Revision Surgery After Laparoscopic Sleeve Gastrectomy Introduction to bariatric surgery When to Revise a Weight Loss Surgery? Options for redo surgery. Laparoscopic Roux-en-Y gastric Bypass.

1. Revision Surgery After
Laparoscopic Sleeve Gastrectomy
Advanced Laparoscopic in Robotic and Bariatric Surgery
King Saud University Medical City
30 December, 2018
Ibrahim Abunohaiah
R1, Urology

2. Introduction
Bariatric operations produce weight loss through at
least two mechanisms:
• Restriction of intake.
• Malabsorption of ingested food.

3. Bariatric Surgeries, MOA
Adapted from Schwartzs Principles of Surgery, 10th Edition.

4. Bariatric Surgeries, Effects

5. Bariatric Surgeries, Indications
Adapted from Schwartzs Principles of Surgery, 10th Edition.

6. Bariatric Surgeries, Contraindications
Adapted from Schwartzs Principles of Surgery, 10th Edition.

7. Introduction
It is estimated that 179,000 weight-loss surgeries were
performed in 20131.
Of those, 42% were sleeve gastrectomy, 34% were gastric
bypass, 14% were gastric band, and 1% were biliopancreatic
diversion with duodenal switch. The remaining 6% were
revisional procedures.
1. connect.asmbs.org/may-2014-bariatric-surgery-growth.html (Accessed on April 12, 2016).

8. What is revision surgery?
In general, between about 10 and 30 per cent of patients
having any type of weight loss surgery will end up needing
later surgery to treat complications or weight regain.
When an ineffective procedure results in weight regain, a
revision procedure may be the best solution.
http://www.sydneyobesity.com.au/revision-surgery.html
https://www.smartdimensions.com/bariatric-weight-loss-orange-county/revision-bariatric-surgery/

9. When to Revise a Weight Loss
Surgery?
A small number of patients who have weight loss surgery
relapse years later. These individuals may benefit from an
additional procedure, called revision surgery, to help them
lose again and treat specific symptoms.
There are many different factors that might contribute to
weight regain. Revision surgery may be done because the
patient's anatomy has changed over time and needs repair.
http://columbiasurgery.org/news/2017/08/14/when-revise-weight-loss-surgery

10. Options for redo surgery
http://www.sydneyobesity.com.au/revision-surgery.html
If a patient needs redo surgery we can then create a solution that is specific to your
particular problem that a patient has. Redo surgery can be planned to:
• Fix a complication with an operation
• Repair or fix an operation that is no longer working
• Change an operation to another procedure (band/sleeve/bypass)

11. Revision Surgery for Weight Regain
After Gastric Sleeve (Re-Sleeve)
In some cases, improper eating (frequent large meals,
drinking carbonated beverages, and binge eating) or a failure
to completely remove all necessary portions of the stomach,
can result in weight regain after gastric sleeve surgery.
When significant or lasting weight loss is not achieved in
patients who have undergone gastric sleeve surgery, a “re-
sleeve” may aid in further weight loss.
https://www.smartdimensions.com/bariatric-weight-loss-orange-county/revision-bariatric-surgery/

12. Gastric Sleeve Revision Surgeries
There are 4 gastric sleeve revision surgery options for
addressing inadequate weight loss, weight regain, or
persistent side effects:
• A conversion to a duodenal switch (DS)
• A conversion to a gastric bypass
• Re-sleeve
• A conversion to a Lap-Band
https://www.bariatric-surgery-source.com/gastric-sleeve-revision-surgery.html

13. Reasons for Revision
The most common reasons for gastric sleeve revision surgery
are:
1. Inadequate weight loss
2. Weight regain
3. Side effects like gastric reflux (but are much less common (1)).
https://www.bariatric-surgery-source.com/gastric-sleeve-revision-surgery.html
(1) http://www.soard.org/article/S1550-7289(14)00394-3/abstract

14. Revising a Failed Procedure
A failed weight loss procedure can be defined as one that has
resulted in:
• Less than 50% loss of the expected weight loss
• Weight loss followed by partial or total regain
• An intolerance to normal/solid foods
• Signs that the overall quality of life is diminishing
• Additional health issues caused by the procedure
https://obesitycontrolcenter.com/weight-loss-surgery-options/weight-loss-surgery-revision/

