Bariatric Journal

Gastric Sleeve Revision Surgery Options

Complications or inadequate weight loss may necessitate revision of gastric sleeve surgery in few individuals. Available options are to re-sleeve, conversion to gastric bypass or duodenal switch surgeries. The best choice is determined based on the indication for revision as well as individual patient’s characteristics.

Although gastric sleeve surgery has been shown to be effective with few complications/side effects, rarely, some of these complications may not be amenable to non-surgical management thus necessitating revision surgery. However, the most frequent reason for gastric sleeve revision is weight related issues either inadequate weight loss or re-gaining of the already lost weight after about 1-2 years of surgery.
Inadequate weight loss

An obese person is expected to lose about 40-70% of his/her excess weight within 6-18 months after gastric sleeve surgery. However, some may not achieve this due to many factors. First is the surgeon’s skill.2 Inadequate stomach resection or incomplete removal of the gastric fundus (part of the stomach where appetite hormone “ghrelin” is produced) will result in a stomach with relatively larger capacity and higher appetite. Second is non-compliance with the dietary plan after gastric sleeve surgery. Consumption of high calorie with more refined sugar and carbonated drinks will retard weight loss. The last factor is inadequate exercise.

Regaining of already lost weight

After an initial weight loss, some patients may re-gain the already lost weight and on rare occasion may become more obese than before surgery. This has been associated with permanent stretching and dilatation of the stomach with more capacity, more food intake and weight gain. Although stretching of the sleeve-shaped stomach is inevitable after gastric sleeve surgery due to the strong nature of the stomach wall, however, dietary indiscretion is a significant cause of significant stretching and dilatation that result to weight gain.

While pouch resetting has been used to readjust the stomach size to next post-operative size by recommencing the quick post-operative diet, many patients will still need revision surgery for a permanent solution.

Complications/side effects

Gastric sleeve surgery may worsen symptoms of heartburn or even leads to the development of heartburn. This is due to the reflux of acidic contents from the stomach into the esophagus which is often worse in the supine position. Many patients may respond to the use of antacids or drugs that reduce gastric acid secretion. Those that fail to respond may, therefore, require revision surgery to address this problem permanently.

What to do before revision surgery

In patients who have undergone gastric sleeve surgery as the primary weight loss procedure, revision surgery should be seen as the last option in any case of inadequate weight loss or weight gain. This is because the revision surgeries are not without their complications. Dietary or exercise issues that might have caused weight gain should first be addressed as they may also hamper the success of the revision surgery. Have a discussion with your doctor and dietician to identify the cause(s) of weight gain, join bariatric forums to get motivation and support from people who have had the same problems in the past.
Surgical options for revision

Re-sleeve

The first surgical option is to re-sleeve. By this, we mean doing the gastric sleeve surgery like it was done during the first surgery. This is the initial procedure for a stretched and dilated stomach. The excess stomach is resected, and a small sleeve-shaped portion is left. With the reduction in stomach capacity, food intake is significantly reduced leading to weight loss and improvement in obesity-associated disease conditions.
This procedure can be done by a laparoscopic or open approach like the first surgery. Complications are similar to that of the primary operation but lesser when compared to other revision surgeries. An excess weight loss increase from 25.3% to 56.3% and BMI reduction from 38.9kg/m2 to 32.2kg/m2 in addition to significant improvement in disease conditions were reported in a study.

Conversion to gastric bypass

Even as a primary procedure, Roux-en-Y gastric bypass surgery gives higher weight loss and better improvement in comorbid conditions over gastric sleeve surgery. It has also been shown to reduce the symptoms of heartburn in those with gastroesophageal reflux disease. The further reduction in stomach capacity and the additional of malabsorptive components often result in significant weight loss with a resolution of obesity-associated diseases. However, this procedure comes with complications such as dumping syndrome, hernias, nutritional deficiencies and anastomotic stricture.

Conversion to duodenal switch

Duodenal Switch is another revision surgery for patients with unsatisfactory outcome after gastric sleeve. It is both restrictive and malabsorptive with one of the highest weight loss potentials. The stomach is further reduced to the desired sleeve-shaped size, and the small intestine is re-fashioned to minimize absorption. The drastic weight loss that follows duodenal switch may precipitate the formation of gallstone which is why the gallbladder is removed during this surgery. Complications are those of gastric sleeve surgery in addition to severe nutritional deficiencies, hernias, and strictures. Lifelong dietary supplements may be required. An average of 73% reduction in BMI was recorded after 2years in a study.

In conclusion, there are few surgical options for gastric sleeve revision with potentials for more weight loss. Although they are not without their complications, proper patient selection by a skilled surgeon will help determine the best option for any individual.

References

  • Gagner M, Deitel M, Erickson A, Crosby R. Survey on laparoscopic sleeve gastrectomy (LSG) at the Fourth International Consensus Summit on Sleeve Gastrectomy. Obesity Surgery. 2013;23(12):2013-2017. doi:10.1007/s11695-013-1040-x.
  • Fischer L, Hildebrandt C, Bruckner T et al. Excessive Weight Loss after Sleeve Gastrectomy: A Systematic Review. Obesity Surgery. 2012;22(5):721-731. doi:10.1007/s11695-012-0616-1.
  • Cesana G, Uccelli M, Ciccarese F, Carrieri D, Castello G, Olmi S. Laparoscopic re-sleeve gastrectomy as a treatment of weight regain after sleeve gastrectomy. World Journal of Gastrointestinal Surgery. 2014;6(6):101-106. doi:10.4240/wjgs.v6.i6.101.
  • Buchwald H, Estok R, Fahrbach K et al. Weight and Type 2 Diabetes after Bariatric Surgery: Systematic Review and Meta-analysis. The American Journal of Medicine. 2009;122(3):248-256.e5. doi:10.1016/j.amjmed.2008.09.041.

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