Consideration for Revisional Surgery

Consideration for Revisional Surgery

Kai Tai Derek Yeung and Sanjay Purkayastha


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).

Table 27.1 Classification of revisional bariatric surgery.

Corrective Surgery is performed to rectify a complication or inadequate effect of the index operation
Conversional Surgery is performed to convert the index operation into an alternative procedure
Reversal Surgery performed to restore the normal anatomy

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.


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.


Weight‐related outcomes is one of the most common reasons for revisional surgery. This can be either due to inadequate weight loss or weight regain. Significant weight regain is rare, but patients tend to plateau to a stable weight following surgery from their original weight. Patients should be counselled appropriately regarding this prior to surgery. This cohort of patients can be challenging to manage, and it is prudent that all patients who present as such are thoroughly re‐investigated, re‐evaluated and discussed in a multi‐disciplinary setting prior to any surgical re‐intervention. Clinicians also need to exercise caution when considering further procedures and not allow patient‐driven demand to cloud clinical risk versus benefit judgement.

Anatomical assessment should be performed using a combination of radiological and endoscopic tests to establish any cause of weight regain such as fistulation between the gastric pouch and remnant, dilatation or the presence of a wide gastric pouch or a wide gastro‐jejunal anastomosis.

Behavioural, psychological, metabolic and dietic evaluations should also be performed by the relevant allied health professionals to identify other habitual causes leading to weight regain. Food or alcohol coping mechanisms related to lifestyle or stress can be an important factor in this. A full review is crucial in the assessment phase as performing further surgery on those with unrealistic expectations can be counterproductive or even harmful. In the same way as primary bariatric surgery, surgical treatment for obesity is only a part of the required overall changes needed to achieve successful outcomes. Long‐term patient behavioural modifications are as important if not more important than surgery itself (Table 27.2).

Table 27.2 Investigations for weight regain.

Considerations Investigation
Anatomical and surgical Upper GI contrast swallow
CT scan
SeHCAT scan
Upper GI endoscopy
Helicobacter Pylori breath test
Diagnostic laparoscopy
Thyroid function tests
Behavioural and psychological Assessment of habits/coping mechanisms
Dietitian Assessment of intake
Blood tests including nutritional profiles

Relapse or Inadequate Control of Co‐Morbidities

Weight regain leading to a recurrence of obesity‐related metabolic co‐morbidities such as diabetes is an indication for consideration of surgery. Depending on the index operation, revision to Roux‐en‐Y gastric bypass (RYGB) seems to yield best results including further reduction of weight and reported to show an improvement of diabetes in up to 79% of cases. Revision of the gastric pouch or stoma in those who have undergone RYGB also seems to lead to an improvement of diabetes. The precise mechanisms of what leads to this beneficial clinical effect are yet to be fully understood. The evidence for revisional surgery in those with adequate weight loss but relapse of co‐morbidities is less clear.

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May 14, 2023 | Posted by in GENERAL SURGERY | Comments Off on Consideration for Revisional Surgery

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