15. 1. Inadequate weight loss
The average gastric sleeve patient loses weight at the
following pace:
• 3 months: about one-third of excess weight
• 6 months: about half of excess weight
• 12 months: up to 70% of excess weight
https://www.bariatric-surgery-source.com/gastric-sleeve-revision-surgery.html

16. 2. Weight Regain
As many as 3 out of 10 gastric sleeve patients eventually experience
weight regain.
The amount of regain varies widely, ranging from a few pounds to all of
the weight lost (1) (2). For these patients, the weight begins to creep back
anywhere from 18 months to 6 years after surgery and is the result of:
• The stomach stretching out, causing patients to eat more
• The amount of hunger-causing hormones going back up (e.g., ghrelin) (3) (4)
• Not enough follow-up support for the patient
• Patient not adhering to recommended diet & lifestyle changes
Stomach stretching as a result of overeating is the most common reason
for weight regain after gastric sleeve surgery (3).
https://www.bariatric-surgery-source.com/gastric-sleeve-revision-surgery.html
(1) https://www.sciencedirect.com/science/article/pii/S0899900715003858
(2) https://link.springer.com/article/10.1007/s11695-016-2165-5
(3) https://www.ncbi.nlm.nih.gov/pubmed/20094819
(4) https://www.ncbi.nlm.nih.gov/pubmed/17132410

17. 3. Persistent Side Effects
Although it’s relatively rare, gastric sleeve revision surgery
may be required in the case of persistent side effects like acid
reflux and hiatal hernia (1).
Approximately 2% of revisional surgeries are due to acid reflux
symptoms that haven’t responded to dietary changes or the
use of medication (2).
https://www.bariatric-surgery-source.com/gastric-sleeve-revision-surgery.html
(1) https://www.sages.org/meetings/annual-meeting/abstracts-archive/revision-of-primary-sleeve-gastrectomy-to-roux-en-y-gastric-bypass-indications-and-
outcomes-from-a-high-volume-center/
(2) https://www.soard.org/article/S1550-7289(18)30123-0/fulltext

18. Conversion to Gastric Bypass Surgery for
Weight Regain After Gastric Sleeve Surgery
If gastric sleeve surgery has failed to achieve lasting or desired
weight loss in a patient, conversion to a gastric bypass
procedure can be an effective alternative for additional
weight loss.
There are some cases in which gastric sleeve surgery is
followed by gastric bypass surgery or duodenal switch surgery.
This is often referred to as a “staged” approach to bariatric
surgery and is typically performed in “high-risk” cases where
the second procedure (the gastric bypass surgery) is less risky
than it would have been if performed as the first and only
procedure.
https://www.smartdimensions.com/bariatric-weight-loss-orange-county/revision-bariatric-surgery/

19. Laparoscopic Roux-en-Y gastric Bypass

20. Background
Laparoscopic Roux-en-Y gastric Bypass
• LRYGB was first described in 19942
• By 2003, over 130,000 gastric bypasses were done in the
United States, with more than half of them being done
laparoscopically.
• Currently over 90% are performed laparoscopically.
• It has been established as the gold standard against which
other bariatric procedures are measured.
2. Deitel M. Overview of operations for morbid obesity. World J Surg. 1998;22:913-918.

21. Components of a Roux-en-Y
gastric bypass
It involves the creation of a small gastric
pouch and an anastomosis to a Roux limb
of jejunum that bypasses 75 to 150 cm of
small bowel, thereby restricting food and
limiting absorption.
Adapted from UpToDate.com

22. Background, cont.
• The major feature of the operation is a proximal gastric
pouch of small size (often <20 mL) that is totally separated
from the distal stomach.
• A Roux limb of proximal jejunum is brought up and
anastomosed to the pouch.
• The length of the biliopancreatic limb from the ligament of
Treitz to the distal enteroenterostomy is 20 to 50 cm, and
the length of the Roux limb is 75 to 150 cm.

23. Figure 1
Enteroenterostomy of laparoscopic Roux-en-Y gastric bypass
Adapted from Schwartzs Principles of Surgery, 10th Edition.

