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Revision Procedures for Failed Gastric Bypass

| September 10, 2007

by Manish Parikh, MD; Marc Bessler, MD

Both from Center for Obesity Surgery, Columbia University, New York-Presbyterian Hospital, New York, New York

Disclosures: Autosuture (teaching), Ethicon Endosurgery (consulting), Bariatric partners (consulting), Inamed/Allergan (consulting), and Karl Storz Endoscopy (research).

INTRODUCTION

The Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric procedure in the US. However, the long-term failure rate after RYGB is 20 to 35 percent.[1] Particularly in superobese patients (BMI≥50Kg/m2), this failure rate can be as high as 40 to 60 percent, depending on how failure is defined.[2]
Poor weight loss often leads patients to request a revision procedure. Indeed, the most common indication for reoperation after RYGB is inadequate weight loss.[3] Revision bariatric surgery is technically complex, associated with a high incidence of morbidity, and historically has had questionable efficacy.[4] In the current laparoscopic era, reoperative bariatric surgery has become more popular due to quicker recovery and decreased wound complications compared to open reoperative series.[5] Perhaps even more promising are new endoluminal therapies which avoid intra-abdominal surgery altogether. This review describes the various revision options for failed RYGB, including emerging endoluminal therapies.

Initial Evaluation

Careful nutritional and anatomic evaluation is helpful in understanding the causes of weight loss failure. It is important to differentiate between patients who have never succeeded with the RYGB and patients who regained weight after significant excess weight loss (EWL) with the primary RYGB. Most patients report 50 to 60 percent EWL within two years and then subsequent weight regain. These are the patients who seem to benefit most from a revision procedure to eliminate the weight regain. The patients who never succeeded with a RYGB constitute a difficult population to treat. A thorough assessment of dietary patterns is helpful (e.g., volume-eaters vs. “grazers”). Some benefit from a more restrictive procedure such as the addition of an adjustable band on the gastric pouch. Others may benefit from conversion to the more malabsorptive biliopancreatic diversion with duodenal switch (BPD-DS).

In patients who present with failed RYGB, it is often useful to perform both upper endoscopy and upper gastrointestinal (GI) contrast studies, as they are complementary in the evaluation of anatomy and cause of weight gain after bariatric surgery.[6] Endoscopy provides useful information about the pouch and stoma while upper GI detects esophageal and Roux limb abnormalities. These modalities also effectively diagnose staple line dehiscence and gastrogastric fistula.

We consider a pouch dilated if it is greater than 120cc in volume and a stoma dilated if it is greater than 2cm in diameter. Occasionally patients present with weight regain secondary to maladaptive eating behavior from stomal obstruction. However, most patients who present to us with weight regain after RYGB have technically intact anatomy (i.e., no evidence of gastrogastric fistula) with a dilated pouch and/or dilated stoma.

Surgical Therapies for Weight Loss Failure after RYGB

storically revision for failed RYGB involved reduction of the gastrojejunostomy stoma.[7] In Mason’s series, a significant number (15%) of these patients required an additional revision procedure. Schwartz reported a 50-percent complication rate and negligible weight loss in 42 RYGB patients undergoing gastrojejunostomy revision.[4] Muller, et al., described this laparoscopically (“pouch resizing”) and reported a mean BMI decrease of 3.9Kg/m2 at 11 months.[8]

Others recommend conversion of the failed RYGB to a distal gastric bypass. This entails disconnecting the Roux limb and reconnecting it closer to the ileocecal valve, usually 50 to 150cm proximal to the ileocecal valve. Fobi, et al., reported an average 20Kg weight loss and mean BMI decrease of 7Kg/m2 in 65 patients converted to distal RYGB.[9] However, 23 percent of patients developed protein malnutrition and almost half of these patients required revision surgery for this. Similarly, Sugerman, et al., reported 69-percent EWL at three years in 27 patients undergoing conversion to distal RYGB.10 Five of 27 had a common channel of 50cm and the remainder had a common channel of 150cm. The shorter common channel led to an “unacceptable” morbidity and mortality (all required revision, and two died of hepatic failure). The longer common channel was still associated with a 25-percent incidence of protein malnutrition and a significant number required operative revision. A recent report by Muller, et al., comparing a matched cohort (based on age, gender, and BMI) of standard RYGB (150cm Roux limb) and distal RYGB (150cm common channel) found no significant difference in weight loss or comorbidity reduction at 4 years.[11]

Conversion to the more malabsorptive BPD-DS is another surgical option. The incidence of protein malnutrition seen with BPD-DS may be less than with distal RYGB, partly because the larger stomach and sparing of the first portion of the duodenum affords better digestive behavior.[12] Keshishian, et al., reported 69-percent EWL at 30 months in 46 patients revised to BPD-DS (26 were from RYGB).[13] However, they did report a significantly higher complication rate in the RYGB revision patients, including a 15-percent leak rate.

