Duodenal switch (DS), also known as the biliopancreatic diversion with duodenal switch (BPD/DS), is a predominantly malabsorptive operation. It entails the removal of a portion of the stomach and the rerouting of the majority of the intestinal tract. The combination of reduced caloric intake and the significant malabsorption that ensues leads to a high rate of sustained weight loss. However, the incidence of nutritional deficiencies, metabolic derangements, and other side effects related to the extensive intestinal rerouting, is higher than with other operations. As a result, it is the least performed bariatric procedure (2-3%), often reserved for patients with extreme metabolic disease who have met rigorous selection guidelines to minimize such complications. In the US, the Roux en-Y gastric bypass (RYGB) has mostly replaced the DS, although the latter is the procedure of choice for RYGB “failures.”
At University Bariatrics, one of our primary goals is to educate patients about all of the available options. The ultimate decision, however, rests with you. Should you choose to pursue a procedure not offered directly by us, we can refer you to the most appropriate center(s) that can best meet your goals.
The laparoscopic adjustable band (LAGB), also known as Lap Band®, or Realize® Band, has been available in the US since 2002 after a trl period overseas. Though the concept of oral intake restriction through surgery is not new, previous iterations, such as the banded gastroplasty or the Angelchik® prosthesis, have subsequently been abandoned due to complications or ineffectiveness.
In its current format, an inflatable (adjustable) silicone ring is placed around the upper stomach. It is then connected to a port reservoir that’s attached to and buried in the abdominal wall. The band’s tightness can be adjusted by accessing the port via a needle stick and injecting or removing saline. To achieve the proper balance between satiety, weight loss, and obstructive symptoms, bands do require frequent adjustments, with or without fluoroscopic or ultrasound assistance. Only a limited number of these adjustments are covered by health plans and most patients when faced with high out of pocket costs, would forego additional visits and adjustments.
Compared to stapled operations, the LAGB surgical procedure has a much shorter learning curve for surgeons, and can often be performed on an outpatient basis. In addition, the initial recovery period is quicker than the other operations. Since no stapling or partitioning is involved, it is considered a safer operation initially albeit more (but less severe) complications are seen down the road. Furthermore, in the absence of any intestinal rerouting, the procedure is free of malabsorption issues and does not cause some of the gastrointestinal side effects of the more aggressive stapled operations such as the gastric bypass and duodenal switch.
Finally, the device complex can be removed at any point, although that does cause scarring in the implanted area, which potentially makes future procedures riskier.
Gastric plication or wrap, with or without adjustable banding, is being marketed by some practices in California and other U.S. and international locations. In contrast to the standard procedures, it does not involve any foreign body implantation, stomach partitioning, or intestinal rerouting. The stomach is suture-folded over itself in multiple layers. The final result mimics the sleeve in shape but not in hormonal changes. It is considered an investigational procedure and is currently not approved by any surgical society, health-plan, or regulatory agency. Long-term results, including complications and true reversibility, remain unknown. The severe swelling generated by the folding process, furthermore, may be permanent even if the wrap could be undone. This thickening is well beyond the capability of current staplers to convert it to another established procedure when it becomes necessary. Following guidelines set by the American Society for Metabolic & Bariatric Surgery, University Bariatrics strongly advises patients against pursuing this procedure until further data is available.
Mini gastric bypass or mini loop gastric bypass or mini sleeve bypass has been marketed to California patients. However, as fully discussed in the gastric bypass section, it is not the same operation as the standard RYGB or VSG. Hesitations and restrictions similarly discussed for the gastric plication exist for this procedure as well.
Known by several different acronyms, single incision surgery has been heavily promoted by the surgical industry. Weight loss operations, normally performed laparoscopically thru a few small (5-12mm) incisions, are done via a larger single umbilical incision. Crowding multiple instruments and devices through a small opening, however, typically creates ergonomic and visualization challenges for surgeons. To this date, with the possible exception of cosmetics, no reproducible advantage has been shown in terms of postoperative pain, recovery, and outcomes. Concerns regarding hernias from the larger umbilical incision remain and are being actively followed. The University Bariatrics team continuously monitors the progress in this field and will discuss this option with you at your initial consultation.