24. Figure 2
Creation of gastric pouch for laparoscopic Roux-en-Y gastric bypass
(From Schauer PR, et al, eds. Minimally Invasive Bariatric Surgery, 1st ed. New York: Springer; 2007. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photogra- phy © 2005-2009. All rights reserved.)

25. Figure 3
Gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass
(From Schauer PR, et al, eds. Minimally Invasive Bariatric Surgery, 1st ed. New York: Springer; 2007. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2005-2009. All rights reserved.)

26. Mechanism of Action
• It works by restricting the amount of food one
ingests (restriction) and by limiting the amount of
nutrients absorbed from the ingested food
(malabsorption).
• Ghrelin levels are lower and leptin levels higher after
Roux-en-Y gastric bypass, which results in decreased
hunger and increased satiety, respectively.

27. Physiologic or anatomic reasons
to favor RYGB
• RYGB treats insulin resistance better than other bariatric
procedures, it may be preferred in patients with uncontrolled
type 2 diabetes, nonalcoholic fatty liver disease, metabolic
syndrome, or polycystic ovarian syndrome.
• While sleeve gastrectomy (SG) and RYGB are equally effective
in improving diabetes in the short term, RYGB is associated
with better long-term control of diabetes and lower rates of
relapse3.
• Patients with Barrett's esophagus or severe /
complicated gastroesophageal reflux disease (GERD) are
better candidates for RYGB than for SG.
3. Can Sleeve Gastrectomy "Cure" Diabetes? Long-term Metabolic Effects of Sleeve Gastrectomy in Patients With Type 2 Diabetes.
https://www.ncbi.nlm.nih.gov/pubmed?term=27433906

28. Outcomes of LRYGB
• Patients undergoing LRYGB usually lose between 60% and
70% of excess body weight during the first year after surgery.
• Resolution of comorbidities varies, but is over 90% for GERD
and venous stasis ulcers and over 80% for patients with type
2 diabetes of less than 5 years in duration.
• Hyperlipidemias are almost always improved and resolve
totally in about 70% of cases.
• Hypertension resolves in 50% to 65% of cases.

29. General Complications of Gastric
Bypass
• Leakage along staple lines / surgical connections.
• Strictures / obstructions of the digestive tract.
• Dumping syndrome
• Nutritional deficiencies
• General Surgical risks

30. Complications of LRYGB
• 0.3% incidence of anastomotic leak4
• 0.33% incidence of venous thromboembolism5
• 3% - 5% incidence of wound infections or problems6
• 3% - 15% incidence of marginal ulcers7
• 7% incidence of bowel obstruction8
• 4% incidence of postoperative transfusion9
• 1% - 19% incidence of anastomotic stenosis10 based on
the type of anastomosis created.
4. Masoomi H, Kim H, Reavis K, et al. Analysis of factors predictive of gastrointestinal tract leak in laparoscopic and open gastric bypass. Arch Surg. 2011;146:1048-1051.
5. Finks JF, English WJ, Carlin AM, et al. Predicting risk for venous thromboembolism with bariatric surgery: results from the Michigan Bariatric Surgery Collaborative. Ann Surg. 2012;255:1100-1104
6. Hutter MM, Schirmer BD, Jones DB, et al. First report of the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness
positioned between the band and the bypass. Ann Surg. 2011;254:410-422
7. Gumbs AA, Duffy AJ, Bell RL. Incidence and management of marginal ulceration after laparoscopic Roux-Y gastric bypass. Surg Obes Relat Dis. 2006;2:460-463
8. Parakh S, Soto E, Merola S. Diagnosis and management of internal hernias after laparoscopic gastric bypass. Obes Surg. 2007;17:1498-1502
9. Nguyen NT, Rivers R, Wolfe BM. Early gastrointestinal hemorrhage after laparoscopic gastric bypass. Obes Surg. 2003;13:62-65.
10. Gonzalez R, Lin E, Venkatesh KR, et al. Gastrojejunostomy during laparoscopic gastric bypass: analysis of 3 techniques. Arch Surg. 2003;138:181-184

31. Adapted from Schwartzs Principles of Surgery, 10th Edition.

32. 1. Anastomotic Leak
• In the immediate postoperative period, anastomotic leak is
the single most feared complication after RYGB, either open
or laparoscopic.
• High index of suspicion for this problem are the only
appropriate approach.
• Tachycardia, tachypnea, fever, and oliguria are the most
common symptoms that arouse suspicion for this problem.
• The treatment is surgical except in rare circumstances where
a drain is already in place, no hemodynamic or clinical
deterioration is present, and the leak is contained.11
11. Thodiyil PA, Yenumula P, Rogula T, et al. Selective non- operative management of leaks after gastric bypass: les- sons learned from 2675 consecutive patients. Ann Surg.
2008;248:782-792.

