Reoperative Bariatric Surgery: Revisional? Conversional? or Reversal?

Reoperative Bariatric Surgery: Revisional? Conversional? or Reversal?

Morbid obesity is a rising worldwide epidemic. Some studies have demonstrated the effectiveness of bariatric surgery in improving morbid obesity and comorbidities.

Considering the multitude of bariatric procedures performed all over the world, the necessity of revisional surgery increased in the same way. In 2015, revision surgeries accounted for 13.6% of all bariatric surgeries performed in the USA.

Reoperative Bariatric Surgery: Classification

  • The different re-interventions after bariatric surgery can be classified based on the following criteria:
  1. Indications:

Failures: Weight regain, Failure of weight loss, Recurrence of comorbidities

Complications: Surgical, Nutritional, Metabolic

  1. Types of Procedure:

Revision

Conversion

Reversal

  1. Outcomes

Type of primary: Restrictive vs Malabsorbtive

Type of re-operation: LAGB, RYGB, OAGB, TB, SASI, re-sleeve, reversal

Indications(Failure or Complications)

Surgeon’s experience***

Approach(Open or Laparoscopic)

Insufficient weight loss and significant weight regain following primary surgery are the major indications for revision surgery. Laparoscopic sleeve gastrectomy is currently the most frequent primary bariatric procedure worldwide performed. Sleeve gastrectomy is safe and effective in terms of excess weight loss. It is a restrictive procedure but also a powerful metabolic operation activating significant hormonal pathways (increased GLP-1 hormone and decreased ghrelin) that lead to modifications in eating behavior, glycemic control, and intestinal functions.

Some authors argued that as a consequence of the great diffusion of sleeve gastrectomy, the number of patients who have a weight regain at long follow-up is concordant and physiologic. Different procedures have been proposed as revisional surgery for the increasing number of patients who failed the expected and predictable anthropometric targets after sleeve gastrectomy. One anastomosis gastric bypass (OAGB) and Transit Bipartition/Single Anastomosis Sleeve Ileostomy(TB/SASI) appear extremely effective in inducing weight loss and reducing obesity-related comorbidities after sleeve gastrectomy. Several studies showed that OAGB and TB/SASI  were effective and safe options also as a redo surgery after failures or complications of sleeve gastrectomy.

In conclusion, prospective studies on SASI and TB, which are newer methods as well as classical bypass methods, should be performed in revision or conversion surgery after unsuccessful laparoscopic sleeve gastrectomy.