Revisional Surgery Evaluation and Contraindications

| March 1, 2020

by Marguerite Dunham, CRNP, FNP, MSN, CBN

Ms. Dunham is Program Coordinator for the Institute for Metabolic and Bariatric Surgery at Abington-Jefferson Health in Abington, Pennsylvania.

Funding: No funding was provided.

Disclosures: The author has no conflicts of interest relevant to the content of this article.

Abstract: Bariatric surgery is considered to be an effective treatment for individuals who suffer from the disease of morbid obesity. As the number of primary bariatric surgeries continues to increase, so too does the number of revisional surgeries. Unlike the guidelines related to primary bariatric surgery, there are no current recommendations or guidelines for revisional surgery. Equally important is attention to the preparation required to ensure the success of revisional bariatric surgery. In this article, the author describes the current incidence and indications for revisional bariatric surgery in the United States. Additionally, the author reviews the available literature on preparation methods for revisional surgery, describing the methods best supported by evidence. The author concludes that additional research is needed to determine and define best practices for revisional procedures in bariatrics in order to better serve the growing number of patients undergoing primary weight loss surgery.

Keywords: Bariatric, surgery, revisional, obesity, contraindications

Bariatric Times. 2020;17(3):16–17.

Morbid obesity is a growing healthcare concern—it has been reported that 2.8 million people die every year due to obesity or overweight and their related comorbidities.1 According to the National Center for Health Statistics, 39.8 percent of Americans had either overweight or obesity between the years 2015 and 2016.2

Bariatric surgery is considered to be the most effective method to treat morbid obesity, and during the last decade, there has been an increase in the number of patients undergoing bariatric surgery, with around 220,000 procedures performed in 2009 in the United States, with an increase to 252,000 in 2018, according to the American Society for Metabolic and Bariatric Surgery (ASMBS).3 Primary bariatric surgeries that are currently performed include adjustable gastric band (AGB), vertical sleeve gastrectomy (VSG), Roux-en-Y gastric bypass (GBP), and the biliopancreatic diversion with duodenal switch (BPD-DS).

Incidence of Revisional Surgery

As the number of primary bariatric surgeries has increased, so has the need for revisional bariatric procedures.4 Unsuccessful weight loss and anatomic complications are the two most common reasons for pursuing revisional surgery.3 Elshaer et al1 estimated that 10 to 50 percent of individuals who have restrictive surgeries, such as the vertical banded gastroplasty (VBG), AGB, or VSG, will need a revision at some point in the future. A review of the Swedish Obese Subjects Study revealed that in the 26 years since the study began, more than 25 percent of patients underwent revisional surgery.5 The most common reason for revision in VBG patients was staple-associated disruptions, while the most common reasons for revision in GBP patients were reflux-associated and esophageal-associated complications.5

Frantzides et al6 broke down the incidence of revisions based on the primary types of surgery, reporting that approximately 30 percent of patients with a VBG required a revision. For patients that received an AGB, the revision rate was 10 to 60 percent. Additionally, for those patients who underwent a GBP, 15 to 35 percent required a revision. A study by Tran et al7 reported a slightly lower revision rate for GBP of 10 to 20 percent. More research must be done to determine a more specific incidence of revision following bariatric surgery, but it is clear that there are a significant number of patients who will likely require a revision of their primary surgery at some point in their lifetime.

Indications for Revision

Many patients who seek revisional surgery report insufficient weight loss, weight regain, an anatomic complication, or intolerable gastroesophageal reflux disease symptoms.3,4,8–10 The ASMBS categorizes reoperation into one of three categories: conversion, corrective, or reversal.4 Conversions are used for complications and inadequate response to the primary surgery. Corrective procedures are used when primary surgeries had either a poor construction or a complication. Reversal procedures are needed when the primary surgery has caused an intolerance, such as malnutrition.4,5,10

Anatomical reasons to revise primary surgeries might be the easiest to identify. Anatomic complications include band erosion, gastric-gastric fistulas, breakdown of a gastric staple line, severe reflux, repair of a marginal ulcer that has not responded to conservative measures, or malnutrition related to intolerance of the primary procedure. These complications will require a revision in order to correct the underlying anatomic problem.

Weight gain or weight recidivism can lead to comorbid metabolic disease, and patients who experience weight regain might be good candidates for revisional surgery as well. Initial responders to surgery can have late weight regain, and revision has been shown to improve glycated hemoglobin (HbA1c) levels, lower low-density lipoprotein and triglyceride levels, and improve hypertension.4 The option to surgically revise these patients would be based on an examination of the risk versus benefit. A revision procedure could lead to a percentage of weight loss and disease resolution, making it a viable option for some.

