Revisions from Lap-band surgery
Early experience in the United States indicated a high revision rate for the lap-band. Revisions were reported due to slipping of the band or problems that necessitated removal of the band. The lap-band is a device, and like all devices, at some point may fail. Balloons have broken and port sites have needed changes. The difference is that most lap-band revisions involve minimal laparoscopic surgery.
The band can erode into the stomach, but even this can be repaired through a laparoscope by some surgeons. However, it may require open surgery in others. Still, this surgery remains the safest of all weight loss surgeries.
Revisions from Horizontal Stapling
—How to blow up a stomach
I live in the city that practically invented one of the first bariatric programs based on the horizontal stapling, so it is no wonder that this is the most common revision that we see at my hospital. This surgery worked well for a very short period of time. If the patient ate more than he should, the upper pouch easily enlarged to the original size of the stomach. This has to do with the anatomy of the stomach. The outer curve was greatly prone to stretch, and once it stretched it kept going. It is like blowing up a balloon. The first few breaths are difficult, but once it is stretched a bit it is a lot easier to blow it up more—as with the stomach. The VBG was developed because the vertical staple line reinforced the otherwise thin portion of the stomach, making it difficult to enlarge the pouch.
This part of the stomach is thin and can stretch. As this pouch enlarges, it takes more food to fill up a person. Ultimately, the advantage of the "stomach stapling" is lost. This is why the "horizontal" stapling was replaced with the vertical banded gastroplasty.
Roux-en-Y gastric bypass surgery revision
The most common revision is done when the stomach was stapled into two sections instead of cut (transected). A leak between the upper and the lower stomach makes the patient feel as if they can eat almost anything, and often they can. To solve this, the patient’s stomach is transected.
The second has to do with the pouch size. If the pouch has enlarged, revision decreases it to a smaller pouch. While this sounds fairly simple, it can be a technically challenging procedure, and the concern is always that the blood supply to the stomach might be compromised, leading to an increased incidence of leaks.
Some very obese patients have had revisions from a proximal to a distal RNY bypass. Mary is one of my favorite patients—she has a smile as wide as Georgia and a "can do" attitude that is infectious. She weighed over 460 pounds when she had a RNY proximal bypass. She went to the gym and water aerobics four times a week and lost nearly 100 pounds. Then she reached a plateau and couldn’t seem to lose any more. On her evaluation we found her pouch was a bit larger than it should be and recommended that we revise that, as well as her small bowel to a long-limb RNY bypass. Since Mary often complained of constipation, I assured her that by revising to a longer limb bypass we would solve the constipation problem. Mary had the surgery and did great. Mary also goes to TOPS (Take Off Pounds Sensibly). She came in third place for the most weight loss in a year in the State of Arizona. Mary also is no longer constipated.
The stoma between the stomach and the intestine can require a revision. Often this stoma can scar and become too narrow to admit food, and even sometimes liquid. This can be dilated during an endoscopic evaluation, often with a balloon dilator (a balloon is put through the narrow stoma and inflated to a specific size, much like balloon dilation of a blood vessel). Some gastroenterologists are not comfortable dilating these and will recommend surgery to revise the stoma. If you need dilation, it is helpful to go to a gastroenterologist who is familiar with bariatric surgery and works with a surgeon on a regular basis.
The stoma may need revision and this often has to be done in the operating room. If a stoma becomes too large, food will pass too quickly into the intestine and you will lose the benefit of the stoma. Recently developed procedures might allow a less invasive reduction in the stoma size. In this procedure, the stoma is injected with a solution to make it scar to a smaller size.