Revision of Older Bariatric Operations

Many people had weight-loss surgery in the 1970s, 1980s or 1990s with operations that are rarely performed today. These include the vertical banded gastroplasty (VBG), sometimes called stomach stapling; the jejunoileal bypass (JIB), an intestinal bypass used mainly in the 1960s and 1970s; banded or silastic ring gastric bypass; early loop or mini-gastric bypass operations; and other forms of gastric stapling. Decades later, some of these patients develop problems such as narrowing, vomiting, reflux, malnutrition or weight regain.

These operations were replaced for good reasons. In a long-term study, more than half of patients with a VBG were estimated to need revisional surgery within 12 years, compared with a much smaller share after gastric bypass (van Gemert et al., Obesity Surgery, 1998). The jejunoileal bypass was abandoned because of serious long-term effects on the liver, kidneys and nutrition (Singh et al., World Journal of Gastroenterology, 2009).

If you had one of these operations and are having problems, or even if you feel well but have never had a check-up, an evaluation can tell you where you stand. Revision of older operations is some of the most complex work in bariatric surgery, and Dr. de la Cruz-Muñoz performs revisions of several of these procedures. For an overview of all revision options, see revisional bariatric surgery.

Revision has one of two goals: fix the problem the old operation is causing, and, when it helps, change the anatomy to a modern operation that works better over time.

• For a VBG or gastric stapling: the narrowed outlet, the band or ring, and the old staple lines are taken down, and the stomach is usually converted to a Roux-en-Y gastric bypass. This relieves the blockage, controls reflux and adds a modern weight-loss mechanism (Tevis et al., Obesity Surgery, 2011).

• For a jejunoileal bypass: the bypassed small intestine is reconnected so food again passes through the whole intestine. This stops the harmful effects of the bypassed bowel. Because weight usually returns after reversal, it is often combined with, or followed by, a modern operation such as a gastric bypass or a sleeve gastrectomy (Singh et al., World Journal of Gastroenterology, 2009).

• For a banded or ring bypass: an eroded, slipped or too-tight ring is removed, and the pouch or connection is repaired if needed.

• For an older loop or mini-gastric bypass: bile reflux or other problems may be treated by converting to a Roux-en-Y gastric bypass.

• Relief of blockage, vomiting and food intolerance caused by a narrowed band or ring.

• Better control of reflux, especially when a VBG is converted to a gastric bypass.

• Protection of the liver, kidneys and nutrition after a jejunoileal bypass is reversed (Singh et al., World Journal of Gastroenterology, 2009).

• Fewer repeat operations over time: in one study, patients whose failed VBG was converted to gastric bypass did not need further revision, while many patients whose VBG was simply redone did (van Gemert et al., Obesity Surgery, 1998).

• The chance to address weight regain with a modern operation.

You may benefit from evaluation if you had an older weight-loss operation and have:

• Vomiting, food getting stuck or being able to eat only soft foods (common with a narrowed VBG band or ring).

• Heartburn or regurgitation.

• Weight regain, often because the staple line has opened.

• After a jejunoileal bypass: chronic diarrhea, malnutrition, kidney stones, kidney problems, liver disease, vitamin deficiencies, joint pain or skin problems (Singh et al., World Journal of Gastroenterology, 2009).

• Pain, bleeding or anemia that may come from an ulcer or an eroded band or ring.

Patients with a jejunoileal bypass who feel well should still be checked, because liver and kidney damage can develop quietly over time (Singh et al., World Journal of Gastroenterology, 2009).

Mapping the old anatomy

Records from operations done decades ago are often unavailable, so the first step is to find out exactly what was done. This usually includes an upper endoscopy to look at the stomach, the band or ring and any ulcer; an upper GI contrast study to show the shape of the stomach and any narrowing or opening in the staple line; and often a CT scan to show the intestines and the overall anatomy. After a jejunoileal bypass, blood tests check liver and kidney function and nutrition.

The operation

Whenever possible, the revision is done with minimally invasive (laparoscopic or robotic) surgery. Because older operations were often done through a large open incision, there may be many adhesions, and sometimes an open approach is the safest choice. In a series of patients with failed VBG, laparoscopic procedures were associated with a shorter operation and hospital stay, and laparoscopic conversion to gastric bypass was favored when feasible (Tevis et al., Obesity Surgery, 2011).

For a VBG, the band and narrowed area are freed and removed or bypassed, and a new gastric pouch is created and connected to the small intestine as a Roux-en-Y gastric bypass. For a jejunoileal bypass, the bypassed intestine is reconnected to restore continuity, and a modern weight-loss operation may be added at the same time or later. Some patients need nutrition support before surgery to be strong enough for the operation.

