revision surgery

Revisional Bariatric Surgery

Revisional Bariatric surgery is performed on patients who have already undergone bariatric surgery and who are either not happy with its results, regained weight after adequate weight loss or facing complication post-surgery. Revisions are also performed as a second stage of a pre-planned modality due to high-risk. This Surgery is mostly done through laparoscopy except in rare cases where it has to be converted to open surgery in view of safety of the patient in a re-operative setting. Due to the nature of the surgery, revisional procedures must carefully be chosen as per stringent protocols after thorough assessment and identification of the cause and only if the surgery is extremely warranted. It needs to be addressed by an experienced surgeon under a tertiary care set-up as the failure of revisional surgeries is high-risk in nature.

INADEQUATE WEIGHT LOSS

Inadequate weight loss from an earlier surgery is a common case when revisional surgery is suggested. About 5% of all bariatric surgery fails to deliver the minimum requirement of 50% excess weight loss. The sub-optimal weight loss  can be contributed to several causes. The main cause being the patient’s failure to adapt to the changed lifestyle and dietary habits post-surgery. Surgical factors of inadequate technique and genetic / hormonal nature also plays a role. Once the causes of failure is determined the type of surgery to rectify these causes are recommended. Common reasons for inadequate weight loss includes: 1. lack of compliance, 2. metabolic syndromes like diabetes, hypothyroidism, pituitary, adrenal diseases, 3. complications of primary bariatric surgery, and 4. technically less powerful/faulty surgery. The revisional procedure may be similar to earlier procedure or totally different and the decision is made as per the detection of the causation and according to the need of the individual.

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WEIGHT REGAIN

Weight regain happens in up to 20% of individuals who underwent bariatric surgery. Surgery provides a powerful tool for significant weight-loss, but without proper lifestyle care “the tool” can lose its effectiveness, leading to weight regain. There are several causes of weight regain after weight-loss surgery, most of which if addressed properly, results in a loss of the gained weight and resumption of weight maintenance. Some common causes of weight regain are: 1. Pouch dilatation, 2. Anastomotic/Sleeve dilatation, 3. Gastric band issues (balloon leak, slippage, erosion. port disconnection, etc.), 4. Gastric-gastric fistula (Reconnection of the separated stomach) and 5. Certainly medical / hormonal conditions. In most patients, weight regain is the result of the patient slipping back into old, unhealthy habits. Team BAROS will do a detailed assessment and recommend the right line of management accordingly.

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COMPLICATIONS NEEDING REVISIONS

Revisional surgery can also be recommended due to the complications arising from the original surgery which accounts for 1-4 % of all surgeries as per literature. These are sometimes is performed as an emergency life-saving procedure. The procedures interfering with the digestive tract can sometimes cause complications which are later rectified with surgeries in appropriate cases. The most dreadful complications that need revision are: 1. Sleeve / Anastomotic Leak, 2. Sleeve / Anastomotic Stricture, 3. Gastric band issues (balloon leak, slippage, erosion, etc.), 4. Gastric-gastric fistula (Reconnection of the separated stomach), and 4. Internal Hernia (Small intestine). Endoscopic Bariatric is used as the first step in such situations to avoid surgery. However, re-exploration is warrant in few cases as a life saving measure. Few dedicated high volume centers line BAROS are equipped to handle such situations

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REVISION AS THE SECOND STAGE

In a subset of super-obese patients with BMI > 50 kg/m2, the one-stage Laparoscopic Bariatric surgery can be associated with significant morbidity and mortality. Few limiting factors making bariatric surgery challenging in the super-obese are: 1. The high anaesthetic risk for a complex surgery, 2. The high volume of the left lobe of the liver hindering with the operative space, 3. Too dense omental fat interfering with the procedure, and 4. Technical difficulty / intraoperative errors. To reduce the perioperative risks associated with the super-obese, two-stage operations are devised. This two-stage operation consisted of a Ist stage intragastric balloon / gastric band / sleeve gastrectomy, followed by a suitable bypass procedure as 2nd stage with an interval of at least 12 months between the two surgeries. This may reduce the potential postoperative risk by half and is an effective alternative if a single stage procedure is proved to be of very high risk.

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