LESS

Laparosc Endosc Surg Sci 2017;24(2):63-66

Invited Review

DOI: 10.14744/less.2017.69885

Revisional bariatric surgery: An update

Isabelle Debergh,1 Bruno Dillemans,1,2
1
Department of General, AZ Sint Jan AV, Ruddershove, 10, 8000 Brugge, Belgium
2
Pediatric and Vascular Surgery, AZ Sint Jan AV, Ruddershove, 10, 8000 Brugge, Belgium

ABSTRACT
Obesity can be defined as a chronic disease with a serious impact on an individual’s quality of life; moreover,
it is a leading risk factor for global death. Bariatric surgery has already proven its efficacy in providing the
patient with a healthier life. Nonetheless, failure of initiated treatment can occur in medical practice. We
can and should offer our patients correct, patient-tailored revisional therapy conducted by an experienced
surgeon in a high-volume hospital facility. In this article, current indications and strategies for secondary
bariatric procedures were summarized.
Keywords: Duodenal Switch; revisional bariatric surgery; Roux en Y gastric bypass; single anastomosis gastric bypass;
sleeve gastrectomy.

Introduction
According to the World Health Organization (WHO), more formulates advice for an individual patient, societal mea-
than 500 million adults world wide or 11% of the popula- sures, and food industry to prevent and cure this chronic
tion at the age of 20 and older were obese in 2008. Since disease. The responsibility of having an easily accessible
then, 3.5 million adults have died each year as a result of healthcare system, not only for preventing overweight, but
being obese or overweight.[1] Moreover, serious morbidities also for curing obesity is not discussed. In this setting, bar-
are related to obesity like the burden of diabetes, ischemic iatric surgery has already proven its efficacy and was found
heart disease and cancer. At this point, unfortunately, obe- to be more effective than non-surgical treatment methods
sity is linked to more global deaths than the underweight. in achieving weight loss and remission of comorbidities.[2]
In low- and middle income countries, the problem of obe- A patient-tailored approach for choosing the best surgical
sity is rapidly rising to the levels of high-income countries. strategy is initially necessary to cure the patient in the long
Another disturbing evolution in developing countries can term. However, when this therapy fails, a revisional opera-
be seen in younger populations, with a 30% increase of tion can be offered in well-selected patients.
childhood obesity compared to developed countries. Glob-
ally, 42 million children under the age of 5 were overweight Motivation and Indication for Revisional
Bariatric Surgery
or obese in 2013. Therefore, WHO developed a Global
Strategy on Diet, Physical Activity and Health with the aim The problem of failed bariatric procedures is multifactori-
of halting global obesity rates by 2020. This action plan al. Before proposing bariatric surgery in the first place as

Received: 10.12.2014 Accepted: 16.12.2014

Correspondence: Bruno Dillemans, M.D., AZ Sint Jan AV Ruddeshove,
10 8000 Brugge Belgium
e-mail: bruno.dillemans@azsintjan.be
 64 Laparosc Endosc Surg Sci

