Giving a Masterclass in Revisional Bariatric Surgery is not easy, mostly because there is so much to say that it would take many hours to do it.
I’ve decided to simplify this theme and approach the most commonly performed procedures – Sleeve Gastrectomy (SG) and Roux-en-Y Gastric Bypass (RYGB): when to revise them and when not to.
Bariatric surgery complications can be divided into early and late complications. Late complications include Weight Regain/Insufficient Weight Loss.
Early Morbidity
SG
Clinical Background
Early dysphagia is a rare complication of SG. It is usually caused by swallowing and usually can be treated conservatively.
Leaks occur at the staple line, most commonly at the level of the angle of His. It has a prevalence of 0 to 11% and can be acute, early, late or chronic. Early management may involve drainage, endoscopic closure (stent, endo-sponge, overstitch, etc.), parenteral nutrition and dilatation of the pylorus. Eighty to ninety percent of leaks resolve in 4-6 weeks. If conservative treatment fails, surgery is the next step.
Bleeding is a rare complication and, just like leaks, it occurs in the staple line. It should not happen in more than 1% of the procedures and treatment through conservative approach to re-laparoscopy.
Technique Description
RYGB
Bleeding can happen in the first days after surgery. Prevalence is supposed to be below 2.2%. Tachycardia is the main clinical sign. A CT scan provides diagnosis and helps in the evaluation of hemoperitoneum in stable patients. In cases of endoluminal bleeding, endoscopy is not only diagnostic, but also therapeutic.
Stricture may happen days to weeks after surgery. It is exceedingly rare with linear anastomosis and more frequent with circular ones. Initial approach may also be conservative.
Obstruction may be an acute or late complication. Clinical presentation depends on the level of obstruction. In patients with obstruction affecting the BP limb, the most pathognomonic sign is extreme nausea without vomiting.
Leaks are relatively rare in RYGB. Diagnosis is confirmed by CT scan and endoscopy and is guided by clinical presentation. Treatment is not always surgical.
Late Morbidity
SG
GERD is a very prevalent complication of SG. Endoscopy and manometry are important parts of the diagnosis and PPI is the primary treatment.
Chronic stenosis may occur in 0.1 to 3.5% of patients. The cause may be a too narrow sleeve, a torsion, or a hypertrophy of the pylorus. Treatment may be endoscopic or surgical.
RYGB
Internal Hernia manifests as postprandial pain, avoidance of food intake, pain, and typical symptoms of small bowel obstruction. Treatment is surgical and usually entails closure of mesenteric defects.
Excessive weight loss has a prevalence of 1.4% in patients submitted toRYGB. Patients should be offered the option of reversal before deficiencies and other manifestations of excessive weight loss occur.
Insufficient Weight Loss/Weight Regain
Obesity is a chronic disease and, as such, relapsing may occur.
Insufficient weight loss may refer to a patient who does not reach the ideal weight goal, or a patient who loses weight and then regains it. The definition is not solid and is a topic for a whole debate. The key concept to keep in mind regarding the approach to these patients is that it is multidisciplinary. Every aspect of the previous procedure and patient must be analyzed and evaluated. Treatment can be conservative or surgical. Surgical treatment will depend on the index procedure and cause of failure.
Many of the complications of BS can be treated conservatively. It is important to perform an accurate diagnosis, to evaluate the patient in a multidisciplinary setting, and to refrain from unnecessary interventions.
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