33. 1. Anastomotic Leak, cont.
• In the first few hours or day after surgery, hematemesis
indicates bleeding from the gastrojejunostomy unless proven
otherwise.
• Any obstructive symptoms in the first few weeks after
surgery or any signs of obstruction of the biliopancreatic limb
on postoperative swallow studies due to stenosis of the
enteroenterostomy require immediate surgical intervention
to prevent rupture of the distal gastric staple line.

34. 2. Stomal Stenosis
• Stenosis of the gastrojejunostomy has been remarkably
reduced by the use of a linear stapling technique.12
• Stenosis symptoms usually appear from 6 to 12 weeks
postoperatively, but less commonly can occur later.
• Diagnosis is by upper endoscopy.
• Treatment is balloon dilatation.
• Resolution normally occurs with one or two treatments.
12. Schirmer BD, Lee SK, Northup CJ, et al. Gastrojejunal anastomosis stenosis is lower using linear rather than circular stapling during Roux-en-Y gastric bypass. Presented
at SAGES 2006 Scientific session, April 2006.

35. 3 & 4. Marginal ulcers and GG fistula
• Patient presents with pain in the epigastric region
that is not altered by eating.
• Diagnosis is by endoscopy.
• Treatment is medical with proton pump inhibitors,
which are effective in 90% of cases.
• Only those with a gastrogastric fistula to the distal
stomach, severe stenosis of the lumen of the
gastrojejunostomy, or acute perforation require
surgical therapy.

36. 5. Dumping Syndrome
• After RYGB, approximately 50% of patients will experience
symptoms of flushing, crampy diarrhea, palpitations, and
diaphoresis after ingesting a meal rich in simple
carbohydrates.
• This may contribute to weight loss by encouraging patients
to replace simple sugar with high-fiber, complex
carbohydrate, and protein-rich food items.

37. 6. Small bowel obstruction
• This complication must be treated differently than in the
average general surgery patient, whose complication is
usually from adhesions and often will resolve with
conservative, non-operative therapy.
• Patients who have had LRYGB who present with obstructive
symptoms generally require surgical therapy on an
emergent basis.
• This is because the etiology of the bowel obstruction after
LRYGB is often an internal hernia from inadequate or
nonclosure of the mesenteric defects by the surgeon at the
time of operation.

38. 6. Small bowel obstruction
• The cecum and terminal ileum are identified laparoscopically,
and the bowel is followed retrograde from the terminal ileum
to determine the anatomy.
• Often much of the small bowel is herniated through a
mesenteric defect.
• If the bowel is viable, suturing the mesenteric defect is all that
is needed for treatment.

39. Obstruction of contrast at enteroenterostomy with small bowel obstruction from internal hernia after laparoscopic Roux-en-Y gastric
bypass.
Adapted from Schwartzs Principles of Surgery, 10th Edition.

40. Nutritional Complications
Postoperative nutritional complications after LRYGB includes:
• 66% incidence of iron deficiency.
• 5% incidence of iron deficiency anemia.
• 50% incidence of vitamin B12 deficiency.13
• At least 15% incidence of vitamin D deficiency,14 which
usually is present preoperatively.
13. Aarts EO, van Wagenhingen B, Janssen IM, Berends FJ. Prevalence of anemia and related deficiencies in the first year following laparoscopic gastric bypass for morbid
obesity. J Obes. 2012;2012:193705.
14. Clements RH, Yellumahanthi K, Wesley M, et al. Hyperparathyroidism and vitamin D deficiency after laparoscopic gastric bypass. Am Surg. 2008;74:469-475.

41. References
• Schwartzs Principles of Surgery, 10th Edition.
• UpToDate.
• Obesity Surgery Principles and Practice.
• PubMed.