Do You Do Revisions?

A commentary by Bariatric Times Clinical Editor Raul J. Rosenthal MD, FACS, FASMBS

Raul J. Rosenthal, MD, FACS, is Clinical Editor, Bariatric Times, Professor of Surgery and Chairman, Department of General Surgery; Director, The Bariatric and Metabolic Institute; Director, General Surgery Residency Program and Fellowship in Minimally Invasive and Bariatric Surgery, Cleveland Clinic Florida, Weston, Florida.

Bariatric Times. 2012;9(7):8

For the last 16 years since my first entry into the world of bariatric surgery, I hear the question being asked, “Do you do revisions?” At the beginning of my career as a bariatric surgeon, I answered a plain “yes.” However, as I got to do more and more of these “revisions,” I began trying to engage those who ask me that question by responding “What kind of revision do you mean? Or do you mean reoperations?”
In the last couple of years, we were privileged to publish our results on this subject,[1,2] and by doing so, I learned that revisions is a section in the world of what I like to call “re-operative bariatric asurgery.” It is imperative that we all start working to change our language and put order to our household. Otherwise, with the increasing number of re-operations we are all performing, we will get ourselves and our patients into trouble.

I would like to start classifying the re-operative bariatric surgical procedures based on etiology: Failures versus complications (Table 1). This first major classification is a crucial one to understand, specifically for medical directors, insurance carriers, and surgeons. Complications after bariatric surgery should be excluded from the language used by insurances in contracts that state “approved for one bariatric procedure only.” Surgery (reoperations) for a bleeding or perforated marginal ulcer, a partial small bowel obstruction, a gastro gastric fistula, or a stricture (just to mention a few) are not bariatric procedures for weight loss and are not second bariatric operations. If these patients are not operated on in a timely manner, in some circumstances, the complication can become a lethal one, and complications, such  as the ones mentioned, can indeed appear early or late in the postoperative period. When I say “late,” I mean really late—years.

In the world of complications we should then distinguish between and and then separate the type of procedures upon which we have to operate, such as bypass, bands, and sleeves. Once we are in the next big division of complications (early or late, e.g., with Roux-en-Y gastric bypass [RYGB]), we should then make a difference between reversals, conversions, and revisions. Here, we are entering another major subdivision of reoperative surgery. Ressecting the anastomosis of a gastro-jejunostomy after a RYGB complicated by a nonhealing marginal ulcer is not the same reoperation as reversing the whole operation. Naming these two operations revisions and putting them all in the same bucket creates confusion and will make our results questionable. While reversals in hands of experts has excellent results,[3] revisions of the gastro-jejunostomy in the hands of others have a totally different outcome with staple line disruptions close to 12 percent.[1] The outcomes are most likely different not only due to the wide experience and skills of the surgeon on call, but also because the type of procedure we are performing is more difficult and, as such, an unpredictable one.

Last but not least, we need to understand that conversions are probably the most difficult and occur in the majority of cases related to failures of weight loss or weight regain. Results after conversions, such as laparoscopic adjustable gastric banding (LAGB) to RYGB or LSG, or LSG to RYGB or biliopancreatic diversion with duodenal switch (BPD-DS), have a wide variation. Nevertheless, as my mentor Dr. Peter Benotti used to teach me, “There is a price to pay when performing reoperative surgery.” We should be careful when selecting patients for one procedure or the other and understand the risks involved with these types of procedures. Data collection should follow certain guidelines and order so that outcomes can be better understood, analyzed, and risk stratified accordingly.

REFERENCES
1.    Patel S, Szomstein S, Rosenthal RJ. Reasons and outcomes of reoperative bariatric surgery for failed and complicated procedures (excluding adjustable gastric banding). Obes Surg. 2011;21(8):1209–1219.
2.    Patel S, Eckstein J, Acholonu E, et al. Reasons and outcomes of laparoscopic revisional surgery after laparoscopic adjustable gastric banding for morbid obesity. Surg Obes Relat Dis. 2010;6(4):391–398.
3.    Brolin RE, Asad M. Rationale for reversal of failed bariatric operations. Surg Obes Relat Dis. 2009;5(6):673–676.

FUNDING: No funding was provided.

DISCLOSURES: Dr. Rosenthal is a speaker, consultant, and advisory board member for Ethicon Endo-Surgery, Cincinnati, Ohio.

Category: Commentary, Past Articles