At our institution, we frequently offer the adjustable gastric band as a surgical option for failed weight loss after RYGB. It is a technically simpler and safer operation to perform compared to other revision procedures and offers reasonable weight loss. The adjustable band is placed around the proximal gastric pouch and above the gastrojejunostomy. The remainder of the RYGB is left in-situ. O’Brien, et al., and Kyzer, et al., originally described converting any failed bariatric procedure (including gastric bypass) to the Lap-Band system.[14,15] Both series reported good weight reduction; however, subgroup analysis for failed RYGB was not provided.

A previous report from our own institution looked specifically at the use of adjustable gastric banding as a revision procedure for failed RYGB in eight patients.[16] Mean BMI prior to revision was 44.0±4.5Kg/m2. Patients had an average of four band adjustments over one year. Mean EWL was 38.1±10.4 percent at 12 months and 44.0±36.3 percent at 24 months. Another more recent report from NYU Medical Center revealed a mean 6.3Kg/m2 BMI decrease and approximately 20.8±16.9-percent EWL at 12 months in 11 failed RYGB patients.[17] Both series had minimal complications (mostly port-related).
Key technical points in placing the adjustable band on the upper pouch include the use of upper endoscopy to verify that the band is placed around the gastric pouch and not the esophagus, making sure that the band is at least 1cm proximal to the gastrojejunostomy, and using the fundus and the anterior wall of the bypassed stomach to plicate (with permanent sutures) above and below the band to ensure adequate anterior fixation. Sometimes, the gastric pouch alone is large enough to be used for the fundoplication.

Endoscopic Therapies for Weight Loss Failure after RYGB

Endoscopic therapies consist of either sclerotherapy or transoral endoscopic reduction. The goal of sclerotherapy of the gastrojejunostomy is to reduce the diameter of the gastrojejunostomy in a minimally invasive, low-risk manner. Specifically, submucosal and intramusuclar injections of five percent sodium morrhuate are placed circumferentially around the gastrojejunostomy to reduce the stomal diameter (by inducing tissue retraction and scarring). Data is limited regarding the efficacy of this technique. Spaulding reported a small series (n=20) of RYGB patients with weight gain who underwent sclerotherapy.18 Although sclerotherapy was 100-percent successful in diminishing the diameter of the gastrojejunostomy, the clinical effects were marginal: Seven to nine percent EWL overall, 25 percent regained weight, and only 45 percent noticed a “lasting difference.” Catalano, et al., recently reported more favorable results with sclerotherapy in 28 RYGB patients with weight regain (>18Kg after initial successful weight loss) and a stoma size >12mm.[19] They injected 2 to 4mL of sclerosant (sodium morrhuate) per quadrant circumferentially. Success (defined as stoma size <12mm and loss of >75% of regained weight) was achieved in 64 percent of patients. Mean stoma diameter decreased from 17 to 12.7mm and average weight loss was 22.3Kg (ranging from 3Kg weight regain to 37Kg weight loss). Problems encountered included shallow ulcers at the anastomosis (in nearly one-third of patients), stomal stenosis (requiring dilation), and post-injection pain (in 75% of patients).

Another emerging endoscopic technique is endoscopic suturing to narrow or plicate the gastrojejunostomy and thus reduce the stomal diameter. Schweitzer reported successful stomal plication in four patients; although all patients experienced early satiety, the absolute weight loss was not reported.[20]

Thompson, et al., reported a series of eight patients with gastrojejunostomies greater than 2cm who underwent endoscopic anastomotic reduction using the EndoCinch suturing system (C.R. Bard Inc., Murray Hill, NJ).[21] Seventy-five percent(6/8) of the patients lost weight (mean 10kg) at four months and overall EWL was 23.4 percent. There are several other promising endoluminal therapies on the horizon.[22-23] Further studies are required to determine if these new techniques deliver sustained weight loss.

