Bariatric surgery, also known as weight loss or metabolic surgery, encompasses a range of procedures designed to aid individuals struggling with obesity and related health conditions. These operations modify the stomach and intestines to limit food intake, alter nutrient absorption, and positively impact metabolism. While initial bariatric surgeries often yield significant results, some patients may require additional procedures, known as bariatric revision surgery, to address complications, inadequate weight loss, or weight regain.
Understanding Bariatric and Metabolic Surgery
Weight loss surgery is also known as bariatric and metabolic surgery. These terms are used in order to reflect the impact of these operations on patients’ weight and the health of their metabolism (breakdown of food into energy). In addition to their ability to treat obesity, these operations are very effective in treating diabetes, high blood pressure, sleep apnea and high cholesterol, among many other diseases. These operations also have an ability to prevent future health problems. Today’s metabolic and bariatric operations have been refined over the course of many decades and are among the best studied treatments in modern medicine. They are performed with small incisions using minimally invasive surgical techniques (laparoscopic and robotic surgery). These advancements allow patients to have a better overall experience with less pain, fewer complications, shorter hospital stays and a faster recovery. The goal of these operations is to modify the stomach and intestines to treat obesity and related diseases. The operations may make the stomach smaller and also bypass a portion of the intestine. This results in less food intake and changes how the body absorbs food for energy resulting in decreased hunger and increased fullness. The common procedures endorsed by the American Society for Metabolic and Bariatric Surgery are listed and explained below. Each surgery has its own advantages and potential drawbacks.
Common Bariatric Procedures
Several bariatric surgery procedures are available, each with unique mechanisms and outcomes. The American Society for Metabolic and Bariatric Surgery endorses the following:
Laparoscopic Sleeve Gastrectomy: Often called the “sleeve”, is performed by removing approximately 80% of the stomach. The new stomach holds less food and liquid helping reduce the amount of food (and calories) that are consumed. By removing the portion of the stomach that produces most of the “hunger hormone”, the surgery has an effect on the metabolism. It decreases hunger, increases fullness, and allows the body to reach and maintain a healthy weight as well as blood sugar control. Sleeve gastrectomy involves removing approximately 75-80% of the stomach, leaving behind a small sleeve-shaped portion. This reduces the stomach's capacity, leading to decreased food intake and appetite suppression. Unlike gastric bypass, sleeve gastrectomy does not involve rerouting the intestines, and there is no malabsorption of nutrients. Endoscopic sleeve gastroplasty (ESG) is a minimally invasive procedure that reduces the size of the stomach, leaving a narrow, tubular, sleeve-shaped stomach. ESG reduces the stomach’s capacity by folding the portion of the stomach on itself which is responsible for the hunger sensations leading to reduced food intake and increased feelings of fullness.
Roux-en-Y Gastric Bypass: Often called the “gastric bypass”, has now been performed for more than 50 years and the laparoscopic approach has been refined since 1993. It is one of the most common operations and is very effective in treating obesity and obesity related diseases. First, the stomach is divided into a smaller top portion (pouch) which is about the size of an egg. The small intestine is also divided and connected to the new stomach pouch to allow food to pass. The gastric bypass works in several ways. Like many bariatric procedures, the newly created stomach pouch is smaller and able to hold less food, which means fewer calories are ingested. Additionally, the food does not come into contact with the first portion of the small bowel and this results in decreased absorption. Most importantly, the modification of the food course through the gastrointestinal tract has a profound effect to decrease hunger, increase fullness, and allow the body to reach and maintain a healthy weight. The impact on hormones and metabolic health often results in improvement of adult onset diabetes even before any weight loss occurs. The operation also helps patients with reflux (heart burn) and often the symptoms quickly improve. This procedure involves creating a small pouch at the top of the stomach and then connecting it directly to the small intestine.
Read also: Weight Loss Guide Andalusia, AL
Adjustable Gastric Band: Is a device made of silicone that is placed around the top part of the stomach to limit the amount of food a person can eat. It has been available in the United States since 2001. The impact on obesity related diseases and long-term weight loss is less than with other procedures. The feeling of fullness depends upon the size of the opening between the pouch and the rest of the stomach. The opening size can be adjusted with fluid injections through a port underneath the skin. Food goes through the stomach normally but is limited by the smaller opening of the band.
Biliopancreatic Diversion with Duodenal Switch (BPD-DS): Abbreviated BPD-DS, begins with creation of a tube-shaped stomach pouch similar to the sleeve gastrectomy. The smaller stomach, shaped like a banana, allows patients to eat less food. The food stream bypasses roughly 75% of the small intestine, the most of any commonly performed approved procedures. This results in a significant decrease in the absorption of calories and nutrients. Patients must take vitamins and mineral supplements after surgery. Even more than gastric bypass and sleeve gastrectomy, the BPD-DS affects intestinal hormones in a manner that reduces hunger, increases fullness and improves blood sugar control. BPD/DS is a more complex procedure involving two steps. First, a portion of the stomach is removed to create a smaller stomach pouch similar to a sleeve gastrectomy. Then, a significant portion of the small intestine is bypassed to reduce the absorption of calories and nutrients. This procedure results in significant weight loss and is particularly effective for individuals with a very high BMI or severe obesity-related health conditions. This weight loss surgery combines aspects of both the sleeve gastrectomy and the duodenal switch. It involves creating a sleeve-shaped stomach and rerouting a portion of the small intestine, bypassing part of the duodenum.
Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy (SADI-S): Is the most recent procedure to be endorsed by the American Society for Metabolic and Bariatric Surgery. A loop of intestine is measured several feet from its end and is then connected to the stomach. When the patient eats, food goes through the pouch and directly into the latter portion of the small intestine. The food then mixes with digestive juices from the first part of the small intestine. This allows enough absorption of vitamins and minerals to maintain healthy levels of nutrition.
What is Bariatric Revision Surgery?
Bariatric revision surgery is an additional surgery for patients who have already had at least one previous bariatric surgery. Patients who have experienced complications or negative effects as a result of weight-loss surgery may require additional procedures to correct the original operation, called revisional weight-loss surgical procedures. Bariatric revision surgery provides a specialized solution for patients who previously underwent weight-loss procedures, but aren’t experiencing the best results. The goal is to correct the problem that brings a patient under our care and make the revisional weight-loss surgery a definitive procedure.
Reasons for Revision Surgery
Several factors can lead to the need for bariatric revision surgery:
Read also: Beef jerky: A high-protein option for shedding pounds?
- Mechanical Failure: Mechanical failures are caused when the anatomical changes made during the original bariatric surgery are not maintained.
- Inadequate Weight Loss or Weight Regain: Patients may not achieve their desired weight loss goals or may experience weight regain after the initial surgery.
- Complications: The most common complications that require revisional bariatric surgery are ulcers, pouch enlargement, or the loosening of a LAP-BAND.
- Metabolic Failure: Bariatric surgery can metabolically fail the patient. Co-morbidities also can remain after bariatric surgery. These generally are related to the factors causing metabolic failure, as co-morbidities are strongly associated with metabolism.
More than 10 percent of LAP-BAND procedures require revision within two years.
Types of Revision Procedures
Bariatric revision surgery is for people who have already undergone a weight loss surgical procedure. A revision is tailored to the patient’s needs. The specific type of revision procedure depends on the patient's individual circumstances, the original surgery performed, and the reason for the revision. Here are some common types of revision procedures:
- Conversion of Gastric Band to Sleeve Gastrectomy or Gastric Bypass: This involves removing the gastric band and converting the anatomy to either a sleeve gastrectomy or a gastric bypass. As an example, many people who don’t lose significant weight with a LAP-BAND experience weight loss after a revision to the gastric bypass.
- Revision of Gastric Bypass: This may involve resizing the stomach pouch or revising the connection between the stomach and small intestine.
- Transoral Outlet Reduction (TORe): Is a minimally invasive procedure designed for individuals who have regained weight after gastric bypass surgery. Using an endoscope, the procedure reduces the size of the gastric outlet-the opening between the stomach pouch and small intestine-to slow stomach emptying and enhance feelings of fullness.
Who is a Candidate for Revision Surgery?
People who experience complications, poor weight loss, or weight regain after their original procedure may qualify for revisional bariatric surgery. Your surgeon will determine the best surgical approach for you. You don’t need to have your original bariatric surgery at Penn Medicine to qualify for revisional surgery with our bariatric surgeons.
Considerations and Expectations
Revision procedures do carry additional risks compared to initial surgeries. Revision outcomes depend on the type of revision surgery you are having and the reason behind that revision. Most people lose less weight after a revision than after their original surgery, but results vary. Your results also depend on your prior bariatric procedure. In addition to the above, revisions may lead to better health following surgery, like fewer symptoms from weight-related health conditions.
Pre-Operative Evaluation
We carefully evaluate you and review your case to determine why you experienced complications or weight gain after a previous surgery. Then we recommend a revisional approach suited to your individual needs and goals. During the process, you will have a few consultations with clinicians.
Read also: Inspiring Health Transformation
Recovery and Follow-Up
Recovery times vary depending on the type of revision needed. Follow-up care is important for recovery and long-term weight loss from any bariatric procedure. Successful bariatric surgery requires a team-based approach including your surgeon, dietitian, psychologist, nurse case manager, and obesity medicine specialist who will focus on taking you through each step of the journey. Your bariatric care team will provide you with lifelong support to succeed and maintain a permanent healthy lifestyle including changes to your diet and regular physical activity.
Lifestyle Adjustments
As with any bariatric surgery, maintaining a healthy lifestyle, including a balanced diet and regular exercise, is important for long-term success. Patients will do better if they continue to eat healthy, engage in physical activity, keep their appointments with obesity medicine providers, and take vitamins and mineral supplements as instructed. Brigham and Women's offers ongoing weight loss support.
Expertise and Accreditation
Expertise matters when it comes to bariatric surgery, especially revisional procedures. People who have bariatric revision surgery within an accredited center are less likely to experience surgical complications. Our board-certified bariatric surgeons have specialized training in weight loss procedures.
Insurance Coverage
Insurance coverage for revisional procedures varies and is determined by your insurance provider and your plan. Our team will work with you and your insurance company to help you receive coverage.