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Revision of failed Gastric Bypass Surgery

Patients who have under-went gastric bypass surgery for some reason, seek revision of this surgery generally for two reasons.

  1. Patient fails to lose the weight adequately /or weight regain
  2. Post-operative medical complications (this may lead to the failure of surgery)
Failure of Gastric Bypass surgery may be due to mechanical or metabolic complications. However, the eating behaviour of a patient should also be sought out. In fact, the most important first step in assessment of a patient who fails to lose adequate amount of weight after Gastric Bypass, is to look carefully at the patient’s dietary habits. Take a detailed history of food diary. Patients often get shocked on knowing how many calories they were consuming daily. When a patient is not taking diet according to physician’s advice, getting him /her back on tract is crucial to relieve the symptoms. A number of things that could happen next are:

  • Some patients start following the physicians advice, essentially getting back on track and start losing weight.
  • A few may not be successful at losing weight despite returning to proper dietary behaviours.
  • The others may never be able to return to proper eating habits. This could mean the patient is non-compliant but not necessarily.

Video of Gastric Bypass Surgery Revision in Lebanon

Revision of a dilated gastric pouch with a hand-sewn anasotomosis.

Dr Nagi Safa is highly specialized in the revision surgeries, and have performed hundreds of laparoscopic revisional surgeries. He is one of the pioneers to have converted the gastric band surgery to gastric sleeve surgery, by removing the band and cutting the stomach at the same time. He have published in 2012 with his team in Canada, the largest study in the world about the gastric band removal and sleeve gastrectomy as single procedure (Laparoscopic Sleeve Gastrectomy (LSG)—A Good Bariatric Option for Failed Laparoscopic Adjustable Gastric Banding)

Reasons for Gastric Bypass failure

There are mechanical complications that may hinder a patient from adopting a healthy eating behaviour (e.g. patient with an anastomotic stricture may develop “soft-calorie syndrome” because the soft foods are the only foods that the patient can tolerate without vomiting). One more point to take into consideration is exactly what the compliance is after Gastric Bypass. Proper eating of a patient with Gastric Bypass Surgery represents a 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 help of a small gastric pouch. Habits and character of a person does not always contribute to this problem.

Gastric Bypass surgery may fail because of the following mechanical reasons:

  1. gastro-gastric fistula
  2. pouch dilation
  3. anastomotic dilation

Gastro-gastric fistula is formed when the stomach pouch grows back and re-connects to the bypassed stomach to form an abnormal passage. This may be a consequence of a pouch leakage, where the resulting local inflammation from the leak point disrupts the staple line of the bypassed stomach. Gastro-gastric fistula formation is usually a result of a less acute, slower process. Regardless of the cause, gastro-gastric fistula allows food to pass from the pouch to the bypassed stomach through this abnormal passage, effectively partially reversing the Gastric Bypass. A revision surgery for this condition may include the closure of the fistula, to restore the original surgical Gastric Bypass anatomy. Vertical Sleeve Gastrectomy based procedure is another alternative option, especially if there are factors other than mechanical failure that explain the patient’s weight gain as well.

Pouch dilation is a condition where the wall of stomach pouch stretches out and enlarges. Anastomotic dilation is where the connection between the stomach pouch and the intestine stretches out. Both conditions permit a patient to resume eating more than the one should take.

Re-trimming the pouch to reduce its size is one approach to manage pouch dilation. Endoscopic fixation and surgical banding are two approaches being used to treat an enlarged anastomotic connection. The approaches to pouch and anastomotic dilation are both directed towards restoring the anatomy of the Gastric Bypass procedure back to what it was prior to the stretching. Another approach is to make a paradigm shift and convert to a more metabolically active procedure e.g. Duodenal Switch. The other Vertical Sleeve Gastrectomy based procedures are the other treatment options, especially if the patient’s Gastric Bypass is complicated by nutrient mal-absorptions, e.g. osteoporosis and anemia.

Conversion from Gastric Bypass to Duodenal Switch is the most definitive revision procedure for those with inadequate weight loss or weight regain after Gastric Bypass Surgery. This approach addresses the issues of metabolic failure and maladaptive eating as causes of failure. This conversion may be done open or laparoscopically. A potential concern with this procedure is optimum stomach function after surgery. The stomach, which was bypassed, is now brought into use again, and some patients may have had the nerves to the bypassed stomach cut during their original Gastric Bypass procedure. This is not a big problem, as the nerves seem to grow again as the bypassed stomach “wakes up” and resumes working again. At times, it may not be safe to re-connect the gastric pouch to the bypassed stomach due to excessive scar tissue. If the patient has tolerated proteins and adopted a satisfactory Calcium metabolism, a conversion to a Scopinaro-type Bilio-Pancreatic Diversion makes a very satisfactory treatment option.

Medical issues complicating Gastric Bypass Surgery include stricture, marginal ulcer and severe dumping syndrome. These conditions are most of the times treated conservatively, but when conservative treatment fails a revision surgery is indicated. The treatment for ulcer or stricture is the resection of the ulcerated /strictured area. Another approach is a Vertical Sleeve Gastrectomy-based procedure because stricture and marginal ulcer are conditions that arise as a result of the intrinsic physiology of Gastric Bypass. This approach is also favoured for cases of severe dumping syndrome, as it is the inherent nature of the Gastric Bypass itself that results in this condition. Sometimes, reversal of Gastric Bypass may be needed for the cases of malnutrition, including some vitamin and mineral mal-absorptions. Reversals for nutrient mal-absorption may be accompanied by revision to non-malabsorptive weight-loss procedures, allowing patients to stave off any regain of weight that may otherwise result from the reversal of their mal-absorption.

Mini Gastric Bypass Surgery Revision
Revision of Mini Gastric Bypass operations is similar as for Roux-en-y Gastric Bypass. Bile reflux is a potential complication which is very specific to this type of Gastric Bypass Surgery. Although the risk of bile reflux is uncommon and the probability is more theoretical than actual, converting a Mini Gastric Bypass to Roux-en-Y Gastric Bypass is sufficient to manage this condition. This is a straightforward revision surgery to complete and is performed without having to interrupt the first anastomosis made between the stomach pouch and intestine.