Conclusions

Patients who have failed RYGB (especially after initial successful weight loss) are challenging. As the number of RYGB increase in the US, bariatric surgeons are likely to see this problem more frequently. Surgical treatment options include revision of the gastrojejunal anastomosis, placement of an adjustable gastric band on the pouch, conversion to distal gastric bypass, and conversion to duodenal switch.

Emerging endoluminal therapies include sclerotherapy and stomal plication. Longer-term studies are required to determine which treatment option is best. Careful risk benefit analysis is warranted in dealing with this difficult clinical and technically challenging situation.

References
1. Christou N, Look D, MacLean L. Weight gain after short- and long-limb gastric bypass in patients followed for longer than 10 years. Ann Surg 2006;244:734–40.
2. Prachand V, DaVee R, Alverdy J. Duodenal switch provides superior weight loss in the super-obese (BMI>50Kg/m2) compared with gastric bypass. Ann Surg 2006;244:611–9.
3. Behrns K, Smith C, Kelly K, Sarr M. Reoperative bariatric surgery—Lessons learned to improve patient selection and results. Ann Surg 1993;218:646–53.
4. Schwartz R, Strodel W, Simpson W, Griffen W. Gastric bypass revision: lessons learned from 920 cases. Surgery 1988;104:806–12.
5. Gagner M, Gentileschi P, De Csepel J, et al. Laparoscopic reoperative bariatric surgery: Experience from 27 consecutive patients. Obes Surg 2002;12:254–60.
6. Brethauer S, Nfonsam V, Sherman V, et al. Endoscopy and upper gastrointestinal contrast studies are complementary in evaluation of weight regain after bariatric surgery. Surg Obes Relat Dis 2006;2:643–50.
7. Mason E, Printen K Hartford C, Boyd W. Optimizing results of gastric bypass. Ann Surg 1975;182:405–13.
8. Muller M, Wildi S, Scholz T, et al. Laparoscopic pouch resizing and redo of gastro-jejunal anastomosis for pouch dilatation following gastric bypass. Obes Surg 2005;15:1089–95.
9. Fobi M, Lee H, Igwe D, et al. Revision of failed gastric bypass to distal Roux-en-Y gastric bypass: A review of 65 cases. Obes Surg 2001;11:190–5.
10. Sugerman H, Kellum J, DeMaria E. Conversion of proximal to distal gastric bypass for failed gastric bypass for superobesity. J Gastrointest Surg 1997;1:517–25.
11. Muller M, Rader S, Wildi S, et al. Matched pair analysis of proximal vs. distal laparoscopic gastric bypass with 4 years follow-up. Surg Endosc 2007;21:S369.
12. Rabkin R. The duodenal switch as an increasing and highly effective operation for morbid obesity. Obes Surg 2004;14:861–5.
13. Keshishian A, Zahriya K, Hartoonian T, Ayagian C. Duodenal switch is a safe operation for patients who have failed other bariatric operations. Obes Surg 2004;14:1187–92.
14. O’Brien P, Brown W, Dixon J, Racog D. Revisional surgery for morbid obesity—Conversion to the Lap-Band system. Obes Surg 2000;10:557–63.
15. Kyzer S, Raziel A, Landau O, et al. Use of adjustable silicone gastric banding for revision of failed gastric bariatric operations. Obes Surg 2001;11:66–9.
16. Bessler M, Daud A, DiGiorgi M, et al. Adjustable gastric banding as a revisional bariatric procedure after failed gastric bypass. Obes Surg 2005;15:1443–8.
17. Gobble R, Parikh M, Grieves M, et al. Gastric banding as a salvage procedure for patients with weight loss failure after Roux-en-Y gastric bypass. Surg Endosc 2007;21:S301.
18. Spaulding L. Treatment of dilated gastrojejunostomy with sclerotherapy. Obes Surg 2003;13:254–7.
19. Catalano M, Rudic G, Anderson A, Chua Y. Weight gain after bariatric surgery as a result of a large gastric stoma: Endotherapy with sodium morrhuate may prevent the need for surgical revision. Gastrointest Endosc 2007 (epub).
20. Schweitzer M. Endoscopic intraluminal suture plication of the gastric pouch and stoma in postoperative Roux-en-Y gastric bypass patients. J Laparoendosc Adv Surg Tech A 2004;14:223–6.
21. Thompson C, Slattery J, Bundga M, Lautz D. Peroral endoscopic reduction of dilated gastrojejunal anastomosis after Roux-en-Y gastric bypass: a possible new option for patients with weight regain. Surg Endosc 2006;20:1744–8.
22. Herron D, Birkeet D, Bessler M, Swanstrom L. Gastric bypass pouch and stoma reduction using a transoral endoscopic anchor placement system: A feasibility study. Surg Endosc 2007;21:S333.
23. Himpens J, Cremer M, Cadiere G, Mikami D. Use of a new endoluminal device in the transoral endoscopic surgical procedure for the treatment of weight regain after Roux-en-Y gastric bypass. SAGES Emerging Technology Oral Abstract #15 2007.