Revisional surgery for weight gain without comorbidities remains controversial, and little has been published on this topic. The most commonly used definition of failure of a primary bariatric surgery is less than 50 percent of excess weight loss with or without a body mass index greater than 35kg/m2 at 18 months postoperation. This definition is, at times, flawed because it is still an arbitrary measure of success.11 It should also be understood that failure to achieve adequate weight loss is not necessarily an indication of patient failure, but it could also be related to medical therapies that lead to decreased weight loss and possible regain.4

In cases of insufficient weight loss, providers should evaluate the reasons a patient is not losing weight or is regaining weight after the primary bariatric procedure. These reasons can assist in the decision-making process. In cases of weight gain, the risks and benefits should be assessed, with serious consideration on what surgical approach, if any, should be pursued.

Preparation for Revisional Surgery

There is a paucity of published data on the best method of preparation for revisional surgery. Until such guidelines are established, following the evidence-based protocol developed for primary bariatric surgery might be the safest method when preparing patients for revisional surgery. Primary bariatric surgery guidelines recommend patients should undergo an evaluation of underlying diseases associated with weight gain before surgery. A comprehensive evaluation should include medical history, psychosocial history, and a physical exam. This evaluation is essential to determine surgical risk and appropriateness for revisional surgery.12,13 A copy of the primary surgery team’s operative report should be obtained and reviewed.14 This might be difficult in some cases in which the surgery occurred longer ago than records are commonly held.

In 2013, clinical practice guidelines for preoperative nutritional, metabolic, and nonsurgical support of bariatric surgery patients were updated.15 These pertain to the preparation of a patient before a primary bariatric surgery but could also be applied to revisional procedures. As with primary procedures, evaluation of nutritional health will help to establish readiness for surgery. This includes routine labs, such as blood sugar, lipids, kidney function, and a complete blood count, and nutrient studies, such as iron, folic acid, vitamins B12 and D, and possibly vitamins A and E. This review will give the team an opportunity to assess the patient’s current health as well as allow time to correct any deficits before revisional surgery. If warranted, cardiac and pulmonary assessments to verify stability for surgery would also be included. If not being done by the bariatric surgeon, a gastrointestinal (GI) assessment with endoscopy should also be done to assess anatomy. Upper GI contrast studies may be complementary in some circumstances.14

An evaluation by a registered dietitian (RD) is essential to assess the patient’s current understanding of their primary procedure and any possible revisional procedures as they relate to nutrition.3 The RD is in a position to assess the eating habits of the patient and establish if there are any red flags related to nutrition that should be addressed prior to revisional surgery. For example, if a patient has developed maladaptive eating habits as a consequence of an anatomical issue, the RD can create an eating plan and re-educate the patient before a revisional surgery.3 The RD can also assess the patient’s readiness to change and can begin instituting or resuming vitamin supplements and/or replacements as needed.10

While no standard has been set for nutritional guidelines before a revisional surgery, it is essential to identify any eating habits (e.g., grazing, high carbohydrate consumption, skipping meals) that will hinder a patient’s successful weight loss after surgery. In the case of weight regain, patients might have fallen off track with both diet and supplementation, thereby needing intense, directed education prior to surgery. It might be helpful to have a standard pathway in place for patients preoperatively that includes a set number of months a patient should meet with the RD. At these meetings, the RD can set goals to monitor progress and commitment to changes before revisional surgery. This time with the RD is not intended to be a time of weight loss, per se, but an opportunity to measure the patient’s willingness to eliminate harmful habits and reintroduce more healthy ones. It serves as a measure of the patient’s commitment to the program,4 and if some weight loss occurs, that is certainly a bonus. The RD is also in a position to evaluate whether there would be any cost barriers to revisional surgery; for example, the cost of supplementation might be prohibitive for a patient and is best identified prior to surgery.

As with primary surgery, a psychosocial-behavioral evaluation is an integral part of the work-up to revisional surgery.1,4,10 In cases of weight regain as a reason for revision, it is essential to understand the reasons for the weight regain and to address those prior to surgery. A strong evaluation and treatment plan can make patients more successful in the short- and long-term after revisional surgery. This evaluation is also an opportunity to identify a patient’s expectations of revisional surgery. It is vital that a patient has realistic expectations and an understanding of the potential outcomes of surgery.16 Based on the evaluation, an ongoing mental health plan might need to be developed. As with the nutritional evaluation, no set protocol has been determined related to behavioral health prior to revisional surgery. It might be helpful, especially in cases of weight regain, to require attendance in some behavior modification program prior to surgery.

As a chronic disease, obesity requires lifelong treatment. Revisional surgery to correct complications, with or without weight regain, carries a higher risk than a primary surgery. Pinto-Bastos et al10 estimate a mortality rate of revisional surgery to be about two percent, which is higher than the expected range for primary bariatric surgery (0.1–1.1%). As such, there are instances where the risk might be higher than the intended benefit. Particular attention should be paid to surgical candidates who have demonstrated difficulty with engaging in healthy eating behaviors. Revisions for nonemergent reasons should be thoroughly assessed for risks versus benefits.

Informed consent is an essential component of revisional surgery since the risks of revisional surgery are higher than primary surgeries.10 Risks and benefits, the need for long-term follow-up, and the need for ongoing lifelong supplementation should all be included in consents for revisional procedures.