Minilaparoscopy has emerged as a viable and sensible alternative to single incision surgery. The surgeries are carried out in a fashion similar to standard multiport surgery, whilst utilizing 3mm instruments. University Bariatrics will be exploring this option shortly while at the same time cautioning patients against prioritizing cosmetics over safety and health concerns.
Robotic surgery is an alternative and highly marketed laparoscopic method to perform various bariatric and non-bariatric surgeries. With the surgeon sitting at a remote console, the robotic arms that traverse multiple 12mm laparoscopic ports, mimic his/her hand motions to perform some parts of the operation. Similar to single incision surgery, no advantage has been shown in terms of postoperative pain, recovery, or outcomes. The University Bariatrics team continuously monitors the progress in this field and will discuss this option with you at your initial consultation.
Open surgery through a large midline abdominal incision is still a viable option albeit uncommonly used in the era of laparoscopic surgery. University Bariatrics surgeons would reserve that only for unexpected intraoperative concerns that are not amenable to safe laparoscopic surgery.
What is Revisional Surgery?
Revisional bariatric surgery, typically applies to planned reoperations for either inadequate weight loss, or for problems inherent to the original surgery which did not manifest early on. Having another operation to address something related to an original bariatric procedure is probably not high on any patient’s postoperative expectations list.
These procedures are best carried out by more experienced bariatric surgeons at facilities that can provide the necessary support, like those we feature here at University Bariatrics. The high level of skill necessary to perform these operations makes experience and a proven track-record of excellence a must.
For revisional bariatric surgery in Thousand Oaks, Simi Valley, Moor Park, Newbury Park, Westlake Village, Agoura Hills, Camarillo, Conejo Valley, Ventura County and Oxnard, University Bariatrics has the state-of-the-art resources and talent needed to provide you with the care you deserve.
Types of Revisional Surgery Offered by University Bariatrics:
- Lap-Band or Realize Band Removal
- Vertical Banded Gastroplasty Reversal
- Vertical Sleeve Gastrectomy Revision
- Re-sleeve gastrectomy
- Conversion to Gastric Bypass
Vertical Banded Gastrectomy Revisional Surgery:
The vertical banded gastroplasty was a popular operation in the 1980’s and early 90’s. The stomach was partitioned but not fully divided into two segments. The smaller portion was further restricted by placement of a band at its end to obstruct oral intake and cause early satiety. Intestinal rerouting was not utilized. Gradually, VBG was abandoned in favor of the gastric bypass procedure, in part due to complications related to the band or the staple line. The University Bariatrics team has performed several laparoscopic revisional surgeries including full reversal or conversion to the gastric bypass.
Vertical Sleeve Gastrectomy Revisional Surgery:
Laparoscopic conversion of sleeve gastrectomy to gastric bypass is typically carried out for technical complications seen in poorly performed sleeves, incomplete resolution of comorbidities, or side effects such as reflux unresponsive to medical therapy. Typical revisions include resleeve gastrectomy or conversion to a Roux En-Y gastric bypass.
Roux-En-Y Gastric Bypass Revisional Surgery:
Complete reversal of the RYGB is rarely performed but may be necessary in cases of medical or surgical side effects refractory to conservative therapy. The University Bariatric team has successfully performed these cases laparoscopically with no complications or the need for open conversion. The “Roux-En-Y Gastric Bypass” can also be converted successfully to the duodenal switch under certain circumstances and we can refer you to programs that have extensive experience in performing them.
For more information, and to find out if revisional weight loss surgery is right for you, contact us today at: (805) 379-9796.
Goals/Motivation for General Revisional Surgery:
Multiple procedures have been introduced by the industry to address ongoing and lingering issues after surgery. Their common goal is to provide additional restriction by adding foreign bodies, tightening, or even re-stapling/trimming of gastric pouches and surgical anastomoses. Although the stretching of surgical areas is a natural and well-described phenomenon, the extent of influence on recidivism is debated.
