Gastric Revision Surgery
Gastric Revision Surgery following a Gastric Band
Gastric bands have been placed in patients for almost 30 years. For many patient’s long term results of gastric bands are disappointing with poor weight loss, weight regain and side effects such as regurgitation, reflux and obstructed eating, being the main problems encountered. As a result, many patients who have gastric bands ask for revision surgery to improve their weight loss and remove the unwanted side effects. Gastric Band removal The simplest form of revision surgery after a gastric band is to simply remove the gastric band. This is a quick 30-minute laparoscopic operation done under general anaesthetic, usually as a same-day procedure. It usually requires only three of the previous laparoscopic incisions to be used. The gastric band, tubing and filling port are simply removed, returning the stomach to normal. Gastric band removal and gastric revision to further weight loss operation If the band is being removed principally because of insufficient weight loss, then usually a further gastric revision procedure is advisable. It is very rarely advisable to place a further gastric band in this situation. The most commonly used gastric revision operations after gastric band removal are. Conversion to laparoscopic gastric bypass Roux-en-Y Conversion to laparoscopic sleeve gastrectomy Conversion to single or one-anastomosis gastric bypass (OAGB), or Mini-Gastric Bypass All these operations are performed laparoscopically and can be done either at the same time as the gastric band is removed or can be done as a second operation if the gastric band was removed previously as an emergency or as an urgent procedure. In many cases the gastric band will have already caused significant dilatation/stretching of the gastric pouch above the band with or without dilatation/stretching of the oesophagus and possibly with stretching of the opening in the diaphragm causing a hiatus hernia. It is really important that during gastric revision surgery following a gastric band that any hiatus hernia is searched for and repaired before continuing with the Gastric Revision Surgery. Removal of a Gastric band and revision to Gastric bypass Roux-en-Y This is the most commonly performed revision operation after an ineffective laparoscopic gastric band. It is particularly good for patients with type 2 diabetes or metabolic syndrome, (Type 2 diabetes, hypertension and elevated lipids) but is appropriate for any patient with weight regain or unpleasant symptoms following a gastric band. The operation takes approximately two hours and begins with removal of the gastric band through standard laparoscopic incisions. While the band is being removed any significant adhesions/scar tissue relating to the band are identified and removed. Once the gastric band has been removed and the band and stomach inspected to ensure that there is no sign of any gastric band erosion/scarring then the tunnel that was created by suturing the stomach over the gastric band is dissected free to restore the stomach completely to its normal anatomy and position. Once the stomach has been restored back to completely normal anatomy the ‘capsule’ of the gastric band needs to be removed from the stomach. This capsule is a plastic like layer which forms between the gastric band and the stomach and is the body’s immune reaction to the gastric band. It looks like a layer of plastic but it is actually natural scar tissue and is relatively easy to remove by lifting it from the stomach and carefully dissecting it away until the entire capsule encircling the upper stomach has been removed. It is vital that this capsule is removed before any stapling is undertaken on the stomach so that the staples may be used on the normal supple stomach tissue where there is less chance of staple leakage. Once the capsule has been removed then assessment for any hiatus hernia can take place as well as checking that there are no capsule adhesions to the back of the stomach. Once any hiatus hernia has been repaired, a standard Roux-en-Y gastric bypass can be undertaken. It is Mr Whitelaws practice to use a calibration tube of around 13 mm to make the correct diameter of the gastric pouch for the gastric bypass. The pouch would typically be 8 to 10 centimetres long and about 13.6 mm wide. Removal of Gastric band and revision to Sleeve Gastrectomy Removal of a gastric band and conversion to sleeve gastrectomy is less popular than conversion to gastric bypass. This is probably because surgeons worry about placing staples directly across the stomach tissue which has previously been affected and constricted by the gastric band. However, despite the fact that there is a theoretically a higher chance of staple leakage from doing this in reality, this does not appear to be a significant issue. The start of the operation is the same as for gastric bypass, the gastric band is removed, the anatomy of the stomach is restored to normal by opening the gastric band tunnel, the band “capsule” is removed and any capsular adhesions, particularly at the back of the stomach are removed. The hiatus is inspected carefully for a hiatus hernia or laxity which is then repaired. A standard sleeve gastrectomy using a calibration tube of around 13mm is typically done. The whole operation usually takes between 60 and 90 minutes and can be done as a daycase procedure, either Laparoscopically or robotically. Gastric band removal and conversion to one-anastomosis gastric bypass (OAGB), Mini Gastric Bypass As with the previous two operations the gastric band and band capsule is removed, and the stomach is returned to normal position and anatomy. Any hiatus hernia found is repaired. This operation involves stapling the stomach to create an approximately 10-12 cm stomach tube but leaving the remainder of the outer stomach in place and undertaking a single anastomosis (join) between the tube of stomach and the small intestine. Once again, this operation takes between 60-90 minutes and can be done as a day case procedure, either laparoscopically or robotically. Results of conversion of Gastric band to gastric bypass, gastric sleeve or one-anastomosis gastric bypass (OAGB)(mini gastric bypass) Conversion of a gastric band to a gastric bypass or gastric sleeve is usually very effective at removing the obstructive symptoms commonly found in an ineffective gastric