The Panoramic View of Revisional Bariatric Surgery

Abstract

Introduction:

Obesity remains a major public chronic disease, and the multifactorial components of its relapse in many patients remain inevitable.

Methods:

This article provides a panoramic view of the most commonly performed revisional bariatric surgery (RBS). RBS is a complex procedure; thus, primary procedures should be well chosen and performed to avoid the increasing number of RBS cases.

Results:

Bariatric surgery is the only successful long-term treatment for obesity. However, a proportion of primary bariatric surgeries has failed during the follow-up period. In recent decades, the solution for these complications is by performing RBS. It is mandatory to understand obesity as a chronic disease to appropriately treat patients. Treatment strategies are needed to determine the indications for revision. RBS requires a meticulous evaluation to facilitate good long-term results.

Conclusions:

Treatment strategies will be a fundamental pillar to wisely determine the indications for revision and identify the factors influencing failure by prudently and rationally evaluating the revisional procedure that the patient will benefit from and acquiring a high level of surgical skills.

Introduction

Obesity remains a significant global public health concern. In the 2018 report of the World Health Organization (WHO), the prevalence of obesity has tripled between 1975 and 2016. We cannot deny the fact that the numbers are overwhelming; in fact, in 2016, more than 1.9 billion people >18 years of age were overweight, and 650 million were considered obese.¹

Bariatric surgery is currently the only successful and durable long-term treatment for the management of obesity and its comorbidities.^2–4 As in every chronic disease, the long-term results of bariatric surgery must be evaluated from all the possible perspectives, including nutritional, psychological, functional, physical productivity, and quality of life, among others. The identification of surgical candidates relies on a wide range of aspects that cannot be narrowed to only the surgeon's discretion, but naturally influenced by a multidisciplinary team.

Given that bariatric surgery has been performed for more than two decades and has demonstrated reliable results with low morbimortality rates, the number of patients who are undergoing bariatric surgery has had an exponential increase,⁵ and with this increment, it can be noted that some failures are inevitable. In the last report of the International Federation for the Surgery of Obesity (IFSO) in 2016, 685,874 bariatric procedures were performed; of these, 634,897 (92.6%) were primary interventions and 50,977 were revisions (7.4%).⁶

Revisional bariatric surgery (RBS) is a complex subfield in bariatrics, even for highly proficient surgeons, and determining the indication for revisional surgeries is often challenging owing to the obesity's multivariable causality and recidivism. Task forces have been trying to establish management criteria; however, it was difficult to delimit these parameters owing to their complexity. Recently, the first international consensus on RBS has been published with the proposal of defining the guidelines of these challenging procedures.⁷ The consensus evaluation showed that the majority of studies are of low quality, leading to an inability to perform strict standardization. The frequent basis for all of the procedures is an individualized assessment of patient's needs, as well as environmental and psychological stress factors.⁸

Methods

What is a “failure?”

At present, “failure” is better defined according to a multiperspective view that includes the surgeon, his or her team, the patient, the society, and health care providers. The technical “errors” are the presence of any of the clearly recognized errors, such as the use of out-of-date techniques or procedures that cause complications, including gastroesophageal reflux disease (GERD), cholelithiasis, or internal hernias, among others.

The most common indication for revision surgery is inadequate weight loss, although there is an inconsistency of the definition of failure in primary surgeries. A previous systematic review investigating 20 studies reported that 7 studies defined failure as a loss of <50% of excess weight with or without a body mass index (BMI) of 35 kg/m² at 18 months postoperatively. The second common definition was the Reinhold criteria, which considered failure as <25% weight loss with or without a specified time.⁹

Another complex terminology is the weight regain, which takes into account the concept of the weight nadir, or minimum weight reached, as well as the amount of weight regained and the time to achieve the loss; weight regain can result in the relapse of comorbidities. As a result, these patients could be candidates for RBS.¹⁰ Brolin and Cody found either a resolution or improvement in most of the comorbidities in a cohort of 151 patients.¹¹ If the second bariatric procedure can improve, or even treat, the comorbidities, RBS is justified in the well-selected cases.

