By Dr Ian Baxter
In the next few years there is no doubt that revisional bariatric surgery will become a large component of bariatric surgical practice. We have been doing Lap Band surgery for 20 years and Lap Sleeve surgery for 10 years. Certainly with thousands of sleeve patient’s out there, over the next 5 years we will be seeing an increase incidence of patients requiring revisional surgery for sleeve gastrectomy.
Revisional surgery for a lap band is usually due to obstructive symptoms because of the nature of the band around the upper part of the stomach. Weight regain is generally seen in patients who get fed up with obstructive symptoms and move onto high-density liquid calories and weight regain occurs.
In general we assess the patient whom has had a band and is struggling, with consultation, bloods and a barium swallow. Assessment by the team is important particularly when looking at revisional surgery. We revisit the dietetic and psychological aspects of why the patient has not done well with their particular bariatric procedure.
The band usually has to be removed as an individual operation. We would wait 6 to 8 weeks post band removal and contemplate either a sleeve or bypass as a revisional bariatric procedure for the patient. Determining whether to perform a sleeve or bypass is done after assessment by the team, looking at their eating behaviour and assessment of reflux symptomatology.
We are now in an era where patients with a sleeve gastrectomy will re-present with weight regain and/or reflux and consideration given for revisional surgery.
The process is similar to a band revision with recontacting the team, assessment of why they are running into trouble, a barium swallow can occasionally be useful but more commonly these days a fizz CT is performed. We have organised with a local radiologist for the CT scan to be programmed to perform this. The patient is given a carbonated contrast drink and a volumetric assessment of the sleeve is made, you also get an assessment of the shape of the sleeve.
Revisional surgery is generally looking at either a mini loop bypass or a Roux-en-Y bypass. Dr Baxter does not think re-sleeving a sleeve makes a lot of sense unless the sleeve was done in a centre where the sleeve was performed differently i.e. Fundus left intact or antrum left intact. He has seen some examples from Mexico and Thailand where consideration could be given for re-sleeve in the those circumstances.
Most importantly Dr Baxter thinks that a bariatric procedure should be done properly the first time with formal assessment and follow up by a bariatric team. Most of the talk at major national and international bariatric surgical conferences nowadays is about the dietetic and psychological aspects of bariatric surgery. That gives the best chance of a patient doing well long-term.