band. These symptoms resolve almost immediately as does any reflux and the sensation of food being stuck that patients frequently get after a gastric band insertion. After the standard eight week post operative transition diet (please see this described in Gastric Bypass and Gastric Sleeve sections) during which time, weight is usually lost at approximately 2 to 4 lbs per week, patients usually experience ongoing significant weight loss. However, the sense of early satiety, reduced appetite and eventual weight loss is typically less than would be expected if a gastric bypass is done as a primary procedure. It is unclear why this is the case but it's likely to be due to the fact that the oesophagus and stomach are already accustomed to being stretched to accommodate food despite the small size because of the previous gastric band. Having said this, for patients with ineffective gastric bands and weight regain conversion to gastric bypass or sleeve gastrectomy is a worthwhile operation and results in a return to weight loss and a significant reduction or erradication of any uncomfortable symptoms related to the gastric band. Patients who have conversion to one-anastomosis (join) gastric bypass or mini gastric bypass have a higher incidence of bile reflux than those having conversion to gastric bypass Roux-en-Y or sleeve gastrectomy.
Gastric Revision Surgery following a Gastric Sleeve
There are three main reasons why revision surgery may be needed after sleeve gastrectomy. Severe reflux following sleeve gastrectomy, Poor weight loss or weight regain following sleeve gastrectomy or As the second part of a planned 2-stage bariatric operation. Severe reflux following sleeve gastrectomy Sleeve gastrectomy may cause significant gastro-oesophageal reflux (GORD) This may often not occur until some months or years after the original sleeve gastrectomy surgery. The majority of patients with significant acid reflux following sleeve gastrectomy may use medication to reduce acid secretion and this can be very effective for the majority of patients. For those who have severe reflux which is not helped by any medication then gastric revision surgery may be the only way to solve the problem. In this situation the best operation choice is usually a simple conversion of the sleeve gastrectomy to a gastric bypass Roux-en-Y. This is a relatively straightforward laparoscopic operation where the stomach sleeve is stapled approximately 10 centimetres from the top of the stomach, re-fashioned using a calibration tube with further staples to form a 13.3 mm diameter pouch and then joined to the small intestine in the standard way of a gastric bypass. This operation is very effective at reducing reflux. It may also be used for patients who have a ‘twisted sleeve’ or stenosis or stricture (tightening) of the sleeve, due to ulceration or narrowing of the original gastric sleeve. Despite this operation being very effective in improving reflux it only rarely helps to achieve a large amount of further weight loss and is unlikely to be effective for patients with significant weight regain and reflux. If this operation is being done for reflux it is important that both barium swallow examination and an endoscopy have been carried out before the surgery to identify any significant hiatus hernia present which can then be repaired at the time of the conversion to a gastric bypass. Poor weight loss or weight regain following sleeve gastrectomy In patients with weight regain following sleeve gastrectomy there are two gastric revision surgery options which can be expected to result in further significant weight loss. These are the SADI-S operation and the Duodenal Switch operation. Both of these operations are more radical than a simple gastric bypass or OAGB (mini gastric bypass) and require careful attention to be paid to the length of small intestine both upstream and downstream of the join with the duodenum. They also require that the gallbladder be removed during the surgery to avoid gallstone complications later. Both operations can be done laparoscopically or robotically The SADI-S operation is a single anastomosis (join) bypass but with the join to the small intestine done just beyond the Stomach and pylorus valve at the bottom of the stomach. This operation involves stapling across the duodenum just beyond the stomach and then constructing a single join between the small intestine and the duodenum. The length of intestine upstream and down stream of the join needs to be carefully measured and recorded. The operation usually results in significant additional weight loss. The duodenal switch operation is almost identical to the SADI-S operation but instead of having one join with the duodenum, there is a Roux-en-Y construction with two small intestine joins (similar to the Roux- en-Y-gastric bypass) They're both usually associated with good weight loss following gastric revision surgery but can result in loose stool, diarrhoea and micronutrient deficiencies. This is particularly true of the Duodenal switch operation. In this situation, iparticularly important deficiencies of fat soluble vitamins A, E & K may arise which require special replacement and monitoring. The SADI-S operation being a single anastomosis operation is less radical than the duodenal switch and causes slightly less weight loss overall but with a lower chance of micronutrient deficiencies. These operations are routinely carried out laparoscopically but increasingly in Mr Whitelaws practice can be carried out robotically as well. As the second part of a planned 2-stage weight loss operation Many surgeons offer a sleeve gastrectomy as a first stage operation in patients with a BMI greater than 50. In this situation, if weight loss stalls or indeed if weight regain occurs after the first stage sleeve, then a SADI-S procedure or Duodenal switch (DS) are the best options for the second stage operation. Gastric revision surgery of sleeve gastrectomy to one-anastomosis gastric bypass (OAGB) or Mini Gastric Bypass This operation involves stapling across the stomach sleeve approx. 12-15cm below the top of the gastric sleeve and joining the stomach to the small intestine with a single join. This operation may produce more weight loss than a conversion to a standard gastric bypass but should not be undertaken in someone who has significant reflux as a result of their sleeve gastrectomy.