Logical statements can be made, when the indication for RBS is due to inadequate weight loss or weight regain, but considerations should be given as to whether the restriction fails; in which case, the indication is to restore it. Moreover, if the restriction persists, then the malabsorptive component should be improved or added depending on the case.¹² Regarding the complications, assessment relies on whether the component is restrictive, malabsorptive, or both, and actions must be performed accordingly.

Recently, the bariatric community has tried to use the term “partial response” instead of “failure” based on the premise that obesity is a chronic disease. Today, we can compare surgery to chemotherapeutic treatments, as they sometimes result in partial responses in the patients. However, none has considered that these patients cannot be treated with other lines of chemotherapies. In this sense, it should be understood that this disease can “reappear” and does not have an “ideal” technique that is suitable for each patient.¹³

The performance of this type of surgery comes with an enormous responsibility, since it is well known that bariatric surgery is highly technically demanding. The increase in the number of complications and mortality has been reported. For instance, in Roux-en-Y gastric bypass (RYGB), one of the most commonly performed procedures, the revisional surgery has a higher estimated blood loss, longer operative time, higher risk of intensive care unit stay, and longer hospital stay than primary surgery. Moreover, there were more intraoperative injuries, postoperative complications, readmissions, and reinterventions at 30 days for revision surgery.¹⁴

Results

In our country, the Spanish Society for the Surgery of Obesity (SECO) and the Spanish Society for the Study of Obesity (SEEDO) recommend this type of surgery with a degree of C and a Level of Evidence of 4, respectively. Following a failure of restrictive procedures, screening is recommended only in patients with complications related to the first procedure and not in those patients with adequate weight loss or regain at follow-up.

Most published studies involve the management of specific procedures; however, there are few reviews on the revisional surgery field. Therefore, we provide an overview of the most commonly performed RBS.

Adjustable gastric banding

Introduced in the early 1990s and accepted in 2001 by the U.S. Food and Drug Administration (FDA), the gastric band is among the restrictive procedures that have been highly performed, despite presenting a high incidence of failure.^15,16 The revisional procedure after adjustable gastric banding (AGB) is performed in one or two stages. The first stage consists of removing the gastric band and simultaneously performing an additional bariatric procedure. The second stage involves the initial removal of the gastric band and performance of revisional surgery during the same surgical time. As a step-up approach, we consider two surgeries, with one performed to remove the gastric band and the other to add the bariatric component.

In a 2-year analysis comparing the one-stage and two-stage approaches following AGB failure, Theunissen et al. found excellent results in the one-stage approach without any significant difference in terms of complications, hospital readmission, or weight loss per year.¹⁷ In the latest meta-analysis published by Dang et al., the most common indication in the one-stage procedure was the failure to lose weight, whereas that of the two-stage procedure was reservoir dilatation. They consider both approaches as safe.¹⁸

The management can be heterogenous. A systematic review of the results of RBS after an AGB failure found that the revision was performed with the one-stage approach in 10 studies, two-stage approach in three, and combined one- and two-stage approaches in 19, whereas 4 of the studies did not specify their approach. In the studies with available data, the AGB was converted to an RYGB in 79.7% of the patients (1117 out of 1402) and AGB to sleeve gastrectomy (SG) in 47.2% of patients (412 out of 873), with the most common indication being the insufficient weight loss.¹⁹

The indication to perform the one- or two-stage approach relies on the indication of the revision. The outcome in terms of complications and morbidity between the approach stages in patients converted to RYGB and those with SG is comparable. Angrisani et al. reported a similar percentage of weight loss after AGB removal and during follow-up at 1, 3, and 5 years when comparing SG and RYGB.²⁰ However, Wu et al. reported a better weight loss at 12 and 24 months after RYGB, but with an increase in postoperative complications and hospital readmissions.²¹

We recommended that if the revision indication is derived from a technical problem in the band placement, such as migration, SG should be considered. In the case of acute settings or cases with complex adherence and inflammation, the two-stage approach can be advised.