Revising an older operation is more complex than a first operation. Scar tissue, altered anatomy and sometimes poor nutrition raise the risk of bleeding, leaks, infection, injury to the bowel, blood clots and a longer hospital stay. Some patients need more than one operation. In a series of VBG revisions, complication rates did not differ by surgical technique, but recovery was faster after laparoscopic surgery (Tevis et al., Obesity Surgery, 2011).

After a VBG is undone without conversion, most patients regain weight (Tevis et al., Obesity Surgery, 2011). After a jejunoileal bypass is reversed, weight usually returns too, which is why a modern operation is often added. Your surgeon will review your personal risks in detail.

Recovery depends on the operation. Most patients stay in the hospital for a few days. You will walk early, start with liquids and progress through the staged bariatric diet over several weeks. Patients who were malnourished before surgery may need extra nutrition support and closer follow-up. Most people return to desk work within two to four weeks.

In published series, converting a failed VBG to a gastric bypass was associated with weight loss in most patients and with fewer later revisions than redoing the VBG (van Gemert et al., Obesity Surgery, 1998) (Tevis et al., Obesity Surgery, 2011). For a jejunoileal bypass, prompt reversal is recommended to limit further harm to the liver, kidneys and nutrition, and lifelong follow-up is important (Singh et al., World Journal of Gastroenterology, 2009). With any revision, lifelong vitamins, lab checks and regular visits help protect your results.

More in revisional surgery

Related procedures: Gastric Bypass (RYGB), Sleeve Gastrectomy, Gastric Band Removal, Gastric Bypass Reversal and Gastric Bypass Stricture Management. For an overview of all options, see Revisional Bariatric Surgery.

Conditions treated: Weight Regain, Malnutrition After Bariatric Surgery, Stomach Narrowing (Stricture) After Bariatric Surgery, Vomiting After Bariatric Surgery, Acid Reflux (GERD).

Revising operations that were retired decades ago requires careful planning, patience with difficult scar tissue and comfort with every modern option. Dr. de la Cruz-Muñoz is a national leader in complex revisional bariatric surgery. He has been performing bariatric surgery for over 25 years, has performed more than 9,000 bariatric operations, a volume few surgeons reach, and has performed over 5,000 Roux-en-Y gastric bypasses, the most common conversion for a failed VBG.

Each plan starts with a full evaluation of your anatomy, nutrition and goals, and the operation is chosen for your safety. To schedule an evaluation, call 305-692-0392 or contact the office.

Reflux is common after a VBG or other gastric stapling, often because food backs up above a narrowed band. Converting to a Roux-en-Y gastric bypass is generally the best way to control it, because the small new pouch makes little acid and diverts bile away from the esophagus.

• VBG or gastric stapling: conversion to Roux-en-Y gastric bypass is the most common and best-studied option (van Gemert et al., Obesity Surgery, 1998) (Tevis et al., Obesity Surgery, 2011). Simply removing the band or redoing the VBG is less durable.

• Jejunoileal bypass: reversal (takedown) with restoration of intestinal continuity, often with conversion to a gastric bypass or sleeve, in one or two stages (Singh et al., World Journal of Gastroenterology, 2009).

• Banded or silastic ring bypass: ring removal, with repair of the pouch or connection when needed.

• Older loop or mini-gastric bypass: conversion to Roux-en-Y gastric bypass for bile reflux or other problems.

If you have an adjustable gastric band, see gastric band removal.

Revision for a medical problem, such as blockage, vomiting, malnutrition, reflux or the complications of a jejunoileal bypass, is often covered when medical necessity is documented. Imaging, endoscopy, lab results and any old records help support the request.

Preparation usually includes bloodwork with nutrition labs, an upper endoscopy, an upper GI study, and often a CT scan. After a jejunoileal bypass, liver and kidney tests are also important, and some patients need nutrition support before surgery. You will meet with the nutrition team and complete a medical evaluation. Please send any records you have from your original operation, even if they are incomplete. If you smoke, you will be asked to stop before surgery.

You will follow the staged bariatric diet (liquids, then pureed, soft and regular foods) over several weeks, with a focus on protein and hydration. Lifelong bariatric vitamins and regular lab checks are needed, and patients who were malnourished before surgery will have closer nutrition follow-up.

Walk the day of surgery or the next day, and often after that. Avoid heavy lifting for about four to six weeks, especially if an open incision was needed, and build up activity gradually as advised by the team.

Many patients with older operations had surgery in another city or country, and the original records are often lost. That is common, and testing will show us the anatomy. You can start with a virtual first visit, and our entire staff is bilingual in English and Spanish. Plan to stay in Miami for about 7 to 9 days after revisional surgery.