Obesity has become a serious global public health problem, affecting over 600 million adults worldwide in 2014, with prevalence doubling since 1980. Bariatric surgery is a highly effective and durable therapy for weight loss in individuals with severe obesity. Laparoscopic sleeve gastrectomy (LSG) has gained popularity due to its perceived technical simplicity, feasibility, and safety. However, a subset of patients may require modifications due to weight regain or complications. This article explores various revision options available after sleeve gastrectomy, including sleeve-in-sleeve revision, Roux-en-Y gastric bypass (RYGB), duodenal switch (DS), and other emerging techniques.
Understanding the Need for Revision Surgery
Revision surgeries have become increasingly indispensable in bariatric surgery, accounting for 7.4% of procedures in 2016. The American Society for Metabolic and Bariatric Surgery (ASMBS) categorizes reoperative surgery into corrective, reversal, and conversion procedures. Corrective procedures address poorly constructed initial operations or complications, while reversal procedures restore normal gastrointestinal anatomy for nutritional deficiencies or psychological issues.
Currently, no set criteria exist for assessing bariatric surgery success or failure, making it difficult to define the necessity for revisional surgery. Weight regain (WR), defined as regaining weight to achieve a BMI >35, affects approximately 14% of patients after bariatric surgery, leading to the reappearance of obesity-related complications.
Several factors contribute to WR after LSG:
- Sleeve Dilatation: Incomplete fundus excision during LSG might lead to sleeve dilatation, increasing ghrelin release and contributing to weight regain.
- Inadequate Initial Restriction: While the optimal bougie size is suggested to be 32F-36F, the impact of bougie size on weight loss after sleeve gastrectomy (SG) remains controversial.
Sleeve-in-Sleeve Revision
What is Sleeve-in-Sleeve Revision?
Sleeve-in-sleeve revision is a minimally invasive procedure designed for individuals experiencing weight regain or inadequate weight loss after gastric sleeve surgery. Over time, the stomach may stretch back to its original size due to overeating. This procedure creates a new, smaller sleeve within the original gastric sleeve to reduce stomach size and capacity.
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How Does it Work?
The procedure involves a specially trained doctor passing an endoscope (a flexible tube with a lighted camera and stitching instrument) into the mouth and down into the gastric sleeve while the patient is under general anesthesia. The doctor sews the stomach into a smaller sleeve shape without making incisions on the skin.
Expected Weight Loss
Patients undergoing sleeve-in-sleeve revision can expect to lose around 7-17% of their total body weight in one year. This number is influenced by the amount of weight regained and adherence to a healthy lifestyle.
Procedure Details
- Duration: The procedure lasts about 60-90 minutes.
- Recovery: Many patients go home the same day.
- Post-Procedure Care: The care team provides post-recovery instructions and a post-procedure diet plan.
Candidacy
Sleeve-in-sleeve revision may be an option for adults who:
- Have struggled with weight regain or unsatisfactory weight loss after gastric sleeve surgery.
- Are overweight with a body mass index of 27 up to 50.
- Have not been successful in losing weight through diet and exercise alone.
- Are looking for an alternative or don’t qualify for bariatric surgery.
This procedure may not be suitable for individuals with significant medical conditions or health problems. Consulting a primary care doctor is essential when considering a sleeve-in-sleeve revision.
Preparation
Before scheduling the procedure, the provider will perform an evaluation and thoroughly review the medical history. The care team will discuss weight loss goals, insurance, and payment options. Enrolling in a medically supervised weight loss program may be required.
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Recovery
Most people go home the same day after recovering from sedation. Detailed instructions on the post-operative diet are provided by the doctor and clinical team.
Risks
There is a low risk of serious complications. Minor side effects, such as nausea or discomfort, may occur but usually last only a few days.
Other Revisional Bariatric Surgeries
Roux-en-Y Gastric Bypass (RYGB)
RYGB is a common revisional surgery after LSG, particularly for patients with complications like gastroesophageal reflux disease (GERD). It involves creating a small gastric pouch and connecting it directly to the small intestine, bypassing a portion of the stomach and duodenum.
Duodenal Switch (DS)
DS is another revisional option, often considered the most effective for weight loss. It begins with a sleeve gastrectomy and then involves a small bowel bypass. Converting an existing sleeve gastrectomy to a duodenal switch simply involves doing the small bowel bypass. This procedure is low risk and can be done as a single anastomosis, meaning with one connection, which minimizes the risk of the operation.
Re-Sleeve Gastrectomy (ReLSG)
ReLSG involves reducing the size of the sleeve to restore restriction. A tube is placed down the sleeve, and staples are applied along the tube, similar to the primary sleeve gastrectomy.
Read also: Comprehensive Sleeve Diet
Emerging Techniques
Other revisional bariatric surgeries after LSG include biliopancreatic diversion, duodenal-jejunal bypass, one-anastomosis gastric bypass, single anastomosis duodeno-ileal bypass (SAID), and transit bipartition.
Addressing Complications After LSG
Revision surgeries may also be necessary to address complications arising from the initial LSG procedure.
Gastroesophageal Reflux Disease (GERD)
LSG can sometimes exacerbate or lead to GERD due to increased intra-abdominal pressure, impaired gastric emptying, and decreased lower esophageal sphincter (LES) pressure.
Treatment Options:
- Proton Pump Inhibitors (PPIs): PPIs can be used to treat mild GERD.
- Roux-en-Y Gastric Bypass (RYGB): RYGB is considered the optimal treatment approach when PPIs are ineffective.
- Ligamentum Teres Cardiopexy (LTC): LTC combined with the closure of the gastric crus is another approach, creating an artificial valve to restore the angle of His and reduce reflux.
Gastric Sleeve Stenosis
Gastric sleeve stenosis, a narrowing of the gastric sleeve, is a relatively frequent complication after LSG. It can be caused by mechanical factors (e.g., sharp angulations of the stapler) or functional factors (e.g., twisting).
Treatment Options:
- Endoscopic Dilation: Repeated dilation using the Savary bougie is an effective, safe, and durable method for managing stenosis.
- Stent Placement: A stent can be considered, although it may be poorly tolerated due to pain and discomfort.
- Surgical Revision: Surgical revision options include laparoscopic RYGB, wedge gastrectomy, or seromyotomy.
Gastric Leak (GL)
Gastric leak is one of the most serious complications after LSG. It can be caused by mechanical or ischemic factors.
Treatment Options:
- Endoscopic Operations: Most early gastric leaks can be resolved by endoscopic operations, such as endoscopic stent, fibrin sealant injection, percutaneous glue, and hemoclips.
- Revisional Bariatric Surgery: Revisional bariatric surgery is usually suitable for patients with chronic leaks that are difficult to treat endoscopically.
The Role of Lifestyle Modifications and Support
Like all weight loss procedures, the best results are achieved with a commitment to living a healthier lifestyle. Access to a specially trained team and weight loss experts, including behavioral health therapists, registered dietitians, and exercise specialists, is crucial for long-term success.
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