Category: Surgical Perspective

Comments (15)

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  1. LaVon says:

    I had RNY several years ago….I did not know that you could re gain the weight.
    I started out at RNY at 265 pounds and only lost to 195 pounds
    After that, the weight loss stopped.

    After a short period of time, I started to re gain. I am now back to 257 pounds.

    This is very depressing. I feel like I did the ultimate, but I am just a failure.

    Hope that others out there are having better luck or success.

    LaVon

  2. joan says:

    i had rny gastric bypass surgery last november and only lost weight the first three months. my total weight loss was 37 pounds. After 90 days post surgery my weight loss stopped and has stayed where it is for just short of a year. When I called my surgeon at 5, 7 and 9 months post surgery they said that i should just consider it a failure and I probably wont loose any more weight. Why is it when i started with whole food the weight stopped. I exersize regularly, eat low fat, maintain my calories. Yet my fat percentage is and has always been 50%. I have had my thyroid checked and it is fine. can you help?

  3. Yvette says:

    I had gastric bypass surgery in 2003 but i have noticed that it has come to a complete stop. I haven’t lost anymore weight and am currently weighing now 204 pounds I have started to get help for my weight and am currently seeing a weightloss doctor which prescribed 3 different medications and i am also getting counseling by a life coach which doesn’t seem to be explaining much about which diets to follow. My fears are to gain all the weight back and more. I was weighing 314 when i under went the gastric bypass and would like to know if i qualify for the Rose procedure to correct my problem. Please help me with my situation.

  4. Jenni says:

    I had gastric bypass in 2001 at 389, got down to 185, now I’m at 285 and feel like a failure.

  5. Carrington says:

    Had surgery in 2005 at 269 and initially didn’t lose very much weight but lost inches. After 6 sclerotherapies got down ultimately to 178 and a size 14 (from a size 32). Was content. Then had a psychiatrist put me on Abilify where I gained 68 pounds and am now back up to a size 22 and cannot get the weight back off. SEVERELY DEPRESSED AND FEEL LIKE everything I did was for nothing.

  6. Sydney says:

    I had surgery on March 30th. For three weeks I drank nothing but liquids and rapidly lost weight. By the fourth week, I introduced soft foods, soup, jello, etc., and continued to lose weight. This progressed for several weeks and I lost a total of 50 lbs (from 270 to 220). I work out, do aerobics, and yet for three months have not lost pound one. Worse, if I don’t watch every bite I eat, I put on weight. I have a problem with will power, which was part of why I got the surgery – for the added help the tool could provide. However, I can still eat anything I want, in any quantity I want, and it’s only been 6 months since I’ve had the surgery. Nothing, and I do mean nothing, is off limits to me. It’s been really discouraging and now I am having to work with a nutrionist who has me on an all liquid diet again to lose weight. Shouldn’t the surgery have done more for me when I’m only 6 months out and have no ill effects, can eat anything (including all sugars). Why don’t I have dumping syndrome, why don’t I get sick, why isn’t my stomach pouch limiting what I can intake. All these questions run through my mind when I think of the cost of this surgery I feel as if I’ve been ripped off.

  7. Connie says:

    I had a bypass done about 4 years ago and I am the same way. I lost around 100 pounds and never did get under 230 pounds and went up again never to see 200. I feel like I have let everyone down and now I have to have knee replacements and If I could only lose 80 pounds. Why can’t they fix their mistake!!!!!!!

  8. Harlee says:

    Well, at least I see now that I am NOT aloane. I had proximal RNY in 1998 and did well after, got down to 180 from 300 and at 5’10” I looked great. Now, I have heartburn so badly and the only thing I find helps is eating something, so I graze. Ive tried all of the meds for heartburn and none work for long. Now, I’m heaing back up the scale…@230 now and only exercise I can do is walking (I’m 50% titanium adn just had back surgery Nov 11,2010).
    I,too, feel like a huge failure! I did so good for so long.

