Revision Gastric Bypass
Repeat surgery on the stomach is significantly more difficult (and more risky) than the primary operation.
The increased difficulty and risk come from the scar tissue that is naturally left by the preceding operation. This scar tissue causes two types of problems: 1) scarred tissues stick together a lot more than normal tissues, and 2) scarred tissue does not heal as reliably as tissue that has never been through the trauma of surgery.
Normally all the internal organs slide smoothly against each other, but the unavoidable scar tissue from previous surgery causes the stomach to be stuck to everything else that is nearby. Some of the nearby organs that are often stuck to the stomach after previous surgery are the spleen, liver and pancreas. Generally this scar tissue must be dissected free in order to accomplish the revision operation, and sometimes this dissection to separate the stomach from nearby organs actually creates injury to these organs.
In the case of the spleen, such injury causes bleeding that may only be stopped by removing the spleen. In the case of the liver, dissection of the scar tissue or adhesions can cause substantial bleeding or perhaps leakage of bile, but rarely requires removal of liver tissue. Damage to the pancreas can result in inflammation of the pancreas (called pancreatitis, which can be very dangerous) or leakage of pancreatic digestive juices.
The presence of the scar tissue is also likely to impair the quality of the stapling or sewing revisions done on the stomach or small intestine. All surgical techniques involving intestinal surgery depend on the patient’s intestine to heal appropriately in place after the procedure is accomplished, and the presence of scar tissue in the area of the procedure may interfere with appropriate healing of the revision or repair that is created. This means that there is a higher chance of a leak (possibly life threatening) or poor function of the new stomach after revision surgery. If a leak occurs, multiple additional procedures may be required and the healing process is usually several months long.
Unfortunately, the weight loss after the second procedure is rarely as dramatic as we see following a Gastric Bypass the first time around. It seems that the body is “surprised” by the sudden calorie deprivation after the first procedure, and there is a long “honeymoon period” of easy rapid weight loss. The second time around the body is smarter, and adapts quickly by burning fewer calories, so that weight loss after a revision procedure is usually modest.
In summary, the patient who requires repeat surgery after prior weight loss surgery must know that there is substantially increased difficulty with the actual conduct of the operation, in comparison to the first weight loss procedure. This increased difficulty does not simply mean that the surgery will take longer or the surgeon will work harder – it also means that the risk of leak and other risks are greater, so that risk to life is greater, and the chance of a desirable long term outcome is not as good. Many patients who require additional stomach surgery have lost a great deal of weight since their first operation, and such weight loss does reduce systemic risk somewhat; however, improved systemic risk (if present) does not usually outweigh the increased difficulty in the area of the stomach itself.
Because of these difficulties, we are reticent to take on revision surgery when the first operation was done by other surgeons. For patients who have problems after a weight loss procedure, the first avenue to work on the problem should always be with the original surgeon. In circumstances that make it unreasonable for the primary surgeon to carry the care to a desirable conclusion (surgeon retired, patient moved, or significant surgeon/patient conflict) we are willing to take on the care of patients who may need revision surgery. We must have the following information before an appointment is made:
- Copy of prior operative note and discharge summary. We are also interested in other medical data from the time around surgery.
- Upper GI x-ray – we need to see if the anatomy is surgically correctable.
- Upper endoscopy – also called a “scope” or esophagogastroduodenoscopy – required in selected cases.
- Established contact of the patient with a primary physician – because of the increased complexity of a revision procedure a patient should have a professional medical advocate.
Conversion of a Vertical Banded Gastroplasty (VBG) or “stomach stapling,” or Gastric Banding to a Roux-en-Y Gastric Bypass
This is the most common type of revision required in our experience. Other than the technical risks outlined above, the main point of education is about diet changes after Gastric Bypass. Many patients who have undergone prior weight loss surgery believe that they “understand” the diet. Please pay close attention to the dietary instruction you receive, because the diet after GBP really is different. In gastric restrictive procedures, many patients develop a habit of eating until they feel full, and if necessary they throw up to relieve the pressure. After a GBP, a more conscious effort is required.
A patient must stop eating before feeling full. The different anatomy after GBP may not induce vomiting, but it may cause nausea or an otherwise ill feeling. A patient who regularly eats to fullness after GBP is also likely to stretch out the pouch or outlet, resulting in less-than-ideal weight loss. Last, a reminder that enriched liquids, especially those that contain sugar, are absolutely contraindicated after GBP.
Re-division of staple line
If a patient has an identified connection between the stomach pouch and the lower stomach where one is not supposed to exist, then an operation to re-accomplish separation of the stomach by dividing it at the site of the staple line may be appropriate. All of the precautions about potential damage to nearby organs and increased chance of leak from poor healing that are described above are true for this procedure.