Gastric Revision Surgery following a Gastric Bypass
Weight re-gain following laparoscopic gastric bypass is a common problem once five to ten years have passed following surgery. The options for gastric revision surgery in this situation are more limited than for the same situation with sleeve gastrectomy. Minimiser Ring / FOBI ring / Lap Banded bypass Minimizer rings or Fobi rings may be inserted around a gastric pouch (or sleeve gastrectomy) to enhance the restriction of eating after the operation. This is generally a very short, day-case laparoscopic operation lasting approx. 30 minutes where a Sterile silicon ring is inserted around the gastric pouch midway between the join with the small bowl on the top of the gastric pouch. The ring is then stitched in place to avoid slippage or movement. They can be adjusted to the correct tightness using a calibration tube as a guide to provide more restriction, particularly for a dilated gastric pouch. The Benefits of this type of revision surgery are that they are easy to perform, with low risk and with no cutting or stapling of the stomach. This can be done as a same day-case under general anaesthetic and takes approximately 30 minutes. Downsides of this operation are occasional fracture of the silicon band which would then require replacement. There is a very rare chance of the band eroding in the stomach or slipping and then requiring removal. The ring may also be removed if other gastric revision surgery is being contemplated. In some hospitals standard Lap adjustable gastric bands have been inserted around sleeve gastrectomy or gastric bypass pouches to provide more restriction but this operation is much less successful as it is not possible to fix the gastric band to the sleeve or pouch adequately and band slippage is a significant risk. Minimiser and Fobi rings have also successfully been used as revision procedures following sleeve gastrectomy. Endoscopic Trans-oral reduction (TORe) for dilated gastric pouch in gastric bypass Patients with a standard gastric bypass or one-anastomosis gastric bypass (mini gastric bypass) with a dilated gastric pouch or stretched anastomosis (join between the gastric pouch and small intestine) have another gastric revision option available which is Endoscopic stitches to narrow the pouch and the opening into the small intestine. This is a specialist endoscopic procedure, done under general anaesthetic which involves using an endoscopic suturing device to narrow the oppening. Gastric revision surgery options for weight regain after Gastric bypass Pouch and anastomosis revision in patients where the gastric pouch is extremely large or the anastomosis (join) between the pouch and the small intestine has stretched significantly, can undego a simple re-fashioning of the gastric pouch and re-do of the join to the small intestine. It is a relatively simple Laparoscopic or robotic operation which can be done as a day case procedure and takes approximately 45-60 minutes to undertake. Complex revision operations for an ineffective gastric bypass Other more complex revision operations following a failed gastric bypass involve complete reversal of the gastric bypass and conversion to a Duodenal switch or or SADI-S operation with the reconstituted stomach being converted to a sleeve gastrectomy at a later operation. These are 2 stage operations where the reversal of the bypass and the conversion to SADI bypass or Duodenal switch bypass is done at the first operation and then conversion to a sleeve gastrectomy is done as a second operation some weeks or months later. These operations provide similar weight loss and complication rates to the standard SADI-S and Duodenal switch operations. They are complex surgeries and in the unit at The Luton and Dunstable University Hospital are done either laparoscopic or robotically.
Appointments
Mr Whitelaw holds weekly in person clinics on a Thursday evening at Spire Bushey from 6pm, Friday evening at The Cobham Clinic from 5pm. Additionally he holds virtual clinics on Monday evening from 6pm and Wednesday evening from 7pm. Please either pop over to the appointment page here or call 07715 346331 to arrange a virtual apt.