entering our program)
• Learn and adhere to a sensible diet plan
• Think lifestyle change rather than sticking with the diet mentality
• Find new and exciting way to stay motivated
• Indulge in your bariatric treats once in a while
• Find enjoyment in activities other than eating
• Reward yourself for reaching weight loss goals, but not with food.
• Connect with friends and ask for support
• Be accountable for your eating, even on your down days.
• Eat small meals at specific schedules to avoid feeling hungry
• Don’t skip meals
• Create lighter versions of your favorite meals that you can enjoy eating

Post bariatric surgery diet guidelines are fully discussed with patients during their comprehensive nutritional evaluation prior to surgery.  Patients follow a Stage I diet for the first 4-6 week after surgery.  This includes all foods that are soft, mushy and/or pureed consistencies.  Examples for pureed foods are anything blended and smooth such as baby foods, fruitless yogurt, cottage cheese and hummus.  Soft/mushy foods include chopped up ground meats such as turkey, veal, chicken or pork, soft, white, flaky fish that is baked, broiled or grilled, scrambled eggs and egg whites.  Solid foods of all kinds should be completely avoided until weeks 4-6 or when the surgeon allows it.

This practice stresses the importance of good hydration, using non carbonated, decaffeinated, sugar free beverages.  We always promote good quality proteins to be consumed from day one after bariatric surgery.  High sugar and high fat foods are limited and very specific guidelines are provided to help equip patients with a clear-cut way to determine which foods are healthy for them to eat.  Fruits, vegetables, and high fiber foods are reintroduced after the first 3 months.  All patients get full details on dietary progression from our experienced nutritionists at their follow up visits.

The New York Bariatric Group is fully dedicated to promoting high standards for nutritional health. That doesn’t mean that patients should not enjoy eating. The New York Bariatric Group weight loss program has been designed to help patients lose weight rapidly, but provide you with resources to help enjoy your new lifestyle by keeping the flavor and fun in eating. Each patient is given the option to enroll in our Store. We brought together great tasting meals and supplements for breakfast, lunch, dinner and even snacks which can be ordered on our website.