Revisional intervention can include placement of rings or even Lap Bands around them. Endoscopic suturing of pouches and surgical hookups can be performed as well. Whereas their short-term results have held promise, most have been ineffective in the longer run. Foreign bodies left behind as part of these procedures, furthermore, will impede safe application of surgical staplers during their ultimate conversion to gastric bypasses and duodenal switches.
The University Bariatrics team believes that by playing on patients’ hopes and fears, some programs tend to overstate potential benefits without giving much detail on side effects and alternatives. The resolution and improvement of medical comorbidities are the primary objectives of the bariatric surgery we perform, and not an idealized final weight. Focusing on the latter, furthermore, can lead to the very same issues and coping mechanisms that resulted in morbid obesity in the first place. Inadequate weight loss and significant weight regain are multifactorial issues that often do not lend themselves to just adding more surgery. It requires a more fundamental approach to the whole patient, which our multidisciplinary group is able to offer.
Reasons for Revisional Surgery:
- Weight Concerns After Surgery
- Nonresolution of obesity related comorbidities such as diabetes
- Lap-Band Explantation due to:
- Foreign body reaction
- General intolerance
- Inadequate weight loss
- Surgical Side-Effects
For more information, and to find out if weight loss surgery is right for you, contact us today at: (805) 379-9796.
Revisional Surgery Frequently Asked Questions
When do I consider revisional surgery?
There are many reasons why one may qualify for revisional bariatric surgery at University Bariatrics. The most common reasons why our patients undergo revisional bariatric surgery are as follows: continued weight concerns after the original surgery, stretching of surgical areas, Lap-Band explantation for any reason, or any other negative unplanned surgical side-effects. If you are suffering from any of the above conditions or have any other concerns which you believe may qualify you for revisional surgery contact us today and schedule a consultation!
Will you do my revision if another surgeon performed the original surgery?
Yes! The location of your original surgery has no effect on qualifying for revisional surgery with University Bariatrics! Our highly-skilled surgeons are the best in the area at performing revisional surgeries to correct any bariatric issue where the original surgery may have lapsed or failed.
What are the results I can expect to see from a revisional surgery?
The resolution and improvement of medical comorbidities are the primary objectives of the bariatric surgery we perform, and not an idealized final weight. However, this does not mean that losing the weight is not a focus. Our revisional bariatric surgery is aimed at both reducing the impact of comorbidities as well as helping you to fix the issues with your original surgery. The end goal of our revisional surgery is for the resolution of the issues caused by the original surgery or reducing comorbidities, which may ultimately result in a significant amount of weight being lost!
What can I expect the day of my revisional surgery?
Depending on the procedure, the “day of” surgery expectations may vary. However, a standard experience at University Bariatrics has the patient resting in our recovery room after the procedure until the patient feels able to return to their home, the same day as the surgery or a few days later. Our experienced surgical and support teams are able to execute these procedures quickly and with the high level of performance you expect from University Bariatrics
Are there dietary expectations following my revisional surgery?
This is dependent upon the specific type of revisional surgery as well. However, as an overarching generalization, we suggest following a healthy lifestyle including exercise and a healthy diet as part of your recovery program.
Can I get pregnant after my revisional surgery?
Yes! Often times our patients whom have suffered through infertility as a comorbidity of their obesity are much more likely to be able to become pregnant after losing the weight. If this is a concern for you or a particular focus for your revisional surgery call our office today at (805) 379-9796 and speak with our team today!
Will revisional surgery cure my diabetes?
We cannot guarantee that any revisional procedure will “cure” or completely alleviate any comorbidities of obesity which a patient suffers from. However, it has been scientifically proven in many medical studies and medical journeys that bariatric surgery and weight loss have positive effects upon many comorbidities of obesity, including type 2 diabetes. To find out more information about the probability of seeing a reduction in your comorbidities call our office and speak with a member of our team today!
Is revisional surgery a painful procedure?
All of our revisional surgeries are performed in a minimally-invasive “keyhole” style. While the patient may experience mild pain or discomfort from the actual surgery, if you experience significant pain or discomfort following your revisional bariatric surgery, please contact our office immediately and speak with your surgeon!