a primary treatment for obesity, every patient should be loss and similar rates of improvement and remission of
worked-up in a multidisciplinary team. A patient-tailored coexisting conditions compared to primary RYGB.[13]
approach can lead to better outcomes in weight loss and
morbidity relief in the long term. For instance, patients Revision of VBG
with co-morbidities related to metabolic syndrome will
Reasons for re-intervention of vertical banded gastroplas-
have proven to benefit after performing Roux-en-Y gastric
ty (VBG) have been described to be unsatisfactory weight
bypass (RYGB), and in patients presenting with reflux dis-
loss, emesis, pyrosis and maladaptive eating. Band ero-
ease, RYGB might also be the first choice procedure.[3] On
sions, pouch or esophageal dilatation, stapler line dehis-
the contrary, sleeve gastrectomy will be the preferred pri-
cence, and band-related stenosis are reported anatomical
mary treatment in case of osteoporosis, dumping symp-
complications, for which RYGB is considered as the pre-
toms, or vitamin deficiencies.
ferred revisional procedure[14,15] although some report also
Consequently, weight or morbidity recidivism, or anatom- acceptable results with conversion to sleeve gastrectomy.
ical/technical complications can be related to an inap- [8]
As most patients suffer from reflux and established mal-
propriate primary surgical strategy, but also to changes adaptive eating, we can not support sleeve gastrectomy or
in surgical knowledge and techniques, or patient related pouchogastrostomy as revisional options after failed VBG.
factors. An inconsistent definition of failure of a primary
bariatric procedure is the reason of heterogeneous num- Revision of SG
bers in the reported literature. The most frequently used Sleeve gastrectomy (SG) can be considered a primary
definition of failure of the initial operation is <50% of ex- procedure or the first restrictive step of a 2-step bariatric
cess weight lost (EWL), with or without a BMI of >35 m/ therapy. Inadequate weight loss is an important reason
kg² at 18 months post-operatively.[4] None of the reviewed for re-intervention, but severe stenosis or reflux (20% of
articles described failure of remission of type 2 diabetes or patients after SG) can also form the motivation for conver-
hypertension as an indication for reoperation. sion to RYGB[16] if endoscopic therapy fails.[17] In rare cases,
Henry Buchwald has stated recently that revisional bariat- conversion to RYBG can be the solution for chronic gastric
ric surgery is a moral obligation to the patient with a failed fistula after SG.[14] A recent systematic review concerning
bariatric procedure.[5] This expressed indignation arouse failed sleeve gastrectomy due to inadequate weight loss
in a climate of negative responses to revisional bariatric has concluded that both RYGB or re-sleeve gastrectomy
surgery manifested in the US healthcare system. However, are appropriate procedures with similar weight loss out-
evidence-based literature supports a reoperation strategy comes after 24 months,[18] depending on whether malab-
for conversion or correction of acute or chronic compli- sorption or more restriction has to be added.
cations after failed bariatric surgery. An improved weight Each decision has to be tailored depending on a specific
loss, reduction in comorbidities, and resolution of compli- case. Other strategies can include conversion to a classic
cations is achieved after re-intervention.[6,7] duodenal switch operation (with Roux-en-Y configuration)
or tosingle anastomosis duodeno-ileal bypass with sleeve
Revision of LAGB
gastrectomy (SADI-S) to add malabsorption, with good re-
High rates of failure in weight loss due to maladaptive sults in primary cases in terms of additional weight loss
eating, and band-related complications such as slip- and normalization of HbA1c levels in diabetic patients.
page, tubing leakage, esophageal motility disorders (and [19,20]
In 2002, Santoro et al. developed a procedure combin-
pseudo achalasia)are reasonswhy placing a laparoscopic ing sleeve gastrectomy with enterectomy thatretains the
adjustable band (LAGB) has almost currently become ob- first 50 to 100 cm of jejunum and the last 200 to 250 cm of
solete as primary bariatric treatment. A few studies have the ileum[21] and also reported good initial weight loss. An
reported success rates in converting LAGB to sleeve gas- important goal with this type of interventions is to change
trectomy when performed in a one-or a two-step proce- neuroendocrine responses in bariatric patients, which is
dure,[8,9] but overall, RYBG is the revisional procedure of also targeted in sleeve gastrectomy with ileal transposi-
choice. In most cases, conversion to RYGB can be perfor- tion. Although it is interesting, these new developments
medin a one-step procedure.[10–12] In the postoperative fifth currently lack evidence, and can only be used in well se-
year, revisional RYGB provides good additional weight lected cases and in experienced hands.
 Revisional bariatric surgery: An update 65