  9. Nicole B says:

    Well, I had th RNY in June 2003. Started out at 285lbs and got down to 150lbs. I went form a 24 to a 9. Needless to say I am now 242lbs after having my son in 2007. I have been to the doctor but, they say my pouch is super small and don’t know why I am not losing weight. IT SUCKS!! So I feel all of your pain!

  10. Cathy says:

    I had a Roux-En-Y bypass by Bernard Flint in 1981 in my 20’s. I was 327 lbs. and lost 189 lbs. and stayed between 138 and 145 for years and thought I was home free. Then slowly I started gaining and now I’m up to 250 lbs. and really want a revision if at all possible. I broke my back and have had a knee replacement surgery the same year and I can’t get around very well because of the back…use a scooter a lot and can’t walk very far without back spasms still. I’m starting to stoop and can’t straighten up.

    Is a revision even possible on a 56 year old woman? I retired because of the back only because my supv. would never have let me work with a body brace, crutches, and a scooter (safety hazard), so I retired – not on disability either. I still have good insurance that “may” pay for a revision, depending on requirements. I so want to be able to get around, the hell with looks at my age!

  11. Kim says:

    WOW, I’m not alone. I never felt that gastric bypass results were as good as many I knew that had it. Mine was done laproscopically. I lost around 85 pounds but never got to my goal weight. It has been over 10 years now and the past 5 years have been bad. I never had any problems, just didn’t lose as much as I thought I should of and now have regained a good portion of it. Now I feel like more of a failure than I did before. I do anything to have it fixed. I hate being fat and the depression that goes with it is uncontrollable. It’s all I think about. I don’t want to do anything anymore. My husband never complains but I do. It makes things really hard for us. I need some advice and am looking for an answer to get me fixed.

  12. Ellen says:

    I see a lot of people commenting on weight-regain. But, i do not see any solutions being offered. My RNY was in 2004 and i went from 256 to 163 (93 lbs). I was happy and satisifed. In 2009, the weight started to creep back on. I am now at 198 (35 lbs regained). Where are the recommended strategies beyond dieting and exercise. If these were solutions for our group, we would never have needed the original WLS in the first place.

  13. Polly says:

    I had gastric bypass in November of 2004. 7 years ago. I was 215 and dropped to 119. 119 was too small for me and I stressed that I could lose even more. Now 7 years later, I’m 165 and regret not eating healthy consistently all of these years. Due to WLS I could only eat small amounts but I graze all day long. I can eat and 15 minutes later, I’m snacking again. It worked for me…. but I’m didnt go through radical surgery like this to start creeping to my presurgery weight. I have to loose this weight I put on.
    It’s discouraging. It’s discouraging to hear people say “your not heavy” and “you don’t need to loose” I’m thinking I’m well on my way to where I started and scared to death!

  14. Lois says:

    I have been reading all these comments and I have the same feeling like I failed….my highest weight was 3l7 but lost before surgery, my lowest was 204, now for the past year I am fighting 2l9…..I am four years out and had rny and can eat a hoagie, and not feel full…..I fight everything I put in my mouth from going to my hips and upper legs, I feel I am ungrateful for feeling this way and should appricate what I have done but I don’t….all my other friends have made goal and I never did…when I meet people at my support groups, some of them are only 205 and just getting the surgery……wow, whaqt does that do to your brain….I would like to have a revision, I am 59 and have medicare and a secondary insurance also…..I had plastics done one year out on my arms, three years out had a corset trunk plasty, so I have flat flat stomach and small waist….do you know of anyone in the PA area that does the revisions and do I qualify, I feel my own doctors think I should be satified where I am, and maybe they are right, but for someone who has been obese there whole life, to be satisfied where I am is what I did all my life, I want to be a winner for a change….thank you for listening.;

  15. Gina says:

    I too am like the comments listed here. I was banded in 2006, lost about 72lbs, and have now gained about 30 back. I have suffered slippage twice and I constantly struggle to lose the weight and keep from gaining even more. I would love to just have the band removed, but during the terrible economy I lost my full time job and insurance. I just can’t afford to have it removed, or revision and can barely afford to have the fills done. Was it worth the initial 72lbs weight loss for such a short period of time, I question myself. I’m truly trying to do the right thing, eating right and exercise. I don’t want this weight on me for the rest of my life. Now I beleive that I am suffering from yet another slippage, but I just can’t afford the cost of the barium swallow, so I will begin the liquids phase and hope that helps me feel better. Good Luck to everyone out there – I totally understand!!