In cases of weight regain with no comorbidities, revisional surgery might be contraindicated for individuals who have not demonstrated a commitment to following their initial postoperative plan. Possible evidence of a lack of commitment includes a lack of adherence to diet plans, supplementation, and follow-up visits.7 Individuals that are identified as having an unrealistic expectation of the possible weight loss after surgery should also be approached with caution. Chew et al11 noted that patients who seek a revisional surgery based on disappointment with their primary surgery’s outcome are also unlikely to be satisfied with the revisional outcome. These patients should be recommended to an extended follow-up with the RD and a behavioral health professional prior to any revisional surgery.

Conclusion

Revisional bariatric surgery is highly technical, can be complex, and carries a higher risk of complications than primary bariatric surgery.7,11 As the number of patients who might require revisional surgery increases, a standardized approach must be created. The base of these protocols should be similar to those used for primary surgery candidates. In addition, complete metabolic testing and radiologic studies should be obtained. To understand what was done during the primary surgery, access to the previous operative notes are important to prevent possible surprises in the operating room.

Having patients undergo a nutritional assessment by an RD and a psychological assessment by a behavioral health specialist should also be implemented prior to revisional surgery to assess a patient’s readiness. Early identification of any issues by the team and the creation of a customized treatment plan will improve a patient’s opportunity for success both before and after revisional bariatric surgery.13

With a projected increase in the need for revisional bariatric surgery, bariatric surgical teams must be prepared for the challenges that this population presents. The decision to revise should involve a detailed history and evaluation. Also, when possible, the same team that was involved in the primary bariatric surgery should be consulted, or at least the original operative note and documentation should be obtained and reviewed. The involvement of an RD and a mental health provider should be integral to the revisional plan. As with primary surgeries, revisional surgeries require research to determine the best practices and procedures to ensure the best possible outcomes for this growing population of patients.

References

  1. Elshaer M, Hamaoui K, Rezai R, et al. Secondary bariatric procedures in a high-volume centre: prevalence, indications and outcomes. Obes Surg. 2019;29:2255–2262.
  2. Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of obesity among adults and youth: United States, 2015–2016 (National Center for Health Statistics Data Brief No. 288). Atlanta: Centers for Disease Control; October 2017. Available from: http://www.cdc.gov. Accessed August 24, 2019.
  3. Shimizu H, Annaberdyev S, Motamarry I, et al. Revisional bariatric surgery for unsuccessful weight loss and complications. Obes Surg. 2013;23:1766–1773.
  4. Ma P, Reddy S, Higa KD. Revisional bariatric/metabolic surgery: what dictates its indications? Curr Atheroscler Rep. 2016;18(7):42–47.
  5. Hjorth S, Näslund I, Andersson-Assarsson JC, et al. Reoperations after bariatric surgery in 26 years of follow-up of the Swedish Obese Subjects Study. JAMA Surg. 2019;154(4):319–326.
  6. Frantzides CT, Alexander B, Frantzides AT. Laparoscopic revision of failed bariatric procedures. JSLS. 2019;23(1):e2018.00074.
  7. Tran DD, Nwokeabia ID, Purnell S, et al. Revision of Roux-en-Y gastric bypass for weight regain: a systematic review of techniques and outcomes. Obes Surg. 2016;26:1627–1634.
  8. Yilmaz H, Ece I, Sahin M. Revisional surgery after failed laparoscopic sleeve gastrectomy: retrospective analysis of causes, results, and technical considerations. Obes Surg. 2017;27:2855–2860.
  9. El Chaar M, Stoltzfus J, Claros L, Miletics M. Indications for revisions following 630 consecutive laparoscopic sleeve gastrectomy cases: experience in a single accredited center. J Gastrointest Surg. 2017;21:12–16.
  10. Pinto-Bastos A, Conceição EM, Machado PPP. Reoperative bariatric surgery: a systematic review of the reasons of surgery, medical and weight loss outcomes, relevant behavioral factors. Obes Surg. 2017;27:2707–2715.
  11. Chew CAZ, Shabbir A. Revisional bariatric surgery: focus on quality of life. J Obes Metab Syndr. 2017;26:97–101.
  12. Kichler K, Rosenthal RJ, DeMaria E, Higa K. Reoperative surgery for non responders and complicated sleeve gastrectomy operations in patients with severe obesity. An international expert panel consensus statement to define best practice guidelines. Surg Obes Relat Dis. 2019;15:173–186.
  13. Brethauer SA, Kothari S, Sudan R, et al. Systematic review on reparative bariatric surgery: American Society for Metabolic and Bariatric Surgery Revision Task Force. Surg Obes Relat Dis. 2014;10(5):952–972.
  14. Sarr MG. Reoperative bariatric surgery. Surg Endosc. 2007;21:1909–1913.
  15. Mechanick JI, Youdim A, Jones DB, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Surg Obes Relat Dis. 2013;9(2):159–191.
  16. Fried M, Yumuk V, Oppert JM, et al. Interdisciplinary European guidelines on metabolic and bariatric surgery. Obes Surg. 2014;24:42–55.

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