Revision of RYGB which will increase the risk of bleeding and anastomotic
complications. A safe approach is necessary using the pre-
Severe dumping symptoms or invalidating hypoglycemic
ferred conventional laparoscopic approach. This minimal-
episodes, refractory to any conservative therapy, can some-
ly invasive technique has the advantage of giving a good
times be the reasons to convert a RYGB to normal anatomy
two-dimensional presentation of the region of the upper
or SG. More frequently, inadequate weight loss after RYGB
or weight recidivismis the cause for considering alternative gastrointestinal tract. However, if this operative strategy
surgery. Options includeeither conversion of RYGB to du- is not safe, open surgery must be considered. Nowadays,
odenal switch, distal bypass, adjustable banding, pouch robotic surgery is also being used for revisional bariatric
revision, or endoscopic procedures. Endoscopic gastric surgery, leading to a three-dimensional vision, and ampli-
plication results in weight regain after one year, and is fied dexterity of the surgeon. In highly selected cases and
not generally accepted as treatment strategy.[22] In selected in experienced hands, these robot-assisted interventions
patients with increased caloric intake or dilated gastroje- are reported to be safe and effective, without causing high-
junostomy, favorable results have been described adding er costs In the long term.[28] Currently, general evidence
LAGB.[23] Other cases with anatomical gastric pouch en- to use a robotic approach in revisional bariatric surgery
largement on barium esophagograms can benefit from per- is lacking, as only small case series have been reported.
forming gastric pouch or gastrojejunal revision, leading to Moreover, this technique is still very cumbersome, which
significant weight loss one year after revisionalsurgery.[24] is illustrated in the study of Bindal et al. as the mean op-
In patients known to have low caloric intake (<1500 kcal/ erative time for robotic revisionalRYGB was 226±45.3 min.
day), without vitamin deficiencies or anatomical deformi- Therefore, we can conclude that laparoscopy for bariatric
ties, a laparoscopic lengthening of the Roux limb[25] or bil- re-interventions remains the preferred approach.
iopancreatic limb in case of failed RYGB[26] will offer good
additional weight loss. Conclusion
The worldwide problem of overweight and obesity de-
Revisions of BPD
mands a multifactorial approach. Obesity has to be con-
In case of weight regain afterbiliopancreatic diversion sidered a chronic disease, in which bariatric surgery is an
(BPD), pouch revision will be necessary. On the other evidence-based therapeutic option with excellent results
hand, nutritional deficiencies, underweight, and frequent on excessive weight loss and remission of co-morbidi-
mal-absorptive diarrhea after BPD will be the motivation ties.[2] Nonetheless, some individuals will be refractory to
for offering the patient a re-intervention. These adverse ef- initiated treatment or will present with complications or
fects can consequently lead to a serious decrease in qual- adverse effects. We need to offer an alternative therapy to
ity of life, despite good weight loss results. Conversion this group of patients. In experienced hands, revisional
with lengthening of the common limbby reconnecting the bariatric surgery can be performed laparoscopically in a
alimentary limb proximal on the biliopancreatic limbis safe way with low complication ratesand excellent results
the solution to these problems.[27] Often, this revisional on additional weight loss.[29,30]
procedure cannotbe performed laparoscopically, and the
If metabolic surgeons want to gather and keep support in
open procedure will result in longer hospital stay. Postop-
the provider community, they have the responsibility to
erative ileus will also be influenced by the laborious ac-
report the results of primary and secondary bariatric pro-
tivation of peristalsis in a formerly inactive part of bowel
cedures, hospitalization, complication rates and health-
(biliopancreatic limb).
care costsin a standardized way. There is need to reduce
Approach: Open vs Laparoscopic vs Robotic? invasiveness of bariatric therapy and re-interventions in
the futureto enhance societal support, and more impor-
Revisional surgery is always technically challenging for tantly, to enable the treatment of more individuals.
the bariatric surgeon. These operations carry the possibil-
ity for a staged approach or conversion, and a higher risk Disclosures
of complications. This is due tothe presence of scarring,
adhesions and inflammation with difficulties of identify- Peer-review: Externally peer-reviewed.
ing anatomical landmarks, and harming vascular supply, Conflict of Interest: None declared.
 66 Laparosc Endosc Surg Sci

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