Vertical banded gastroplasty revision surgery

Vertical banded gastroplasty (VBG) was developed in 1980 by Mason²² as a bariatric procedure that involved the creation of a 50-mL reservoir tutorized by a 32-Fr Ewal probe with an undivided vertical stapling line. In Spain, this technique is still performed in patients. Unfortunately, they sometimes suffer from stenosis due to the gastric band of Marlex, which causes GERD and stenosis. Some patients present with repermeabilization of the vertical stapling line, which at the time was not used to section the stomach, thereby resulting in the weight to regain in the gastro-gastric fistula.

Khewater et al. reported conversion of VBG to RYGB in a cohort of 305 patients over a 12-year-old period; the incidence of complications in long-term revision surgery occurred in 14.2% of patients and the need for surgical management in 12.4%, the most frequent complications being internal hernia in 5.3% and trocar in 3.1% of patients.²³

SG revision surgery

SG was initially introduced in the field of bariatric surgery as part of the biliopancreatic diversion (BPD), with a later adoption as a primary bariatric procedure for adequate weight loss. To determine the strategy after an SG failure, we must carefully delimitate the sleeve anatomy through an imaging study by either barium swallow or esophagogastroduodenoscopy to evaluate the presence of a dilatation or GERD. SG redo is considered an option that has shown significant weight loss in some series.^20,24

Super obese patients with a BMI of 50 kg/m² may benefit from BPD or single duodeno-ileal anastomosis or Single Anastomosis Duodeno Ileal with Sleeve Gastrectomy (SADI-S).²⁵

The results of inadequate technical expertise can confer SG stenosis mostly for cases with an obstruction at the level of the angular incisure. This can be resolved with myotomy,²⁶ gastroplasty procedures, or RYGB or DS conversion.²⁷

Among the most common causes of conversion from SG to RYGB are inadequate weight loss or gain and GERD. SG has an incidence of GERD de novo of 20%–30%; thus, a re-sleeve could not be considered, and the antireflux operation will ultimately be the RYGB.²⁸ Excess weight loss seems to be less than the one obtained from a primary RYGB; thus, it may be considered a good option when the indication is the presence of GERD.²⁹ In a 5-year retrospective analysis of 48 patients in whom conversion from SG to RYGB was evaluated, the cause of revision was GERD in 29.2%, lack of weight loss or regain in 22.9%, and GERD and lack of weight loss in 33.3% of the patients.³⁰

SADI-S is a relatively new bariatric operation based on the principles of biliopancreatic procedures that can be performed with the one- or two-stage approach.^31,32 To preserve the pylorus, the reconstruction based on one anastomosis is required, as it reduces the operative time and avoids mesenteric defects. However, metabolic complications can also occur, and conversion to a procedure with a lower malabsorptive power can be indicated, such as RYGB or single anastomosis duodenojejunal bypass with SG.³³

Revision of RYGB

RYGB remains the most frequently performed procedure. However, failure to lose weight has been reported to be 10.2%.³⁴ The gastrojejunal (GJ) anastomosis diameter of the stoma plays a fundamental role in bariatric procedures. The technical options available include the revision of the gastrojejunostomy, recently by endoscopic techniques such argon plasma coagulation (APC), and resuturing to diminish the anastomosis diameter with full-thickness plication systems. The endoscopic suture patterns have been evaluated by Patel et al. who compared continuous versus interrupted stitches in 50 patients and found an average excess weight loss at 6 months and 1 year postoperatively of 13% and 10%, respectively. Both groups showed a resolution of the comorbidities.³⁵

The surgical revision consists of the reduction of a gastric reservoir with the creation of a new 1.5-cm gastrojejunostomy.³⁶ The consensus of RBS considers that lengthening the biliopancreatic loop may be an option on the basis of the increase in the malabsorptive component, thereby improving weight loss.⁷

Another major revision for RYGB is reversal to the normal anatomy (adding an SG), which can be indicated with complications such as severe malnutrition, vitamin deficiency, refractory marginal ulcers, and postprandial hyperinsulinemic hypoglycemia.³⁷ Some important aspects to consider are the critical technical aspects during a reversal of the gastro-gastric anastomosis. In our experience, the three anastomotic types used are suitable, mechanical circular, posterior linear, and hand-sewn, which are pitfalls during the creation of anastomosis when the antrum is included.

