Introduction

Currently, the most effective long‐term treatment for morbid obesity and its associated co‐morbidities is bariatric surgery. Bariatric surgery has been shown to improve outcomes and even lead to the resolution of associated conditions, such as diabetes, heart disease, hypertension, obstructive sleep apnoea and polycystic ovary syndrome. There is a reduction of cancer risk and obesity‐related infertility. Overall, quality of life, morbidity and life expectancy are also improved after surgery.

The chronic nature of morbid obesity means some patients may suffer from weight recidivism or recurrence of associated co‐morbidities over time. Response to treatment may be variable, inadequate or even too severe. Very rarely, patients may suffer from intolerance of procedures, excessive weight loss, reflux, diarrhoea and malnutrition. Revisional surgery is an option for these long‐term complications. The American Society for Metabolic and Bariatric Surgery (ASMBS) classifies revisional surgery into three broad categories: corrective, conversional and reversal (Table 27.1).

Revisional surgery may be technically challenging, and procedures are often more complex with higher associated risks and complication rates. These risks can be acceptable, but surgery should only be offered at specialist high volume units. They must also be weighed against possible benefits in an informed manner with the patient. The efficacy of revisional surgery is still widely debated.

There is currently no majority consensus of criteria that defines success or failure in bariatric surgery. Weight and BMI are often the focused outcome, but other metabolic measures such as improvement in conditions such as diabetes, hypertension and obstructive sleep apnoea are equally important and should also be measured. This uncertainty leads to difficulty when considering indications for revisional surgery. Practice is varied across the globe with multiple influences including commissioning from public‐based healthcare systems to insurance‐based private healthcare.

Another concept in the treatment of chronic disease is established algorithms in conditions such as hypertension, diabetes and chemo or radiotherapy in malignant diseases. It can be argued that revisional surgery should be considered a second‐line therapy rather than a failure of previous treatment. Nevertheless, the therapeutic goal should be to improve quality of life, improve medical co‐morbidities and prolong life expectancy.

Indications

Operations performed for acute or early complications defined as within 90 days of the primary procedure are not revisional surgery. These includes staple line or anastomotic leak, bowel obstruction, bleeding or perforation. All of which often require prompt surgical re‐intervention.

There are also instances where patients are planned for multi‐stage operations. An example of this is a patient may have a gastric balloon inserted several weeks prior to surgery. Following on, after initial weight loss and removal of the balloon, a sleeve gastrectomy is performed. A third stage in the form of Roux‐en‐Y gastric bypass may subsequently be offered. These are beyond the context of this chapter.