A reversal is a challenging technique with a reported incidence of complications of 29% at 30 days postoperatively, which mostly include anastomotic leakage, sepsis, and bleeding. Based on this high morbidity rates, previous researchers have recommended reversal surgery after a failed RYGB, and the indication should be well selected.³⁷ Sometimes, when weight regain is anticipated, the procedure can be added to a gastric reduction procedure with SG to maintain some restrictions.^38,39

Systematic mesenteric defect closure (entero-enteric and Petersen's defects) does not guarantee effectiveness in terms of prevention of internal hernia⁴⁰; this is a common cause of post-RYGB pain. When the pain is acute, an immediate intervention is required to resolve the occlusion. As for technical advice, a gentle exploration of the ileocecal valve with proximal traction of the handles until the reduction of the herniated loop is achieved is recommended.

The role of endoscopy in bariatric surgery failure

The majority of endoscopic techniques after failure bariatric surgery have been studied in patients post-RYGB.^41,42 Based on the previously described data that the diameter of the GJ and correlation of weight regain, endoscopic techniques have been considered a less invasive approach for RBS implementation of contactless coagulation methods, such as APC, to promote scar tissue formation. de Quadro et al. found, in their randomized control study for APC, that the treatment was performed over a circumferential halo every 2 months until the anastomosis diameter was between 10 and 14 cm; better results in terms of reduction in gastrojejunostomy diameter, weight loss, early satisfaction, and quality of life improvement were found in patients who underwent APC compared to the control group.⁴¹

The application of endoscopic full-thickness sutures has been also implemented after APC as an adjunct therapy for GJ narrowing. The suture device required a higher price than the APC application alone. Moreover, the use of full-thickness sutures has been described for gastro-gastric fistula closure after weight regain.⁴²

Role of robotic-assisted surgery

Robotic surgery was developed in an attempt to address the drawbacks of laparoscopy, especially in complicated cases, with the objective of decreasing the morbidity and mortality rates of robotic-assisted procedures that have been implemented. However, the evaluation of a large database, such as the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, which compared laparoscopic-assisted to robotic-assisted SG and RYGB found that RSG had a higher overall morbidity. Regarding RYGB, there was no difference in the rate of overall morbidity, anastomotic leakage, and mortality between the two procedures; however, the primary surgery was not evaluated.^43–48

Surgical technical pitfalls during RBS

In general, we can classify RBS as corrective, conversion, and reversal surgeries. Understanding the aim of RBS requires a standardized methodology and patient evaluation within a multidisciplinary experience center, which can offer the most significant benefit in terms of disease and complication control. The technical aspects during surgery play a vital role, including the definition of the new anatomy created during the primary bariatric procedure, landmark identification of all involved anatomical components, the limbs, and staple line identification. Following the meticulous dissection with respect to the irrigation patterns, the appropriate assessment of the anastomosis must be done by performing leakage tests. The use of intraoperative endoscopy can be beneficial in these surgeries.

Conclusions

Bariatric surgery remains to be the best current management for patients with obesity. The best strategy will be the prevention of complications by choosing the best surgical procedure during patient evaluation. However, due to its chronicity and heterogenous characteristics of the population, some patients will have RBS failure. The field RBS will expand in the coming years, and many challenges will arise in its subspecialties. The complexity of procedures in revisional surgery is more significant when compared to that of primary surgeries, which leads to a higher incidence of postoperative complications even when the procedure is performed by experts. Treatment strategies will be a fundamental pillar to wisely determine the indications for revision and identify the factors influencing failure by prudently and rationally evaluating the revisional procedure that the patient will benefit from and acquiring a high level of surgical skills.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Footnotes

Acknowledgments

The authors want to thank Guy Temporal for editing the proof.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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